Quality Account
2014/15
Contents
Welcome by the Chief Executive ....................................................................................... 3
Statement of directors’ responsibilities............................................................................... 5
Introduction ....................................................................................................................... 6
Background to the Trust .................................................................................................... 7
Priorities for improvement 2014/15.................................................................................. 19
Priority one: continued development and improvement of the patient journey and
experience through accident and emergency patient pathway ......................................... 19
Priority two: improved patient experience ........................................................................ 21
Priority three: measures to reduce harm .......................................................................... 31
Quality Improvement goals agreed with commissioners .................................................. 36
Review of quality indicators ............................................................................................. 39
Other national and local Key Performance Indicators (KPI) ............................................. 42
Challenges ...................................................................................................................... 44
Priorities for improvement in 2015/16.............................................................................. 46
Priority one: reduce avoidable patient harm ..................................................................... 48
Priority two: patient experience ........................................................................................ 57
Priority three: improve the emergency care pathway ....................................................... 61
In-year monitoring of priorities ...................................................................................... 64
CQUIN Goals for 2015/16................................................................................................ 65
Statements of assurance .................................................................................................. 67
Data quality statements ................................................................................................... 68
Information Governance .................................................................................................. 69
Participation in clinical audit and national confidential enquiries ...................................... 70
Participation in clinical research....................................................................................... 82
Registration with the Care Quality Commission (CQC) .................................................... 86
Who has been involved in the development of this Quality Account? ......................... 87
Statements from our partners .......................................................................................... 87
List of Abbreviations ........................................................................................................ 97
For a translation of this leaflet or for an English version in large print, audio or
Braille please ask a member of staff or call 0800 783 4372.
Quality Account 2014/15
2
Welcome by the Chief Executive
On behalf of our Trust, I am pleased to present this report which looks back at our quality
achievements in 2014/15 and sets out our quality priorities for 2015/16. This document sits
alongside our annual report, which I would encourage you to also read, as this will give you
a fuller picture of our progress and plans for the future.
During 2014/15 we gathered views from patients, their representatives, Healthwatch, staff,
commissioners (CCG) (the NHS organisations who buy services from the hospital on behalf
of our patients), Local Authorities and the Trust Development Authority about what is
important to them. This information, along with the nationally set quality priorities for the
NHS, has enabled us to set the quality priorities for the coming year. I would like to take this
opportunity to thank everyone who has made a contribution.
It has been another busy year, with the Trust treating more patients than ever before. The
vast majority of our patients have received safe and effective care within our target waiting
times. During this period we have also continued our work to reduce inefficiencies and have
invested in staff and facilities.
In May 2014, The North West London Healthcare NHS Trust received an announced routine
inspection from the Care Quality Commission (CQC) – the independent regulator of all
health and social care services in England – to check that we were meeting essential
standards of quality and safety.
We were pleased that the CQC’s subsequent report of their findings recognised the many
good aspects of our care for patients and that the majority of feedback they received from
people who use our service and their representatives was positive. The overall results were
that Northwick Park and St Mark’s Hospitals required improvement and Central Middlesex
Hospital was rated as good.
We take the recommendations very seriously and since the CQC inspection we have
implemented a compliance action plan, which overall, has been completed. The outstanding
recommendations are to increase the number of beds at Northwick Park Hospital and
undertake a redesign of the children’s ward, Jack’s Place. These outstanding actions are
planned to be complete by winter 2015. You can read more on the CQC website at
www.cqc.org.uk
It is always a great concern and disappointment when care is not provided to the standard
that we aspire to deliver. ‘Never events’ are defined as: “serious largely preventable patient
safety incidents that should not occur if the available preventative measures have been
implemented by healthcare providers”. It is regrettable that during 2014/15 the Trust reported
three Never Events for the period April 2014 to March 2015. One involved a misplaced
Naso-gastric Tube (feeding tube). The second was as a result of a gauze swab being left in
place following a gynaecological operation and the third was as a result of a small superficial
incision being made on the wrong side of the right finger.
Over the past few years there has been an increasing drive towards greater transparency
and openness, something that is also part of our own vision. People can now access a
wealth of information about their local health services and compare their performance.
Quality Account 2014/15
3
It is now easier than ever for people to give feedback on their experiences of the NHS. The
Friends and Family Test has been a feature in 2014/15 with 25,358 patients telling us they
would recommend our services.
We recognise the value of involving our local community in decisions about our services and
priorities for improvement and always listen to the feedback we receive when things have
gone well and what we could have done better. This feedback has played a key role in
setting our priorities for 2015/16.
Quality improvement is an ongoing cycle and we will continue with our aspiration to offer first
class services for our communities.
Finally, on behalf of the Board, I would like to thank our staff and volunteers for their
continued dedication to improving quality and safety and without whom the improvements
delivered this year would not have been possible. I can confirm, in accordance with my
statutory duty, that to the best of my knowledge, the information provided in this quality
account is accurate.
Signature
Jacqueline Docherty DBE
Chief Executive
Quality Account 2014/15
4
Statement of directors’ responsibilities
The directors are required under the Health Act 2009 to prepare a Quality Account for each
financial year. The Department of Health has issued guidance on the form and content of
annual Quality Accounts (which incorporates the legal requirements in the Health Act 2009
and the National Health Service (Quality Accounts) Regulations 2010 (as amended by the
National Health Service (Quality Accounts) Amendment Regulations 2011).
In preparing the Quality Account, directors are required to take steps to satisfy themselves
that:
 the Quality Accounts presents a balanced picture of the Trust’s performance
over the period covered
 the performance information reported in the Quality Account is reliable and
accurate
 there are proper internal controls over the collection and reporting of the
measures of performance included in the Quality Account, and these controls
are subject to review to confirm that they are working effectively in practice
 the data underpinning the measures of performance reported in the Quality
Account is robust and reliable, conforms to specified data quality standards
and prescribed definitions, and is subject to appropriate scrutiny and review
 the Quality Account has been prepared in accordance with Department of
Health guidance.
The directors confirm to the best of their knowledge and belief they have complied with
the above requirements in preparing the Quality Account.
By order of the Board
29 June 2015
Peter Worthington
Chairman
29 June 2015
Jacqueline Docherty DBE
Chief Executive
Quality Account 2014/15
5
Introduction
This is our sixth annual Quality Account which specifically reviews the quality of care and
services provided by London North West Healthcare NHS Trust (‘The Trust’), previously The
North West London Hospitals NHS Trust and Ealing Hospital NHS Trust, prior to merging on
1 October 2014. This document complies with the Trust’s statutory duty under the Health Act
2009 and formally records the steps we have taken over the last year, and will be taking over
the coming year, to ensure we maintain a strong focus on improving the quality of care and
the services we provide to our local community.
Reflections on 2014/15
Our Quality Account is a reflection of the progress we have made to improve the quality and
safety of our services during 2014/15, what we have learned, and our priorities for the
coming year.
Any discussion this year relating to quality and safety must start with reference to a Care
Quality Commission (CQC) inspection that took place at Northwick Park, Central Middlesex
and St Marks Hospitals in the first part of the year. The headline news focused on the overall
assessment that we required improvement. We agreed fully with this assessment. However,
the key issues for me within the assessment was that the inspection found us to be open,
both within and without the organisation, there was clear care and compassion and good
medical and nursing care wherever the inspection team went. The culture of openness and
honesty without fear is important to patients and us as an organisation. It is the key to
continuous improvement.
Our challenges in terms of quality, and therefore our ongoing priorities, remain as waiting
times, patient experience and our basic processes of administration of care. We have seen
significant progress in terms of meeting our planned care commitments and Ealing Hospital’s
performance against the emergency care target is amongst the best in London. However,
there is now clear agreement and sign up to what needs to be done amongst all parties
involved in caring for patients through their emergency care journey. The progress made
encourages us to believe that we will be delivering the emergency care performance that is
required and needed by our patients.
We know from benchmarking that our performance on some of the basic markers of nursing
care, quality and safety such as infection control, pressure ulcers and falls are good. These
are very reassuring to me in amongst all the national focus on waiting times. However, we
also know that our administration of services, such as booking or changing appointments,
organisation of outpatient services and our response to complaints leave much room for
improvement.
Finally, the merger of the two legacy organisations has been a long drawn out affair which
concluded in October 2014. We still expect to see significant benefits to patients associated
with having all the community and hospital services together, thereby easing the journey
through care. We have already seen some benefits in terms of waiting times for care, yet the
immediate priority was to achieve the merger safely with no drop off in performance or
confusion to our staff and patients.
David McVittie
Former Chief Executive
Quality Account 2014/15
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Background to the Trust
Who we are
London North West Healthcare NHS Trust is one of the largest integrated care Trusts in the
country, bringing together hospital and community services across Brent, Ealing and Harrow.
The Trust was established on 1 October 2014 as a result of the merger of The North West
London Hospitals NHS Trust and Ealing Hospital NHS Trust.
We care for a diverse population of nearly 900,000 people living in Brent, Ealing and Harrow,
as well as patients from all over the country and internationally at St Mark’s, our specialist
hospital for colorectal diseases.
Some 11,500 people will be employed by the Trust in 2015/16, including over 1,300 doctors
and 4,000 nurses, as well as therapists, scientists, other health professionals, and
administrative and support staff. This makes the Trust one of the largest employers in the
three local boroughs.
Research and development and undergraduate and postgraduate education and training
play a vital role in the Trust. Driving improvement and excellence in the way healthcare is
provided, improving clinical management and helping to disseminate best practice.
What we do
Our core services include:
 full emergency department service for major and minor accidents and trauma at
Northwick Park and Ealing Hospitals. Both of these departments are supported by
a separate on site urgent care centre
 emergency assessment and treatment services including critical care. The Trust
is a designated trauma and stroke unit
 acute and elective surgery and medical treatments such as day and inpatient
surgery and endoscopy, outpatients, services for older people, acute stroke care
and cancer services
 comprehensive maternity services including consultant-led care, midwifery-led
natural birth centre, community midwifery support, antenatal care, postnatal care
and home births. There is also a special care baby unit
 children’s services including emergency assessment, inpatient, outpatient and a
range of universal community services
 a variety of community services for adults including district nursing and the
community bedded facilities at Denham, Willesden and Clayponds
 specialist community services supporting older people and those with long-term
conditions and disability such as diabetes, podiatry and musculoskeletal services
 diagnostic services including pathology and imaging services
 a wide range of therapy services including physiotherapy and occupational
therapy
 education, training and research
 corporate and support services.
Quality Account 2014/15
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Vision
The simple and compelling vision of London North West Healthcare NHS Trust is:
“To provide excellent clinical care in the right setting by being compassionate,
responsive and innovative.”
Close partnership with local patients and the wider public, GPs and other key health and
social care partners, will continue to be important as services are integrated and
transformed, enabling the Trust to achieve its ambitions for 2015/16.
Our ambitions
 To deliver safe, high quality services that meet national standards
 To realise the benefits of merger
 To pursue a vigorous programme of clinical integration
 To achieve significant improvements in key areas including cancer services, frail
elderly care and continuing to improve the emergency pathway.
Values
A key aim over the coming year will be to achieve a unified culture that reflects the needs
of patients, GPs, other stakeholders and staff. Consistent values were adopted in both
legacy Trusts prior to the merger, to ensure all our patients are cared for with dignity and
respect whilst ensuring that the Trust delivers excellence and professionalism in all that
its staff do.
Our promise:
 To continuously improve our services and create a positive learning environment
 To do everything we can to make our services safe
 To show compassion and support for our patients
 To provide care that addresses individual needs of our patients, their families and
our staff
 To take responsibility for our actions
 To treat others as we would expect to be treated.
Key facts and figures 2014/15
Outpatient attendances
Total emergency department (ED) attendances
Total urgent care centre (UCC) attendances
Total patients ED & UCC
Inpatient admissions
Babies delivered
Patients operated on in our theatres
X-rays, scans & procedures carried out by clinical
imaging
Community Services Activity (Brent, Ealing, and
Harrow)
*Number of staff
2013/14
627,733
142,699
176,404
319,103
162,946
7,442
77,038
2014/15
660,566
133,674
198,013
331,687
163,864
7,341
82,261
+/- %change
5.2%
-6.32%
12.25%
3.94%
0.6%
-1.4%
6.8%
496,525
516,772
4.1%
1,130,717
1,128,877
-0.2%
10504
11290
7.48%
* This is the number of people not number of posts / whole time equivalents (WTE).
Quality Account 2014/15
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Quality narrative
Clinical integration
Since the merger in October 2014 an extensive programme has been put in place to
integrate clinical teams across the new organisation. A clinician-led integration team is in
place, working with the new divisional structures to develop and implement plans to bring the
clinical teams together to improve the quality of patient care. We believe this work will bring
benefits in the following areas:






Clinical and operational resilience
Clinical pathway efficiency
Organisational culture change
Patient outcomes and experience
Responsiveness and communication
Staff training and opportunities.
Work across all divisions has identified over 100 schemes in 31 specialities, such as
developing single operational/clinical policies, developing new joint services and single on
call speciality teams.
The Trust executive, working with the frontline management teams, has identified six key
projects that will work across the divisions. These have been chosen to have the greatest
impact on what we believe are the key areas where we can improve clinical quality. Each
project has identified executive and operational leadership and will work closely with frontline
staff to deliver real benefits for patients and staff. These projects are:
Project
area
Vision / anticipated benefits

Emergency
pathway


Improved patient care throughout the emergency presentation, admission and
discharge process
Better patient outcomes and experience
Standardised processes delivering resilient working and consistent performance
against emergency indicators.
Cancer


Improved patient outcomes and experience
Single cancer governance and MDT processes delivering resilient performance
against current and future cancer targets.
Outpatients


Single points of Access for acute and community services
Improved communication with GPs and other health and social care professionals.
Key enabler to facilitate shared care with community and GP colleagues.

Maximise theatre utilisation and capacity across all sites, separating elective and
emergency workload. Key enabler to streamline emergency surgery and abolish
cancellation of elective surgery for ‘non-clinical’ reasons.

Increase the provision of care to patients in home or community care settings,
working closely and aligned with local partners including CCGs and Local
Authorities as part of Whole Systems Integrated Care.
Theatre
capacity
Elderly
services
across
acute and
community
Central
Middlesex
Hospital

Building on the work already completed to develop and deliver a sustainable level
of clinical activity on site.
Quality Account 2014/15
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Shaping a Healthier Future (SaHF)
London North West Healthcare NHS Trust (LNWHT) formerly comprised of North West
London Hospitals Trust and Ealing Hospitals NHS Trust worked with other providers and
commissioners to support the development of a set of proposals in 2012 to transform the
way healthcare is delivered for people in North West (NW) London. Clinical leaders from
across NW London proposed changes to create fewer, more comprehensive and better
staffed hospitals, able to provide the best quality care throughout the whole week, whilst
developing out-of-hospital services to allow co-ordinated integrated care for people with less
severe acute illness and those with chronic conditions.
The proposals are aimed at helping NW London meet the challenge of the NHS mandate,
save lives and improve clinical outcomes. The NHS in NW London is facing a range of
pressures and challenges. From a clinical view, there is increased demand caused by the
ageing population and increased prevalence of long term conditions and co-morbidities.
There are also unacceptable variations in the quality of care provided, evidenced by higher
mortality rates for patients who are treated in hospital at night or during the weekend.
Alongside this, there are financial pressures which require the NHS to deliver efficiency
savings for reinvestment. As such, doing nothing is not an option. The SaHF Case for
Change was developed with clinicians, who looked at the current and future demands on the
NHS in NW London, and showed that a new configuration of services was necessary to
deliver high quality care within the financial constraints on the system.
In order to significantly improve the maternity, neonatal and paediatric services provided to
women, children and families in NW London, these proposals included the intention to close
the maternity, neonatal and paediatrics services currently delivered on the Ealing Hospital
site. In October 2013, the Secretary of State for Health accepted the Independent
Reconfiguration Panel (IRP) recommendations to implement all of the SaHF proposals due
to the compelling evidence for how services will be improved. For maternity and neonatal
services this included the consolidation of maternity (delivery) and neonatal services from
seven sites to six sites (Chelsea and Westminster, Hillingdon, Northwick Park, Queen
Charlotte’s, St Mary’s and West Middlesex.
Ealing CCG was notified of a letter from the Deputy CEO of Ealing Hospital to the Medical
Director of NHS England (London region) highlighting the issue of reduction in deliveries and
the impact this could have on training and the ability to fulfil physician rotas. In response to
this letter Ealing CCG Governing Body, on 19 March 2014, as the lead commissioner for
non-specialist services at Ealing hospital, made a decision to invest in contingency plans for
the transition of maternity and neonatal services from Ealing Hospital by 2015.
Following this, on 8 October 2014, Ealing CCG Governing Body met in public and agreed
the need to plan for the transition of maternity and any other necessary, clinically
interdependent services from Ealing Hospital as soon as possible, noting that the earliest
that any service transition could take place is March 2015 when additional system capacity is
made available.
The Shaping a Healthier Future programme has undertaken detailed work to establish an
optimal date for the move. This exercise is clinically-led and involved clinicians, managers
and patient representatives from across North West London. The recommendations have
been endorsed formally by the SaHF Paediatric and Maternity Project Delivery Boards and
the SaHF Clinical and Programme Boards. The SaHF programme recommended to the
Ealing CCG Governing Body that:
 maternity and neonatal services close at Ealing Hospital on the 1st July, with the last
births taking place on 24th June 2015
 paediatric A&E and inpatient services close at Ealing Hospital in summer 2016.
Ealing CCG Governing Body agreed this proposal.
Quality Account 2014/15
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The teams have been working together across North West London to plan the transition
when a decision is taken. This includes supporting staff to remain at Ealing until the unit
closes and a detailed handover plan for each individual woman to ensure they are handed
over from Ealing hospital into the unit they have chosen to deliver their baby in.
The Trust is fully supportive of the planned maternity and neonatal service reconfiguration
and will contribute to achieving the following benefits:
 LNWHT midwife to birth ratio will continue to be 1:28. Overall improvement in
midwife to birth ratios across all five Trusts in NWL, following transition, with
improvement as a sector reaching the target of 1:30 overall (from 1:32 in 2014/15)
and an additional 105 midwives being recruited
 LNWHT improvement in consultant presence on the labour ward from 98 hours
to 108 hours by December 2015 following transition, increasing to 168 hours by
2017/18. Overall improvement in consultant hours on labour ward across all
five trusts in NWL from an average of 101 hours in 2014/15 to 126 hours in 2015/16
(an additional 12 WTE consultants) and on a trajectory towards 168 hours by
2017/18
 Improved maternity and neonatal estates for women in NWL as a result of the
reconfiguration
 Improved community model of care for women – for the first time a consistent
model of care will be implemented across NWL which creates greater resilience to
build and develop the home birth offer in NWL allowing end to end care by the same
organisation
 More women will have a named midwife that provides their antenatal and
postnatal care across NWL
 Improved continuity of care across the whole pathway as providers extend their
community midwifery boundaries and offer to women
 Increase in midwifery led services, with all six maternity units providing alongside
midwifery led births options
 Increased awareness of choice across NWL and improved compliance for 12+6
week bookings target
 Implementation of the NWL Maternity Booking Service so women are supported
when they don’t secure their first choice maternity provider and there is a
common acceptance criteria for all women when booking into maternity providers
across NWL
 Investment in achieving a target of 20% deliveries in Alongside Midwifery led
Units (AMUs) will result in an increase in normal deliveries and a reduction in Csections across the sector
 Facilitates the creation of sector wide posts for perinatal mental health, domestic
violence and safeguarding
 Facilitates sector approach to community breastfeeding support. NWL aims to
be one of the first sectors to achieve sector wide accreditation in Breastfeeding
Initiative
 Development of sector wide model for transitional care, with a sector approach to
multi-disciplinary education, aiming to reduce the number of babies separated from
mothers
 Facilitates a sector wide review of community obstetric provision supported by
consultants and providers – Northwick Park and Hillingdon already have plans to
run this model out of the Ealing hospital site following transition and following an
evaluation of the success this may be extended to all providers in the future
 Partnership working with GPs and CCGs to improve maternity referral patterns
across NWL
 Better alignment between numbers of medical trainees and overall delivery
activity to address historical misalignment
Quality Account 2014/15
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Messages from of our mums
“Thank you so much for everything you did for us during my labour to deliver my son. We are
so grateful to you and the other midwives who helped deliver our beautiful baby. Your
kindness and calm manner put me at ease and helped me get through the afternoon and
evening!!”
“The midwives at Northwick Park are lovely, smiley and compassionate. I have felt welcome
and feel cared for. The most important aspect to me is that I have not been made to feel like
a burden or ‘just another patient’ I have been treated like an individual. That does make a big
difference. Keep up the good work!!!”
"The Trust is extremely lucky to have these people working there. Thank you thank you
thank you”
“Thank you to the entire team of Ealing Maternity Wing. This could not have been better
than this. Thank you for all your support and care for our little shapaya and the mummy.
God bless you all. You guys do an excellent job. Keep it up!!”
“I want to thank all the team for their efforts and extra care given to me and my baby during
our stay. A special Thank you to (list of staff). I had a wonderful stay in the ward and would
definitely recommend its services to others.”
“We wanted to say a massive thanks for all that you did for us with the birth of our little boy.
You were fantastic and a great help and we can’t thank you enough.”
“I just wanted to say thank you to all staff who looked after me and my bump during my
recent stay on the ward. The standard of care I received, from both a medical and emotional
point of view was excellent. I am very pleased that I will be having my baby at Ealing in the
summer time, as I know we’ll be well looked after. As a thank you I have made a donation to
Bliss Special baby Charity.”
Quality Account 2014/15
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Quality Improvements
Acute services
Infectious Diseases Service
The Infectious Diseases department at the trust is located in The Lister Unit at Northwick
Park and on at the 8th Floor at Ealing Hospitals. Serving one of the most ethnically diverse
populations in the UK, the department has become the first choice for Infectious Diseases
(ID) referrals in North West London and increasingly the region. The trust looks after the
largest TB cohort in the country with excellent results and a uniquely efficient ambulatory
care model based in the ID assessment room(s) (IDAR). IDAR is the venue for over 1000
urgent GP referrals per year with suspected conditions including TB, HIV/AIDS, tropical
fever, infections requiring outpatient antibiotic therapy (OPAT) and treatment for viral
hepatitis. The unit is now established as the network hub for inpatient HIV care and during
the current Ebola outbreak became the referral site for possible category 4 cases picked up
by the Public Health England screening programme at Heathrow. Staffed by an expert and
enthusiastic medical and nursing team the department thrives on the variety and excitement
of providing excellent clinical care for any sick and vulnerable patients presenting with
infectious diseases.
One stop cardiology services at CMH.
This year we have moved to offer one stop clinics for patients needing both cardiology tests
and consultant review. This means that GP’s can access the service 5 days a week and get
patients seen rapidly, with everything done at one visit. This avoids patients having to attend
A&E. This is proving very popular with our local GPs and patients.
Radiology
The Radiology department at Northwick Park has now established an acute
team, comprising two consultants and three registrars, that provides a 24 hour turnaround
for Computed Tomography scans (CT), Ultrasound and Magnetic Resonance Imaging
(MRI) within 24 hours of request Monday – Friday. This has helped with faster decision
making and treatment for inpatients and emergency pathway patients. The Radiology
management team are striving to extend this service to seven days and have linked it to a
CQUIN target which is supported by the CCGs. This also offers the registrars excellent
training opportunities to work alongside their consultant colleagues.
The Radiology team also support the excellent service provided by Ambulatory care with the
provision of US scanning service – a Sonographer led service for DVT and acute abdominal
pain and developing other pathways in conjunction with the Ambulatory Care Clinicians.
We have piloted a direct to test service for CT Colonography where GPs can refer patients
with bowel symptoms straight to test. Following feedback from GPs and clinicians, this
pathway is being revised to reflect these changes. We are also working with the
commissioners and chest clinicians to develop a straight to test pathway for lung cancer.
Our vision is to provide a seven day service that is consultant led and where today’s work is
done today. Patients that require imaging should not have to wait for results of their imaging
so that faster diagnosis and treatment plans can be achieved.
Ambulatory Care
Working with our commissioners over the last two years we have set up one of the busiest
ambulatory care services in the country. The team sees, on average, 180 patients per week
who need urgent care but don’t need to be admitted for the care. These are patients who
might have a blood clot in their leg or have had a fit for the first time.
Quality Account 2014/15
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The service is led by Dr. Shahir Hamdualy who now speaks nationally on this development.
The unit has been so successful we had to move them to a bigger space so they can see
more patients. Patients are referred from A&E and from the GP. Not content with this
success, we are still aiming to see more people with different conditions in the unit and
similarly expand the unit at Ealing hospital.
STARRS (Short Term Assessment, Rehabilitation and Reablement Services)
STARRS is an intermediate care service that focuses on admission avoidance and early
supported discharge. The Rapid Response team sees approximately 570 patients a month
and manages to avoid around 430 admissions a month by providing comprehensive, holistic
assessment and ongoing clinical care at home for patients at risk of hospital avoidance.
Early supported discharge aims to provide intensive clinical support for patients in their own
homes for patients who are inpatients in acute wards. The team provides clinical care at a
patient’s home after discharge, facilitating earlier discharge from hospital and reducing the
LOS. We support approximately 340 patients a month from our acute wards.
Chest Pain Assessment Unit (CPAU)
CPAU was established four years ago with the primary aim to improve the pathway of
patients admitted with suspected Acute Coronary Syndrome and manage them in an
efficient and timely fashion. The other main objective was to offload pressures from A&E and
the GIM teams so those patients could be admitted directly to us from A&E, whenever the
bed situation allows. It took a big team effort and eventually we started with a x4 male and
x2 female six bed unit on Jenner ward.
The first year proved the unit to be very successful in the rapid identification, investigation
and treatment of suspected ACS patients. The need for a larger unit was clearly required
and within less than a year, largely due to the strong support from senior management, we
made it happen despite the logistical difficulties. We created a state of the art, fully
monitored 10 bed unit on Jenner ward.
With our excellent staff training and commitment the new unit became very quickly even
more popular and a new national standard for excellent care. The unit is operated by highly
qualified nursing staff who are now regarded as experts. There are two full ward rounds
every day to facilitate and expedite any outstanding investigations and discharges. The
result was a hugely enhanced patient experience, due to a fast and outstanding level of
care.
A second audit, performed at the end of last year, showed even more astonishing results.
The appropriateness of admissions was 90% or higher, the mean length of stay was reduced
by nearly two full days and the treatment was delivered in many cases within less than 24
hours from admission to the CPAU. This clearly demonstrates the impact that the dedicated
CPAU has, both for our patients and the Trust as a whole. It has set a new standard of care,
Quality Account 2014/15
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and not just for our hospital but one that should be adapted as a model nationwide. An
abstract with analysis of our unit operational procedure was presented at the European
Society of Cardiology Acute Cardiac Care Conference in Geneva last year and was highly
praised by international experts in the field.
The feedback by patients and their families was extremely gratifying and this, above all, is
what drives us to continuing our hard work and to meet the unprecedented demand for more
CPAU beds. A big thank you to all the staff who made this happen and for their ongoing
dedication and support. It wouldn’t have been possible without them
ENT (Ear, Nose & Throat)
This year, the department of ENT and Head & Neck Surgery at Northwick Park celebrates its
25th year of delivering a top class clinical service. From a brand new unit with four
consultants in 1989, it has grown to 10 consultants covering a catchment area of
approximately a 1.5 million patients. The unit provides all aspects of general ENT but offers
a tertiary referral service for Head & Neck cancer, a regional Voice Clinic, and specialist
services to Stanmore and Harefield hospitals. It is also a core department for Specialist ENT
training for the London Deanery. There are plans to further expand the unit which will see an
expansion of services.
Training of juniors has always been a rewarding experience with several progressing to gain
key consultant posts in teaching hospitals both locally and further afield.
Development of the ENT service has benefitted from close work, both clinically and in
management, with Oral and Maxillofacial colleagues as well as having managers of very
high calibre, with enthusiasm and a passion to support the ENT department. We look
forward, with confidence, to the next 25 years of ENT and Head and Neck Surgery across
the Trust to continue to service its local, regional and national patient referrals and training
the surgeons of the future.
Community Services
Developing the clinical strategy
The Trust delivers a wide range of specialist adult and children’s community services in
Brent, Ealing, Harrow, Hammersmith & Fulham and Hounslow. The newly merged Trust is
developing a clinical strategy for all of its services for completion in early 2015/16. This
emerging clinical strategy supports the delivery of accessible community services focused
on prevention, self-care, early diagnosis and anticipatory care of long term conditions and
the diagnosis and treatment of those with ambulatory emergency conditions in the
community, where appropriate. It also supports seamless, joined up care from the ‘cradle to
the grave’, working across traditional organisational boundaries.
At the heart of our vision is providing ‘the right care, in the right place, with the right
professional and at the right time.’
We need to radically change the way we deliver care and we are committed to continuing to
work with our commissioners, key partners and stakeholders to transform how our
community services are currently delivered, based on increasing population and changing
health needs. Our aim is always to deliver high quality, anticipatory and responsive care
closer to home, in a timely way, to a consistently high standard.
In the latter part of 2014/15 the Trust completed the business planning process for the year
ahead, which in turn, is shaped by national policy and commissioner intentions which have
informed the Trust corporate objectives for 2015/16.
Quality Account 2014/15
15
Key to all clinical areas is building and developing the workforce of the future. This element
of the strategy requires more work, in particular, as part of the integration agenda. The Trust
aims to be the training facility of choice for a number of professions.
Brent, Ealing and Harrow community services will continue to deliver core services (including
district nursing, health visiting and rehabilitation units) alongside services commissioned on
a borough basis.
Health visiting service: Health visiting academic hub
The Trust’s first health visiting academic hub is set to transform the health visiting profession
in Brent, Ealing and Harrow with its unique approach to training students and its professional
development of current health visitors. The hub, one of three support training centres in
London, was started in May 2014 following a Department of Health initiative to increase the
number of health visiting students in the capital.
The hub has a new model of training, which has been adopted by others, with three students
to each specialist community practice teacher (SCPT). The SCPT is supported by health
visitors who have been trained to be mentors. Experts from other parts of the Trust are also
used to deliver training sessions, making sure that the hub makes the most of the expertise
within the organisation.
The training was extended to the existing workforce following a survey that showed 75 per
cent of health visitors felt they had no career path. As a result, the hub offers tailored training
for their professional development, which includes leadership skills and shadowing.
Sharin Baldwin, Health Visiting Clinical Academic Lead explains: “When we became a super
training hub for health visitors we saw it as an opportunity to make changes to benefit not
just students but all health visiting staff. We are keen to ensure the delivery of first class
primary and early intervention health visiting services for every child and family in our care.
We can only do this by training our students and current health visitors to the highest
possible standard.”
Recruitment
Since October we have recruited 52 health visitors across the Trust, which is an exceptional
achievement for a 'difficult to recruit to' area of nursing. Over the last year we have increased
the number of health visitors in the Trust by 16 per cent with 21 health visitors appointed to
Brent, 24 to Ealing and seven to Harrow. There has been a concerted effort to provide a fast
Quality Account 2014/15
16
track application and recruitment process. This has ensured a fast, efficient and seamless
recruitment process which is co-ordinated by a project lead, working with the assistant
director and the health visiting academic hub team. Our focus on recruitment will continue
until the transition to local authority commissioning in October 2015, where we hope to have
recruited to our call to action trajectory.
New tool to tackle National £8.1bn cost of postnatal depression
Our health visitors have designed a new tool to help tackle the national £8.1bn per year
issue of mental health problems – including depression and anxiety – during the time from
pregnancy to the end of the first year after child birth. The team has developed a userfriendly ‘wheel’ that gives parents and health professionals access to a range of useful
information about postnatal depression and the support that is available.
Sharin Baldwin, Health Visiting Lead says:
“Postnatal depression is a major issue, affecting
10-15 per cent of mothers in the UK and up to ten
per cent of fathers. The latest research shows that
perinatal depression, anxiety and psychosis carry
a combined, long-term cost to society of £8.1bn for
each one-year cohort of births in the UK.
“Given the scale of the issue, we wanted to create
an easy-to-use source of information that pulls
together all the latest thinking and can be used by
health professionals and parents to help them deal
with postnatal depression. We reviewed all the
studies on this subject and came up with the idea
of a ‘wheel’, which sets out the signs and
symptoms associated with postnatal depression,
the triggers that can bring it on, and also explains
how people can cope and where they should go for support.
“Importantly, postnatal depression is not just an issue for new mothers”, continues Sharin.
“One in ten fathers are also affected, so we made sure that the wheel included a section with
information specifically aimed at men.”
The new wheel has been officially endorsed by the Institute of Health Visiting (iHV) and it is
now available to buy nationally via
www.kmmdpublishing.com/KMMDpublishing/DevWheel14.htm
Quality Account 2014/15
17
Tablet gives nurses more time to care
Tablet technology is enabling community nurses in Ealing, Brent and Harrow
to review and update patient records while carrying out home visits. This use
of technology not only saves time on administration but also allows nurses to
spend more time supporting and caring for patients.
Since the start of October, more than 240 community and district nurses
have been given a tablet computer to support their work. Fiona Murray,
community nurse explained how the use of technology is improving care:
“Before I arrive at a patient’s house I have all the patient’s details to hand. In
the past, I just had a patient name and details of the care that I needed to
provide. Being informed when you meet a patient really improves the care
that district nurses can provide. I can discuss the patient’s needs with them
and if equipment is required to make their home life easier, I can order it
there and then.”
The real time information provided by the tablet computers will also allow
other health professionals, including GPs, to advise if patients need to be
referred for further treatment within hours of the district nurse’s visit, making
patient care faster and more efficient.
The project has received a £450k grant from the Nurses Technology Fund
and is also supported by local Clinical Commissioning Groups.
Quality Account 2014/15
18
Priorities for improvement 2014/15
In this part of our Quality Accounts we review our performance against our key quality
priorities for 2014/15. We also provide key data relating to our performance and outline our
priorities for improvement in 2015/16.
The Trust Board agreed the following corporate objectives for 2014/15:
 Priority one: continued development and improvement of the patient journey and
experience through accident and emergency patient pathway
 Priority two: improved patient experience
 Priority three: measures to reduce harm.
Priority one: continued development and improvement of the patient
journey and experience through accident and emergency patient
pathway
Taskforce
To help improve the flow of patients from the emergency department into the hospital, a
taskforce was set up to look at all procedures across the hospital and community setting. A
major success of the taskforce was the launch of a new rapid assessment process and care
pathway allowing the emergency department team to treat stable emergency patients
quickly, without taking up additional beds. The taskforce are now looking to improve access
to community beds and care services so that patients, who are ready for discharge, can
leave hospital.
Emergency department performance
Ealing Hospital has consistently delivered in excess of 95% for all emergency patients
coming to the site and met 95% for emergency department (ED) patients frequently.
Pressure increased alongside all Trusts in North West London from mid-August to
December and systems, processes and capacity were inadequate for the increased
demand, which led to a significant dip in performance. This was recovered in mid-January
2015 and this has been maintained through to the end of March 2015. The clinical team
have introduced a new model of care for acute medical admissions and increased the
number of patients looked after in ambulatory care which has supported this good
performance.
Meeting emergency care standards has been a challenge at Northwick Park Hospital for
over five years, with 11 external reviews. Despite delivering all the actions from each review,
the target has still not been sustained. The team continue to work hard to give better care to
patients.
In September 2014 the team closed the emergency department and acute medicine at
Central Middlesex Hospital as part of the Shaping a Healthier Future programme to reshape
all healthcare services in North West London. This followed the installation and go-live of a
new computer system, Symphony. The planning then began for the move to the new
department at Northwick Park Hospital on 10 December 2015, which went according to plan,
thanks to the hard work and commitment of everyone involved. Most staff from the
emergency department at CMH joined the team at Northwick Park Hospital in time for the
opening of our new £21m emergency department and urgent care centre on 10 December
2014.
The best part of two years’ planning, building, training and hard work by staff across the
organisation went into this opening and all involved are very proud.
Quality Account 2014/15
19
The state-of-the-art department provides a dedicated treatment area for children and
includes 40 individual bays, giving patients a greater level of privacy.
The new department has been very busy during its first six months. To help improve the flow
of patients from the emergency department (ED) into the hospital, a taskforce has been set
up to look at all procedures in the hospital. The aim is to improve and speed up processes,
allowing patients to be discharged from hospital more swiftly. The knock-on effect of this
should see patients move through all areas of the hospital more quickly. In addition to this
work, two new modular wards will be opened in 2015 bringing 63 new beds to the Northwick
Park Hospital site.
The ED was not our only new service, in September a modern 20 bed medical unit opened
on Carroll ward. This new unit has the latest pharmacy equipment, allowing staff to provide
medication for patients more effectively and safely. Kathy Carruthers, Matron of Carroll ward
said: “This fantastic new service prevents patients who have been referred by their GP being
caught up in ED. We assess all patients on arrival at the ward and following diagnosis,
patients can stay here under observation for up to 24 hours. They can then go home after
receiving treatment, saving admission into hospital, or be transferred directly to an
appropriate ward. In our first 24 hours of opening, we prevented ten patients from being
admitted by providing this alternative care.”
Since September 2014, there has been a concerted effort to improve performance on the
Northwick Park Hospital site, with key interventions such as the care pathway, which
introduced a new way in which patients who could walk whilst in ED were seen in an
improved environment, with early intervention from senior staff. There have also been
improvements on the wards, with clearer, refreshed standards introduced on acute wards
and also for support times from specialty teams into ED.
The ambulatory emergency care unit (AECU) at Northwick Park hospital was opened in
January 2013 providing acute and specialist medical care in a day case setting with the
overall aims of improving patient care, diverting patients from ED, avoiding admission and
reducing length of stay in a hospital bed. Over the last year activity in the unit has steadily
increased and now reviews up to 250 patients per week which includes direct referrals from
primary care, ED and in-patient areas. Consequently up to 30 per cent of acute medical
admissions are diverted through AECU. The unit has evolved further over the last year with
comprehensive access to diagnostics including CT imaging, ultrasound and ECHO.
The unit is fully staffed with nurse practitioners and a full medical team including acute
medical consultants. Pathways have expanded to incorporate up to 20 disease conditions
including atrial fibrillation, syncope and low risk heart failure. In addition the unit also reviews
miscellaneous conditions defined by the AMB score which has enhanced throughput within
the unit. The success of the unit has been recognised nationally by two awards for
innovation provided by NHS elect.
Quality Account 2014/15
20
Priority two: improved patient experience

Develop a new customer care programme to reflect current national initiatives
which can also flexibly meet the needs of different services
The customer care programme was reviewed during the early part of 2014/15 when
educational material ‘Good Attitude’ was introduced to individuals and teams to improve
customer care. ‘Good Attitude’ uses role play and videos to support the learning of what
good care and communication looks and feels like, versus poor care and communication, as
well as the effects each have on how a patient, their family or carer feels. This feedback is
used to inform local and Trust wide improvement plans. In addition the Trust has developed
a customer care policy that sets down the expected standards when answering the phone or
meeting patients and members of the public in the hospital or community setting.
The chief nurse and director of human resources are responsible for the work stream
focused on embedding a culture of care and compassion through leadership programmes,
gap analysis of current training provision, staff development and a re-launch of appraisal and
recruiting for values.
The Trust is also working with Macmillan cancer services to deliver Sage and Thyme training
to promote resilience and resourcefulness. A plan is in place to deliver the Macmillan values
based standard, which has demonstrated improved patient experience through eight key
behaviours.
The Trust has engaged in a national campaign, transforming patient experience in the breast
unit, provided by McKinsey Hospital Institute (MHI) in association with the Disney Institute,
which was structured on building leadership, influencing and improving skills at the frontline.
As part of the process the Trust worked with Derby NHS Trust and University College
London Hospitals NHS Foundation Trust who have similar patient experience projects.
Quality Account 2014/15
21

Improve the capacity and capability across the organisation to respond to
complaints in an appropriate and timely way
Acting on complaints and compliments
The Trust welcomes feedback from the people who use our services and learns from
comments received, using them to improve patient service and care.
Complaints
The complaint regulations, published in 2009, gave NHS Trusts the ability to negotiate a
timeframe for responding to a complaint with each complainant, and for a second date to be
agreed with the complainant if the first response date is not met. These regulations also
gave guidance that all complaints should be responded to within six months. Overall, of the
complaints that the Trust responded to last year, 73% were within the timescale agreed.
Number of formal
complaints received
Location
2013/14
2014/15
Ealing Hospital
147
118
North West London
784
822
Hospitals
Brent community
23
13
services
Ealing community
23
17
services
Harrow community
30
46
services
Total
1007
1016
Data Source: London Northwest Healthcare NHS Trust
change
Response rate
%
#
%
-29
-20%
85
+38
5%
73
-10
-43%
100
-6
-26%
100
+16
53%
100
+9
1%
N/A
Overall London North West Healthcare NHS Trust received a similar number of complaints
to the previous year, but within this there have been changes with an increase of complaints
in Harrow services and significant decrease at Ealing Hospital. During 2014/15 there was a
concerted effort to be proactive in obtaining face to face patient feedback ‘in the moment’ to
help ensure a positive experience and mitigate concerns, this involved ward staff and
effective working of the Patient Advice and Liaison service. The increase in complaints
within Harrow was mainly related to the additional Urgent Care Centre service at Hillingdon.
Themes of complaints
The top four themes of complaints responded to in the last year were as below. This is
reflective of the themes that The NHS Information Centre 2013/14 report for England for
formal complaints.
Number
349
146
119
114
%
33
13
13
11
Subject
All aspects clinical treatment
Communication / information to patients (written and oral)
Attitude of staff
Appointments, delay / cancellation (outpatient)
Number
334
210
159
%
43
27
20
Profession
Medical
Trust administration
Nurses, midwives, health visitors
Quality Account 2014/15
22
Compliments
1 April 2014 to 31 March 2015, 763 formal compliments were received at London North
West Healthcare NHS Trust. These are in addition to the many cards, letters and tokens of
appreciation received directly by wards and departments.
ACAD department - theatre extended recovery (posted on 9 January 2015)
My wife Mary was treated with the upmost dignity and respect during her short stay today 09
Jan 2015. All the staff involved had an air of efficiency and courtesy amongst them, which
translated to my wife, giving her the feeling that she was in good capable hands. A good
point within the process was that my wife was consulted both before and after the operation
by Staff Nurse, the anaesthetist and the lead Surgeon giving further assurance to her. Can
you [give] my thanks to a very caring team.
Great Care - excellent staff (posted on 7 January 2015)
What I liked
My mother-in-law was recently admitted to Ealing hospital and the level of care she received
from all staff was excellent. I have also attended the hospital as a day patient and once
again been very impressed with the level of care from staff and the patience they show
despite on occasions being put under immense pressure by situations and also the rude
attitudes of some of those they are trying to help.
A&E & Carroll ward (posted on 12 March 2015)
My father was brought into A&E at NPH - the staff were brilliant & caring, all had the best
interest of my father, he had a seizure at home. Very quick CT scan & x-Ray then
transferred to Carroll ward. Again can't fault the care, the referrals to other depts, facilities
etc. We are so lucky to have such a good hospital on our doorstep. Thank you.
PALS
During the year, 1 April 2014 to 31 March 2015, the NWLH Patient Advice and Liaison
Service (PALS) received 4,806 and Ealing PAL’s received 2,533 comments and enquiries
from patients and visitors to the Trust.
NHS Choices
Feedback placed on the NHS Choices website, much of which is anonymous, is also
accessed by the patient relations team and passed on to teams for action as necessary.
Some of this feedback raises concerns, but an increased number of postings are positive
comments.
Principles for remedy
In handling complaints the Trust adheres to the Parliamentary and Health Service
Ombudsman’s (PHSO) six principles for remedy. These highlight best practice for
organisations to ensure complainants are treated in a fair, open and accountable manner,
and that appropriate and proportionate remedies are offered.
Complainants can also ask the PHSO to review the way in which their complaints have been
handled if they remain dissatisfied with the investigation and action taken by the Trust in
response to their complaint.
Quality Account 2014/15
23
Acting on complaints
As a result of the comments we received in 2014/15, we made a number of changes to
services, examples include:
 The need for clear and effective communication continues to be re-enforced in all
customer care and complaints management training to promote a shared
understanding between staff and patients of their options for current and on-going
care.
 Improved communication from multidisciplinary team meetings with patient and
families
 Patient discharge co-ordinators are in place to improve discharge processes and
communication
 Guidelines for audiology for new GP referral have been reviewed and disseminated
to all the staff in the department.
 A risk assessment has been introduced within 6hrs of a patient’s admission for those
patients who are admitted with anti-embolic stockings to help avoid pressure ulcers
developing as a result of ill-fitting stockings. This is now undertaken in conjunction
with the pressure ulcer and skin care assessments.
 A named registrar has been allocated to review all cardiac patients on Jenner ward
on the day of their discharge to ensure no last minute change in the patient’s
condition.
 To ensure clear communication and decision making all options for the management
of ectopic pregnancy are offered to women with clear explanation of reasons for
suitability
 Increased the involvement of our patients in the co-design of our services, especially
as part of the merger integration programme and impact of the changes outlined in
the Shaping a healthier future initiative.
Improving performance
The Trust continues to review systems and process to ensure complaints are managed well
to meet the needs of the complainant.
During 2015/16 the Trust will be:
 Ensuring the lead investigator speaks to the complainant to ensure the concerns and
issues are clearly understood, so that the response fully meets the complaints needs.
 Increasing the promotion of more local resolution meetings
 Increasing the number of lead investigators
 Providing on-going complaints management training to staff
 Strengthen the monitoring and operational performance management of the
complaints process.

Reinvigorate the Trust’s patient experience committee in liaison with Ealing
Hospital NHS Trust with an updated patient experience strategy and
implementation of a framework to drive measurable improvements and
accountability
During 2014 the two previous Patient Experience Committees of the legacy organisations
merged. As part of the process a new Patient and Public Involvement strategy was
developed, supported by a patient experience policy which outlines the different forms of
feedback methods used, governance structure and process. This committee reports to the
Clinical Performance and Patient Experience Committee (subcommittee of the Trust Board).
The key priorities during 2014/15 have been to launch the new committee, agree the PPI
strategy, develop a divisional reporting template, set standards for customer care and
support and challenge staff to progress the national survey improvement plans.
Quality Account 2014/15
24

Strengthen the mechanisms for real time feedback from patients and service
users, including the Friends and Family test, enabling services to react more
quickly in making improvements
Patient experience boards were mounted in all ward areas to promote open and informative
patient and user feedback. Information TV screens have also been installed in some
outpatient areas to deliver key Trust messages. This was also supported with the
implementation of quality boards on all wards to inform patients and their families of the
wards performance against key indicators.
The Trust selected a company to provide an electronic real-time patient survey system in
early 2014 which has improved patients’ feedback. There are a number of kiosks also
situated in the outpatient areas to ensure we capture patient views of the service. The 100
voices programme was held Trust wide in October 2014 which aimed to find out what
patients and staff thought of their experience at our hospitals. Responses were received
from 705 staff members and 360 patient surveys, which helped to improve patient care.
The report was shared with the divisional management teams for local action and key
themes were identified at corporate level.
Thematic analysis from the multiple feedback methods above help identify key areas where
patients feel services should be improved. In January 2015 we analysed the Friends and
Family results for quarter 3 2014/15 for in-patient wards across the acute Trust. This
involved a total of 2886 survey forms with free text comments from patients explaining the
reason for their FFT score.
A manual check of the surveys was undertaken, looking at the key themes and trends as
they emerged. These themes were interpreted using 5 of the 10 survey sections of the
National CQC Adult In-patient Survey:
 The hospital and ward (environment)
 Doctors
 Nurses
 Caring and treatment
 Operations and procedures
The reviewers identified positive and negative patient feedback against these five domains in
each of the months in question. This audit highlighted a number of key factors:
 The overwhelming positive nature of the comments in relation to front line staff’s
care, compassion, competence and professionalism, ranging from the domestic staff
to all professional groups. Doctors and nurses were often mentioned by name for
commendation and praise for their hard work and dedication to providing high quality
care.
 The key factors that patients comment on for improvement are around food, facilities,
processes, environment and staffing levels.
Some of the free text comments from patients provided to improve performance were as
follows at NPH &CMH:
 Food provided – menu choice and timing of meals, although some positive
comments received also
 Bathrooms and facilities require review and upgrading in areas known to the Trust
 Lack of televisions in the ward areas / lack of day rooms
 Delays in surgery/discharge/pharmacy
 Difficulty in sleeping due to noise/lights/activity ( Carroll ward, Dryden and Dickens)
 Nursing understaffed and lack of doctors at weekends
 Car parking
Quality Account 2014/15
25
At Ealing hospital the comments were as follows:
 Food – quality/ choice
 Noisy ward environment affecting sleep
 Nursing Staffing levels – perceived as understaffed
 Cleaning /environment / building
A number of actions have been taken in response:
1. A new range of food choices were introduced in 2014 and patients’ feedback is being
monitored to ensure we meet the needs of our culturally diverse local population
2. Ward staff were made aware that they can order additional food 24/7 to meet
patients’ needs
3. Staff have been reminded to try to reduce noise at night where possible by
minimising the number of patient movements, effectively managing confused patients
and those with dementia and ensuring they were appropriate shoes and speak
sensitively.
4. The Safer Staffing tool is used to collect data on nurse staffing on a monthly basis to
ensure it remains under constant review and sufficient nurses are on the ward to
provide high quality care. The results are shared with the public on NHS Choices.
5. The Trust has undertaken a conditions survey of all ward areas to inform priorities for
refurbishment.
6. A Customer Care policy has been developed outlining clear expectations of staff to
ensure a responsive and personal service in every care setting.
Friends and Family Test (FFT)
All NHS Trusts are required to implement the NHS Friends and Family survey. This was
officially launched in April 2013, and expanded further in October 2014 to community
healthcare services across the boroughs of Brent, Harrow and Ealing, in preparation for
national implementation on 1 January 2015. We have also introduced the Friends and
Family test as a pilot in the outpatient departments and adult and children’s day care
services. The Friends and Family test also asks patients for their comments and below is an
example:
What we are getting right
“The care received from A&E through to acute care and finally
Clarke ward was wonderful. The care was constant – right through the
medical team/doctors and nurses to the cleaning staff, admin staff and many
others. Thank you so much for your care and attention”.
“Everyone was amazing, not only all the medical staff but with the care and
patience every member of staff showed. I cannot praise everyone
enough, amazing team”!
February 2015
Quality Account 2014/15
26
Inpatients
In 2014/15 the Trust received 12,058 completed Friends and Family Tests from patients on
discharge from hospital. There were 8,055 patients from the legacy NWLH and 4,003 from
the legacy Ealing Hospital NHS Trust. The overall response rate for the Trust was 31%,
which is just above the national target of 30%, with the London average achieved at 37.8%.
% of respondents that would recommend the Trust to friends
& family
Inpatients 2014/15
100%
95%
90%
85%
80%
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Ealing
86%
86%
86%
83%
81%
84%
81%
93%
88%
91%
91%
94%
North West London
93%
93%
92%
92%
90%
92%
93%
96%
94%
98%
96%
95%
London North West
91%
92%
90%
89%
86%
89%
88%
95%
92%
95%
93%
95%
Ealing
North West London
London North West
Patients are asked to indicate how likely they are to recommend the hospital ward to their
friends and family and from the completed responses, overall 88.3% said that they would
recommend the Trust, and only 1.2% would not do so. At the legacy trusts, NWLH 93.2% of
patients said they would recommend the Trust and at Ealing Hospital NHS Trust, 86.1% of
patients said they would recommend the Trust. .
At Ealing Hospital, 4003 inpatients completed a Friends and Family survey with an average
response rate of 37%, above the target of 30%. At NWLH, 7730 inpatients completed a
Friends and Family survey with an average response rate of 29%, which is just below the
target of 30%.
Quality Account 2014/15
27
Accident and emergency FFT
In total over 60,000 patients attended the accident and emergency departments at Northwick
Park and Ealing hospitals during 2014/15, of these 11,172 patients completed a FFT survey.
Of these patients 7,700 (69%) were at The North West London Hospitals NHS Trust legacy
organisation and 3,472 (31%) at Ealing Hospital NHS Trust legacy organisation.
The Trust achieved an overall response rate of 18% completed surveys against a national
target of 20%, with 16.2% attained at the former legacy organisations and 24.6% at the
latter.
When asked how likely they would be to recommend the A&E department to their friends
and family, 81.6% of our patients would recommend the Trust and 11.7% would not do so.
The London performance was at 87% and England 90.4%.
% of respondents that would recommend A&E to
Friends & Family
100%
90%
80%
70%
60%
50%
40%
Apr
May
Jun
Jul
Aug
Sep
Central Middlesex
94%
94%
88%
98%
83%
93%
Ealing
89%
88%
89%
92%
84%
Northwick Park
81%
90%
70%
67%
83%
London North West
88%
91%
79%
79%
84%
Central Middlesex
Ealing
Oct
Nov
Dec
Jan
Feb
Mar
89%
87%
97%
93%
94%
95%
91%
74%
58%
47%
59%
83%
91%
91%
78%
68%
65%
61%
88%
94%
91%
Northwick Park
London North West
Please note Central Middlesex Hospital closed in September 2014
Quality Account 2014/15
28
Maternity services
From over 6000 responses across the year, 92% of clients would recommend maternity
services across London North West Healthcare. The monthly breakdown is displayed in the
chart below:
% of who would recommend the Trust's maternity services to
friends & family
100%
95%
90%
85%
80%
Overall
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
91%
91%
91%
90%
91%
91%
93%
94%
95%
92%
96%
90%
The feedback from the surveys across all service areas are used by the individual wards and
service teams to both celebrate success and positive feedback as well as use the areas for
improvement to inform their local improvement plans. The results are displayed locally on
patient information boards and ‘You Said - We Did Boards’ are being rolled out across the
Trust to ensure patients have confidence that we are acting on their feedback.

Embedding Compassion in Practice (DH 2012), which articulates our six
fundamental values: care, compassion, competence, communication, courage
and commitment, underpinned by six areas of action to support professionals
and care staff in delivering excellent care
In preparation for the merger, a new nursing and midwifery joint strategy, ‘for compassion,
quality and safety in practice 2013-16’ was developed along with an action plan in response
to the care, compassion, competence, communication, courage and commitment and
monitoring framework. Progress is being monitored against key milestones across all
services.

Roll out of nursing comfort rounds
Comfort rounds, also known as intentional rounding, are set up to review patients regularly
rather than as a response to a call bell. These have been in place at the Trust for more than
four years, however a review was undertaken this year to ensure they still remain effective.
The review demonstrated varied compliance with the rounds and a good practice model
has been identified at Ealing Hospital NHS Trust, which link the checks to patient
assessments such as those undertaken for falls and nutrition. A project group was set up
to implement this system trust wide in May 2014 and underpinned by training, competence
assessment, guidelines and audit. Comfort rounds are continually being reviewed and relaunched to ensure they meet the needs of patients.
Quality Account 2014/15
29

Work with local community services, mental health teams and voluntary
organisations to support the pathway for patients with dementia.
Dementia is a life limiting illness with diagnosis leading to increasing dependence and
vulnerability. Approximately 800,000 people in the UK currently suffer from dementia, with
one third of those being over the age of 95 years.
The Trust has been working with local community services, mental health teams and
voluntary organisations to support the care for patients with dementia. The Mental Capacity
Act and Deprivation of Liberty Safeguards (DoLS) are regular agenda items at quarterly
meetings.
A dementia strategy has been developed and was approved in April 2014 to ensure that the
Trust is working towards being dementia friendly. The overall aim is to improve care and
experiences for those with dementia and their carers across the following four domains:




Ensuring the right environment for care
Having the right pathways for treatment and care
Providing care and support for patients and their carers
Raising awareness, changing attitudes.
This year the multidisciplinary team has implemented a dementia bundle (checklist) which
has provided a structure to help ensure staff assess patient needs accurately. The mini
mental evaluation score alerts GPs and the psychiatric liaison team to the patient’s possible
need to attend a memory clinic.
This is supported by dementia passports which ensure all hospital and community staff can
support patients early in their diagnosis and to identify and assess their cognitive
impairment. Working with GP colleagues, the Trust will continue to roll out dementia
passports.
The Trust has employed psychiatric consultants to support patients whilst in hospital and to
work alongside external partners to deliver services at home. A matron for dementia has
also been appointed to work closely with the learning disabilities nurse as this patient group
is known to suffer from dementia-like symptoms earlier than able bodied patients. Dementia
training has also been introduced as a compulsory e-learning module for staff with
compliance increasing from 66% to 78% in year with plans to increase further in 2014/15.
The Trust has secured funding from the hospitals League of Friends for a dementia sensory
room, which is now in place on an acute elderly medical ward. It has been shown in studies
that these sensory rooms calm and bring patients ‘back to self’ effectively, which aids
effective and rapid recovery.
In addition thanks to a successful dementia enhancement refurbishment project bid a ward
at Ealing had been upgraded and now offers a compliant dementia friendly environment.
Quality Account 2014/15
30
Priority three: measures to reduce harm

Continue to recognise the early deterioration of patients, ensure appropriate
escalation, treatment and care
The Trust priority is to ensure we are able to identify patients whose health is deteriorating.
This is done through use of early warning scoring systems, which assign a score for vital
signs, such as pulse, blood pressure, temperature and respiratory rate which are outside the
normal range. For adults we use the National Early Warning System (NEWS) and for
children the Paediatric Early Warning System (PEWS).
High score results are escalated to clinicians for a review of the patient – this will be a
member of the regular medical team or an anaesthetist if the patient is very unwell. A
programme of training is in place for clinical staff to ensure they are familiar and consistently
use the NEWS and PEWS scores correctly and take any required action as a result.

Harm free care: performance using the National Safety Thermometer
Table 1: harm free care
The national picture with regard to the outcomes for the NHS Safety Thermometer for March
2014-March 2015 was published in April 2015 and gave bench marks for all Acute Trusts.
The Trust has used this data as a benchmark to compare and identify areas which need
improvement or where the Trust is better than the national figures.
What is the NHS Safety Thermometer?
The NHS Safety Thermometer provides measures of harm and the proportion of
patients that are ‘harm free’ from pressure ulcers, falls, urine infections for
patients with a catheter and venous thromboembolism.
The Safety Thermometer is a point of care survey that is carried out on all patients
on one day each month.
Old Pressure Ulcers – Old pressure ulcers developed within 72 hours (3 days) of
admission. The category of the patients’ worst old pressure ulcer is recorded.
New Pressure Ulcers – New pressure ulcer developed 72 hours (3 days) or more
after admission to organisation
Patient falls – Any fall that the patient has experienced within the previous 72
hours in a care setting (including home if the patient is on a district nursing
caseload). The severity of the fall is defined in accordance with NRLS categories
(none, no harm, low harm, moderate harm, severe harm, death)
Catheters – An indwelling urethral urinary catheter in place at any point in the last
72 hours.
UTIs – Any patient being treated for a UTI. Old indicates treatment started before
the patient was admitted and New where treatment started after admission.
VTE – Where a patient is being treated for VTE. Old indicates where the patient
had the VTE prior to admission, New where the patient developed VTE after
admission.
Quality Account 2014/15
31
Measures to Reduce Harm Introduction
The Trust continued to monitor patient outcomes and learn from incidents in order to
improve patient care and develop measures to reduce harm to patients. Using the National
NHS Safety Thermometer as a monitoring tool, the Trust set a target to meet 95% for harm
free care for hospital acquired harm for 2014/15. The Trust has consistently achieved and
reported above 96% harm free care from new harm or hospital acquired harm throughout
2014-15. At the end of the year, the Trust reported 98% harm free care from new harm (see
graph below). This means that 98% of the patients surveyed where free from hospital
acquired harm during the audit period.
The Trust achieved 94% harm free care for All Harms if the old harm, those acquired before
admission are included. Old harms include old pressure ulcers (community attributed), old
urinary tract infection (UTI), old deep vein thrombosis (DVT) and pulmonary embolism (PE).
Continuous collaboration and engagement with other community health and social care
provider is promoted to reduce patient harm across the local health economy.
The national picture with regard to the outcomes for the NHS Safety Thermometer for March
2014-March 2015 was published in April 2015 and gave bench marks for all Acute Trusts.
The Trust has used this data as a benchmark to compare and identify areas which need
improvement or where the Trust is better than the national figures.
NHS Safety Thermometer Results (April 2014- March 2015)
% Harm Fee Care – All Harms and New Harms
100.0%
98.0%
96.0%
94.0%
92.0%
90.0%
NHS England- All Harms
NWLH NHS Trust-All Harms
NHS England- New Harms
LNWH NHS Trust-All Harms
EHT NHS Trust-All Harms
NWLH NHS Trust-New Harms
The tables on the next few pages demonstrate the legacy Trusts and the LNWH NHS Trust
Safety Thermometer results from April 2014 until March 2015. The results below are
benchmarked against the NHS England NHS Safety Thermometer with regards to patient
harm attributed to pressure ulcers, falls, catheter UTI and new VTE (venous
thromboembolism).
Quality Account 2014/15
32

Further reduce the incidence of grade 2, 3, and 4 avoidable pressure ulcers
The Trust has continued to reduce the number of hospital acquired pressure ulcers at all
grades by promoting incident reporting through DATIX and root cause analysis process to
identify barriers to maintaining harm free care and gaps in practice.
The Trust has reduced the number of hospital acquired pressure ulcers from a baseline of
0.71% (NPH and Ealing Hospitals) at end of year 2013/14 to 0.58% at end of 2014/15. In
March 2015, LNWH reported 4.01% prevalence rate of old and new pressure ulcers which is
lower in comparison to NHS England prevalence rate of 4.5% in the same month. The Trust
prevalence rate of all pressure ulcers at the end of 2014/15 was 3.55% based on the survey
reported in the NHS Safety Thermometer.
There was an increase in terms of hospital acquired pressure ulcer during 2014/15 in
comparison to previous year. All grade 3 and 4 hospital acquired pressure ulcer were
investigated and copy of the reports were forwarded to the relevant commissioners. Hospital
acquired pressure ulcers’ monitoring is conducted down to ward level and this forms part of
the wards monthly key performance indicators that is discussed monthly in the Matrons and
Heads of Nursing meeting.
NHS Safety Thermometer Results (April 2014- March 2015)
% Pressure Ulcers (PU) Harm
6.0%
5.5%
5.0%
4.5%
4.0%
3.5%
3.0%
2.5%
2.0%
1.5%
1.0%
0.5%
0.0%
NHS England- New PU
NWLH NHS Trust- New PU
NHS England - Old & New PU
LNWH NHS Trust-Old & New PU
LNWH NHS Trust- New PU
EHT NHS Trust- New PU
NWLH NHS Trust- Old & New PU
EHT NHS Trust -Old & New PU
Quality Account 2014/15
33

Continued reduction of harm from falls
The Trust continues to use a falls care bundle (checklist) as part of its falls assessment and
strategy to reduce the risk of patient harm from falling. Using the safety thermometer to
monitor harm from falls the Trust reported a percentage of 0.29% for 2014/15 which is lower
than the NHS England reported falls with harm of 0.6%.
The Trust acute hospital wards falls incidence rates in the 2014/15 was 2.7 per 1,000 bed
days which is lower in comparison to NPSA 2010 incidence rate benchmark for the acute
hospital of 5.6 per 1,000 bed days. The community bedded units incidence rate of 2.3 per
1,000 bed days were lower in comparison to NPSA 2010 benchmark for community
hospitals - 8.6 falls per 1,000 bed days.
The Trust formed a new falls committee with representation from the falls group of legacy
Trusts. The falls policy, strategy and fall bundles were reviewed and merged across the
organisation.
NHS Safety Thermometer Results (April 2014- March 2015)
Falls with Harm (%) percentage of patient
0.8%
0.7%
0.6%
0.5%
0.4%
0.3%
0.2%
0.1%
0.0%
NHS England

LNWH NHS Trust
NWLH NHS Trust
EHT NHS Trust
Implement and roll out the Medicines Safety Thermometer in 2014/15
The Trust has had a local medication safety dashboard since February 2013 based on local
risks associated with medicines use, such as documentation of allergy status, prescribing
legibility and missed doses. The national Medication Safety Thermometer was developed in
the Midlands and the Trust signed up to implement this quality and safety initiative during
this financial year. The thermometer captures similar data to the local dashboard but until the
national scheme is embedded into practice throughout the Trust, the local scheme will
continue. The local scheme will then be used to address further issues arising from local
incident reporting. The data collected by the national scheme includes management of high
risk medicines, whether the admission was due to a high risk medication, missed doses,
number of medicines etc.
Quality Account 2014/15
34
The scheme was discussed with the matrons and it was agreed at NWLH for Gray ward to
be used as a pilot, which commenced in December 2014. The scheme has subsequently
been rolled out to Gaskell, Carroll, Jenner and Abbey wards. The aim is to roll out to two
new wards every month until completion. In Ealing the Medication Safety Thermometer is
currently on one 24 bedded ward (5N - care of the elderly) which has been established since
November 2014. The plan is to roll out to four medical wards over the next 12 months.
Data is collected monthly by a senior pharmacist, the matron or the ward manager. Data is
collected for all patients, although many Trusts are capturing a sample. Mobile devices are
being used to capture the data.
Real-time monthly feedback has been shared with the teams. The analysis is undertaken
centrally by NHS England. Challenges for this initiative have been the availability of mobile
devices to capture the data.
This scheme is particularly valuable as it provides real time feedback to the senior
pharmacist and the nurse in charge who conduct the audit. The results are then shared with
the rest of the team to support driving a reduction in medication related harm.

Ensure patient risk status is identified on admission e.g. vulnerability,
safeguarding, dementia
Admission documentation was reviewed within the year to include prompts / sections for the
patient risk stratus on admission. This has ensured care and support from the multidisciplinary team and multiple agencies have been available to meet the patient’s individual
needs. This has also resulted in an increase in patient passports being developed in
conjunction with the patient and their family / carers.

Ensure safe levels of nursing care on all wards
Safer staffing is assessed daily and throughout the day and if necessary escalated using the
agreed escalation policy to ensure staffing resources are used effectively across the Trust to
meet patient needs. Ward Sisters with their Matrons undertake a ‘look back’ as well as a
‘look forward’ to reflect on staffing needs for the previous week as well as review the plans
for the week ahead. Information is continually collected which feeds in to the monthly ward /
department staffing review, this report reviews staffing levels and triangulates this with
quality indicators such as the number of complaints, incidents on the ward as well as patient
satisfaction. This information is in addition to the bi-annual acuity and dependany review
informs the required planned staffing numbers and skill mix to ensure safe quality services
are maintained.

Introduce a new trust wide system for the identification of possible avoidable
deaths, to inform clinical practice and improve the patient’s quality of care
The mortality review meetings across the legacy trusts were reviewed to plan for one Trust
wide Mortality and Morbidity Review Committee and give an agreed trust wide structure and
process to the new divisional meetings. The committee reviews all deaths and receives
exception reports from the divisions to support learning.
Quality Account 2014/15
35
Quality Improvement goals agreed with commissioners
A proportion of London North West Healthcare NHS Trust’s income in 2014/15 was
conditional on achieving quality improvement and innovation goals agreed between the Trust
and any person or body they entered into a contract, agreement or arrangement with for the
provision of NHS services, through the Commissioning for Quality and Innovation (CQUIN)
payment framework. Further details of the agreed national goals for April 2014 to March
2015 and for the following 12 month period are available electronically on the following weblinks: 2014/15: http://www.england.nhs.uk/wp-content/uploads/2014/02/sc-cquin-guid.pdf
#
Goal
#
1.1.1
1
1.1.2
Early implementation
1.1.3
Phased expansion
Friends & Family
Test (FFT)
1.2
1.3
2
NHS Safety
Thermometer
2.1
3.1
3
Dementia and
delirium
3.2
3.3
4.1
4
Shared patient
records and real
time information
systems
Indicator
Implementation of
staff FFT
4.2
4.3
Increased or
maintained response
rate
Increased response
rate in acute inpatient
services
NHS Safety
Thermometer Improvement
[pressure ulcers]
Find, Assess,
Investigate and Refer
(FAIR)
Clinical Leadership
Supporting carers of
people with dementia
Shared patient
records and real time
information systems acute element
Achievement¹
Achieved
Partially achieved
Achieved at Ealing
Not achieved at
NWLH
Achieved
Partially achieved
Not achieved
In-patient response
rates above required
30%
A&E response rate fell
to 17% in last 6
months at NPH
Did not achieve
required 40%
response rate
Achieved
Partially achieved
The target was not
consistently met
throughout the year.
Achieved
Under review
*Performance under
discussion with
commissioners
As above
Partially achieved
Shared patient
records and real time
information systems community element
NW London
Diagnostic Cloud
Comments
Achieved
Partially achieved
Quality Account 2014/15
*Performance under
discussion with
commissioners
36
#
Goal
#
5.1
5
Improving the
emergency care
pathway
5.2
5.3
6.1
6
Improving the
planned care
pathway
6.2
7.1
7
Planning and
implementation
of ‘seven day
services’
programme
7.2
7.3
8.1
8.2
8
Hospital
avoidance for
dementia
patients
8.3
8.4
Indicator
Implementation of
MCAP (or equivalent)
in A&E and wards.
Notify to the GP
within 24 hours of the
admissions of all nonelective patient
admissions
Reduction in Reattendance in A&E
within seven days of
previous attendance
Implementation
and/or complete rollout of co-ordinate My
Care
Achieve a reduction
in the number of
visits that a patient
has to make to
hospital
Action plans for the
delivery of the clinical
standards, seven
days a week
Provision of seven
day on-site A&E
consultant cover
Seven day access to
diagnostic services
for inpatients
Avoidance of acute
hospital admission for
people dementia
Reduce hospital
attendance for
dementia patients
Enhancement of
skills and expertise in
dementia
Provision of
information and
signposting of
support services for
patients newly
diagnosed with
dementia (and their
carers)
Achievement¹
Partially achieved
Comments
*Performance under
discussion with
commissioners
Achieved
NWLH achieved.
Partially achieved
Partially achieved
NWLH achieved.
Ealing performance
under discussion with
commissioners
NWLH achieved
reduction target.
Partially achieved
Achieved
Achieved
Partially achieved
Under review
Under review
Under review
*Performance under
discussion with
commissioners, data,
query
*Community ‘roll out’
evidence is being
reviewed
*Community ‘roll out’
evidence is being
reviewed
*Community ‘roll out’
evidence is being
reviewed
*Community ‘roll out’
evidence is being
reviewed
Under review
Quality Account 2014/15
37
#
9
Goal
Community
nursing case
management
patient reported
outcome
measure
District nursing /
STARRS and
10
step up beds
transfer of care
Co-ordinate My
11
Care
#
Indicator
Achievement¹
9.1
Measurement of
patient’s health
related quality of life
Under review
10.1
11.1
Seamless transfer of
care between
community based
admission avoidance
services
Roll-out of coordinate My Care
across EICO services
Under review
Under review
Comments
*Community ‘roll out’
evidence is being
reviewed
*Community ‘roll out’
evidence is being
reviewed
*Community ‘roll out’
evidence is being
reviewed
¹The achievement ratings are based on Trust reported performance and are subject to commissioner sign-off
Friends & Family Test (FFT)
Response rates at North West London Hospitals for inpatient services were above the target
of 30% at 33%. A&E response rates fell to 17% in last 6 months of the year below target of
20%. Ealing Hospital response rates were above the target of 20% for A&E at 43% and
inpatient responses were at 33% above the target of 30%. The Trust did not achieve the
further stretch target of 40% response rate for inpatient areas.
NHS Safety Thermometer
North West London Hospitals completed a variation CQUIN goal in place of the Safety
Thermometer regarding patient Early Warning Score (NEWS) compliance. A target was set
for 95% of patients to have had an appropriate observation scored and escalated as
appropriate. This has now been adopted as a KPI for Nursing and is monitored monthly.
Dementia and delirium
North West London Hospitals did not meet the target for this CQUIN for the year despite
reporting an achievement of 95.5% for March. Systems and processes have been changed
to enable the assessment to be owned at ward level and we have seen weekly reports of
achievement of 100%. Ealing Hospital met the target for the first three quarters of the year.
Q4 reported a lower than target achievement which was due to personnel changes. The
trust is now looking at how processes can be standardised to ensure that all areas own the
target.
Quality Account 2014/15
38
Review of quality indicators
The table below presents a summary overview of the Trust’s achievement against a
selection of key performance measures compared with national averages and the highest
and lowest scores in the selected criteria.
The Trust considers that this data is as described for the following reasons: the data
reported above is as extracted from the Health & Social Care Information Centre (HSCIC).
Criteria
1a
1b
2a
2b
2c
2d
3a
3b
4
SHMI: Summary
Hospital Mortality
Indicator
Palliative care
coding: % of patient
deaths with palliative
care coded at either
diagnosis or
specialty level for
the trust for the
reporting period.
PROMS† score for
groin hernia surgery
PROMS score for
varicose vein
surgery
PROMS score for
hip replacement
surgery
PROMS score for
knee replacement
surgery
28 day
readmissions: % of
patients aged 0 to
15 readmitted to a
hospital which forms
part of the trust
within 28 days of
being discharged
from a hospital
which forms part of
the trust
28 day
readmissions: % of
patients aged 16
and over readmitted
to a hospital which
forms part of the
trust within 28 days
of being discharged
from a hospital
which forms part of
the trust
The Trust's
responsiveness to
the personal needs
of its patients
Trust
Previous
Value¹
0.84
0.83
Trust
Current
Value²
0.86
%
23.2%
22.3%
EQ-5D
index
1.00
Highest
national
score
1.20
Lowest
national
score
0.60
Current
Value
Period
Oct-13 →
Sep-14
22.8%
25.3%
49.4%
0%
Oct-13 →
Sep-14
*
*
0.084
0.155
0.009
Apr-14 →
Dec-14
EQ-5D
index
*
*
0.102
0.158
0.009
Apr-14 →
Dec-14
EQ-5D
index
*
*
0.439
0.449
0.548
0.335
Apr-14 →
Dec-14
EQ-5D
index
*
*
0.256
0.319
0.414
0.226
Apr-14 →
Dec-14
%
7.8%
10.5%
N/A
N/A
N/A
N/A
Data not
refreshed
%
12.1%
11.8%
N/A
N/A
N/A
N/A
Data not
refreshed
Number
59.3
65.9
N/A
N/A
N/A
N/A
Data not
refreshed
Unit
Score
National
average
Quality Account 2014/15
39
Criteria
5
6
7
8a
8b
8c
8d
Friends and
Family: The
percentage of staff
employed by, or
under contract to,
the trust during the
reporting period who
would recommend
the trust as a
provider of care to
their family or
friends.
VTE: The
percentage of
patients who were
admitted to hospital
and who were risk
assessed for venous
thromboembolism.
C difficile: The rate
per 100,000 bed
days of cases of
C.difficile infection
reported within the
trust amongst
patients aged 2 or
over
Safety incidents:
The number of
patient safety
incidents reported
within the trust.
Safety Incidents:
The rate (per 100
admissions) of
patient safety
incidents reported
within the trust.
Safety Incidents:
The number of such
patient safety
incidents that
resulted in severe
harm or death.
Safety Incidents:
The percentage of
such patient safety
incidents that
resulted in severe
harm or death.
Trust
Previous
Value¹
61.7%
65.1%
Trust
Current
Value²
56.3%
%
96.0%
91.8%
Rate
64.7%
Highest
national
score
89.3%
Lowest
national
score
38.2%
Current
Value
Period
2014
94.9%
95.9%
100%
79.2%
Q4
2014/15
9.4
13.4
8.6
8.7
14.7
37.1
0
Apr-13 →
Mar-14
Number
1,229
2,062
1,894
3,901
4,196
12,020
35
Apr-14 →
Sep-14
Rate²
N/A
N/A
23.75
30.88
35.29
74.96
0.24
Apr-14 →
Sep-14
Number
14
15
17
13
20
97
0
Oct-13 →
Mar-14
%
1.1%
0.7%
0.9%
0.3%
0.5%
82.9%
0%
Oct-13 →
Mar-14
Unit
%
National
average
Notes
(¹) Two values: the top value for each criteria relates to Ealing Hospital NHS Trust; the bottom value relates to
Northwest London Hospitals NHS Trust (NB. all previous values displayed as legacy trusts)
(²) The single values relate to London North West Healthcare NHS Trust – this is used where data is available
(*) Indicates that, due to reasons of confidentiality, figures between 1 and 5 have been suppressed by HSCIC
(†) Patient Reported Outcome Measures (PROMs) assess the quality of care delivered to NHS patients from the
patient perspective. PROMs calculate the health gains after surgical treatment using pre- and postoperative surveys
① The current value has been derived from local trust information systems. The national information for the
comparative period is not available
② Values relate to Small Acute Trusts only
Quality Account 2014/15
40
The table below details the actions the Trust will take to improve the above scores.
The Trust intends to take the following actions to
improve the scores, and so the quality of its
services, by...
Criteria
1a
SHMI: Summary Hospital Mortality
Indicator
1b
Palliative care coding: % of patient
deaths with palliative care coded at
either diagnosis or specialty level for
the trust for the reporting period.
PROMS score for groin hernia surgery
PROMS score for varicose vein
surgery
PROMS score for hip replacement
surgery
PROMS score for knee replacement
surgery
28 day readmissions: % of patients
aged 0 to 15 readmitted to a hospital
which forms part of the trust within 28
days of being discharged from a
hospital which forms part of the trust
28 day readmissions: % of patients
aged 16 and over readmitted to a
hospital which forms part of the trust
within 28 days of being discharged
from a hospital which forms part of the
trust
The Trust's responsiveness to the
personal needs of its patients
Friends and Family: The percentage
of staff employed by, or under contract
to, the trust during the reporting period
who would recommend the trust as a
provider of care to their family or
friends
VTE: The percentage of patients who
were admitted to hospital and who
were risk assessed for venous
thromboembolism.
C difficile: The rate per 100,000 bed
days of cases of C.difficile infection
reported within the trust amongst
patients aged 2 or over
Safety incidents: The number of
patient safety incidents reported within
the trust.
Safety incidents: The rate (per 100
admissions) of patient safety incidents
reported within the trust.
Safety incidents: The number of such
patient safety incidents that resulted in
severe harm or death.
Safety incidents: The percentage of
such patient safety incidents that
resulted in severe harm or death.
2a
2b
2c
2d
3a
3b
4
5
6
7
8a
8b
8c
8d
Continuing to work with our Commissioners and key
stakeholders in the monitoring and reviewing of SHMI
information and to take action as appropriate.
Continuous training of coding staff and through regular
internal spot audits on clinically coded activity
Strengthening the collection and reporting of PROMs
data for all appropriate patients and to enhance the
reporting of the results within the Trust
Continuing to work with our Commissioners and other
healthcare partners to prevent unnecessary
readmissions through the urgent care pathway review
and overall provision of alternative settings of care
across the local health community. This is a key priority
and will be progressed through the delivery of the
2015/16 quality objectives as set out in this Quality
Account.
Delivering the patient satisfaction objectives as set out
in this Quality Account
Survey staff on a quarterly basis and acting upon the
feedback received through this process. The Trust is
taking this opportunity to elicit further detailed feedback
from staff
Continuous enforcement and training of staff to ensure
risk assessments for VTE are completed for all
appropriate patients
Maintaining its progress on reducing the overall
number of hospital acquired C. difficile infections
Work is underway to introduce a new Trust wide
incident reporting system. The training and support
alongside the new system will improve access and
usability for staff reporting incidents and for leaders to
manage the incidents. The training will align the
grading of incidents supporting our ability to compare
and analyse incident data and more importantly
escalate concerns about potential severe incidents and
share the learning to reduce the risk or reoccurrence
Quality Account 2014/15
41
Other national and local Key Performance Indicators (KPI)
This sub-section of the Quality Account also includes supporting commentary covering key
themes discussed with our Commissioners in clinical quality group meetings over the year.
Venous thromboembolism (VTE)
VTE is a condition in which a blood clot (thrombus) forms in a vein. VTE embraces both the
acute conditions of deep vein thrombosis (DVT) and pulmonary embolism (PE).
The requirement to carry out VTE risk assessments became mandatory in 2010/11. The
minimum national standard of achievement is for at least 95% of patients to receive a risk
assessment upon admission. This is a clinically led programme, with significant focus on
ensuring compliance across the whole organisation.
Indicator
VTE risk assessment for
inpatient admissions
Standard
greater than or
equal to 95%
Performance
Ealing M1-6
96.1%
NWLHT M1-6
92.6%
LNWHT M7-12
94.7%
94.2&
(Full year)
Data source: UNIFY2
To improve and sustain performance above the 95% standard there has been reinforcement
of the required record keeping standards and increased frequency of audit and escalation of
non-compliance to Clinical Directors and the Medical Director. In particular, current audits
are addressing the discrepancies between the prescription of thromboprophylaxis and the
VTE risk assessment on the drug chart and what is recorded on the electronic discharge
notification which is sent to GPs. Monitoring of the performance has also been strengthened
through the performance management process.
Healthcare-acquired infections (HCAIs)
Methiciliin-Resistant Staphylococcus Aureus (MRSA)
MRSA is a bacterium that is carried in the nose and on the skin and can cause serious
infection in vulnerable patients. The most serious consequence of MRSA is a blood stream
infection (MRSA bacteraemia) and these cases are part of mandatory surveillance.
Indicator
Hospital acquired MRSA Bacteraemia
Data source: Public Health England
Standard
Zero
Performance
1
Clostridium difficile
Clostridium difficile is a bacterial infection of the intestine which causes severe diarrhoea.
One in four individuals carry Clostridium difficile in the gut and an infection can occur
following the use of antibiotics when the gut flora is disturbed.
Indicator
Hospital acquired Clostridium difficile
Standard
less than or
equal to 26
Performance
41
Data source: Public Health England
Quality Account 2014/15
42
Never events
Never events are incidents that can lead to serious patient harm which are considered to be
completely preventable if best practice and policies are adhered to. A national policy on
never events was introduced in the NHS from April 2009. This policy is designed to promote
transparency and accountability when serious patient safety incidents occur.
3 Never Events for the period April 2014 to March 2015, 1 involved a misplaced Naso-gastric
Tube (feeding tube). The second was as a result of a gauze swab being left in place
following a gynaecological operation and the third was as a result of a small incision being
made on the wrong site for a minor surgical procedure. All 3 of the incidents have been
reported to the regulators and external agencies as per the Trusts statutory requirements.
The patients and families were informed as soon as it became apparent that an error had
been made and apologies were made to them with explanations of the planned investigation
processes. As with all Serious Incidents these 3 were investigated by
senior Trust managers and independent experts. In all 3 incidents
conclusions were made with recommendations by the panels to
reduce the risk of reoccurrence and actions plans subsequently
drawn up to implement the recommendations. All serious incident
action plans are monitored for implementation against the planned
timescales and exceptions to achieving these are reported and
monitored by a sub-committee of the Trust Board.
*Maintaining safety standards is the responsibility of everybody across the organisation.
Quality Account 2014/15
43
Challenges
As an organisation our operational performance has been challenging for a variety of
reasons in 18 weeks referral to treatment time, emergency care and cancer targets.
18 week Referral to treatment (RTT) performance
A significant amount of work has been done to improve the data quality and ensure that we
are counting the waits of people accurately. This resulted in a positive review from the
National Audit Office. We are not complacent though as our own internal audits show we
still have work to do in terms of recording the accurate reason for discharge from clinic for
example. The trust worked hard with the CCG to reduce the numbers of patients waiting
over 18 weeks for treatment, this meant that the trust did not hit the standards, but it is very
important for our patients that we actively reduce their overall wait. This work is ongoing and
essential to reaching the target for those patients requiring admission. Our expectation is
the target for admitted patients will be met in quarter 2, whilst we expect to reach the target
for those not admitted more quickly in quarter 1. Patients on waiting lists are reviewed daily
by the teams. The Trust continues to be supported by the National Intensive Support Team
to ensure delivery of the standards. This is a key focus for the coming year.
Indicator
18 weeks RTT - admitted patients
18 weeks RTT - non-admitted patients
Standard
Performance
greater than or
equal to 90%
81.6%
greater than or
equal to 95%
94.9%
Data source: UNIFY2
Emergency Care
This has remained a challenge and like all Trusts in the country we had a winter surge in
pressure which caused deterioration in performance at both emergency departments (ED) in
the Trust. Ealing ED was able to take quick action to look at ways of dealing with hourly
surges, which has been successful, and the target has been successfully recovered above
the 95% all types target. Unfortunately this is not the case at Northwick Park Hospital where
the wait in the department remains at an unacceptable level. This is especially the case for
patients who are seen in the main ED, rather than in the urgent care centre co-located with
ED. Although there is not national target for this element of care, Northwick Park Hospital is
currently achieving on average 70% of patients being discharged or admitted in this time. In
part, additional bed capacity will support significant improvement of this and alongside this
the Trust is looking at all systems and processes to maximise bed usage.
Indicator
Four hour emergency department target
Standard
Performance
greater than or
equal to 95%
90.7%
Data source: UNIFY2
Quality Account 2014/15
44
Cancer waiting times
The Trust has traditionally performed well across a number of these indicators, except for
one, which was the 62 days from referral to treatment, which has remained a challenge
throughout the year, although the Trust did meet the 62 day target in March 2015. Further
work to make this resilient is on-going both within the Trust and across the whole of North
West London as many patients on these pathways require care from more than one
organisation.
Many of the patients who don’t meet the 62 day target are complex and need care from a
number of Trusts in NWL. We are confident that we will streamline the care for these
patients both within the Trust, by doing early diagnostic tests, and across the Trusts
providing the care. We expect to meet the target in July and be more robustly meeting this
going forward.
Indicator
Standard
Performance
Two week wait for suspected cancer
greater than or
equal to 93%
95.5%
Two week wait for breast symptoms other than
suspected cancer
greater than or
equal to 93%
96.8%
31 day diagnosis to treatment for first definitive
treatments
greater than or
equal to 96%
97.0%
31 day diagnosis to treatment for subsequent
treatment (drugs)
greater than or
equal to 98%
99.2%
31 day diagnosis to treatment for subsequent
treatment (surgery)
greater than or
equal to 98%
95.0%
62 day referral to for first definitive treatments (GP &
dental)
greater than or
equal to 85%
82.3%
62 day referral to treatment from screening
greater than or
equal to 90%
95.6%
greater than or
equal to 85%
96.7%
62 day referral to for first definitive treatments
(consultant upgrade)
Data source: National Cancer Database
Quality Account 2014/15
45
Priorities for improvement in 2015/16
This section of the report sets out the Trust’s quality improvement priorities for 2015/16 and
forms the Trust Quality Strategy annual quality improvement plan. Some of the priorities
(e.g. reducing number and severity of falls and pressure ulcers and infection from urinary
catheters) have been rolled over from the previous year, 2014/15. Progress during the last
year is reported in the ‘looking back at 2014/15’ section of this report.
The Trust embraces the three key components of ‘high quality care for all’ where quality is
placed as the organising principle in the NHS. Quality is defined in relation to three domains:
 Patient safety
Treating and caring for people in a safe environment and protecting them from avoidable
harm, for example, ensuring that medicines are managed safely, reducing the number of
patient falls and hospital acquired pressure ulcers.
 Clinical effectiveness
Clinical effectiveness is about whether or not a patient’s care or treatment was successful.
In other words, did it have the impact that it was supposed to have? And did it achieve the
best possible result for the patient? This may include improvement in specific medical or
health conditions and treatments or working with our community colleagues to ensure there
is a stronger focus on improving quality of life and prevention of disease.
 Patient and carer experience
Patient experience is about ensuring patients, relatives and carers have as positive
experience as possible at every stage of the care or treatment that is being provided. Patient
experience refers to the overall experience throughout the course of treatment, and not just
the results that were achieved at the end.
Quality care is not achieved by focusing on one or two aspects of this definition; rather, high
quality care encompasses all three aspects with equal importance.
In drawing up priorities for 2015/16 the main emphasis is placed on the following issues that
characterised the Trust’s underperformance in 2014/15:

Delivering safe, high quality services that meet national standards, especially in the
areas of greatest challenge to the Trust (as they were for many other providers),
namely ED, waiting times for elective treatment and timely diagnosis and treatment of
cancer.
Each division has taken account of these in drawing up their priorities for 2015/16.
The three overarching quality improvement priorities for 2015/16 are to continue to:



Reduce avoidable patient harm – how safe the care provided is
Improve patient experience – how patients experience the care they receive
Improved the emergency care pathway.
Quality Account 2014/15
46
The Trust has set the following priorities for 2015/16:
Priority one: reduced patient harm
1. Reduce the number of grade 3 and grade 4 avoidable Trust acquired pressure ulcers
2. Reduce the number of patients with urinary catheters developing urinary tract
infections
3. Ensure effective management of patients requiring a naso-gastric tube
4. Ensure sustained effective management of the patients cancer pathway
5. Reduce harm from falls
6. Strengthen compliance with Venous thrombosis embolism (VTE) standards
7. Reduce the number of Trust attributed healthcare associated infections (HCAI)
8. Maintain the Standardised Hospital Mortality Indicator below 90
9. Embed a culture of learning from complaints and incidents
10. Develop a supportive infrastructure to enable clinical supervision for front line staff.
11. Improve recruitment and retention of staff
12. Improvements in data quality and information assurance
Priority two: patient experience
1. Sustain and improve performance of the suite of national patient satisfaction surveys
2. Improve compliance with the Patient Led Assessment of Care Environment (PLACE)
audit standards
3. Improve the quality of the discharge process
4. Improve the end of life experience for patients and their relatives
5. Improve patients’ health and well-being by providing activities to support their holistic
needs.
Priority three: emergency care pathway
1.
2.
3.
4.
5.
6.
Improve patient information to support timely access to services
Reduce London Ambulance Service breaches
Reduce the time patients have to wait to be seen
Improve the pathway of care for frail elderly patients
Ensure appropriate seven day patient discharge for patients attending the hospital
Improve 4 hour performance in line with agreed trajectory.
Quality Account 2014/15
47
Priority one: reduce avoidable patient harm
1. Reduce the number of grade 3 and grade 4 trust acquired pressure ulcers
Trust leads: deputy chief nurse / senior nurse - quality / assistant director of
professional standards community nursing - adults
Why is this important?
Patients cared for by our services should not experience harm as a result of the care they
receive. Pressure ulcers are, on the whole, preventable and every effort needs to be made
to ensure that they do not occur. Identifying those patients who are at risk and taking
precautions to protect skin integrity should be standard practice as should preventing those
who already have tissue damage from experiencing further deterioration. Pressure ulcers
can result in longer stays in hospital and community beds and exposure to increased risk of
pain and infection as well as a poor experience of care.
What are we going to do in 2015/16?
 Re-launch the updated pressure ulcer management policy supported by a
comprehensive training programme
 Use ward and service data on all pressure ulcers and compliance with the safety
thermometer to set local stretch improvement targets and monitor performance
 The Patient Safety and Quality Committee will continue to monitor the number and
grade of pressure ulcers across the organisation which will enable informed changes
in practice
 The tissue viability team’s within the acute and community settings will be integrated
in to one team, to help facilitate compliance with core standards of assessment and
care and enable more flexible use of resources to support wards and services with
the greatest need for improvement
 Deliver a training programme specifically targeted at areas where there is a higher
than average incidence of pressure ulcers
 Review patient information to support patients and carers identify and actively
manage a pressure sore
 Ensure information on skin care and use of pressure relieving equipment is available
in all ward and service areas
 Review and ensure availability of pressure relieving equipment
 Undertake regular audits as well as root cause analysis of pressure sores that
develop to monitor and act promptly on poor areas of practice
 Include pressure ulcers incidence rate and number of avoidable hospital acquired
Grade 3 & 4 pressure ulcer in the wards’ monthly nursing quality dashboard and KPI
 Re-launch the tissue viability link nurse scheme to produce champions at ward level.
How will we know how we are doing?
 There will be a minimum of a 10% reduction in the incidence of hospital acquired
grade 3 and grade 4 pressure ulcers
 Staff will be trained and will be proficient in assessing the risk of pressure ulcers, how
to prevent them and how to manage effective healing
 Link nurse scheme will be up and running
 Appropriate pressure relieving equipment will be available when it is required.
Quality Account 2014/15
48
2. Reduce the number of patients with urinary catheters developing urinary tract
infections.
Trust leads: deputy chief nurse / senior nurse - quality / assistant director of
professional standards community nursing - adults
Why is this important?
For a number of patients as part of their care it may be necessary to have a urinary catheter
(a tube used to drain and collect urine from the bladder) inserted. This carries with it the risk
of acquiring a urinary tract (where our bodies make and get rid of urine) infection. The longer
the catheter remains in situ the greater that risk. Therefore, catheters need to be removed
when they are no longer required. To support the use and removal of urinary catheters and
prevention of urinary tract infections a robust bladder care pathway will be developed using
national best practice and will be implemented across the organisation.
What are we going to do in 2015/16?
 Review and re-launch the guidelines for care of patients with urinary catheters
 Use ward, service and safety thermometer data on all patients with urinary catheters
developing urinary tract infections to set local stretch improvement targets and
monitor performance
 The Patient Safety and Quality Committee will monitor the number of urinary tract
infections across the organisation and enable informed changes in practice
 The catheter care pathway will be more widely rolled out
 The use of the catheter care passport will be monitored and audited
How will we know how we are doing?
 There will be a reduction in the number of unnecessary catheter days
 There will be a reduction in the number of urinary tract infections associated with
urinary catheters
 The catheter care passport will be in place and in use.
3. Ensure effective management of patients requiring a naso-gastric tube
Trust leads: chief nurse / divisional head of nursing - surgery
Why is this important?
Patients, who for a number of reasons, are not able to receive oral hydration and nutrition,
need to be assured that if a naso-gastric tube is required, this will be undertaken in a safe
manner and will not cause them harm. The insertion, checking and use of naso-gastric tubes
carry the potential misplacement and subsequent feeding into the wrong place (the lungs), if
not prevented this can have fatal consequences. It is therefore essential that all possible
steps are taken to prevent this occurrence and ensure that those who undertake this
procedure are fully competent to do so and that there is appropriate documentation in place
to support this practice. The Trust has reported 6 incidents over in the past year and we
therefore want to ensure that further incidents are prevented.
What are we going to do in 2015/16?
 Re-launch the policy on guidance on the management of naso-gastric tubes.
 Develop a core improvement plan from the individual never event action plans and
revised policy to communicate core standards, facilitate monitoring and mitigate risks
of a miss-placed naso-gastric tube. This will be overseen by the Clinical Performance
and Patient Experience sub-committee of the Trust Board
 Develop a protocol to ensure that patients are adequately hydrated and medicated
when it is not possible to use their naso-gastric tubes
Quality Account 2014/15
49
How will we know how we are doing?
 Data will support 100% compliance with correct practice for inserting, checking and
use of naso-gastric tubes
 Audits results will demonstrate that patients are appropriately nourished and
hydrated at all times.
4. Ensure sustained effective management of the patients’ cancer pathway
Trust leads: chief operating officer / clinical director / divisional general manager
Why is this important?
Receiving a diagnosis of cancer is distressing for patients, their family and close friends.
During this time they require information in a way that they can understand, support and
investigations and treatment as soon as possible to give them the best chance of either
making a positive recovery, minimising the impact of the illness and / or supporting them as
they maximise their life as they live with their cancer and the outcome that will follow.
What are we going to do in 2015/16?
The Trust will continue to work to improve the delivery of cancer care, improving quality,
performance and patient experience. Main areas of focus include:








Building on the merger benefits to ensure that patient care is delivered to the same
best standard across all sites. The multidisciplinary teams and patient pathways
across all sites are being reviewed and restructured. We continue to work in
collaboration with our partner organisations, Imperial College Healthcare NHS Trust
and East and North Herts NHS Trust (Mount Vernon Cancer Centre) to deliver this.
We will improve the provision of oncology expertise and care, including appointing
consultants to provide specialist cover every weekday (with support at weekends) at
both acute sites.
We are redesigning our Cancer MDT (multidisciplinary team) administration,
including implementing a new information system, so that we can more easily ensure
that patients are supported along their cancer pathways, and to improve our ability to
audit our performance and quality.
In 2014/15, we improved our performance on the ‘decision to treatment’ targets and
now routinely achieve monthly compliance. We will build on this work and aim to
achieve compliance with the ‘referral to treatment’ targets from Quarter 2 onwards.
We will work with other hospitals and CCGs in North West London regarding this,
and will agree an action plan with commissioners.
We have brought together specialist nursing teams between Ealing and legacy
NWLH, spreading best practice in this vital service.
With our partners improve the patient’s pathways across the whole of North West
London to ensure timely transfer of care across organisations.
Where clinically appropriate implement a process where patients receive their
investigation tests before they see their consultant facilitating a more timely
diagnosis.
Continue to implement a detailed action plan developed and agreed with
commissioners to support continuous improvements in the patient’s care pathway.
How will we know how we are doing?
 Achievement of the agreed trust recovery plan.
 Positive feedback following the launch of the communication strategy
Quality Account 2014/15
50
5. Reduce harm from falls
Trust leads: deputy chief nurse / senior nurse - quality / divisional head of nursing - medicine
Why is this important?
The causes of falls are complex and multiple. All patients can be prone to a fall due to their
medical condition and medication. However older people are particularly at risk of falling
whilst in hospital or a community bedded facility as a result of their medical condition or
problems with strength, mobility and memory or because of disorientation within the ward
area. In addition many of them are receiving rehabilitation and this can result in falls many of
which are assisted with the support of staff to minimise injury.
The following chart demonstrates the severity of harm from falls at the Trust in over a three
year period. During 2014/15 patient falls accounted for 16.4% of all clinically reported
incidents.
Severity of harm from falls 2012-2015
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
NWLH (2012-13)
EHT ICO (2012-13)
NWLH (2013-14)
EHT ICO (2013-14)
NWLH (2014-15)
EHT ICO (2014-15) NWLH & EHT ICO
(2012-2015)
% of Patient Falls Resulting in No Harm
% of Patient Falls Resulting in Low Harm
% of Patient Falls Resulting in Moderate Harm
% of Patient Falls Resulting in Severe Harm/Death
The chart clearly demonstrates that through education and support for openness and
transparency the trend is for reporting more patient falls. Positively, the trend is for more of
the falls to result in No Harm or Low Harm for the patients and despite the increase in the
number of falls being reported the, the number resulting in Moderate or Severe Harm has
remained static.
Relatives and carers should expect that their family members are safe whilst within the
hospital and community bedded environment. Clearly any patient fall is of significance, not
only in relation to the patient experience, but also because of the risk of injury and an
extended stay in hospital. It is therefore our aim to see a reduction in the level or harm
suffered as a result of patient falls.
Quality Account 2014/15
51
What are we going to do in 2015/16?
 Re-launch the revised falls management policy supported by a comprehensive
training programme
 Use ward and service data on all falls and compliance with the safety thermometer
data to set local stretch improvement targets and monitor performance
 Include falls incidence rate and number of patient falls resulting in major and severe
harm in the wards’ monthly nursing quality dashboard and KPI
 The Patient Safety and Quality Committee will monitor the number and grade of
patient falls across the organisation which will enable informed changes in practice
 Develop a core improvement plan from the learning from patient fall root cause
analysis to drive improvements, facilitate monitoring and mitigate risks patients
sustaining a fracture. This will be overseen by the Patient Safety and Quality
Committee
 Review and ensure the availability of falls prevention equipment
 Implement a traffic light system to ensure staff are aware of patient’s current level of
mobility
 Ensure patient risk of falls is communicated effectively as part of the handover
situation, background, assessment, recommendation (SBAR) process
 Raise awareness of all staff on how to minimise the risk of falls with the aim to train
1,200 of nurses and midwives as a minimum
 Re-launch the falls link nurse scheme to produce champions at ward level.
How will we know how we are doing?
 The Trust will see a continuing trend of number of patient falls and their severity of
impact decreasing over the year
 Staff will be more aware of falls risks and how to prevent them
 Link nurse scheme will be up and running and this will have a direct impact on the
number of patient falls.
6. Strengthen compliance with Venous thrombosis embolism (VTE) standards
Trust leads: medical director / clinical directors / head of pharmacy
Why is this important?
Proactive assessment and treatment of patients with a suspected VTE can help prevent
more serious health consequence of an embolism; this will improve the patient’s clinical
outcome
What are we going to do in 2015/16?
 Reinforce the required record keeping standards
 Increase the frequency of audit
 Escalate non-compliance to Clinical Directors and the Medical Director.
 Introduce ward level electronic VTE monitoring.
 Strengthen the performance monitoring.
How will we know how we are doing?



95% of patients to receive a risk assessment upon admission.
Patients will receive a timely re-assessment if required.
Audit results will show alignment between assessment, treatment and discharge
documentation.
Quality Account 2014/15
52
7. Reduce the number of Trust attributed healthcare associated infections (HCAI)
Trust leads: chief nurse / infection control leads / divisional heads of nursing
Why is this important?
Reduction of hospital acquired infections remains a priority for us because we know that
infection is one of the issues that our patients are anxious about. Infections cause pain,
dysfunction and distress in often frail and vulnerable patients, and contribute to longer stays
in hospital. Year on year, the Trust has seen a reduction in the number of hospital acquired
infections and in 2015/16 we are determined to continue this improvement by reporting no
cases of MRSAb (Meticillin resistant Staphylococcus Aureus blood stream infection)
attributed to the hospital and no more than 37 cases of Clostridium difficile (C. difficile) in
patients who have been in hospital more than 72 hours. MRSA bacteria access the
bloodstream most commonly where there is a breach in the skin, for example wounds and
devices. Insertion of intravenous lines provides a route for the bacteria to enter into the
bloodstream.
What are we going to do in 2015/16?
In order to prevent MRSAb, we will focus:
 Screening all emergency and elective patients for MRSA
 Ensure all MRSA positive patients receive colonisation reduction therapy (a
treatment to reduce MRSA bacteria from the skin and nose)
 Promoting the use of long lines (mid-lines and peripherally inserted central catheters
or PICCs) for long term use
 Promoting IV to oral antibiotic switch and removing the need for peripheral cannula
 Education to ensure Visual Infusion Phlebitis (a measuring tool used to review
patients who have an intravenous line inserted) scores are observed and recorded
twice daily.
In order to prevent cases of Clostridium difficile we will:
 Ensure prudent antibiotic prescribing and stewardship
 Ensure hand hygiene meets the required standards
 Ensure medication is used in line with NICE guidance and best practice
 Isolate patients if suspected of having C. difficile and use personal protective
clothing
 Ensure patient equipment is effectively decontaminated
 Provide clear communication to staff and patient.
To support high standards of cleaning and suitable environment in addition to the routine
cleaning audits and monitoring that is undertaken informal as well as annual formal PLACE
inspections will be undertaken quarterly. Teaching on prudent antibiotic use and audits to
ensure compliance with Trust antimicrobial guidelines will be part of the measures to control
cases of C. difficile. There will be a zero tolerance for staff to address non-compliance with
policies and procedures.
How will we know how we are doing?
 Infection control and cleaning audits, including the ‘clinical Thursday’ audits will be
used to demonstrate that staff are complying with relevant policies and practices
 Safety workarounds conducted by the infection prevention and control team and
Matrons will be used to observe practice and identify barriers to compliance
 There will be a reduction in the number of hospital acquired infections reported in the
organisation.
Quality Account 2014/15
53
8. Maintain the Standardised Hospital Mortality Indicator below 90
Trust leads: medical director / divisional clinical directors
Why is this important?
The Standardised Hospital Mortality Indicator is a measure which compares mortality rates
at the Trust with those seen at other similar hospital across England. A value below 100 is
better than average and value above 100 are worse than average.
It is important that our patients know that we monitor our mortality rate in relation to other
trusts, assess where we can make improvements and have robust processes in place to
minimise mortality at the hospital.
What are we going to do in 2015/16?
We already have a system in place to review every death in the hospital on a monthly basis.
Every death is reviewed by the divisional clinical teams and summary reports are presented
to the Trust wide Mortality Review Group, chaired by the Medical Director.
Our first priority is to ensure we are able to identify patients whose health is deteriorating.
This is done through use of early warning scoring systems, which assign a score for vital
signs, such as pulse and blood pressure, which are outside the normal range. For adults we
use the National Early Warning System (NEWS) and for children the (PEWS).
High score results are escalated to clinicians for a review of the patient – this will be a
member of the regular medical team or an anaesthetist if the patient is very unwell. A
programme of training is in place for qualified nurses and healthcare assistants to ensure
they use the NEWS and PEWS scores correctly and take any required action as a result.
The Trust has developed many care bundles over the last five years. Use of care bundles
ensures patients receive consistent ‘gold standard’ treatment and make it easier to monitor
that the correct treatment has been given. The Trust has a number of care bundles including
the management of patients with chronic obstructive airways disease, sepsis, non-invasive
ventilation.
Other processes which we will put in place to improve care are:
Ensure appropriate escalation and management of the deteriorating patient, by proving
education and simulation training and auditing practice to improve care
 Continuing to promote the role of the critical care outreach team
 Increasing the number of consultants so that surgical and sick medical patients can
be reviewed each day of the week including weekends
 Increasing the hours during which emergency department consultants are present in
the department to include evenings and weekends
 Review and re-launch the care bundle and procedure for handover of patients from
the emergency department to the wards, from ward-to-ward and hospital to hospital.
 Review and re-launch the clinical handover guidance at shift handover and between
clinical teams.
How will we know how we are doing?
 We will audit the processes listed above to make sure that they are in place
 Monitor incidents, and review of the management of a random sample of patients
whose condition deteriorates to ensure appropriate care provided
 We will monitor the Standardised Hospital Mortality Indicator on a monthly basis to
ensure it reduces and remains below 90
Quality Account 2014/15
54
9. Embed a culture of learning from complaints and incidents
Trust leads: deputy chief nurse / acute and community directors of operations
Why is this important?
Improving the experience of those who use our services and ensuring their safety is an
absolute priority for the organisation. Learning from complaints and incidents is essential for
the organisation to develop and continue to be a healthcare provider of choice for our local
population.
What are we going to do in 2015/16?
 Divisions will monitor response times and ensure that complaints are being
responded to within the timeframe agreed with the complainant
 Work with staff to ensure a culture of reporting incidents is maintained
 Continue to ensure that complaints and incidents are reviewed, addressed and
changes implemented by the divisions
 Ensure that action plans are implemented and monitored on a timely basis
 Provide feedback to reporters of incidents.
How will we know how we are doing?
 We will respond to a minimum of 100% of complaints within the timeframe agreed
with the complainant
 Complaints and incidents with similar themes will decrease.
10. Develop a supportive infrastructure to enable clinical supervision for front line staff
Trust leads: chief nurse / medical director
Why is this important?
Supporting staff through clinical supervision will enable a more confident workforce who feel
valued by the organisation and are more likely to continue to work for us. Creating a space
for staff to reflect on practice provides the opportunity for them to learn from experience,
raise issue of concern; with the aim of delivering safe, high quality care to our patients.
Supervision is available in a number of services but not consistently provided across the
Trust. The Trust employs many junior nurses and a large number of staff recruited
internationally, clinical supervision allows them to develop and explore clinical issues in a
safe environment and the Trust to ensure high level of standards of care are proved by
competent nurses, midwives and health visitors.
What are we going to do in 2015/16?
 Launch the new clinical supervision policy
 Identify those who are suitable as supervisors and provide appropriate training
 Enable staff to understand the benefits of clinical supervision and take up the
opportunity to use this form of support
 Embed clinical supervision as a part of the usual practice of the organisation
 Evaluate staff experience and benefits of supervision.
How will we know how we are doing?
 A suitable model of clinical supervision for the organisation will be described
 An adequate number of supervisors will be identified and trained
 A system of clinical supervision will be in place and available to all staff who choose
to use it
 Front line staff will take up the opportunity for clinical supervision on a regular basis
 Positive evaluation of the experience and benefits of improving patient care.
Quality Account 2014/15
55
11. Improve the recruitment and retention of staff
Trust leads: human resources director / divisional general managers
Why is this important?
Satisfactory care and the consequent minimisation of harm depends as much as anything on
safe levels of properly-trained staff who are familiar with the needs of their patients and the
environment that they are working within. In turn, this requires effective recruitment and
retention policies and practices.Continuity of care is best ensured by a directly-employed,
permanent workforce, where staff are encouraged to remain within the Trust and where
there are the minimum possible gaps between those who move and their replacements
starting work.
What are we going to do in 2015/16?
 Further improve and streamline the recruitment processes to reduce time to recruit.
 Actively recruit in the UK, EU and overseas to get the best clinical staff available
 Develop a set of branded materials for the new trust for use in recruitment.
 Engaging with academic institutions such as schools, colleges and universities.
 Ensure that staff are aware of diverse range of employment benefits available to
them both in monetary and non-pay terms.
 Design new roles and ways of working.
 Review options for employment contracts.
 Develop new recruitment methods.
 Establish recruitment and retention plans for each clinical division.
 Improve internal bank capacity to meet short term increases in demand
How will we know how we are doing?
 Achievement of overall and divisional recruitment targets.
 Reduction in vacancies and inappropriate fluctuations in staffing levels.
 Reduction in the use of temporary workers (agency)
 Reduction in the percentage of staff leaving
 NHS staff survey and NHS Friends and Family Test show that the Trust is a good
place to work.
12. Improvements in data quality and information assurance
Trust leads: Chief Information Officer / Head of Information Assurance
Why is this important?
Data Quality impacts on all areas of the organisation from the delivery of patient care right
through to income recovery and strategic decision making. Some of the programmes that
are planned for 2015/16 are included below.
What are we going to do in 2015/16?
 Development of a governance structure to report on data quality to the board
 Implementation of clinical and administrative systems which are better at capturing
information within clear data standards
 Training programmes for users
 Investment in capacity and capability to investigate and resolve data quality incidents
quickly as they occur
How will we know how we are doing?
 The success of these programmes will be measured through a series of local audits
planned throughout the year.
Quality Account 2014/15
56
Priority two: patient experience
1. Sustain and improve performance of the suite of national patient satisfaction surveys
Trust leads: deputy chief nurse / divisional heads of nursing / divisional general managers /
clinical directors
Why is this important?
The annual patient surveys demonstrate that there are aspects of the patient experience that
could be improved. Patient satisfaction can impact on the Trust reputation, commissioning of
services and patient trust and confidence when choosing or receiving services.
What are we going to do in 2015/6?
 Raise awareness of the questions and required standards within the national surveys
 Action plans have been developed to address different aspects of the suite of
national patient experience surveys, where patient experience is below expectation
 Implement the Macmillan Values Based Standard across the Trust, the standard is
structured around eight behaviours that can be used as indicators of service quality.
These behaviours are designed to effect positive change in staff/patient relationships,
to drive up performance, especially in patient experience, satisfaction and outcomes
and protect care rights
 Streamline the way patient’s book, change and attend out-patient appointments.
 Start planning for the establishment of a contact centre which will provide one point of
contact for all patient appointments.
 Use multiple feedback methodologies to make a difference ‘in the moment’ to
patients and their carer’s
 Implement the recommendations from the PLACE audits
 Establish a Patient Engagement Forum
 The Patient Experience Committee will support and challenge improvement action
plans, help share best practice and lead trust wide work streams.
 Assurance will be presented to the Clinical Performance and Patient Experience
Committee.
How will we know how we are doing?
 The annual national survey programme results will provide a benchmark with results
in previous years and with other organisations to measure whether there have been
in year improvements
 The out-patient do not attend (DNA) rate will reduce and patient’s wait for an
appointment will reduce.
 Regular internal patient feedback through patient stories, surveys including the
Family & Friends Test will provide a regular method of hearing patients concerns and
monitoring performance
 Staff survey results will also provide a gauge on how staff feel about the care and
experience of patients by feeding back whether they would recommend the trust to
their family and friends
 Complaints, compliments and other feedback will be used to triangulate with other
feedback to determine where improvement have been made and is still required.
Quality Account 2014/15
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2. Improve compliance with the Patient Led Assessment of Care Environment (PLACE)
audit standards
Trust leads: director of estates and facilities / deputy chief nurse
Why is this important?
The environment in which staff work and patients’ receive care is important to ensure safety
and support a positive experience, by ensuring the right level of cleanliness is adhered to,
patients receive the right level of nutrition and patient’s privacy and dignity is maintained.
These standards can help minimise the risk of infection, ensure adequate nutrition and
confidence in the services provided.
What are we going to do in 2015/16?
- In addition to the formal annual PLACE audit the trust is going to undertake selfassessment internal audits quarterly to ensure standards are met consistently.
- The improvement plan will be continually updated as PLACE and other audits results are
known.



Establish a working group to support and drive the improvement work streams
The Patient Experience Committee will support and challenge improvement
action plans and help share best practice
Assurance will be presented to the Clinical Performance and Patient Experience
Committee.
How will we know how we are doing?
 Local audit results will provide in year monitoring
 The annual national audit survey results will provide a benchmark with results in
previous years and with other organisations to measure whether there have been in
year improvements
 Complaints, compliments and other feedback will be used to triangulate with other
feedback to determine where improvement have been made and is still required.
3. Improve the quality of the discharge process
Trust leads: clinical directors / heads of nursing / heads of therapies
Why is this important?
Ensuring safe, timely discharge is a priority for the Trust as it impacts on the experience of
care for the majority of our patients. Delayed discharges expose patients to a greater risk of
hospital acquired infections and other complications of being in hospital that can be harmful
for patients and costly for the organisation.
Working with social services, particularly on complex discharges, is essential to achieve a
smooth and seamless experience and prevent unnecessary re-admissions to hospital.
Making sure that patients have good quality information on discharge improves
communication, prevents anxiety, supports health promotion and management of long term
conditions and supports continuing care and knowledge of access to relevant services that
can help ensure they receive care as close to home as possible.
What are we going to do in 2015/16?
 Ensure that a realistic expected date of discharge is set on admission
 Ensure consistent discharge planning from admission
 Deliver training to all staff involved in the discharge process to ensure correct use of
discharge pathways
Quality Account 2014/15
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






Audit compliance with pathways set out in the discharge policy
Continue to work with community partners to streamline the discharge process
Work with colleagues to identify patients who can be safely discharged at weekends
Continue daily discharge meetings
Continue meetings with community partners to review patient pathways
Work with community partners to develop early supported discharge and out of
hospital strategies and initiatives
Review the discharge checklist and patient information.
How will we know how we are doing?
 Compliance with discharge pathways in the discharge policy will be improved
 Reduced delayed transfers of care
 Reduced length of stay
 Complaints and incidents regarding discharge will decrease
 Compliance with discharge pathways in the discharge policy will be improved.
4. Improve the end of life experience for patients and their relatives
Trust leads: divisional head of nursing, integrated clinical services / Macmillan lead cancer
and palliative nurse / lead consultant / senior chaplain
Why is this important?
Patients and the people important to them will be supported in decision making leading to
coordinated and planned care at the end of life.
This includes symptom control, compassionate communication, liaison with healthcare
professionals and transfer of care to a place of the patients choosing as appropriate.
What are we going to do in 2015/16?
 Establish an End of Life Care Steering Group involving a broad representation of
stakeholders to improve end of life care practice
 Re-launch the End of Life Care multi-disciplinary group, ensuring wide multidisciplinary and agency cross organisational representation
 Develop the use of the Coordinate My Care database (programme) and facilitate the
use of Advanced care Planning across the Trust
 Develop and deliver End of Life Care training for all healthcare staff focusing on The
Five Priorities of Care
 Work with (voluntary) identified/appropriate/associated organisations to support
patients wishing to receive End of Life Care in their choice of setting (own homes)
How will we know how we are doing?
 Patient and family satisfaction and experience with End of Life Care will reflect
positively from the implementation of the new End of Life Care policy.
 Audit results will demonstrate that staff have increased confidence and competence
when providing good end of life care.
Audit results will indicate an increased effective use of End of Life documentation
Quality Account 2014/15
59
5. Improve patients’ health and well-being by providing activities to support their holistic
needs
Trust leads: Deputy chief nurse / head of inclusion, equality and diversion / senior chaplain
Why is this important?
In addition to receiving care and treatment patients require other activities and services to
meet their social, spiritual, mental, emotional and rehabilitation needs. This can benefit their
mood by reducing levels of anxiety, recovery and general well-being.
What are we going to do in 2015/16?
 Review and provide a greater variety and number of games and equipment that will
support patients with their recovery and rehabilitation
 Develop a calendar of activities for patients
 Continue to recruit volunteers to act as befrienders
 Increase the awareness of spiritual services within the Trust
 Provide information on services and opportunities available within the local
communities.
How will we know how we are doing?
 Patient and carer feedback through stories and surveys.
Quality Account 2014/15
60
Priority three: improve the emergency care pathway
Trajectories for 2015/16 have been produced for the emergency departments based on the
following assumptions:




Modular beds coming on stream at Northwick Park Hospital on 1 November 2015
Community bed capacity and Ealing Hospital escalation capacity remaining in place
Admissions remaining static i.e. no additional demand created by modular beds
Delayed transfer of care (DTOC) remaining below 10 at Northwick Park and Ealing
Hospitals, respectively.
On this basis, Northwick Park Hospital will achieve 95% in December 2015 and the Trust will
achieve 95% in February 2016. Key actions in 2015/16 within the emergency pathway
transformation programme include:



Standard ward rounds
Emergency department care path modifications including rapid assessment and
triage
Schemes to manage demand bottlenecks.
The ambition of the transformation is zero 12 hour breaches in 2015/16, from nine breaches
on four occasions in 2014/15. Lessons learned from root cause analyses of these instances
have fed into the action plan.
There are still many opportunities to provide improved care to our patients on both sites and
we need to empower and support the teams to reach out and grab them. This will then move
us ever closer to achieving and then exceeding the 95% standard.
Our plans have greater focus on achieving improvements within our own internal processes,
with greater emphasis on regularly and rigorously interrogating data with the Division’s
triumvirate groups accounting for performance and identifying and developing further plans
to improve efficiency and flow.
1. Improve patient information to support timely access to appropriate services
Trust leads: deputy chief nurse / head of nursing / communications lead
Why is this important?
Ensuring the public access the right services at the right time ensures effective treatment
and care.
What are we going to do in 2015/16?
 Review the information within the emergency departments, urgent care centres and
on patient discharge to ensure people / patients are correctly signposted to services.
How will we know how we are doing?
 The number of patients attending urgent care centre (UCC) and emergency
department (ED) when this should not have been the first point of care will reduce.
Quality Account 2014/15
61
2. Reduce London Ambulance Service breaches
Trust leads: divisional general manager / general manager / clinical lead and head of nursing
Why is this important?
These breaches do not provide a positive experience for patients, their carers or staff and
can result in assessment and care being delivered in the wrong setting.
What are we going to do in 2015/16?
 Work with the London Ambulance Service (LAS) to improve handover times.
 Further enhanced the pit stop process to ensure patient safety at times of pressure
which leads to patient handover delays.
 Increase the bed capacity
How will we know how we are doing?
 Reduced number of LAS breaches
 Reduction in complaints
 Improved staff satisfaction
3. Reduce the time patients have to wait to be seen
Trust leads: General Manager / clinical lead / head of nursing
Why is this important?
Patients attended the A&E as they have concerns about their health and want an expert
opinion to assure them of the right care and treatment and / or to allay their fears and
worry’s.
What are we going to do in 2015/16?
 Ensure the right levels and competency of staffing in place at the right time to meet
demand
 Continue to implement the Care Path process for ambulant patients.
 Develop and implement a reviewed pathway of assessment and care for patients not
receiving care in majors.
 Implement schemes to manage demand bottlenecks.
 Ensure patients can receive ongoing care in the right setting either by being
supported at home, transfer to a community bedded unit, another hospital or
admitted to a hospital bed.
 Expand the ambulatory care pathways at Ealing Hospital to offer easier access for
ED, UCC and GP patients.
 Increase the bed capacity at Northwick Park Hospital
 Continue to embed ward round standards
 Progress seven day working to ensure appropriate discharges at weekends.
How will we know how we are doing?
 Reduction in patient wait and four hour breaches
 Reduction in complaints
Quality Account 2014/15
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4. Improve the pathway of care for frail elderly patients
Trust leads: Medical Director / Head of Nursing / General Manager
Why is this important?
The age of the local population is rising and peoples healthcare requirements are
increasingly complex therefore services need to be reviewed and redesigned so that they
meet the particular needs of this patient group.
What are we going to do in 2015/16?
 Provide expert dedicated consultant time in the accident and emergency department
to ensure that the patient’s complex needs are met by a robust care plan to support
the right care in the right setting.
 Review the impact of the above service and use evaluation to expand the service and
develop a full frailty unit.
 Continue to recruit care of the elderly consultants for both the acute and community
services to ensure senior input and more frequent assessments and care planning for
our more elderly and complex patient’s.
How will we know how we are doing?
 The community bed occupancy will increase
 Overall length of stay will reduce
 There will be a reduced number of complaints
 Improved patient satisfaction and experience.
5. Ensure appropriate seven day patient discharge for patients attending the hospital
Trust leads: Medical director / chief operating officer
Why is this important?
Patients should not stay in hospital if not required as this can impact on ongoing recovery
which would be improved in their own home environment. Unnecessary patient stay in
hospital can result in a reduction of available beds for planned and unplanned admissions to
hospital facilities; this may results in a longer wait for patients in A&E to be admitted to a bed
and or cancellation of elective surgery due to unavailability of a bed.
What are we going to do in 2015/16?
 Ensure all patients are given an expected date of discharge (EDD)on admission.
 Continue to implement the ward round standards
 Continue to work with agency’s to ensure ongoing timely packages of care for
patients who require support on discharge
 Review and re-launch nurse led discharge
 Progress seven day working to ensure appropriate discharges at weekends.
 Ensure support services are provide to meet demand e.g. pharmacy
How will we know how we are doing?
 Increased number of patient discharged at the weekend.
 Reduced patient length of stay
 Audit results of EDD and ward round standards
Quality Account 2014/15
63
6. Improve 4 hour performance in line with agreed trajectory
Why is this important?
Patients who are cared for by the Emergency Department (ED) team should receive the
appropriate care in a timely manner. ED are measured on the performance against many
targets and the main one is that patients should be seen and discharged within 4 hours. The
4 hour performance at Northwick Park is challenged mainly as a result of inpatient bed
capacity issues which should improve when the new Modular Ward Block opens in
December 2015. Aside from the capacity increase the Trust is looking at processes that will
help to deliver improved performance before the new ward opens. As a result of continued
steady improvement we anticipate an increase in patient satisfaction.
What are we going to do in 2015/16?
An action plan has been developed with the Clinical Commissioning Group (CCG) and local
partners in our health economy. The action plan is made up of various schemes looking at
the patient flow, patient transport, and inpatient ward discharge processes and out of
hospital services. The initiatives have been devised by different workgroups and new
schemes will be added if and when required.
Each scheme has a project lead and the progress of the delivery of the initiative is discussed
both internally by the Trust and during meetings with our partners. Weekly Emergency
Pathway performance meeting has been established to discuss all aspects of Trust
performance and possible changes discussed and separate projects are devised and
implemented.
Collaborative work with Urgent Care Centre provider is ongoing to ensure effective and
efficient interface to help drive performance improvement.
How will we know how we are doing?
 Improvement in the 4 hour performance.
 The Trust performance continues to meet the agreed trajectory.
 Increase in patient satisfaction through various surveys.
 Reduction in patient complaints.
In-year monitoring of priorities
The Quality Account priorities for improvement for 2015/16 will be monitored by the Clinical
Performance and Patient Experience (CP&PE) subcommittee of the Trust Board on a
quarterly basis. The CP&PE Committee will report compliance directly to the Trust Board.
Quality Account 2014/15
64
CQUIN Goals for 2015/16
The table(s) below set out the CQUIN goals to be delivered in 2015/16. The first five goals
are nationally mandated as outlined in the national CQUIN guidance for 2015/16 which can
be accessed via the following link: http://www.england.nhs.uk/wpcontent/uploads/2015/03/9-cquin-guid-2015-16.pdf
Scheme #
N1
N2
N3
N4
N5
Regional 1
CQUIN scheme description
Acute Kidney Injury
The scheme is linked to NPSA alert for the management of patient care and is
planned to give evidence of the processes in place to ensure patients are
reviewed for the deterioration of renal function.
The Trust has already developed a care bundle through the Quality
Improvement hub based in the Research and Development department. The
pilot has shown a reduction in the number of patients needing HDU and ITU
care and reduced length of stay by 1 day.
The team have already developed a working group to deliver the
recommendations in the NPSA alert. Progress will be reported through the
patient safety committee
Sepsis
This CQUIN is in 2 parts with funding for achieving both elements of the
CQUIN,
The CQUIN is linked to the implementation of the Sepsis tool kit and is
specific in the delivery of antibiotic therapy within 1 hour of the condition being
recognised.
The Trust has implemented a care bundle for Sepsis and has developed a
sepsis group which will deliver the outcomes needed for the CQUI. Progress
will be reported through the patient safety committee.
Dementia
The CQUIN focuses on the assessment of patients over 75 for their risk of
dementia and asks for evidence of education of staff to manage patient care.
The CQUIN also asks the Trust to monitor carers needs through
questionnaire.
Unplanned Emergency Care Reduction of Avoidable Admissions
This CQUIN is linked to the “Itchy,Wheezy,Sneezy”. Quality Improvement
research project developed in partnership with CLAHRC North West London.
The project will entail the set up of community based Consultant clinics to
educate GP and community nurses in the management of childhood Asthma
and Allergies
This CQUIN is a combined scheme with the community schemes
Implementation of 7 day diagnostic services
This CQUIN is split into 3 schemes
The development of MRI Services
The standardisation of imaging processes across the Trust
The standardisation of processes across cardiology diagnostics for
echocardiography.
The schemes are linked to the procurement of MRI services, and the support
needed from diagnostic services to develop the emergency pathway.
Shared IT systems
This is the second year of a CQUIN to develop interoperability for IT systems.
There is a similar CQUIN in community services and Specialist services
The work will be progressed and signed off through a Joint Project board
Quality Account 2014/15
65
Scheme #
Regional 2
Regional 3
Regional 4
Regional 5
CQUIN scheme description
Reduction in A&E re-attendances
This is a joint scheme with community services to enable information
regarding frequent attenders to be discussed with community services to
enable a management plan to be developed to reduce the number of reattendances
Multi-disciplinary Handover
The CQUIN is linked to the RCP guidelines for 7 day Multi-disciplinary
Handover with the emphasis on discharge and management of patients out of
hours through hospital at night processes. The achievement of the CQUIN is
also dependent on the development of a policy for Handover processes.
Reduction in Out Patient referrals and Face to Face Out patient
consultations
The Trust have identified 5 services which will work with commissioners to
develop referral pathways with using the map of medicine.
This will include
Orthopaedic and trauma
Gastroenterology
Urology
General Paediatrics
Long Term Conditions
The Trust has put forward three long term conditions
These are as follows
Development of a Heart Failure Care Bundle. This has been developed in
partnership with CLAHRC North West London and the Quality Research Hub.
Multidisciplinary review of the management of Diabetic patients
This has been piloted at NWLH and will be developed across both acute sites
Section6
Development of Acute Coronary Syndrome discharge bundle.
This has been piloted at the NWLH site and will be implemented across both
acute sites.
62 day Cancer CQUIN
This CQUIN scheme has been developed through the Cancer network and is
based on patients receiving treatment in a timely way. The CQUIN has been
developed with the Clinic Lead for Cancer and the Lead Programme Manager
Quality Account 2014/15
66
Statements of assurance
During 2014/15 London North West Healthcare NHS Trust provided and / or subcontracted
four services for adults and children:
• accident and emergency
• admitted patient care for planned and emergency treatment
• critical care
• non-admitted patient care.
These services covered the following specialities:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
accident and emergency
anaesthetics (op only)
anticoagulant service
audiological medicine
audiology
breast surgery
cardiology
clinical genetics
clinical haematology
clinical oncology (previously
radiotherapy)
colorectal surgery
community paediatrics
critical care medicine
dermatology
diabetic medicine
dietetics
endocrinology
ENT
gastroenterology
general medicine
general surgery
genito-urinary medicine
geriatric medicine
gynaecology
infectious diseases
maxillofacial surgery
medical oncology
midwife episode
neonatology
nephrology
obstetrics
occupational therapy
ophthalmology
orthodontics
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
paediatric audiological medicine
paediatric cardiology
paediatric clinical immunology and
allergy
paediatric diabetic medicine
paediatric ear nose and throat
paediatric endocrinology
paediatric gastroenterology
paediatric gastrointestinal surgery
paediatric infectious diseases
paediatric maxillofacial surgery
paediatric medical oncology
paediatric nephrology
paediatric neuro-disability
paediatric neurology
paediatric ophthalmology
paediatric respiratory medicine
paediatric rheumatology
paediatric surgery
paediatric trauma and orthopaedics
paediatric urology
paediatrics
pain management
palliative medicine
physiotherapy
psychotherapy
respiratory medicine
restorative dentistry
rheumatology
speech and language therapy
trauma and orthopaedics
urology
vascular surgery.
The Trust reviewed all the data available to them on the quality of care in all of these NHS
services. The income generated by NHS services reviewed in 2014/15 represents 100% of
the total income generated from the provision of NHS services by the Trust for 2014/15.
Quality Account 2014/15
67
Data quality statements
London North West Healthcare NHS Trust submitted records during 2014/15 to the
secondary uses service for inclusion in the Hospital Episode Statistics (HES) which are
included in the latest published data. The percentage of records in the published data:
Which included a valid NHS number was:



98.2% for admitted patient care
99.0% for outpatient care
89.0% for accident and emergency care.
Which included a valid general medical practice code was:



100% for admitted patient care
100% for outpatient care
99.5% for accident and emergency care.
Through 2015/16 the Trust will be continuing a range of actions to improve data quality,
overseen by a bi-monthly Data Quality Management Group. This group reports into the
Trust’s Information Assurance Board which was established during 2014/15.
During 2014/15 the Trust has undertaken the following actions to improve data quality:


Conducted a data cleansing and data quality checking exercise in support of the
successful migration onto a unified patient administration system
Implemented a new data quality policy and standardised documentation for reported
key performance Indicators.
The Trust is focusing on improving data quality within the organisation, with particular
emphasis on NHS number completeness and embedding the use of data quality
performance reports and dashboards for specified services and for mandatory data items.
Data Quality impacts on all areas of the organisation from the delivery of patient care right
through to income recovery and strategic decision making. Some of the programmes that
are planned for 2015/16 include:




Development of a governance structure to report on data quality with clear links
straight up to the board
Implementation of clinical and administrative systems which are better at capturing
information within clear data standards
Training programmes for users
Investment in capacity and capability to investigate and resolve data quality incidents
quickly as they occur
The success of these programmes will be measured through a series of local audits planned
throughout the year.
Clinical coding error rate
The Trust was not subject to the payment by results clinical coding audit during the reporting
period. The Trust did commission an external audit as part of the information governance
toolkit requirements and the error rates reported for diagnoses and treatments coding were
as follows:
Quality Account 2014/15
68
Primary diagnosis
correct %
87.5%
Secondary
diagnoses
correct %
88.7%
Primary procedures
correct %
92.93%
Secondary
procedures
correct %
92.35%
During 2015/16 the clinical coding function will be carrying out the following activities to
improve coding accuracy:
 Refresher training programme for all coding staff
 Ad-hoc audits within a targeted internal programme
 Active engagement with clinical staff to extend their involvement in coding activities
 Tracking all audit recommendations through the Trust’s Clinical Coding Quality
Group.
Delivery of performance priorities for 2015/16
Trust performance continues to be monitored by the Trust Development Authority and
commissioners. Throughout 2014 there has been close scrutiny of operational performance
of acute services against RTT, cancer and emergency pathway targets. Delivery of recovery
plans in these areas will continue to be a priority in 2015/16.
Information Governance
All NHS organisations are required to submit an annual Information Governance Toolkit
return which provides an assessment of a number of standards, or requirements, related to
the management of information, information assets and assurances. There are 45 individual
standards which need to have a minimum attainment level met in order to achieve an overall
“satisfactory” score.
The completion of the Information Governance Toolkit is a self-assessment process but is
also subject to Internal Audit review and formal approval by the Trust Board.
London North West Healthcare provided an Information Governance Toolkit return for the
period from its creation in October 2014 to the end of the financial year in March 2015. Up to
October 2014 the two individual Trusts were working with separate Toolkits. The scores
returned up to October 2014 for these Trusts are provided for comparison.
Trust name
Ealing Hospital NHS Trust
Assessment
2013/4
Overall score
79%
Grade
Satisfactory
North West London
Hospitals NHS Trust
London North West
Healthcare NHS Trust
2013/4
71%
Satisfactory
2014/5
66%
Satisfactory
This indicates that all attainment levels met a satisfactory score of “2”; the best score for any
standard being “3”. This provides a firm foundation for moving forward in 2015/16, to
improve and consolidate the Toolkit standards. The lower percentage score is a reflection of
the new Trust having quickly established an appropriately unified assurance and policy
framework, building on aligned approaches that had been in place within the two legacy
organisations up to end September 2014. Our objective in 2015/16 is to progress to “level 3”
scores where these build on the assurance framework in place and reflect standardisation of
supporting procedures and an active monitoring of their effectiveness.
In addition to the Information Governance Toolkit return, the Trust has dedicated staff
ensuring that the management of personal and confidential information, along with the
Trust’s legal obligations in this respect, are managed correctly.
Quality Account 2014/15
69
Participation in clinical audit and national confidential enquiries
Clinical audit is a very important activity for any organisation and is used to evaluate clinical
practice and identify areas for improvement; we encourage all of our departments to perform
their own local audits looking at various aspects of patient care. In addition, there are a
number of National audits which allows us to compare our practice with other similar
services. Each year, the Healthcare Quality Improvement Partnership (HQIP) publishes a
Quality Accounts List on behalf of NHS England detailing the National Clinical Audits,
Clinical Outcomes Review Programmes, and registries that NHS England would like health
service providers to report on. For 2014-15, a list of 42 national audits were published, of
which only 32 national clinical audits covered NHS services provided by the organisation
During the period of April 1, 2014, to March 2015, 32 national clinical audits and 2 national
Confidential Enquiry covered NHS services that London North West Healthcare NHS Trust
provided. During that period:



Central Middlesex Hospital participated in 88% (15/17) of national clinical audits and
100% of national confidential enquiries which it was eligible to participate in
Ealing Hospital Trust participated in 96% (27/28) of national clinical audits and 100%
of national confidential enquiries which it was eligible to participate in
Northwick Park Hospital participated in 97% (31/32) of national clinical audits and
100% of national confidential enquiries which it was eligible to participate in
The national clinical audits that London North West Healthcare was eligible to participate in
during April 1, 2014, to March 2015, are as follows:
Cases
Submitted
Central
Middlesex
Hospital
Cases
Submitted
Ealing Hospital
Cases
Submitted
Northwick Park
Hospital
77 (100%)
470 (100%)
304 (100%)
2 cases and
currently
collecting data
249 cases
(100%)
117 cases and
currently
collecting data
4 cases (100%)
20 cases (100 %)
14 cases (100%)
Severe trauma (Trauma Audit &
Research Network, TARN)
Not applicable
111 (69%)
89 cases
National Comparative Audit of
Blood Transfusion – Sickle cell &
Thalassemia
7 cases
submitted
together with
NPH
6 cases (100%)
30 cases
Bowel cancer (NBOCAP)
Not applicable
21 cases (33%)
214/249 (86%)
Head and neck oncology
(DAHNO)
Not applicable
Not applicable
238 cases
Lung cancer (NLCA)
See NPH data
submitted
together
55 cases (100 %)
95 cases
National Audit
Case Mix Programme (CMP)ICNARC
National Emergency Laparotomy
Audit (NELA)
Not applicable
National Joint Registry (NJR)
Not applicable
Pleural procedures
Quality Account 2014/15
601 cases
70
Cases
Submitted
Central
Middlesex
Hospital
Cases
Submitted
Ealing Hospital
Cases
Submitted
Northwick Park
Hospital
In progress
In progress
In progress
Not Applicable
Not Applicable
In progress
67 cases
227 cases
389 cases
238/238 (100%)
131 cases
(100%)
142/142 (100%)
Not Applicable
Not Applicable
Not Applicable
Coronary angioplasty
Not applicable
In progress
595 cases
National Adult Cardiac Surgery
Audit
Not Applicable
Not Applicable
Not Applicable
National Audit
Oesophago-gastric cancer
(NAOGC)
Prostate Cancer
Acute coronary syndrome or
Acute myocardial infarction
(MINAP)
Cardiac Rhythm Management
(CRM)
Congenital heart disease
(Paediatric cardiac surgery)
(CHD)
Ealing did not
submit data for
this audit
275 cases
(100%)
National Cardiac Arrest Audit
(NCAA)
19 cases
submitted
National Heart Failure Audit
92 cases
National Vascular Registry*
Not Applicable
Not Applicable
In progress
Not Applicable
Not Applicable
Not Applicable
0/30 (0%)
30 cases (100%)
0/30 (0%)
Pulmonary hypertension
(Pulmonary Hypertension Audit)
Adult community acquired
pneumonia
262 cases
submitted
183 cases
Adult Bronchiectasis Audit*
The BTS abandoned this audit, therefore was not carried
out in 2014-15
Diabetes (Adult) ND(A), includes
National Diabetes Inpatient Audit
(NADIA)*
Data collection in progress, annual submission deadline
June 2015
Diabetes (Paediatric) (NPDA)
National Chronic Obstructive
Pulmonary Disease (COPD)
Audit Programme
Renal replacement therapy
(Renal Registry)
Rheumatoid and early
inflammatory arthritis*
Falls and Fragility Fractures
Audit Programme (FFFAP)National Hip Fracture Database
(NHFD)
87 cases
401 Outpatients
(100%)
46 admitted care
(100 %)
124 cases
33 cases (100%)
32 cases (100%)
86 cases (100%)
Not Applicable
Not Applicable
Not Applicable
3
14 cases (100%)
128
Not applicable
159 cases
326 cases
Quality Account 2014/15
71
National Audit
Prescribing Observatory for
Mental Health (POMH-UK)
Mental Health Programme:
National Confidential Inquiry into
Suicide and Homicide for people
with Mental illness (NCISH)
National Audit of Dementia (care
in general hospitals)
National Intermediate Care Audit
Parkinson's disease (National
Parkinson's Audit)
Sentinel Stroke National Audit
Programme (SSNAP)*
Elective surgery (National
PROMs Programme)
Cases
Submitted
Central
Middlesex
Hospital
Cases
Submitted
Ealing Hospital
Cases
Submitted
Northwick Park
Hospital
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Pilot Jan 15, actual audit to commence in 2016
Conducted jointly
with NPH
156/200 (78%)
Audit commenced in 30/4/2015
Adherence to British Society for
Clinical Neurophysiology (BSCN)
Fitting child (care in emergency
departments)
Mental health (care in
emergency departments)
Older people (care in emergency
departments)
Epilepsy 12 audit (Childhood
Epilepsy)
Maternal, Newborn and Infant
Clinical Outcome Review
Programme (MBRRACE-UK)
Paediatric intensive care
(PICANet)
Neonatal intensive and special
care audit
Chronic kidney disease in
primary care*
Specialist rehabilitation for
patients with complex needs
Not Applicable
Not Applicable
1214 cases
See NPH done
jointly
In Progress
860/1353 cases
0/20 (0%)
Not Applicable
Not Applicable
26 cases (52%)
50 cases (100%)
50 (100%)
51 cases (100%)
99 (99%)
100 cases
(100%)
Not applicable
14 (100%)
8 cases
Not Applicable
Continuous data
collection and
submission
4 maternal
6 neonatal
Not Applicable
Not Applicable
Not Applicable
Not Applicable
229 cases
462 cases
Not Applicable
Not Applicable
Not Applicable
Not started
nationally
Not started
nationally
Not started
nationally
Not Applicable
Not Applicable
Not Applicable
Table 1: The national clinical audits that London North West Healthcare NHS Trust
participated in are listed above alongside the number of cases submitted to each audit as a
percentage of the number of registered cases required by the terms of that audit.
Quality Account 2014/15
72
None participation and reduced submissions to National Clinical Audits
Severe trauma (Trauma Audit & Research Network, TARN) - The reduced submission to
the (TARN) data at Ealing has been as a result of the Trauma coordinator leaving, there is
now a replacement in post with a designated administrator identified to support them. At
Northwick Park Hospital 2 additional members of staff are now supporting the submission of
TARN data, with proactive steps being taken to clear the backlog of data.
Acute coronary syndrome or Acute myocardial infarction (MINAP) and National Heart
Failure Audit – The trust is in the process of recruiting a permanent member of staff, whose
remit will be to collect data for these national audits.
National Cardiac Arrest Audit (NCAA) – Lack of capacity has resulted in Ealing being
unable to submit data for this national audit. Sharing Best Practice and joint working across
the all sites of the organisation will make it possible for Ealing to start participating in this
national audit.
Adult Community Acquired Pneumonia – The deadline for submitting data was missed for
the Central Middlesex and Northwick Park sites. The Trust has taken steps to ensure the
three British Thoracic Society Respiratory audits scheduled for the 2015-16 will have data
submitted in a timely manner
National Intermediate Care Audit – This national audit is being repeated again in 2015-16,
and the participation rates for this national audit it is expected to rise in comparison to the
previous year.
Fitting child (care in emergency departments) – The number of submissions required for
this audit was 50 cases, however Ealing Hospital only had 26 children attend the Emergency
Department within the audit time frame specified by the College of Emergency (CEM).
National Confidential Enquiries
There were two national confidential enquiries that London North West Healthcare NHS
Trust were eligible to participate in during the period 1st April 2014 to 31st March 2015. The
studies were:
National Confidential
Enquiries into
Perioperative Deaths
(NCEPOD) Studies
Pancreatitis
Sepsis
Central
Middlesex
Ealing Hospital
Northwick Park
Hospital
13 list of cases
submitted
82 list of cases
submitted
169 list of cases
submitted
1 list of case
submitted
25 list of cases
submitted
20 list of cases
submitted
Table 2: The NCEPOD studies that LNWH participated in and for which data was collected
within the period of 1st April 2014 to 31 March 2015 are listed above.
Quality Account 2014/15
73
There have been two reports published in the 2014-15 year:
Lower Limb Amputation: Working Together (2014) A review of the care received by
patients who underwent major lower limb amputation due to vascular disease or diabetes
Ealing Hospital: This was not applicable as amputations are not carried out at this site. The
report was shared with staff for information.
Northwick Park Hospital: The report has been reviewed and a self-assessment check list has
been carried out by the lead
Tracheostomy Care: On the Right Trach (2014): A review of the care received by patients
who underwent a tracheostomy
Ealing Hospital: a self-assessment was undertaken and an action plan developed to meet
areas of partial compliance and is on track for completion by October 2015.
Northwick Park Hospital: The report has been reviewed and a self-assessment check list has
been carried out. The report has been fed back at a combined Head and Neck, anaesthesia
and Critical Care Clinical Governance Meeting.
The reports of 22 national clinical audits were reviewed by the provider during the period
April 1, 2014, to March 2015 and Ealing Hospital intends to take the following actions to
improve the quality of health provided:
CEM – Renal Colic
Education of new A+E doctors regarding diagnosis, differential diagnosis and investigation of
renal colic, as well as adaptation of national renal colic guidelines to suit local need of Ealing
Hospital. The Guidelines will then be published and poster displayed.
CEM – Paracetamol overdose
The ED lead consultant will provide quarterly training to the doctors in relation to the
paracetamol overdose pathway and protocol. This will be coupled with a local re-audit to
monitor changes/improvements. Ealing ED currently has a Paracetamol overdose proforma
and Northwick Park will be looking to introduce such a proforma, coupled with teaching sessions
and education to improve management of these cases.
CEM – Severe sepsis and Septic Shock
The Sepsis care bundle was introduced at Northwick Park Emergency Department (ED) in
Sept 2014, this will be followed by roll out to the Ealing ED, in addition to adding a new
section within add a section within the new ED CAS card. Re-auditing of sepsis is planned
for October 201
CEM Moderate and Severe asthma
The results for this national audit demonstrated a high level of compliance with the CEM
standards. The ED will revise the departmental guidelines on peak flow measurement, share
results on a daily basis and meetings as well as re-iterating on induction.
National Audit of Seizures in Hospital Audit (NASH) – Ealing and Northwick Park
The London North West healthcare Epilepsy Care Bundle has been introduced to staff and is
used within patient records, as well as being made available on the intranet. This
specifically documents the need to examine plantar relaxes, document that ECG’s have
been performed and discussions with patients about driving.
Quality Account 2014/15
74
The Education session and training presentation given to staff will be updated to include;
examine plantar reflexes, ensure ECG’s are performed and to document conversations with
patients regarding driving. At the Northwick park site, a Business case for an Epilepsy Nurse
specialist for Trust is progressing and a case is being put forward for a Community Epilepsy
Nurse Specialist
National Neonatal Audit programme - Ealing and Northwick Park
 Following on from this national audit, there will be an evaluation of the reasons
for not prescribing steroids, as well as training on temperature management and
infection control measures at Northwick Park hospital.
 The change of database to Badgernet to collect data and the quality of data
should improve the results for the Special Care Baby Unit (SCBU) at Ealing
Epilepsy 12 audit
As a result of this national audit Ealing Hospital will explore provision of a single centralised
service for all children with epilepsy across acute and community settings, as well a
introduce clear protocol for management of children presenting to Emergency Department or
Outpatients with history of seizures. This will be supported by training and on induction for
new trainees
Asthma review
Trust now has a named lead for Asthma who is responsible for training, and sessions have
commenced.
Diabetes in paediatrics
The 2012-2013 data for this audit was collected by hand, a new database became operation
in Spring 2014, allowing for more accuracy in data collection and submission. There has also
been a further appointment of a diabetes nurse specialist and a consultant since this audit
was carried out. In addition, to allow all pathology investigations to be ordered, a new ICE
order set for diabetes patients has been created.
SNNAP (Stroke) National Audit – Clinical
 As a consequence of this national audit, rehabilitation goals for patients are now set
on initial assessment.
 To ensure that patients with atrial fibrillation are discharged on anticoagulants or
have plans to start them have improved to 100% compliance since the revision of the
process
 Adjustment of the paperwork used has meant that 97% of patients discharged are
given a named contact.
National Breast Cancer referral rates audit – Genetics
Prioritising high risk individuals eligible for BRCA gene testing is now possible by utilising a
pre-appointment questionnaire
BTS Non-Invasive Ventilation (NIV) audit
 Instigation of quarterly symposium to be conducted on the theory of NIV, as well as
Practical sessions and provide pocket NIV guides for FY1/FY2/CT2 doctors
 Training to medical staff at Respiratory lunchtime meeting and Junior Doctor teaching
sessions. Implementation of pleural procedure advice sheet and guidelines on
Respiratory ward. Training to interventional radiologists regarding pleural procedures.
 Fundamental respiratory study day to be organized twice yearly where oxygen
prescribing and administration will be taught to all levels of staff to improve
knowledge on the correct set up of oxygen flow meters.
Quality Account 2014/15
75
BTS Pleural Procedures audit
A standardised proforma to be devised in line with BTS guidelines to ensure that respiratory
and Radiology staff complete the essential information when inserting a chest drain. The use
of sutures will be instigated to prevent the risk of drains falling out
BTS – Paediatric Asthma
At Ealing, a teaching session with Paediatric, UCC and Emergency Department will take
place to review the number of chest X-rays undertaken. This will be followed up with a local
re-audit on the number of Chest X-Rays performed for wheeze/asthma, which department
requested these and their indication. For Northwick Park, the aim is to revise the Emergency
Department guidelines on peak flow measurement and moderate to severe asthma.
Inflammatory Bowel Disease - Paediatrics
The method of contacting the service for advice, has been extended to include voicemail and
mail, this will be coupled with an annual patient satisfaction survey. In addition, a new
transition pathway has been designed and disseminated within the Inflammatory Bowel
Disease Multi-Disciplinary meeting.
Inpatient care and inpatient experience of adults with ulcerative colitis
Following this audit, the hospital is supporting the business case for recruitment to a IBD
Nurse post. In addition a local treatment algorithm on the treatment of anaemia will be
written and circulated to the <Multidisciplinary team,
National Audit of Heavy Menstrual Bleeding (HMB)
A Protocol for HMB will devised based on Best Practice – NICE, and patient leaflets will be
devised and once approved will be given to patients who attend Ealing Hospital
National comparative audit of blood transfusion - Anti D
Patient leaflets will be requested from the National Blood Service which provide information
for patients regarding Anti-D treatment. The training provided by the Blood transfusion
Practitioner will be updated to include the findings of the results and ensure documented
consent for patients receiving Anti-D
National Patient Blood Management (PBM) Survey
As a result of this national audit Ealing Hospital will update and merge the blood transfusion
policy with Northwick Park and Central Middlesex and make explicit within the need to
identify and correct the underlying cause of anaemia before considering transfusion. This will
be coupled with a section in the doctor’s e-learning presentation about PBM and how it can
be achieved.
2014 Audit of Patient Information & Consent
The national audit results highlighted that alternatives to blood transfusion were not
explained to the majority of patients, so Ealing will look at the possibility of separate
transfusion consent forms and prescription charts in patient notes for patients receiving
transfusions
National Care of the Dying Audit
One of the key actions from this group is to reconstitute the end of life care group and review
its terms of reference – specifically focussing on national recommendations about end of life
care in the light of the One Chance to Get it Right document.
At Northwick park hospital a a business case has been put forward to increase to 7 day face
to face service. A Non-exec member of the board has responsibility for care of dying, and
the Chaplain are now part of End of Life Steering Group
Quality Account 2014/15
76
The reports of 94 local clinical audits were reviewed by the provider during the period April 1,
2014, to March 2015 and Trust intends to take the following actions to improve the quality of
healthcare provided:
Central Middlesex and Northwick Park Hospital
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To improve the out-patient dispensing service for patients on oral azathioprine,
patients will be given blood test request forms in a pack and to have blood test done
prior to clinic appointment
Following on from an Appendicectomy Audit, there will be more liberal use of imaging
modalities and use of laparoscopy as a diagnostic tool instead of a method to remove
normal appendices
Radiologists to include assessment of the aorta in general US abdomen. A standard
report template has been introduced to help compliance, and incorporated in the
Registrar training
Dieticians. work in collaboration with the Medicines management team to identify and
promote the most cost effective nutritional supplements and determine the correct
length of use, for patients. In addition, the Harrow CCG have also agreed to support
a paediatric dietitian to review the infant formulary guidelines which will improve
paediatric outcomes and assist General practitioners with suggesting appropriate
formularies in paediatrics
An audit of Consenting for Coronary Angiography and Intervention has resulted in a
dedicated educational session for SpRs, educational leaflets for patients and the
introduction of pre-filled consent forms
Following a Patient Satisfaction survey in endoscopy, the reception staff and
schedulers have attended customer care training. The Waiting room carpet and
windows have been cleaned and a TV, water cooler, rolling notice board, new blinds
have been ordered. Nurses will provide aftercare leaflets to patients on discharge.
Ealing Hospital
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The CTPA request form will be modified to include Wells’ criteria and uploaded to
staff intranet and distributed to wards.
A new Patient’s Charter has been developed and shared with the Homecare Provider
and patients.
All ward fridges are continually reviewed and checked to ensure that all medications
are in date and to reduce cost of wastage and destruction of expired pharmacy stock
Swipe access locks on doors will be initiated to limit access to restricted medicines.
Following an audit, more patients will be give lower amounts of antipsychotic
medications, which are associated with a lower rate of clinical incidents, better
outcomes and reduced length of stay.
Healthcare staff the have been given information regarding the risk of using gloves
and re-usable tourniquets. Ealing Hospital’s Supply Office and Infection Control will
not advocate the use of disposable tourniquets, and specific poster have been
created and circulated to ward manager, phlebotomists, nurses and junior doctors.
Patient hematology leaflets will be updated to include more information on the
treatment and side effects of Haematology medication.
Falls e-learning programme will be promoted to all staff with appropriate time given to
complete the training. Falls training to be delivered on every ward.
As a result of an audit, the use of chlorhexidine for skin antisepsis will be
implemented to improve patient outcomes and reduce hospital stay.
All surgical doctors will be educated on the guidelines for antibiotic choice and their
rationale, as well as the importance of sending a sample to pathology.
Quality Account 2014/15
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An audit demonstrated that the Antimicrobial prophylaxis audit used in Ealing is
suitable; however the duration of use could be reduced.
At the Ward Sisters Forum, it was agreed that a single comprehensive catheter
insertion chart would improve current practice. The Junior doctors will be given
training on induction on the use of the new chart.
Junior Doctors will be taught the importance of anti-emetic and laxative prescriptions
in patient who are on opioids.
Following a maternity audit, management will review triage staffing, and midwives will
receive a greater level of feedback following incident reporting.
There will be intensive training of all ED staff on the screening tool and referral
pathways for Domestic Violence including adequate documentation, and ensuring
that the Domestic Violence screening tool is easily accessible in the ED department.
In addition, a ‘useful contacts’ card is available to the public and provided where
appropriate.
The Liaison Psychiatry Team will begin to roll out use of standardised assessment
forms
Following on from the sepsis audit, the hospital will develop a concise
proforma/sticker to aid in sepsis recognition and initiation of the sepsis 6.
Principal pharmacists to include information about antibiotics administration on their
induction talk.
Design and distribute posters to raise awareness regarding Sepsis and antibiotics
Following on from a health visiting audit, the trust will identify a process and
thresholds for managing concerning cases for those families who do not wait for
Ealing Health Visiting service.
Renal function will now be assessed on Mondays and Thursday for all those patients
that are prescribed heparin calcium.
The switching of any thromboprophylactic agent for a patient, will require the
Pharmacists to speak directly with the doctors regarding any such recommendation.
In addition, further education and training will be provided to doctors regarding
thromboprophylaxis
Pharmacy will print and circulate posters on the patient charter for the Pharmacy
Homecare services.
The hospital will follow national guidelines/local protocol and form a larger database
with National TB database.
Following the Neck of Femur Fracture audit, there is agreement between the
physiotherapy team and orthopaedic doctors, that unless expressly stated, all
patients can be mobilized without having to wait for a check X-ray to be documented
as ‘cleared’.
The Fracture Neck of Femur (NOF) forms will be used for the Post-Operative Plan to
ensure consistency and clarity.
Drug chart audit highlighted need to consider designing drug charts with individual
boxes for the drug names
Consider use to labels/stamps with prescriber’s details on, and electronic prescription
service.
Cardiology to distribute leaflets summarising the existing acceptability of CMR
indications.
Radiology promotion of proper care & handling of these Radiation Protective
apparels.
Pharmacy now produces information booklets in Punjabi and Tamil for rivaroxban
and tinzaparin.
Pharmacy to prompt doctors in multidisciplinary team meetings to adhere more
strictly to the London guidelines
Quality Account 2014/15
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Brent Community Services Audits
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Regular additional checks are being conducted ensure that staff are wearing ID
badges at all times.
New package of care leaflet has been developed outlining the treatment that patients
can expect from the dietician.
Updated leaflets will be distributed to patients to increase their intensive lifestyles
programme awareness. And quarterly reviews are undertaken with the NHS health
checks team to discuss referral rates and on-going trends.
Diabetes team now ensure that accurate patient contact details are recorded on RiO
so that text messages can be sent to reduce DNA’s
Special school nursing service now produces health passport for current year 14
leavers.
Following on from an audit, alternative venues for health assessment for children &
young people, such as home visits and cafes will be used to talk about their health
and well-being in a natural environment.
Recording in RiO regarding 2-2.5 years check-up is being standardized
Document of referral pathway for Child Devleopment team will be circulated to Health
Visiting team
Following on from an audit, personalised Catheter Care Plan + Bowel Management
Care plans are being drafted. Guidelines are being introduced for discharging
patients with a urinary catheter, supported by training and feedback at the Integrated
Catheter Group’.
The Human Papilloma Virus (HPV) protocol has been updated to allow recording for
refusal and non-returning consent form
Teams will record the production number of health promotion material provided to the
Client and uploaded onto Client record
As a result of a safeguarding audit, the Health visiting team will ensure linkage of
fathers and significant adults is incorporated in the Safeguarding Children policy and
training
Health Visiting will develop guidance and protocols for the assessment &
management of maternal mental health
A New Birth Policy will be implemented in health visiting teams as well as the
Antenatal Care Pathway. This will be coupled with Enhanced Caseload monitoring
grid in health visiting teams.
Following an audit in Willesden, the Robertson rehabilitation unit will revise food and
menus on offer. In addition, the ward will improve leisure facilities and provide more
social groups and activities
The Willesden Centre for health and Social Care will activate after hours GP cover
for their patients.
Nutrition and dietetics to design a template for recording notes for RiO based on the
model of care recommendations from the British Dietetic Association. To support this
Nutrition and dietetics will request Mencap to provide further guidance on the
importance of learning disability passport and ways to use the passport in current
practice
Musculoskeletal Physiotherapy services to start computerised notes as soon as
possible so there is uniformity of methods of documentation.
CSCNS service to be set for the services to start using the electronic system only
Quality Account 2014/15
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Ealing Community Services Audits
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The audit results demonstrated that the conversion rates by musculoskeletal service
are set at a target rate of 80% which is suitable and clinically safe.
Following on from an audit, the content of the paediatric occupational therapy care
and treatment plan will be reviewed to reduce the time taken for completion and
provide administrative support.
New room space will be given within schools for School Nursing Service and new
School Nurse Crib sheet developed, for distribution during vaccination sessions.
School Nursing Service will have regular drop in sessions for head teachers to raise
any concerns.
Following an audit there will be development of a comprehensive vocational
assessment tool agreed with Occupational Therapy team at Enable.
‘All About Me Book’ is being translated into Hindi, Punjabi and Polish, as well as
reviewing the layout and provide more space for written feedback
A class leaflet will be developed for patients by the Musculoskeletal Service
physiotherapy service. In addition, there will be training sessions, introduction of a
process chart, and the creation of a new record sheet to improve referral process.
Following an audit changes have been reviewed in the acupuncture policy with the
aim to promote a higher level of compliance with acupuncture policy by presenting
audit finding and conducting training sessions.
Following recommendations of an audit, a specific nutrition support service leaflet is
being created.
An audit review highlighted the need to revise the document that Palliative care is
currently using with the multi-professional team.
ICE (Intermediate Care Ealing) staff to review information leaflet and investigate
possibility of NHS lanyard for community staff.
After an audit, GAS goals will be jointly agreed between Occupational Therapist and
Physiotherapists, with therapists taking responsibility for allocating adequate time to
complete these.
For all medication stored in schools, consent to administer medication will now be
completed by both the nurse and the. parent
School nurses to complete documentation with supervision from team lead.
All staff to familiarise themselves with the Trust guidelines for the assessment and
management of perinatal mental health and the relevant referral pathways. To
support this, all health visiting staff will attend the Trust Perinatal Mental Health
training and receive regular updates
Ensure women and their partners/ other family members are informed about perinatal
mental health problems during pregnancy (where possible) and during the new birth
visit. The Trust PND wheel can be used to discuss postnatal depression with mothers
and fathers.
Inform all new mothers about all local support services that are available and how to
access further help if they need it.
Health visiting staff to work with Early Years staff and where possible set up
postnatal support groups for mothers.
Patient to be seen in the Community Nurse Review clinic on months not seen in
medical TB clinic.
Regular review of patient’s compliance and response to treatment will now include
microbiology review and discussion with TB Consultant for treatment regime change
as required.
Quality Account 2014/15
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To contact patients who missed their appointment by phone to check for compliance,
medication supply and rebook appointment. Arranging chest x-ray at 3 and 12
months to exclude active pulmonary TB for patients who declined preventative
treatment
Informing local Health Protection Unit or Find & Treat team after failed attempts at reengaging patients
Following a patient experience survey, staff will reduce interruptions during patient
visits and ensure that they inform the patient when their next appointment is.
ICE staff have changed the way telephone calls are managed to be more effective
and improve patient experience.
The continence service assessment documentation will be reviewed and updated to
include pelvic floor digital assessment
All nutrition and dietetics staff will actively show patients their ID badge when meeting
them and inform patients of the exact time and date of their follow up appointment.
The Trust Post Natal Depression wheel will be used to discuss postnatal depression
so that women and their partners/ other family members are informed about perinatal
mental health problems during pregnancy (where possible) and during the new birth
visit. New mothers will also be informed about all local support services that are
available and how to access further help if they need it. Health visiting staff will aim to
work with Early Years staff and where possible set up postnatal support groups for
mothers.
Dental service will ensure that the necessary patient information is recorded and that
patients with learning difficulties to have a learning passport.
Harrow Community Services Audits
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Leaflets distributed to the referring cardiologists, cardio registrars and junior doctors
summarizing the acceptable, inappropriate and uncertain indications.
Patients are now being offered cardiac rehabilitation exercises either at Wealdstone
Centre or Harefield Hospital depending on the LVEF and severity of heart failure
condition.
Business case is to be undertaken by the Cardiology Team Leader to convince the
stakeholders about the benefits of establishing cardiac rehabilitation exercise
programme for heart failure patients in Harrow and to secure funding to acquire
needed resources to implement the programme.
Harefield Pulmonary Rehabilitation in Harrow to determine whether heart failure
patients can be included into their exercise programme as alternative if establishing a
Coronary Rehabilitation for heart failure is not feasible. For those who are unable to
avail of the rehabilitation programme the service do provide a copy of DVD exercise
for patients to take home.
Clinicians who are in charge of the patient will liaise with the Heart Failure nurses via
telephone call, email or sending a fax message to inform the HCP of impending
discharge of Heart Failure patients needing a follow up in the community.
Heart Failure nurses to ensure that patients are being seen either in clinic or at home
within 2 weeks of being discharge from the hospital.
Following an audit a weekly newsletter and poster in clinical areas will be established
to remind staff about Ottawa rules for foot care. Further training will be provided to
improve understanding of Ottawa Rules.
Dental service will ensure that the necessary patient information is recorded and that
patients with learning difficulties to have a learning passport.
Quality Account 2014/15
81
Participation in clinical research
North West London Hospitals NHS Trust
The number of patients receiving NHS services provided or sub-contracted by The North
West London Hospitals NHS Trust in 2014/15 that were recruited during that period to
participate in research and approved by a research ethics committee was 3,341. This has
already exceeded the proposed annual target of 2,650 participants (February data 2015).
The Trust supported:
Sponsor Type
2013/2014 2014/2015
Non-Commercial (NIHR portfolio)
84
97
Commercial/Industry (NIHR portfolio)
29
31
Non-NIHR Portfolio
21
26
Totals
134
154
This is an increase on the previous year and the numbers of commercial studies continues
to rise with the commercial study pipeline.
Ealing Hospitals NHS Trust
There were 2,714 patients receiving NHS services provided, or subcontracted, by the legacy
Ealing Hospital NHS Trust in 2014/2015 that were recruited during that period to participate
in research approved by a research ethics committee. This is an increase from 1,881
patients recruited in 2013/14.
The Trust has supported the following numbers of studies:
 24 National Institute for Health Research (NIHR) – Non-Commercial;
 Three Commercial (2 NIHR / 1 Non-NIHR).
The Trust has successfully hit its target in opening two new commercial studies in line with
the Government’s priority areas to increase collaboration with industry.
Key Performance Indicators (KPIs)
North West London Hospitals NHS Trust
To date 51 studies have received NHS permission within 15 days resulting in 73% score as
against the National Institute for Health Research (NIHR) national metric target of 70%.
The Department has undergone extensive restructuring and introduced new committees
including an Academic Board chaired by the CEO to support research across the Trust
coupled with an Industry and Feasibility and Monitoring meetings to deliver successful
outcomes for the KPI’s.
 In the third quarter of this year NWLH NHS Trust has the second highest weighted
recruitment within London North West (LNW) sector (31% of total).
 The Trust HIV/GUM clinic at Central Middlesex Hospital successfully recruited over
1100 patients into a point of care Chlamydia screening study.
 The Trust Cardiology department continues to be the leading global recruiter for the
ISCHEMIA study and has successfully taken on the lead role for the UK.
Ealing Hospital NHS Trust
All NIHR national key performance indicators (KPIs) are reported into the Trust R&D
Steering Group to monitor progress and performance. To date 11 studies have been
approved of which nine met the NIHR 15 day target. This is resulted in 82% score against
the National Institute for Health Research (NIHR) national metric target of 70%.
Quality Account 2014/15
82
Genome 100,000
The Kennedy Galton Centre, North West Thames Regional Genetics Service has been
successful in becoming part of the North Thames bid, becoming one of eleven genomics
centres in the UK. The programme will sequence 100,000 whole genomes from NHS
patients by 2017. Its main aims are to create an ethical and transparent program based on
consent, to bring benefit to patients and set up a genomic medicine service for the NHS, to
enable new scientific discovery and medical insights and to kick start the development of a
UK genomics industry.
The patient research forum (comprising of over 40 patients) established by the R&D
Department has supported 15 clinicians with research proposals and grant applications. This
integration has received extremely positive feedback from investigators and researchers and
underpins the Trust’s research strategy on engaging with patients and service users. The
forum meets six times a year and has developed supporting information and guidance to
inform patients about research.
The R&D Department has produced a research video to raise awareness and inform
patients on participating in clinical research at the Trust. The video will be displayed in
outpatients, wards and the Trust’s research web page.
The Trust continues to deliver an extensive programme of lunchtime training modules for all
staff and patient forum members to gain knowledge and experience of the different aspects
of clinical research, ranging from ethical submissions to safety reporting. External training
courses were also delivered by the NIHR to staff on ‘developing a research programme and
delivering commercial research. In addition the existing Trust good clinical practice courses
have taught 75 of staff members, this maximises learning opportunities and quality research.
Members of the R&D department support national committees including; R&D Research
Governance Manager has sat as member on the Health Research Authority non-commercial
clinical trial agreement working group and NHS R&D Forum Confidentiality Agreement
working group providing input into national templates to assist in removing barriers to setup
of clinical research studies within the NHS. The Health Service Research Manager supports
Patient and Public Involvement, sits on the AHSN committee for specific projects and works
closely with HRA on research ethics. The Trust also supports national training programmes
linked to pharmacists to become qualified persons (QP) and to date six pharmacists have
passed their QP exams.
The R&D department operates an intellectual property committee to identify and manage IP
generation, revenue sharing and exploitation of Trust innovations in collaboration with
Imperial Innovations Ltd. This supports the Government’s policy for Health Wealth and
Innovation.
The Trust has an excellent working relationship with the Collaboration for Leadership in
Applied Health Research and Care (CLAHRC) whose role is to embed research findings into
patient care. We have been successful in being identified as the “Outer London Hub” for
CLAHRC and will be leading on a heart failure programme spearheaded by Mark Dancy and
Itchy sneezy wheezy programme led by Prof. Mitch Blair. We are also in the process of
negotiating project led funding and have nine bids (the most across the sector) through to
the second round. We are very hopeful in securing additional funding from this exceptional
performance.
The R&D Department have also registered two logos on behalf of the Trust, the Q3P
supporting the pharmacy training programme and ERICE identifying quality in Education,
Research, Innovation and Clinical Excellence. We are in the process of badging quality
programmes under the banner of ERICE.
Quality Account 2014/15
83
Understanding cancer and rare diseases
Personalising medicine for patients is the long-term aim of the Government’s 100,000
Genomes Project. The hope is that the UK will be the first country in the world to sequence
100,000 whole human genomes to help diagnose and treat patients with rare or inherited
diseases and common cancers. As a partner in the North Thames Genomic Medicine
Centre, the Trust is a key player in the project.
Led locally by Dr Virginia Clowes, Consultant Clinical Geneticist and Stewart Payne, Head of
the Trust’s molecular genetics service, Dr Clowes explained: “Some patients react well to
one medicine and badly to another. By having a sequence of the patient’s genome, we could
more accurately prescribe medicines that will work.”
Stewart said: “When we talk about sequencing a genome, we are referring to the process by
which we take a small sample of blood, or tissue, from a patient and use specialist
equipment to sequence all 20,000 genes within that person’s body. We can examine the
resulting sequence of genes for unusual patterns which may identify the underlying cause of
the condition.
“Researchers have had access to specialist technology to sequence all of our genes for a
few years now. However, it has mainly been used for research and hasn’t been really
available as a diagnostic tool for patients. Here at the Trust, we are able to sequence 94
genes in one go, but the 100,000 Genome Project will allow all 20,000 to be analysed at
once.”
The 100,000 Genome Project is still in its early stages. The North Thames Genomic
Medicine Centre includes London North West Healthcare NHS Trust, Great Ormond Street
Hospital, Bart Health NHS Trust, Moorfields Eye Hospital, the Royal Free Hospital and
University College London Hospitals. The Trust will start recruiting patients with rare
diseases in September 2015 and the project will run until the end of 2017.
Patients eligible for recruitment will be asked to give consent and to provide blood and tissue
samples for genetic analysis. The hope is that in the not too distant future, analysing a
patient’s genome will become a routine test.
Patient and organisational impacts
The North West London Hospitals NHS Trust
The Research excellence awards winner this year was Dr Ajay Gupta and Dr Sushen
Bhattacharya on improving care quality for orthopaedic patients with fractured head to femur.
Which has drawn great interest across the Trust, CLAHRC and the CCG. The CCG has sent
this project as best practice to NHS England.
The Trust researchers have also been successful in obtaining the following grant awards;
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Mitch Blair obtain £7million Euro funding on MODELS OF CHILD HEALTH
APPRAISED (MOCHA) Which involves 11 countries, 19 partners
Chris Norton and Ailsa Hart obtaining a NIHR grant on incontinence in IBD patients
Patricia Kiilu has obtained the Roald Dahl Marvellous Children’s Charity award for
“Children and Adolescents Tele-health in Sickle Cell Disease”.
Trish Winn has received funding from the CCG’s to support changes to the patient
pathway for trips and falls across the primary/secondary care boundary.
Quality Account 2014/15
84
Ealing Hospitals NHS Trust
The London Life Sciences Prospective Population Study (LOLIPOP) programme sponsored
by the Trust has been one of the largest recruiting observational studies within the London
Northwest sector. This has now been extended until October 2015.
The Trust has successfully recruited 140 patients within six weeks into a high impact short
term study on alcohol misuse in the younger populations.
The Trust has also achieved high recruitment into the BADBIR, which is a dermatology study
looking at patient treatment. We were also the highest recruiter in November.
The R&D department has produced a research video with input from patient representatives
to raise awareness and inform patients on participating in clinical research at the Trust. The
video will be displayed in outpatients, wards and the Trust’s research web page.
The Trust has introduced a generic poster to display in outpatients and wards to highlight
research opportunities to patients / service users and how they can get involved. The Trust
celebrated the National Clinical Trials Day last year by introducing a Chocolate Study in the
main foyer to patients and staff to raise awareness of the importance of clinical trials and the
work the R&D department does.
Dr John Chambers has been awarded an EU grant to look at preventing diabetes in at risk
South Asian population. Subjects at higher risk of diabetes will be invited to take part in a
programme delivered by mobile telephone to change their lifestyles. The research will see
how effective this approach is in our local population and in related populations in India and
Pakistan.
The R&D department have also recruited a paediatric research nurse who will help support
studies into childhood diseases headed by Dr Colin Michie. This will open up research at the
Trust to this very important patient group.
Research & Development
The Research & Development department at the Trust is recognised as the North West hub
for the development of translational research to improve the quality of patient care.
Translational research is the moving of evidence based practice to sustained implementation
to give better outcomes to patients. The research uses quality improvement and lean
methodology to change organisational culture, improve processes and efficiency to develop
sustainable models of care with measurable outcomes.
The Trust has become an expert provider of this methodology working with clinical staff
within the Trust to deliver improved outcomes for patients and support the maximisation of
financial benefits through meeting best practice tariffs
This has led to the Trust delivering expert support to outside agencies such as North West of
England Advancing Quality Alliance (AQuA), presenting at international forums in the
Netherlands and more importantly developing funding streams for this research from the
National Institute for Research through CLAHRC and Academic Health Science Network
funding.
This has led to the Trust becoming an Outer London Quality & Research hub for North West
London.
Since 2013 the expert on translational research has been working with clinicians to align the
development of funded research quality improvement projects to the Trusts CQUIN
Schemes to maximise the financial benefits for the Trust.
Quality Account 2014/15
85
Registration with the Care Quality Commission (CQC)
The CQC is the independent regulator of health and adult social care in England. They
register, and therefore license providers of care services if they meet essential standards of
quality and safety. They monitor licensed organisations on a regular basis to ensure that
they continue to meet these standards.
London North West Healthcare NHS Trust is required to register with the Care Quality
Commission and its current registration status is ‘fully registered’ with no conditions. The
CQC has not taken enforcement action against the Trust or legacy Trusts during 2014/15.
To find out more about the CQC visit www.cqc.org.uk.
The Trust has not participated in any special reviews or investigations by the Care Quality
Commission during the reporting period.
CQC
In May 2014, the CQC made a routine inspection to the former North West London Hospitals
NHS Trust as part of their annual scheduled inspection programmes, to review the Trust’s
performance against the standards of quality and safety.
The Trust has developed compliance and quality improvement action plans; assurance is
presented to a quality assurance meeting chaired jointly by the clinical commissioners and
Trust Development Authority. Internal assurance occurs within the divisional governance
meetings and also the Trust Clinical Performance and Patient Experience Committee.
Northwick Park Hospital: overall ratings were:
Accident and emergency
Medical care
Surgery
Critical care
Maternity and family planning
Services for children and young people
End of life care
Outpatients
Requires improvement
Good
Requires improvement
Inadequate
Requires improvement
Requires improvement
Good
Requires improvement
St Mark’s Hospital: overall ratings were:
Medical care
Surgery
Outpatients
Requires improvement
Requires improvement
Requires improvement
Central Middlesex Hospital: overall ratings were:
Accident and emergency
Medical care
Surgery
Critical care
Services for children and young people
End of life care
Outpatients
Quality Account 2014/15
Good
Good
Good
Requires improvement
Requires improvement
Good
Good
86
Who has been involved in the development of this Quality
Account?
The Quality Account has been developed with input from different staff groups in the Trust.
The Trust has shared this document with key stakeholders. These included:
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Ealing, Brent and Harrow Clinical Commissioning Groups (CCGs)
Ealing, Brent and Harrow Overview and Scrutiny Committees
Harrow, Brent and Ealing Healthwatch
Trust Development Authority
London North West Healthcare NHS Trust - Trust Board
Staff, across acute and community services.
External Auditor - Grant Thornton
Feedback was sought from the above stakeholders; some feedback was received directly,
some indirectly. The Trust welcomes any further feedback to this account. Details on how to
give feedback are provided at the end of this document.
Statements from our partners
The Trust has received formal feedback from some of its key stakeholders, as documented
below. The Trust will ensure that we work to address the comments and issues highlighted.
The initial consultation period for first draft of this Quality Account commenced for 30 days
from May 2014. Following on from this period of consultation a number of amendments have
been made to the document. The majority of these were minor textual changes to improve
readability and the correction of some typographical and presentational errors, a number
have been in response to feedback from stakeholders. For changes of a significant nature
these are listed in the table below.
Description of Change
Process for monitoring and reporting achievement against the
priorities
National quality indicator values and actions
2014/15 CQUIN achievement
2015/16 CQUIN schemes
Who has been involved in the development of this account
Priorities for improvement in 2015/16
List of Abbreviations
Quality Account 2014/15
Nature of Change
Addition
Updated
Updated
Updated
Updated
Updated
Addition
87
Independent Auditor's Limited Assurance Report to the Directors of London North
West Healthcare NHS Trust on the Annual Quality Account
We are required to perform an independent assurance engagement in respect of London
North West Healthcare NHS Trust’s Quality Account for the year ended 31 March 2015 (“the
Quality Account”) and certain performance indicators contained therein as part of our work.
NHS trusts are required by section 8 of the Health Act 2009 to publish a quality account
which must include prescribed information set out in The National Health Service (Quality
Account) Regulations 2010, the National Health Service (Quality Account) Amendment
Regulations 2011 and the National Health Service (Quality Account) Amendment
Regulations 2012 (“the Regulations”).
Scope and subject matter
The indicators for the year ended 31 March 2015 subject to limited assurance consist of the
following indicators:
 Percentage of patients risk-assessed for venous thromboembolism (VTE)
 Rate of clostridium difficile infections
We refer to these two indicators collectively as “the indicators”.
Respective responsibilities of directors and auditors
The directors are required under the Health Act 2009 to prepare a Quality Account for each
financial year. The Department of Health has issued guidance on the form and content of
annual Quality Accounts (which incorporates the legal requirements in the Health Act 2009
and the Regulations).
In preparing the Quality Account, the directors are required to take steps to satisfy
themselves that:
 the Quality Account presents a balanced picture of the Trust’s performance over the
period covered;
 the performance information reported in the Quality Account is reliable and accurate;
 there are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Account, and these controls are subject to
review to confirm that they are working effectively in practice;
 the data underpinning the measures of performance reported in the Quality Account
is robust and reliable, conforms to specified data quality standards and prescribed
definitions, and is subject to appropriate scrutiny and review; and
 the Quality Account has been prepared in accordance with Department of Health
guidance.
The Directors are required to confirm compliance with these requirements in a statement of
directors’ responsibilities within the Quality Account. Our responsibility is to form a
conclusion, based on limited assurance procedures, on whether anything has come to our
attention that causes us to believe that:
 the Quality Account is not prepared in all material respects in line with the criteria set
out in the Regulations;
 the Quality Account is not consistent in all material respects with the sources
specified in the NHS Quality Accounts Auditor Guidance 2014-15 issued by DH in
March 2015 (“the Guidance”); and
 the indicators in the Quality Account identified as having been the subject of limited
assurance in the Quality Account are not reasonably stated in all material respects in
accordance with the Regulations and the six dimensions of data quality set out in the
Guidance.
Quality Account 2014/15
88
We read the Quality Account and conclude whether it is consistent with the requirements of
the Regulations and to consider the implications for our report if we become aware of any
material omissions.
We read the other information contained in the Quality Account and consider whether it is
materially inconsistent with:
 Board minutes for the period April 2014 to June 2015;
 papers relating to quality reported to the Board over the period April 2014 to June
2015;
 feedback from the Commissioners dated 12/06/2015;
 feedback from Local Healthwatch dated 23/06/2015 and 24/06/2015;
 the Trust’s complaints reports published under regulation 18 of the Local Authority,
Social Services and NHS Complaints (England) Regulations 2009, dated 30/07/2014
and 31/07/2014;
 feedback from other named stakeholders involved in the sign off of the Quality
Account;
 the 2014 national patient survey;
 the 2014 national staff survey;
 the Head of Internal Audit’s annual opinion over the trust’s control environment dated
May 2015;
 the annual governance statement dated 03/06/2015;
 the Care Quality Commission’s Intelligent Monitoring Report dated May 2015;
 the results of the Payment by Results coding review dated February 2015; and
 the Trust's draft complaints report for 2014/15 to be published under regulation 28 of
the Local Authority, Social Services and NHS Complaints (England) Regulations
2009.
We consider the implications for our report if we become aware of any apparent
misstatements or material inconsistencies with these documents (collectively the
documents”). Our responsibilities do not extend to any other information.
This report, including the conclusion, is made solely to the Board of Directors of London
North West Healthcare NHS Trust.
We permit the disclosure of this report to enable the Board of Directors to demonstrate that
they have discharged their governance responsibilities by commissioning an independent
assurance report in connection with the indicators. To the fullest extent permissible by law,
we do not accept or assume responsibility to anyone other than the Board of Directors as a
body and London North West Healthcare NHS Trust for our work or this report save where
terms are expressly agreed and with our prior consent in writing.
Assurance work performed
We conducted this limited assurance engagement under the terms of the guidance. Our
limited assurance procedures included:
 evaluating the design and implementation of the key processes and controls for
managing and reporting the indicators;
 making enquiries of management;
 testing key management controls;
 analytical procedures;
 limited testing, on a selective basis, of the data used to calculate the indicator back to
supporting documentation;
 comparing the content of the Quality Account to the requirements of the Regulations;
and
 reading the documents.
Quality Account 2014/15
89
A limited assurance engagement is narrower in scope than a reasonable assurance
engagement. The nature, timing and extent of procedures for gathering sufficient appropriate
evidence are deliberately limited relative to a reasonable assurance engagement.
Limitations
Non-financial performance information is subject to more inherent limitations than financial
information, given the characteristics of the subject matter and the methods used for
determining such information.
The absence of a significant body of established practice on which to draw allows for the
selection of different but acceptable measurement techniques which can result in materially
different measurements and can impact comparability. The precision of different
measurement techniques may also vary. Furthermore, the nature and methods used to
determine such information, as well as the measurement criteria and the precision thereof,
may change over time. It is important to read the Quality Account in the context of the criteria
set out in the Regulations.
The nature, form and content required of Quality Accounts are determined by the
Department of Health. This may result in the omission of information relevant to other users,
for example for the purpose of comparing the results of different NHS organisations.
In addition, the scope of our assurance work has not included governance over quality or
non-mandated indicators which have been determined locally by London North West
Healthcare NHS Trust.
Basis for qualified conclusion
The indicator reporting the percentage of patients risk-assessed for VTE did not meet the six
dimensions of data quality in the following respects:
 Accuracy and Validity: In our sample testing we were unable to agree nine cases out of
25 to a signed and completed VTE risk assessment form in the patient records. The
absence of this source documentation meant that we were unable to confirm that the risk
assessment had taken place.
Qualified conclusion
Based on the results of our procedures, with the exception of the matter reported in the basis
for qualified conclusion paragraph above, nothing has come to our attention that causes us
to believe that, for the year ended 31 March 2015:
 the Quality Account is not prepared in all material respects in line with the criteria set
out in the Regulations;
 the Quality Account is not consistent in all material respects with the sources
specified in the Guidance; and
 the indicators in the Quality Account subject to limited assurance have not been
reasonably stated in all material respects in accordance with the Regulations and the
six dimensions of data quality set out in the Guidance.
Grant Thornton UK LLP
Grant Thornton House
Melton Street
London
NW1 2EP
Date: 29 June 2015
Quality Account 2014/15
90
London Borough of Ealing Health and Adult Social Services Standing Scrutiny
Panel Response to London North West Healthcare NHS Trust Quality Account
2014/15
The Ealing Health and Adult Social Services Standing Scrutiny Panel welcomes this
opportunity to comment on the services provided by the London North West Healthcare
NHS Trust, based on our experiences in 2014/15.
The Trust has attended a number of Scrutiny Panel meetings and provided information
when requested. In June 2014 the Panel received an update on the ‘Stronger Together’
merger process between Ealing NHS Trust and North West London Hospital NHS Trust
and in July received the business case prior to it being submitted it to the Trust
Development Authority. The Panel also considered a presentation from the Trust on the
provision of epilepsy services at Ealing Hospital.
The Panel was concerned that the Care Quality Commission Inspection in May 2014
gave the Trust an overall rating of ‘Requires Improvement’. In December, the Trust
attended a Panel meeting to set out the progress it had made against the Compliance
Improvement Action Plan, which had been developed in response to the results of the
CQC inspection. Members had some concerns that the situations highlighted by the
CQC were not just ‘one off’ situations but could be seen as a reflection of common
practice. The Panel was assured that the Trust management had a clear ‘vision’ for
improving services, that policies were being tightened up and refreshed, and that the
actions arising from the Compliance Improvement Action Plan were being met.
The Panel was also concerned to note that the Trust was under-bedded and is pleased
to see the actions set out in the Quality Account to improve capacity. The Panel will
scrutinise progress against this issue and the completion of the CQC compliance action
plan during 2015/16.
Members were disappointed that over the winter period Northwick Park Hospital was
one of the worst performing hospitals in England against the emergency care targets.
The Panel is pleased to note that one of the Trust’s Quality Priorities is to improve the
emergency care pathway by reducing the time patients have to wait to be seen, reducing
the number of London Ambulance Service breaches, and improving the discharge
process.
The Panel notes that Referral to Treatment performance has been challenging for the
Trust and will be interested in the Trust’s progress in meeting its targets in 2015/16.
The Panel commends the Trust for its work on identifying learning from complaints and
PALSs and sharing good practice. We were also impressed with the Trust for
responding to 92% of its complaints within the timeframe agreed with the complainant.
The Panel looks forward to continuing to work with the London North West Healthcare
NHS Trust in 2015/16.
Quality Account 2014/15
91
Healthwatch Ealing Comment on LNWHT Quality Account 2014-15
We need to state the quality account was not sent directly to us , in the future we
would expect the Trust to ensure we receive them in good time to reflect and
comment on the account
Overall it is good see the work the Trust in undertaking to improve services for
people in North West London , we would want to give the following comments :Improvement initiatives
We are pleased to see there a range of initiatives to support the improvement in
quality and patient experience. From a Healthwatch point of view we would like to
see the evidence of patient and carer involvement from the start and embedded in
any improvement initiatives
Patient experience
Based on feedback to us on Ealing Hospital local people continue to raise concerns
about staff attitude and engagement with patients and carers. They do not feel
listened to and understood by medical staff, there is a lack of care and compassion.
There is also a theme about communication between the Trust and patients and
carers in terms of letters, inaccurate records, lack of clarity on follow up post a
hospital stay
In our view, the points above will impact on quality of patient and carer engagement
within the co-production principles. We wish to see ongoing evidence of public,
patient and carers involvement in driving change in improving patient and carer
experience the coming years
Environment
Based on feedback from the public and our involvement in PLACE assessments at
Ealing hospital in particular, we would want to see consistent improvement in the
cleanliness, signage for navigating the site and the overall decorative state of the
hospital.
As Healthwatch Ealing we would welcome the opportunity to follow up with the Trust,
on the points we raised in the coming year
Suzanne Lyn-Cook
Director
Quality Account 2014/15
92
24th June 2015
Carole Flowers
Interim Head of Governance
London North West Healthcare NHS Trust
Re: LNWH Quality Accounts 2014/15
Dear Carole
Thank you for inviting Healthwatch Harrow to make a response to your 2014/15
quality accounts.
We are pleased to note the role Quality Account report plays in making sure that
London North West Healthcare NHS Trust (LNWH Trust) is focused at continually
assessing the quality of its provision and outcomes for the patients and communities
it serves. We also welcome LNWH transparency and willingness to share this
document and seek related opportunities to engage and learn from feedback from
key stakeholders. We welcome this commitment to engage with our local
communities and ensuring that the Trust is accountable to patients and the public
about the quality of service they provide.
We have given your Quality Account Report careful consideration and are impressed
by the scope and quality of its coverage, clarity and accessibility. We are pleased
that the Trust has identified key priority areas for improving quality which include the
findings and recommendations of the recent CQC report. We are also pleased that
the report has moved along and is addressing current issues as well as those which
have been a course for wider community concern and interest such as the pressures
on Accident and Emergency services.
We are pleased to record that we can see significant progress being made in terms
of both the Trust’s ambition and commitment in continually improving the
responsiveness and quality of its services. We can see clear linkages in the Trust’s
Quality Account report and the developments and improvement planning around
priority areas such as A&E and patient experience. The latter is evidenced by the
data collection, analysis of patient feedback and complaints. It is pleasing to see the
Trust place a priority in understanding and addressing the recent relative increase in
complaints overall and particularly of Harrow Services.
We are also pleased to note the follow up action planning aimed addressing these
complaints and the Trust’s approach in identifying practical interventions aimed at
improving patient experience. These include tangible outcomes such as reliving
pressures on car parking, improving quality of food and menus, upgrading bathroom
facilities, increase in provisions of televisions in ward areas etc. Healthwatch Harrow
has emphasized this process element because most of all our feedback from
residents and patients suggest that staff attitude and general environment including
clinical services play a significant part in shaping and influencing patient experience
and dignity.
Quality Account 2014/15
93
A further positive development includes the strengthening of relationships between
Healthwatch Harrow and the Trust by setting up strategic relationship building
meetings with the senior leadership management of the Trust followed by
establishing a lead link senior manager. This has provided Healthwatch Harrow with
a further opportunity to learn in more detail about the Trust’s work and provide critical
challenge where appropriate. It is pleasing to note that there is consistency in the
senior leaderships overall strategic aspirations with the operational objectives and
outcomes sought in the Trust’s Quality Accounts report – a positive element in
ensuring that the Trust’s vision strategy and operational plans are consistent and
complimentary.
Healthwatch Harrow has also been impressed with the determination and ambition of
its in moving forward and addressing areas which need improvement as well as
having high ambitions for the community it serves.
We look forward to this continued improvement and the role we may play as a critical
friend and consumer champion in working in partnership with the Trust.
Yours sincerely
Arvind Sharma
Independent Chairman
Healthwatch Harrow
Quality Account 2014/15
94
12 th June 2015
By Email Only
Jacqueline Docherty, DBE
Chief Executive
London North West Healthcare NHS Trust (LNWHT)
Northwick Park Hospital
Watford Road
Harrow
Middlesex, HA1 3UJ
Executive Office
Wembley Centre for Health & Care
116 Chaplin Road
Wembley
Middlesex HA0 4UZ
Tel: 020 8900 5367
Fax: 020 8900 5301
Email: sarah.mansuralli@nhs.net
www.brentccg.nhs.uk
Dear Jacqueline,
London North West Hospitals Trust Acute &Community Quality Account 2014/15
Please find below the Lead Commissioner statement in relation to the 2014/15 Quality
Account submitted.
Brent Harrow and Hillingdon collaboration of CCG’s welcomes the opportunity to provide this
statement on London North West Hospitals Trust Quality Accounts. We confirm that we have
reviewed the information contained within the Account and checked this against data sources
where this is available to us as part of existing contract/ performance monitoring discussions,
and is accurate in relation to the services provided.
This Account has been reviewed within Brent Harrow & Hillingdon CCGs and by colleagues in
the CWHHE Collaborative of Clinical Commissioning Groups.
We have reviewed the content of the Quality Account and confirm that this complies with the
prescribed information, form and content as set out by the Department of Health. We believe
that the Account represents a summary of the overview of the quality of care at the Trust for
the services covered in the report. We have discussed the development of this Quality
Account with the Trust over the year and have been able to contribute our views on
consultation and content during this time. However, in our experience some of the committees
that overview quality, could become more robust and the data and information the trust
provides could be more extensive.
We would like to commend the trust on the development of this Quality account which now
covers the breadth of services in London North West Hospitals Acute and Community
Chair: Dr Etheldreda Kong
Chief Officer: Rob Larkman
Chief Operating Officer: Sarah Mansuralli
Quality Account 2014/15
95
services. We acknowledge the challenges identifies during the merging of the two trusts last
autumn. The areas of practice which we wish to acknowledge include; The Ambulatory Care
Centre, STARRS team and the Diabetes teams. These services have supported the CCGs to
improve patient outcomes and prevent unnecessary admissions. The stroke services at the
trust also provide outstanding patient outcomes as was noted by the recent audit of the
service by external auditors.
We are encouraged by the inclusion and highlighting of specific challenges in the document
and feel that in addition to these the trust could specify the recruitment issues within
community nursing services and other areas such as maternity consultant recruitment. These
will continue to impact on high quality service delivery. It would also be realistic to
acknowledge other service delivery challenges in Maternity.
The quality Account aspires to involve the patients and the public as much as possible and it
would be beneficial to have expanded on how the trust intends to improve on engaging hard
to reach populations and also persons with learning disabilities.
It would also be useful for the public if the Quality Account final version is devoid of
abbreviations and jargon and that all data omissions are added
We acknowledge the Care Quality Commission have undertaken their review this year and
the compliance action plan which followed, some of which is partially completed.
We have taken particular account of the identified priorities for improvement for the Trust and
how this work will enable real focus on improving the quality and safety of patients.
The three major priorities carried over from 2014/15 (reducing harm, improving patient
experience and developing the emergency care pathway) are set out clearly, but information
on the other priorities flagged up in the introduction (cancer, frail elderly patients, out patients,
theatre capacity and Central Middlesex Hospital) is not so clearly identified.
To conclude we welcome the vision and aspiration described within the Quality Account,
agree on the priority areas and will continue to work with the Trust to continually improve the
quality of services provided to patients.
There is much to celebrate and commend and some excellent innovative practice and also a
great deal of reflection and this will hopefully support improvements going forward.
We look forward to receiving the final version which will include an easy read format.
Yours sincerely,
Sarah Mansuralli
Chief Operating Officer
cc
Jonathan Webster, Director of Quality, Nursing and Patient Safety, CWHHE CCGs Carole
Mattock Interim, Director of Nursing and Patient Safety, BHH Federation of CCGs Javina
Sehgal, Chief Operating Officer, Harrow CCG
Quality Account 2014/15
96
List of Abbreviations
A&E
ACAD
AECU
AMU
AQuA
BADBIR
BRCA
BSCN
BTS
CCG
CEM
CEO
CHD
CIP
CLAHRC
CMP
CMR
COPD
CPAU
CQC
CQUIN
CRM
CSCNS
CT
CT2
DAHNO
DNA
DoLS
DTOC
DVT
ECG
ECHO
ED
EDD
EICO
ERICE
FAIR
FFFAP
FFT
FY1
FY2
GAS
GP
Accident & Emergency
Ambulatory Care and Diagnostic centre
ambulatory emergency care unit
Acute Medical Unit
Advancing Quality Alliance
British Association of Dermatologist’s Biological Interventions Register
National Breast Cancer Audit
British Society for Clinical Neurophysiology
British Thoracic Society
Clinical Commissioning Groups
College of Emergency Medicine
Chief Executive Officer
Congenital heart disease
Cost Improvement Plans
Collaboration for Leadership in Applied Health Research and Care
Case Mix Programme
Cardiovascular Magnetic Resonance
Chronic Obstructive Pulmonary Disease
Chest Pain Assessment Unit
Care Quality Commission
Commissioning for Quality and Innovation
Cardiac Rhythm Management
Community Specialist Children Nursing Service
Computed Tomography
Core Medical Trainee Year 2
Data for Head and Neck oncology
Did Not Attend
Deprivation of Liberty Safeguards
Delayed Transfer of Care
Deep Vein Thrombosis
Electrocardiogram
Echocardiogram
Emergency Department
Estimated Discharge Date
Ealing Integrated Care Organisation
Education, Research, Innovation and Clinical Excellence
Find, Assess, Investigate and Refer
Falls and Fragility Fractures Audit Programme
Friends and Family Test
Foundation Year 1 (medical training)
Foundation Year 2
Goal Attainment Scores
General Practitioner
Quality Account 2014/15
97
HCAI
HES
HMB
HPV
HSCIC
IBD
ICE
iHV
IMT
IRP
KPI
LAS
LNWHT
LOLIPOP
LVEF
MBRRACEUK
MCAP
MDT
MHI
MINAP
MOCHA
MRSA
NAOGC
NBOCAP
NCAA
NCEPOD
NCISH
NDIA
NELA
NEWS
NHFD
NHS
NICE
NIHR
NIV
NJR
NLCA
NOF
NPDA
NPH
NPSA
PALS
PBM
PE
Healthcare-acquired infections
Hospital Episode Statistics
Heavy Menstrual Bleeding
Human Papilloma Virus
Health & Social Care Information Centre
Inflammatory Bowel Disease
Intermediate Care Ealing
Institute of Health Visiting
Information Management Technology
Independent Reconfiguration Panel
Key Performance Indicator
London Ambulance Service
London North West Healthcare NHS Trust
London Life Sciences Prospective Population Study
Left Ventricular Ejection Fraction
Mothers and Babies: Reducing Risk through Audit and Confidential
Enquiries across the UK
Managed Care Appropriateness Protocol
Multi-disciplinary Team
McKinsey Hospital Institute
Myocardial Infarction National Audit Project
Models of Child Health Appraised
Methiciliin-Resistant Staphylococcus Aureus
National Oesophago-Gastric Cancer Audit
National Bowel Cancer Audit Project
National Cardiac Arrest Audit
National Confidential Enquiries into Perioperative Deaths
National Confidential Inquiry into Suicide and Homicide
National Diabetes Inpatient Audit
National Emergency Laparotomy Audit
National Early Warning System
National Hip Fracture Database
National Health Service
National Institute for Clinical Excellence
National Institute for Health Research
Non-Invasive Ventilation
National Joint Registry
National Lung Cancer Audit
Neck of Femur
National Paediatric Diabetes Audit
Northwick Park Hospital
National Patient Safety Agency
Patient Advice and Liaison Service
Patient Blood Management
Pulmonary embolism
Quality Account 2014/15
98
PEWS
PHSO
PICANet
PICC
PLACE
PND
POMH
PROMS
PTL
R&D
RTT
SaHF
SBAR
SCBU
SCPT
SHMI
SOAP
SpR
SSNAP
STARRS
TARN
TB
UCC
UTI
VTE
WTE
Paediatric Early Warning System
Parliamentary and Health Service Ombudsman
Paediatric Intensive Care Audit Network
peripherally inserted central catheter
Patient Led Assessment of Care Environment
Post-natal Depression
Prescribing Observatory for Mental Health
Patient Reported Outcome Measures
Patient Tracking List
Research & Development
Referral To Treatment
Shaping a Healthier Future
situation, background, assessment, recommendation
Special Care Baby Unit
specialist community practice teacher
Summary Hospital Mortality Indicator
subjective, objective, assessment and plan
Specialty Registrar
Sentinel Stroke National Audit Programme
Short Term Assessment, Rehabilitation and Reablement Services
Trauma Audit & Research Network
Tuberculosis
Urgent Care Centre
Urinary tract infection
Venous Thromboembolism
Whole Time Equivalent
Quality Account 2014/15
99