South Tyneside NHS Foundation
Trust
“Choose High Quality Care”
Our Quality Report
2014/15
1
1:
Statement from the Chief Executive
QUALITY REPORT
Part 1 – Chief Executive’s Statement
This year we have produced our sixth annual Quality Report which provides a
summary of our performance against a number of quality measures for 2014/15 and
our quality priorities for 2015/16. We continue to ensure that patient safety and
quality of care is at the forefront of our work. In 2014-15 we had several successful
inspections and accreditations of achievements at service and organisational level.
To help us with this we have selected challenging targets for the year ahead. We will
also report here on the progress we have made in the past twelve months against
the priorities we set ourselves in our last report.
Rates of hospital acquired infection and the performance of hospital A&E
departments are measures that are frequently in the public eye. Once again we have
performed at the highest level nationally in infection control, with only 1 case of
MRSA bacteraemia and 9 cases of Clostridium Difficile in the year. From November,
2014, through to March, 2015, like many other NHS Foundation Trusts, we
experienced significant pressures in the A&E Department, extending throughout the
hospital. Consequently, we failed to maintain the A&E performance above the target
of 95% for the year, achieving just below 92% for the year.
We successfully rolled out the Patient Friends and Family test from ward areas to
Outpatient Departments and Community settings and our results were consistently
high throughout the year, scoring 4.7 out of a possible 5.
From a service perspective we were successful in being awarded a tender by South
Tyneside Local Authority for the development of an Integrated Care Hub, working in
partnership with Age UK, which will provide an 80-bedded unit operating with four
different levels of care, from day attenders through to long-stay care for dementia
patients. This is an exciting opportunity for the Trust and the new unit will open its
doors in the Spring of 2016.
Our commitment to employing talented, caring staff, alongside effective leadership
from the Board and a culture of continuous improvement in safety will ensure that we
will continue to provide the best services for our patients.
There are a number of inherent limitations in the preparation of Quality Accounts
which may impact the reliability or accuracy of the data reported. These include:
•
Data is derived from a large number of different systems and processes. Only
some of these are subject to external assurance, or included in internal audits
programme of work each year.
•
Data is collected by a large number of teams across the Trust alongside their
main responsibilities, which may lead to differences in how policies are
applied or interpreted. In many cases, data reported reflects clinical
judgement about individual cases, where another clinician might have
reasonably have classified a case differently.
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•
National data definitions do not necessarily cover all circumstances, and local
interpretations may differ.
•
Data collection practices and data definitions are evolving, which may lead to
differences over time, both within and between years. The volume of data
means that, where changes are made, it is usually not practical to reanalyse
historic data.
We have sought to take all reasonable steps and exercise appropriate due diligence
to ensure the accuracy of the data reported, but recognise that it is nonetheless
subject to the inherent limitations noted above. Following these steps, to my
knowledge, the information in the document is accurate with the exception of the
matters identified in respect of the 18 week referral to treatment incomplete pathway
indicator as described on page 178.
Lorraine B Lambert
Chief Executive
Date: 21 May 2015
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2:
Priorities for Improvement and Statements of Assurance from the Board
Foundation Trusts are required to publish quality accounts each year, as set out in
National Health Service (Quality Accounts) Regulations 2010 and National Health
Service (Quality Accounts) Amendment Regulations 2012. The quality report must be
included as part of the Trust’s annual report. In addition the report must be prepared in
accordance with annual reporting guidance provided by Monitor and the Department of
Health. Much of the text in the report is therefore both prescribed and mandatory.
In our 2013/14 Quality Report we explained the areas where we would focus attention
on quality improvements during 2014/15. Part 2 of this report highlights our
performance against the indicators we selected and sets out our priorities for 2015-16.
We will also provide statements of assurance from our Board of Directors and
commentary from a range of stakeholders.
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2.1
Progress Made Since Publication of the 2013/14 Quality Report
Our Patient Safety Priorities for 2014-15
Priority 1 Resourcing: Ensure optimum staffing capacity and capability
Rationale for Inclusion:
There is a nationally accepted and growing body of evidence that patient outcomes
are linked to whether are not organisations have the right people, with the right
skills, in the right place at the right time. Following the publication of the of the
report of the Mid-Staffordshire NHS Foundation Trust Public Inquiry and the Keogh
Reviews into 14 Trusts with higher than expected mortality levels, the importance
of NHS Trusts making the right decisions with regard to safe staffing levels is
coming under increasing scrutiny.
Target 2014/15:
We will implement standard processes including across the Trust to ensure
visibility of safe, consistent staffing levels.
Our Progress:
From June 2014 NHS Trusts have been required to report monthly staffing
information, by ward and team, publishing board papers on the Trust website.
There is also a requirement for six monthly staffing reviews using evidence based
tools to be presented to a public Board meeting every six months.
a) Implement a staff allocation system to match staff levels and experience
to need, proactively and flexibly.
Throughout 2014/15 there has been a continuation of the phased roll out of
eRostering, completing inpatient services and specialist departments, and rolling
out to community services. Work continues with teams to ensure the production of
effective rotas. Key performance indicators have been produced for clinical
operational managers to drive improvement and to encourage a more standard
approach to rota production across all teams. These changes have facilitated the
national requirement to report staffing fill rates, comparing planned with actual
levels on both day and night duty.
Positive benefits continue to be the transparency of staffing levels across all the
wards and teams with the opportunity for managers to sign off effective rotas while
highlighting and addressing poor practice with rota makers in a timely fashion.
b) Invest in sufficient levels of appropriately trained staff to deliver safe
patient care
In June 2013 the Board of Directors agreed an investment of £1.8 million in nursing
staff to meet the staffing recommendations from the acute bed base review. This
second phase of this investment was released from reserves in August 2014 to
enable the completion of the recruitment process.
c) Prioritise resources to ensure an appropriate supporting infrastructure
and ring fence or invest in dedicated safety resources to drive projects in
order to help frontline staff to deliver safe patient care
The Executive Director of Nursing and Patient Safety made a decision to use the
Safer Care Nursing Tool (SCNT) to underpin our second staffing establishment
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review in September 2014. This methodology is very different from that used in the
Trust 2013 Staffing Review which was based on bed numbers. The SCNT is an
evidence based tool that enables nurses to assess patient acuity and dependency,
incorporating a staffing multiplier to ensure that nursing establishments reflect
patient needs. The SCNT is also an accredited staffing toolkit in alignment with
NICE guidance for Safer Staffing in Adult Inpatient Areas. We are working to utilise
the 6-monthly establishment analysis using the SNCT to inform the e-roster
baseline and as a result of this the ward establishment. While the £1.8m
investment is in budget lines we continue to have a significant vacancy gap and
board has approved a plan to recruit from a wider catchment area nationally and
internationally. Our revised recruitment plan commences in June with a weekend
open day.
The analysis from data collected on every patient in South Tyneside District
General and Primrose Hospitals, along with St Benedict’s Hospice during
September 2014, indicated variation in registered nurse numbers across three
shifts, and disparity in patient acuity and dependency compared with budgeted and
actual establishments across wards. A second audit cycle was completed in March
2015 on the same wards using the same methodology. Analysis of this latest
dataset will be reviewed alongside the September data and reported to the Board
of Directors in June 2015 with any recommendations that the reviews suggest.
The use of the SCNT to review our nursing establishment will be refined over future
audit cycles which will take place twice per year in September and March. A key
strand of work will be to triangulate the data collected in terms of safety, quality and
experience indicators such as patient harms, staff and patient experience and “red
flags”, to better understand what safe staffing looks like on all our wards and teams
and identify areas for new or shifting investment or a different staffing model. NHS
England has recently published further guidance, “Safer Staffing: A Guide to Care
Contact Time (November 2014),” which focuses on the “value added” work of front
line nurses and carers with a view to maximising these aspects of their work, while
providing support for others, which will help drive improvements in care through
ward led modifications in practice. Some of the examples of good practice
described within the guidance will also be important to understand and may help
reshape how ward teams deliver care.
Priority 2 Leadership: Create a positive patient safety culture
Rationale for Inclusion:
Understanding the patient safety culture in the organisation helps to improve
patient safety and outcomes as every member of staff in the Trust has a role to
play in keeping patients safe and providing high quality care. Evidence suggests
that organisations with a positive safety culture have open communication, a
shared importance about patient safety and managing risk and staff feel supported
in their work.
Target 2014/15:
We will roll out cultural assessment across the trust at team level and above. This
will allow the patient safety team to examine the variation in culture between teams
and target those in need of intensive support and coaching to improve team
motivation.
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Our Progress:
South Tyneside NHS Foundation Trust (STFT) has made further progress to
reinforce our organisational leadership from what was already a strong position in
2013/14. In 2014 our Trust was named as one of the best places to work in the
NHS in England. HSJ’s Best Places to Work, in association with NHS Employers,
is a celebration of the 100 best employers in the health service. To compile the list,
NHS staff survey findings were used to analyse each organisation across seven
core areas: leadership and planning; corporate culture and communications; role
satisfaction; work environment; relationship with supervisor; training and
development and employee engagement and satisfaction. It is especially pleasing
to achieve this acknowledgement in a time of increasing national and local
pressures, both financial and reputational, knowing that working in the NHS has
never been tougher than it is now. Locally, we have faced some difficult
challenges, as have many NHS organisations and it is, therefore, extremely
pleasing and reassuring that, despite those difficulties, our staff, who demonstrate
enthusiasm, compassion and friendliness each and every day, remain positive
about us as an employer.
In January 2014 the “Choose to Lead” leadership strategy was approved by the
Board of Directors and continues to be embedded across the Trust. The strategy
encompasses national strategies and principles aligning these to STFT’s unique
character and culture. This distinctiveness is embodied in our approach to
leadership based on the belief that leadership is not restricted to staff in designated
management or leadership roles, but where leadership behaviours are expected
from everyone in the organisation. This model can be described as shared or
distributed leadership and recognises that everyone contributes to the
organisation’s success. Mandatory training in leadership is being rolled out for all
staff groups, a significant undertaking, which demonstrates the commitment of the
organisation to develop its overall leadership capacity.
In early 2015 a team cultural assessment tool was launched to give us further
intelligence on the culture of our organisation by team. This will add depth to the
intelligence we collected as part of the organisation cultural assessment
undertaken in 2013 and can be triangulated with a range of safety, quality and
experience indicators to give organisational assurance on the quality of care we
give to our patients. The cultural assessment was completed in April and will report
to board in June to include a plan for utilising the findings as part of service level
development plans.
“Hello my name is…” is a national campaign instigated by Dr Kate Granger a
consultant in elderly medicine in Yorkshire who has terminal cancer. Dr Granger
started this campaign on Twitter, the social media platform, after she became
frustrated with the number of staff who failed to introduce themselves to her when
she was in hospital. She describes this simple courtesy as 'the first rung on the
ladder to providing compassionate care' and as the start of making a vital human
connection, helping patients to relax, and building trust. South Tyneside NHS
Foundation Trust pledged its backing in 2014 to 'Hello my name is...', as an
important strand of enhancing our positive patient safety culture, by simply
reminding staff to go back to basics and properly introduce themselves to patients.
In February 2015 the Trust reaffirmed our commitment to the movement with a
formal launch of the campaign led by the Trust Chairman and Chief Executive
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Officer. This level of leadership commitment is essential in signalling the
importance to all staff of acting on what we know; that the smallest things can often
make the biggest difference to how our patients and their families experience their
care. Staff have embraced the campaign which has now gathered huge
momentum right across the Trust.
Priority 3 Safety Metrics: Deliver Open and Honest Care
Rationale for Inclusion:
The development of Trust-wide safety metrics is a key tenet of the patient safety
culture and has now been successfully achieved. The Trust first delivered the data
required by the classic safety thermometer in August 2012 and has been taking
part in Choose Safer Care (nationally known as Open and Honest Care) since
October 2012; we are only Trust in the North East to participate. The Patient
Safety Team has further refined the Trust’s suite of patient safety metrics during
2013/14 and identified a core set of metrics available for all wards/clinical
teams/clinical departments in the Trust.
Target 2014/15:
• We will implement competency frameworks for staff which include measures for
attitude and behaviour which will also form the cornerstone of evidence that
nurses will need to have in order to be revalidated, and therefore registered, from
2015.
• We will continue and expand the medicines safety thermometer across the Trust.
Our Progress:
The Classic Safety Thermometer has been a national requirement since 2012
reporting on four harms: pressure ulcer, falls, catheter associated urinary tract
infection and venous thrombosis. Thirty one clinical teams are surveyed each
month which represents approximately 1600 patients.
The Maternity Safety Thermometer data collection commenced in August 2014
with information from ward 22 and delivery suite.
The maternity safety
thermometer measures harms from:
•
•
•
•
•
•
Perennial and /or abdominal trauma.
Post-partum haemorrhage
Infection
Babies with an Apgar score of less than five at seven minutes
Those admitted to a neo natal unit
Psychology safety: 4 questions related to mothers being separated from
their babies.
Twenty four patients have been surveyed so far with an average of 5 per month.
In 2013 the Trust became involved in the national pilot developing a medicines
safety thermometer collecting data in three clinical areas. The pilot stage is now
complete and there is an expectation that NHS Trusts will roll this out across acute
and community services. From November 2014 in STFT there has been a planned
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rollout of the initiative across a number of clinical teams with only three ward areas
now outstanding: these wards will be joining the data collection in May. Our district
nursing teams have also been recruited with the intermediate care teams next to
join. The medicines management team have developed guidance an intranet
information page to help support the teams deliver the medicines safety
thermometer.
a)
Agree a prioritised list of key metrics for the Board to monitor
In 2013/14 the Patient Safety, Quality and Risk Group (now named Choose Safer
Care Subcommittee) received a standard report from the Patient Safety Panel bimonthly. This report is currently in the process of being updated to contain a
patient safety dashboard which has been developed by the patient safety team.
The dashboard, which will cover acute bedded areas in the first instance, contains
a range of safety, quality and risk indicators which can be weighted and RAG rated.
Areas of exception will be identified objectively using the dashboard signalling the
need for a “deeper dive” into the current intelligence and decisions on further
actions to support teams made in partnership with operational management.
b)
Ensure that the metrics are tailored to different levels of governance
The patient safety metrics have been refined so that they can be reported and
reviewed by ward/team, clinical business unit, division or by organisation.
Assurance matrons triangulate safety, quality and experience indicators by ward
and team every month. This information is shared with operational teams at ward
manager, clinical operational manager and clinical business manager level. This
meeting includes discussion of soft intelligence and any developments or
improvement initiatives. This opportunity for open dialogue is valuable in deciding
appropriate interventions to support clinical teams. The strategic lead safer aligned
to each division has regular discussions with the divisional director with regard to
any areas of concerns. The patient safety panel oversees the safety metrics from
an organisational point of view and reports by exception any areas of concern to
the Choose Safer Care Subcommittee.
c)
Check that the metrics are delivered in conjunction with the staff
In 2014 a patient safety framework known as ‘ASSURED’ was developed by the
continuous quality improvement team (CQI) to support improvement and practice
development at team level. When wards and teams need support to help them
improve patient safety, quality and experience it is important to ensure that the
plans for support are making a real and measurable difference. The ASSURED
framework provides a standard approach to establish performance baselines,
undertake re-measure and evaluation which subsequently means we can be “re
ASSURED’” that improvement is sustained. The success of this ward/team
improvement model is dependent on effective, collaborative relationships between
multi-disciplinary teams and ultimately empowers ward and team leaders to make a
real difference and to sustain positive change over time.
The ASSURED model was presented at an NHS England event to celebrate
nursing innovations in November 2014; this generated interest from other Trusts
who wish to emulate our success.
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Priority 4 Staff Engagement: Embed patient focused care
Rationale for Inclusion:
A measure of success for the organisation will be when everyone in the Trust sees
delivery of the best possible patient experience as their business and can quantify
their contribution to our success and be proud to be part of it. Staff engagement is
the key tenet to both delivering safe and effective patient care and excellent patient
experience.
Target 2014/15:
We will include staff in our Friends and Family Test
Our Progress:
The Staff Friends & Family test was introduced in April 2014 and is reported to the
Board of Directors each quarter. A number of new clinical areas were required to
begin using the Friends & Family Test during the year, including Maternity services
and some community services. We successfully achieved implementation in all
required areas and exceeded the response rates required in the national targets.
At South Tyneside NHS Foundation Trust our aim is to deliver care that is
genuinely focused on the needs and wishes of individual patients, on each and
every occasion. This ambition requires a culture of genuine patient engagement
and an organisational approach to patient experience which is owned and valued
by each member of staff. Every interaction or contact with our services can reveal
attitudes and behaviours that either accelerate or impede a patient centred
approach to care delivery.
The Trust recognises that we need to engage with social media as an effective way
of communicating and engaging with our staff, patients and the public. In 2014 the
STFT Twitter account was established to allow a stream of tweets from members
of the Executive team, clinicians and senior managers reporting innovations,
celebrating success, commenting on work that is underway, reporting national and
local events and news. A Trust “App” is also being developed which contains
information on Trust services and our staff. The App will facilitate the collection of
staff “friends and family” survey data to ensure we reach as many staff as possible
to enable a timely and receptive response to their views.
Engage junior doctors and nurses on the patient safety agenda
In 2012 Guys and St Thomas’ NHS Foundation Trust launched Barbara’s story to
raise staff awareness of what it feels like to be a patient with dementia in unfamiliar
surroundings. The story follows the journey of an older lady called Barbara through
varied stages of her care pathway. The story is narrated by Barbara’s thoughts
and feelings to help staff understand what it feels like to be in their patient’s shoes
helping staff to reflect on how things might appear from the patient’s perspective.
The story highlights scenarios where Barbara is shown simple acts of kindness and
consideration but also more upsetting situations where she isn’t given sufficient
attention or care and the impact these two approaches have on Barbara’s feelings.
Thanks to funding from the Burdett Trust Barbara’s story was launched across the
South Tyneside NHS Foundation Trust in June 2014 and to date 3,901 staff have
joined Barbara on her journey. Staff are asked to tell us what they would do
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differently as a result of seeing Barbara and their comments have been captured
on a short video to promote our commitment to compassion in practice.
In acknowledgement of the organisation’s commitment to Barbara’s story the
Alzheimer’s Society have recently endorsed our programme and will recognise all
staff who have completed Barbara’s journey as “Dementia Friends”.
Maximise opportunities for team work so as to improve staff allegiance
Our staff celebrated NHS Change Day on Wednesday 11 March 2015, with an
event showcasing some of the innovation, improvements and positive changes
which have benefited our patients over the past year.
NHS Change day was the culmination of 30 days of change which ran from 10
February 2015 and involved the CQI team revisiting some of the key changes and
positive improvement stories from the past year. The day itself provided the
opportunity for us to come together, harnessing our collective energy, creativity and
ideas to make change happen. Teams from all areas of the Trust presented over
40 of their projects to their colleagues. There was a real “buzz” in the room as staff
understood the scale of the collective achievement and the real difference they had
helped to make to the care and wellbeing of our patients and families.
NHS Change Day was used as a platform to launch the “change agents
programme” to support leaders make positive changes to their services or patient
pathways through specific improvement projects.
Priority 5
The Learning Cycle: Disseminating learning and
developing practice
Rationale for Inclusion:
Continuous quality improvement is already a key strength of our organisation,
supporting the transformation programme and ensuring that patients are central to
service improvements and best practice is embedded. Improvement events will take
place in 2014 focussed on reducing falls, pressure damage, venous
thromboembolisms and urinary tract infections in patients with indwelling catheters.
The Trust has committed to implementing ‘PERFORM’ in partnership with
PricewaterhouseCoopers LLP (PwC) to embed new ways of working in clinical
teams to increase productivity and effectiveness.
Target 2014/15:
• We will expand the implementation of PERFORM to additional services including
diagnostics, Obstetrics and Gynaecology, Pharmacy and selected community
services.
• We aim to continue to increase our involvement in national development during
2014-15
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Our Progress:
The Trust has been working in partnership with PricewaterhouseCoopers (PwC)
throughout 2014/15 to adapt an innovative reform methodology for health care
settings: the methodology is call PERFORM. PERFORM is described as an
operational excellence approach that rapidly delivers results through optimising what
managers do, how they do it, and the tools they use. PERFORM drives improved
performance through:
• Highlighting operational problems before they escalate
• Increasing Managers’ time spent on coaching
• Supporting effective delegation of work
• Encouraging best practice
• Making performance visible
• Providing clarity on what is required day-to-day
• Balancing workloads between teams
Wards and teams attend a two day “boot camp” which engages staff in the tools and
techniques used by PERFORM and encourages staff to think about the vision for
their service and how they can all play a part in delivering it. Teams then enter a 10
week interactive programme, with intensive coaching to help embed the tools and
techniques while driving new ways of working. A key component of the work is the
design and implementation of an information centre from which all staff can track
team performance on a daily basis. At daily meetings, known as “huddles”, teams
review performance from the previous day and identify today’s priorities. Leadership
of the huddle changes daily and is not hierarchical encouraging leadership
behaviours from all grades of staff. Staff are taught to “problem solve” and take
ownership of ward/ team performance. Teams feel empowered to make decisions
and solve problems they would previously have escalated to their managers.
PERFORM has been initiated in a number of phases. The planned programme
across diagnostics, obstetrics and gynaecology, pharmacy and selected community
services was achieved, although the main work in community services has now
begun in 2015/16.
In 2014/15 the annual plan for continuous quality improvement (CQI) was delivered
supported by the Continuous Quality Improvement Team. The team has delivered
17 continuous improvement events and a further 46 improvement projects. The CQI
team have trained 384 staff in lean methodology and have led 37 improvement
events. The CQI team facilitates practice development to all wards and teams
across the Trust. The following is one example of practice development designed to
lead to a reduction in harm to our patients as a result of pressure ulcers. A similar
piece of work has also been undertaken to reduce falls throughout the organisation
by introducing the Fallsafe Care Bundle. The Fallsafe Care Bundle has been
updated following a pilot on 4 wards. It will be implemented in all care of the elderly
and medical wards by the end of June 2015 and remaining wards (surgical) and St
Benedict’s by the end of July 2015.The intended outcome is to further reduce the
number of falls patients have in our care as a result of identifying all patients at risk
of a fall and ensuring strategies such as falls technology are in place to prevent a fall
occurring. To monitor the reduction and trends in falls the learning from RCA, data
from the NHS Safety Thermometer, Open and Honest Care data and the Safety
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Quality and Experience dashboard will be discussed at the falls operational meeting
to identify interventions needed to continuously reduce patient harm from falls.
SSKIN is an evidence based five step care bundle for pressure ulcer prevention.
The aim of the care bundle is to identify all patients who are at risk of developing
pressure ulcers and then reliably implement prevention strategies identified by NICE
(2005). SSKIN is an aide memoir for the following five strands of care:
•
•
•
•
•
Surface: make sure your patients have the right support
Skin inspection: early inspection means early detection. Show patients and
carers what to look for
Keep your patients moving
Incontinence/ moisture: your patients need to be clean and dry
Nutrition/ hydration: help patients have the right diet and plenty of fluids
Ward 10 was chosen to ‘pilot’ documentation which underpinned the new practice
for 3 months. At the end of each month staff comments and suggestions were taken
into consideration and amendment made to the document itself to ensure it was fit
for purpose and increase staff engagement. A communication strategy was agreed
with the Ward Manager and rolled out to staff at team meetings. The CQI team
provided guidance notes to help staff to easily understand and complete the
documentation. One of the CQI facilitators visited the ward on regular occasions to
support the staff through the change process and a member of Ward 10 team was
given the opportunity to lead the launch of the documentation with their colleagues.
To monitor the reduction and trends in pressure damage the learning from RCA,
data from the NHS Safety Thermometer, Open and Honest Care data and the Safety
Quality and Experience dashboard will be discussed at the pressure damage RCA
panel to identify interventions needed to continuously reduce patient harm from falls.
South Tyneside NHS Foundation Trust is a member organisation of the
Northumberland Tyne and Wear Comprehensive Local Research Network (NTW
CLRN). The CLRN allocate funding to the organisation to support of the approval,
management and delivery of NIHR portfolio studies. The Trust has an active
portfolio of clinical research which reflects the organisation’s commitment to
providing high quality patient care and embed a culture of innovation across the
organisation. During 2014/15 the research team have recruited 350 patients into a
range of studies including 5 commercial studies: STFT are the lead site for the
national Adenoma study. The team has achieved 100% of studies approved within
the 15 day target and 83% of studies recruited the first patient within 30 days which
are excellent results reflecting the commitment of the team.
In 2014/15 the research team has also expanded the Trust research portfolio
delivering studies in areas that have not had an active research profile in the past.
These new areas include anaesthetics, critical care and cardiology.
Incident reporting is a fundamental tool of risk management, the aim of which is to
collect information relating to adverse events, including near misses, which will aid
the Trust in focusing on improvements in safety. As part of the process, relevant
managers receive immediate notification when an incident is reported on the
Datixweb system. It is the managers’ responsibility to investigate the incident and
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advise the Risk and Compliance Team if the incident needs reassigning to another
manager. Notifications are also sent to the Risk and Compliance Team as well as
any specialist role, e.g. security related incident notifications are sent to the Security
Manager, pressure ulcers notifications are sent to the Tissue Viability Team, etc.
Most serious clinical incidents which are identified either through Datix reporting or
management escalation, are investigated by the Assurance Matrons. The only
regular exception to this is the investigation of pressure ulcers. The Tissue Viability
team have a robust process for reviewing root cause analysis and learning from
clinical incidents.
The team of assurance matrons ensure that all serious incidents are investigated in
an objective and standard way: investigations and the development of action plans
are conducted in collaboration with operational teams. The assurance matrons are
responsible for ensuring that all actions are completed and lead any necessary
changes in practice to support patient safety. One example of this was the
implementation across the Trust of yellow ID bands as a visual prompt for patients
with drug allergies. This initiative followed the investigation of a serious incident in
which a patient was administered an intravenous drug for which she had a known
allergy.
In 2014/15 the assurance matrons investigated 39 serious incidents. The final
reports are submitted to the Clinical Commissioning Groups (CCG) and lessons
learned are reported to individual wards and teams as well as in divisional and
professional for a across the organisation. Where possible the assurance matrons
attend the CCG serious incident panel to discuss their findings with commissioners.
All serious incidents are reported to the Patient Safety Panel chaired by the
Executive Director of Nursing and Patient Safety. The Patient Safety Panel agrees
to close serious incidents following all actions being completed and sign off by the
CCG. In a recent innovation the Patient Safety Panel will log all lessons learned
and keep an audit trail of where these lessons have been shared.
Summary of lessons / outcomes / themes from Serious Incidents 2014/15
Incident Category
Pressure Ulcers
Slips, trips, falls
Lessons / Outcome / Theme
Contributory factors:
 Delay in receiving equipment
 Patients choice in not using equipment
 No photograph to use to monitor progression of ulcer
Improvements:
 Improved documentation
 Patient information
 Integration of printer with IT system in development
Contributory factors:
 Patients who fall are often assessed as low risk –
review of falls policy needed in light of NICE
guidance
 Patients attempting to mobilise independently to
toilet against staff advice
 Physical presentation that may lead to fainting
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Suicide / death of a
patient
Medication errors
 Risk assessment on admission changing during stay
and in between re-assessment
 Periods of agitation / restlessness
 Staffing on nightshift
Improvements:
 Falls risk assessment documentation to be used in
maternity documentation
 Significant increase in use of falls technology
 Improvements in documentation including
assessments of risk
 Visuals introduced in clinical areas
 Toilet posters
 Supervision of patients in bathrooms
Contributory factors:
 Homelessness / secure accommodation on release
from prison
 Poor engagement with services
Improvements:
 Multi-agency working and communication
Contributory factors:
 Distraction / preoccupation with other duties
 Time pressures – running late
 Stock not put away when not in use (increases risk
of mixing medicines up)
 Storage of medications (Penicillin v non Penicillin)
 Acknowledgement and Identification of allergies
Improvements:
 Review of all PGDs
 Tidying of clinical rooms following clinical activity
 Implementation of coloured medicine allergy bands
 Use of Extramed system to record allergies
 Medication chart reviewed – drug allergies to appear
on each page
 Visual identity of drug allergies implemented
 Introduction of medicine round audits
 Introduction of 02 carrying brackets for oxygen
cylinders
15
Priority 6 Guidelines and training: supporting staff to remain fit for purpose
and deliver evidenced based care
Rationale for Inclusion:
Well developed, skilled and knowledgeable staff are the most valuable resource in
any organisation. Ensuring staff remain fit for purpose is challenging to any Trust
due to the fast pace of change within the NHS as technologies develop and new
ways of working emerge. Revalidation for Medical staff has been implemented in the
Trust. Revalidation for nurses will become an NMC requirement by 2015 and there
will be a similar revalidation requirement for allied health professionals.
Target 2014-15:
To support nurses and allied health professionals to meet these requirements we will
develop core, specialist and advanced competency frameworks which will be rolled
out to all staff in 2014-15
Our Progress:
The Francis 2 report and the Cavendish review which followed led to a number of
national initiatives to address apparent national failings in recruitment of the right
people into caring roles and ensure that those who are recruited are appropriately
trained and valued as members of the team.
The Trust continues to take an active role in developing systems and processes to
ensure we recruit staff with the values aligned to the “6 Cs” and the “Choose” values
of the Trust. We are continually developing new ways of ensure staff remain
supported to deliver their role with opportunities for development both personally and
professionally.
Give support to clinical area leaders in their deploying of key guidelines.
The Clinical Audit Team has developed a robust in house data base to monitor Trust
compliance with all NICE guidance to support staff in deploying key guidelines in
their areas of practice. There are systems in place to download all new guidance
and the NICE Guidance Review Group then considers whether it is relevant with
regard to the services the organisation provides. Guidance would only be
considered not relevant at this point if the service is not provided as part of our
organisational portfolio. Any guidance considered relevant is then forwarded on to
identified leads, within the appropriate specialty. In the case of uncertainty the
group will refer to the lead clinician in the relevant specialty for advice.
The clinical leads then review the guidance using a baseline assessment tool or
NICE Guidance review template within 8 weeks. This review will establish whether
the Trust is compliant or non-compliant with the guidance, identify any implications
for implementation and in cases of non-compliance prepare an action plan. Noncompliance action plans/gap analyses are reviewed by the NICE Guidance Review
Group for assessment of the potential impact on care. The group then decides on a
Red, Amber or Green (RAG) rating for reporting purposes. The Executive Director
of Nursing and Patient Safety is advised of the reasons for any deviation or deficits
from recommended practice, the detail of which should have been outlined within
the response, action plan and gap analysis.
16
Since April 2012 386 pieces of guidance have been logged on the database and
have been to the NICE Guidance Review Group. Currently as a Trust we are fully
compliant with 47% of relevant guidance with a further 41% still currently under
review. 12% of reviews are still outstanding and are reported by exception at each
NICE Guidance Review Group meeting.
Action plans are monitored within the appropriate Division with any deviation from
plan exception reported to the NICE Guidance Review Group.
Give direction for a review of patient safety training
The Care Certificate was developed in response to the Francis Inquiry and following
a review of non-registered staff working in caring roles which was undertaken by
Camilla Cavendish. The purpose of the Care Certificate is to provide clear evidence
to employers, patients and people who receive care and support, that the health or
social care worker delivering care has been trained and developed to a specific set
of standards and has been assessed for the skills, knowledge and behaviours to
ensure that they provide compassionate and high quality care and support. All new
care workers in England, including healthcare assistants in hospitals and staff in
care homes and who look after people in their own homes, will have to gain the
certificate.
Locally STFT is leading the way in providing special training for health and social
care staff to ensure they have the right qualities and skills to provide high quality,
compassionate care. South Tyneside Foundation Trust was chosen as a test site to
develop the Care Certificate and were keen to take an integrated approach to
piloting this by developing a Care Certificate Programme and Workbook working in
partnership with partners in the Social Care Sector in South Tyneside. Members of
the STFT team worked with private providers in the residential and nursing care
sector as well as those working in domiciliary care or employed to deliver direct care
by South Tyneside Council to develop a programme. The aim of the programme is
to provide all those newly employed to deliver care in hospital, care homes or the
homes of individuals in South Tyneside with the same Care Certificate Programme,
workbook and assessment. The STFT team sought to truly consider the challenges
and good practice already in place and to understand how the Care Certificate can
work both in a small domiciliary care provider to a large nursing home, and from an
NHS Trust to Council services. The team developed a unique and integrated
innovative approach; the only site nationally to build on the diverse range of
strengths that each of our partners bring, to ensure we educate, prepare and equip
our care staff with the skills to deliver high quality care.
About 20 new starters from the Trust and independent care providers in South
Tyneside have embarked on the Care Certificate programme, which the Trust is
running along with partners including Tyne and Wear Care Alliance
17
Priority 7
To strengthen the links between patient feedback and
improvement
Rationale for Inclusion:
During 2014, the annual programme of patient experience studies conducted by the
Trust’s Carer and Patient Involvement Team will be repeated to ensure that the
patient experience in every clinical area across the Trust is conducted within the
year.
Target 2014/15:
• We will roll out our ‘Open and Honest’ point of prevalence patient harm survey to
our community services.
• We will expand the Friends and Family Test to our community teams.
Our Progress:
The direction of patient safety in England is now supported by a number of national
initiatives. STFT has been an early adopter of these initiatives and frequently led the
way both locally and nationally. In 2012 we were first in the north east to publish
“Open and Honest care” information to the public with regard to care in our hospital
settings. In November 2013 we were one of only five Trusts nationally who were
able to publish “Open and Honest care” information relating to care given by our
district nursing teams and in 2014 we began to publish safe staffing information on
our website in line with national requirements. We also include an “easy read”
version of staffing information to help members of the public best understand any
staffing challenges we have had and actions we have taken to support teams to
continue to deliver safe and effective care.
In November 2014 our Executive Director of Nursing and Patient Safety drafted a
proposal to develop and lead a North East Patient Safety Collaborative to reduce the
number of pressure ulcers by 50% in areas selected for intervention. This proposal
has now been accepted with the expectation that work will be completed in May
2016.
Earlier this year STFT signed up to join the national “Sign up to Safety” campaign.
“Sign up to Safety” aims to deliver harm free care for every patient, every time,
everywhere building on the transparency initiatives known as “Open and Honest
care”. This government initiative champions openness and honesty and supports
everyone to improve the safety of patients. The three year objective is to reduce
avoidable harm by 50% and save 6,000 lives.
“Sign up to Safety” contains five key pledges which all member organisations will
commit to:
•
Putting safety first. Commit to reduce avoidable harm in the NHS by half
and make public our locally developed goals and plans
•
Continually learn. Make our organisation more resilient to risks, by acting on
the feedback from patients and staff and by constantly measuring and
monitoring how safe our services are
18
•
Being honest. Be transparent with people about our progress to tackle
patient safety issues and support staff to be candid with patients and their
families if something goes wrong
•
Collaborating. Take a lead role in supporting local collaborative learning, so
that improvements are made across all of the local services that patients use
•
Being supportive. Help people understand why things go wrong and how to
put them right. Give staff the time and support to improve and celebrate
progress.
STFT already has a track record of achieving against each of these pledges. “Sign
up for Safety” provides us with an opportunity to bring together all of the work we
already do onto one plan, including external initiatives, ensuring they add value to
our work and are not “add on” or isolated projects which can potentially distract from
important on-going work.
The Patient Safety Priorities developed in 2014 for 2014 to 2017 will be reviewed
and priorities that remain current will be included on the organisational plan.
Priority 8
To develop assistive technology to facilitate the collection and
distribution of patient feedback
Rationale for Inclusion:
The use of hand held tablets will support wider spread collection of patient stories by
reducing administrative processes and allow more effective and efficient use of the
CAPI team. We will also develop assistive technology for patient areas. This will
allow patients to provide real-time feedback at the point of care. During 2014-15 we
will also develop a database to coordinate patient experiences from a wide range of
sources providing a holistic view of services from the patient’s perspective. This will
allow us to identify and focus on areas which patients and carers feel that we can
improve upon.
Target 2014/15:
We will introduce assistive technology to collect qualitative and quantitative patient
and carer feedback
.
Our Progress:
An important factor in relaying patient feedback to staff with the purpose of engaging
them to improve safety, quality or experience is time. The ability to reflect patient
feedback onto current care delivery makes both the message to frontline staff and
the opportunity to stimulate change much more powerful and immediate. With this in
mind in 2014 the Carer and Patient Involvement Team (CAPI) piloted ‘Real Time’
Patient Feedback within acute wards and departments. The proposal was to
complete the feedback cycle from patient interviews to report within an eight hour
timeframe. A CAPI facilitator visited the pilot wards once a fortnight over a six week
period to interview patients using a series of pre-set questions. The visits were
conducted at appropriate times either in the morning or afternoon. When the
afternoon time slot was selected visitors would also have the opportunity to share
their views and participate in an interview.
19
The pilot was successful with the feedback cycle completed within the allocated
eight hour timeframe. The pilot has proved very popular with ward staff; findings are
shared with all staff at daily ward huddles with actions for improvement identified and
implemented immediately when possible. The real time feedback initiative is now
being rolled out to all acute wards and departments. The development of a
dedicated telephone line and email address is now underway to provide patients and
their relatives an opportunity to tell us about their ‘Real Time’ experiences outside of
the planned visits to the Acute Wards and Inpatient Units.
Priority 9
To raise staff awareness with regard to carers
Rationale for Inclusion:
Most people who need care rely on family members, friends and neighbours i.e.
informal care. Some estimates place the number of informal carers in the UK at 6.4
million. Since many people do not readily distinguish themselves as carers,
identification of carers continues to be a major issue for healthcare providers.
Target 2014/15:
We will develop and roll out training and awareness packages to ensure that our
staff are able to support our carers
Our Progress:
A Trust representative attends the Carers’ Strategy Groups in the three Local
Authority areas to network with other agencies. Specific issues are communicated
directly with clinical teams as appropriate, e.g. Young Carers items with services for
children.
A quarterly newsletter is produced by the Trust to update staff on developments to
support carers and share positive stories of where carers have been supported. All
newsletters are available on the intranet, cascaded to teams and noted in the Trust
Staff Briefing. Contact details for the local carers’ voluntary organisations are
included in the newsletter to enable clinical staff to refer people when required.
A member of the Carer and Patient Involvement Team attends the Trust Discharge
Strategy and Operational Groups to champion the role of carers in the discharge
process.
Where possible, carers’ views are listened to when patients’ experiences are
measured. This is included in the Friends and Family Test Plus, conducted monthly
in every service in the Trust and Real Time Feedback, rolled out in the Trust and
conducted in face to face interviews by the Carer and Patient Involvement Team.
The staff training and awareness has been placed on hold during 2014-15.
Previously, a package was developed and delivered to some Trust clinical teams.
Since then, partner Local Authorities have developed training schemes in
conjunction with the Strategy Groups, with the agreement that this will be the
preferred model in future. Updates are required to accommodate the changes
results from the Care Act and a designated member of the Carer and Patient
Involvement Team will roll out the new training in a planned way during 2015-16.
Meanwhile, facilitators in the Carer and Patient Involvement Team continue to
promote support for carers on an ad hoc basis in their routine work in clinical areas.
20
To demonstrate to patients and families that their
feedback is important and we take action on receiving it
Rationale for Inclusion:
We want to demonstrate that the Trust is able to listen and respond to the views of
patients, their families and the local community and to use feedback constructively
and innovatively to inform local service improvements.
Priority 10
Target 2014/15:
We will develop visibility walls in patient/carer accessible areas. We will use the
visibility walls to show our patients and carers that we are continuously improving
our care on the basis of their feedback.
Our Progress:
A SharePoint site has been developed which holds all the patient safety metrics
available for each ward and team. This site undergoes regular development to
ensure that triangulation of information by ward/team is as simple as possible. The
SharePoint site is available on request to all staff to support involvement,
understanding and ownership of safer care.
Safer staffing data is now displayed for patients and the public in all bedded areas of
the Trust and by community teams. The information is updated daily and includes
the number of staff planned to be on duty for each shift compared to the number
who are actually available.
Many wards and teams display their patient safety, quality and experience
information and over the coming months this will be rolled out to all areas in a
standard format in the coming months.
South Tyneside NHS Foundation Trust was one of only five Trusts able to publish
community safety metrics on our website in line with the national time frame; this
now sits alongside the safety metrics for in patient areas.
Since May 2014 we have published our safer staffing board reports on the public
area of our website. Alongside this we provide an easy to read summary of areas
where we have had staffing levels below expected levels with explanations of how
we have supported those wards and teams to deliver safe and effective care.
21
2.2 Our Priorities for 2015-16
The following list of priorities for improvement for 2015/16 has been developed following
wide consultation. Key areas are identified by our patients and their carers through
surveys, questionnaires and complaints. To gain the contribution of the wider public we
discuss priorities with local Healthwatch organisations, and the three local authority
health oversight committees, and particularly with the public members of our Council of
Governors. Staff engagement in developing priorities continues to come through the
staff side representatives, but increasingly we benefit from staff responses in Choose
Safer Care and through quality improvement activities.
In South Tyneside NHS Foundation Trust we recognise that it is absolutely right to focus
on the importance of having the right organisational culture to deliver high quality,
compassionate care; engaging all staff in a patient centred culture and being open and
honest with our patients and their families.
Priority 1 – Clinical
Effectiveness
To develop and publish a three year Safety
Improvement Plan (SIP) as part of a new 5-year Quality
Strategy
Rationale for Inclusion:
The Trust has ‘Signed Up To Safety’, a national campaign to reduce avoidable
harm by half and save 6000 lives over the next three years. Each participating
organisation is required to publish a Safety Improvement Plan.
Target 2015/16:
Publish Safety Improvement Plan by June 2015 and 2020 Quality Strategy by
December 2015 and deliver Year 1 objectives by March 2016.
Baseline:
This plan and strategy builds on our current Safety, Quality and Experience plans
and a strong foundation of improvement work
Priority 2 – Clinical
Effectiveness
To create and roll out a Safety, Quality, Experience
(SQE) programme that will train front-line teams to
utilise improvement methods in their everyday practice
Rationale for Inclusion:
Building capability and capacity to undertake continuous quality improvement (CQI)
activities is a national priority (Berwick Report, 2013)
Target 2015/16:
Design and implement Phase 1 of the SQE programme between October 2015 and
March 2016.
Baseline:
The SQE programme builds on a foundation of CQI activities across the
organisation.
22
Priority 3 – Patient
To further develop our culture of learning from
Experience
experience
Rationale for Inclusion:
New regulations such as the Duty of Candour further emphasise the importance of
open and honest reporting, learning lessons and demonstrating accountability in
assurance around actions.
Target 2015/16:
To fully implement Duty of Candour requirements, put into place a Patient and
Public Involvement Panel and demonstrate confidence in our approach to systemwide learning and improvement.
Baseline:
The Trust has a robust governance structure, is transparent and engaging with
staff, patients and the public – the challenge going forward is to ensure we learn
and improve at every opportunity, every day.
Priority 4 – Patient
Safety
To provide assurance to the Board and patients that we
are continually focused on demonstrating safe staffing
levels
Rationale for Inclusion:
Safe Staffing is a National Quality Board, NHS England and CQC priority. There is
an increasing evidence-base that demonstrates the link between the number, skills
and mix of staff and the quality of care patients receive.
Target 2015/16:
We will implement NICE Guidance for Safe Staffing in hospitals and participate in
the development of guidance for nursing in the community.
Baseline:
We already fulfil National Quality Board and NHS England requirements to
undertake twice yearly nursing establishment review and are reporting nurse
staffing alongside other indicators of quality to Board of Directors.
23
2.3
Statements of Assurance from the Board
During 2014/15 South Tyneside NHS Foundation Trust provided and sub-contracted
130 relevant health services. South Tyneside NHS Foundation Trust has reviewed all
the data available to it on the quality of care in all of these relevant health services.
The income generated by the relevant health services reviewed in 2014/15 represents
100 per cent of the total income generated from the provision of relevant health services
by South Tyneside NHS Foundation Trust for 2014/15.
The safety, effectiveness and patient experience of all of our clinical services is
reviewed on an on-going basis through a process of Board of Director and Executive
Board oversight. Performance against national and local contractual targets is reported
regularly to the Board of Directors. Patient safety and patient experience reports are
also scrutinised at the Choose Safer Care Subcommittee which is a Board delegated
committee chaired by a Non-Executive Director.
2.4 Clinical Audit and Research
Clinical Audit
Participation in audits and clinical research programmes helps us to review our
performance and standards across a wide range of areas. We participate in national
and local audits and implement a range of developments and changes as a result.
This Clinical Audit Quality Account covers the period from 1 April 2014 to 28 February
2015.
During 2014/15 33 national clinical audits and 5 national confidential enquiries covered
relevant health services that South Tyneside NHS Foundation Trust provides.
During 2014/15 South Tyneside NHS Foundation Trust participated in 94% (n=29)
national clinical audits and 80% (n=4) national confidential enquiries of the national
clinical audits and national confidential enquiries which we were eligible to take part in.
Of the 33 national clinical audits that the Trust was eligible to take part in, participation
was not applicable to 2 audits for the following reasons:
• National Non-Invasive Ventilation Audit (BTS) was postponed by BTS
• National Audit of Dementia Audit was a pilot only and STFT was not selected for the
pilot process.
Of the 31 remaining audits the Trust participated in 29 and did not participate in 2.
The national clinical audits and national confidential enquiries that South Tyneside NHS
Foundation Trust was eligible to participate in during 2014/15 are listed in the table
below.
The national clinical audits and national confidential enquiries that South Tyneside NHS
Foundation Trust participated in during 2014/15 are also listed in the table below.
24
The national clinical audits and national confidential enquiries that South Tyneside NHS
Foundation Trust participated in and for which data collection was completed during
2014/15 are listed in the table below alongside the number of cases submitted to each
audit or enquiry as a percentage of the number of registered cases required by the
terms of that audit or enquiry.
The reports of 35 national clinical audit reports were reviewed by the provider in
2014/15, and South Tyneside NHS Foundation Trust intends to take the following
actions to improve the quality of health care provided:
•
•
•
Ensuring the lead clinician produces an action plan
The action plan is signed off by the appropriate strategic group or committee
Progress is monitored through the appropriate committee.
The reports of 202 local clinical audits submitted in 2014/15 were reviewed by the
organisation and South Tyneside NHS Foundation Trust intends to take actions to
improve the quality of health care provided by ensuring all audit reports and action plans
are reported to the Clinical Audit Committee, and by exception these reports and action
plans are presented to the Board.
Due to the much varied submission/reporting deadlines for ongoing/continuous national
audits, the figures for such audits have been based upon the number of cases actually
submitted out of the number of identified cases from 1 April 2014 to 31 March 2015.
25
National Clinical Audits and Confidential Enquiries for inclusion in Quality Accounts Report 2014/2015
Eligible for participation
Participated
% pts submitted to audit
Adult critical care (ICNARC CMP)
Yes
Yes
Community Acquired Pneumonia (BTS)
Yes
Yes
100%
(n=299)
N/A
Data collection continuing into 2015/2016
CONFIDENTIAL ENQUIRY (NCEPOD)
Acute Pancreatitis
Yes
Yes
N/A
Data collection continuing into 2015/2016
CONFIDENTIAL ENQUIRY (NCEPOD)
Gastrointestinal Haemorrhage Study
Yes
Yes
80%
(n=4/5)
CONFIDENTIAL ENQUIRY (NCEPOD)
Sepsis Study
Yes
Yes
N/A
Data collection continuing into 2015/2016
National Emergency Laparotomy Audit (NELA)
Yes
Yes
National Joint Registry (NJR)
Yes
Yes
National Non-Invasive Ventilation Audit (BTS)
Yes
N/A
100%
(n=73)
(Year 1 Dec 2013 to Nov 2014)
Year 2 data collection continuing into
2015/2016
100%
(n=248)
N/A
Audit postponed by BTS.
Awaiting revised timelines.
Pleural Procedures Audit (BTS)
Yes
No
N/A
Trust unable to participate due to staff
shortage in Respiratory Medicine
Trauma (TARN)
Yes
Yes
86%
(n=138/161)
Acute Care
26
Eligible for participation
Participated
% pts submitted to audit
Patient Information and Informed Consent
Yes
Yes
100%
(n=24)
Audit of transfusion in children and adults with sickle cell
disease
Cancer
No
N/A
N/A
Bowel Cancer - National Bowel Cancer Audit Programme
(NBOCAP)
Yes
Yes
100%
(n=99)
Head and neck oncology (DAHNO)
Lung Cancer - National Lung Cancer Audit (NLCA)
No
Yes
N/A
Yes
Oesophago-gastric cancer (NAOGC)
Yes
Yes
N/A
100%
(n=135)
44%
(n=16/36)
Acute coronary syndrome or acute myocardial infarction
(MINAP)
Adult Cardiac Surgery (ACS)
Yes
Yes
No
N/A
Cardiac arrest (NCAA)
Yes
Yes
Cardiac arrhythmia (Cardiac Rhythm Management Audit)
HRM
Congenital Heart Disease – Paediatric Cardiac Surgery
(CHD)
Coronary Angioplasty
Yes
Yes
No
N/A
100%
(n=63)
100%
(n=99)
N/A
No
N/A
N/A
Heart Failure (HF)
Yes
Yes
Pulmonary Hypertension
Vascular Surgery Registry – VSGBI Vascular Surgery
Database (NVD)
No
No
N/A
N/A
117 patients entered to audit
Unable to determine participation rate as
number of identified patients not provided
by audit lead
N/A
N/A
Blood and Transplant
Heart
27
82%
(n=120/146)
N/A
Eligible for participation
Participated
% pts submitted to audit
Chronic Kidney Disease in primary care
No
N/A
N/A
Pulmonary Rehabilitation Audit
Yes
Yes
N/A
Data collection continuing into 2015/2016
Diabetes - Paediatric (NPDA)
Yes
Yes
National Diabetes Footcare Audit
Yes
Yes
N/A
Approximately 60 cases identified
2014/2015.
System not yet open for 2014/2015
submissions.
Deadline for submissions is not until
September 2015.
Unable to ascertain
Inflammatory Bowel Disease Programme:
Biologics Audit
Yes
Yes
100%
(n=8)
Renal Replacement Therapy
No
N/A
N/A
Rheumatoid and early inflammatory arthritis
No
N/A
N/A
Mental Health: Care in Emergency Departments
(College of Emergency Medicine)
Yes
Yes
100%
(n=50)
Prescribing Observatory for Mental Health (OMH-UK)
No
N/A
N/A
NATIONAL CONFIDENTIAL INQUIRY
Suicide and homicide in people with mental illness (NCISH)
Yes
N/A
N/A
No suitable cases identified for
submission
Long Term Conditions
Mental Health
28
Eligible for participation
Participated
% pts submitted to audit
Yes
Limited - pilot only
N/A
N/A
Sentinel Stroke National Audit Programme (SSNAP)
SSNAP Acute Organisational Audit
Yes
Yes
N/A
Sentinel Stroke National Audit Programme (SSNAP)
SSNAP Clinical Audit
Yes
Yes
Falls and Fragility Fractures Audit Programme:
National Hip Fracture Database
Yes
Yes
Yes
Yes
100%
(n=100)
Elective Surgery (National PROMS programme) – Hernia
Yes
Yes
Data handled by external agency
Elective Surgery (National PROMS programme) – Hips
Yes
Yes
Data handled by external agency
Elective Surgery (National PROMS programme) – Knees
Yes
Yes
Data handled by external agency
Elective Surgery (National PROMS programme) – Varicose
Veins
No
N/A
N/A
National Audit of Intermediate Care
Yes
No
N/A
National Ophthalmology Audit
No
N/A
N/A
Older People
National Audit of Dementia
Older People: Care in Emergency Departments
(College of Emergency Medicine)
Unable to ascertain
100%
(n=188)
Other
29
Eligible for participation
Participated
% pts submitted to audit
Child Health Programme (CHR-UK)
Yes
Yes
Data handled by external agency
Epilepsy 12 Audit (Childhood Epilepsy)
Yes
Yes
CONFIDENTIAL ENQUIRY:
Maternal, infant and newborn programme (MBRRACE-UK)
Yes
Yes
Fitting Child: Care in Emergency Departments
(College of Emergency Medicine)
Yes
Yes
100%
(n=3)
100%
(n=7) obstetric cases
Unable to ascertain neonatal cases
100%
(n=33)
Neonatal intensive and special care (NNAP)
Yes
Yes
99%
(n=105/106)
Paediatric Intensive Care (PICANet)
No
N/A
N/A
Women’s & Children’s Health
Table 1: National clinical audits & confidential enquiries 2013/2014
30
2.4
RESEARCH
South Tyneside NHS Foundation Trust recognises the numerous benefits of Research
to the organisation and more importantly for our patients. According to a consumer poll
conducted in 2013 commissioned by the National Institute for Health Research (NIHR),
87% of people would prefer to be treated in a hospital that does clinical research. Being
a research active Trust demonstrates a commitment to high quality patient care and
embeds a culture of quality and innovation across the organisation.
South Tyneside NHS Foundation Trust is committed to the promotion and conduct of
research. As a partner organisation of the North East and North Cumbria Local Clinical
Research Network (NENC LCRN) South Tyneside NHS Foundation Trust was awarded
approximately £470,555 to support and deliver NIHR Portfolio studies.
Research is underway in a number of clinical specialities, 504 patients had been
recruited to 39 NIHR Portfolio studies. The Trust had a target to recruit to 5 industry
trials in 2014/15 and have exceeded this target recruiting to 6 industry trials recruiting a
total of 52 patients to industry trials.
The table below outlines our recruitment by study to non-commercial portfolio studies
(recruitment data from the NIHR open data platform as at 10th April 2015, full
recruitment numbers for 2014/15 will not be available till after April 24th 2015)
Topic/
Specialty Group
Study Title
Ageing
Reform – a randomised trial of a multifaceted
podiatry intervention for fall prevention in patients
over 65
Mental Health
Anaesthesia
SIPs Jr RCT
A Sprint National Anaesthesia Project (SNAP) to
survey patient reported outcome after
anaesthesia in UK Hospitals
Adenoma Trial
Advanced endoscopic imaging strategies for
colitis surveillance
Chemoprevention of premalignant intestinal
neoplasia (ChOPIN) incorporating inherited
predisposition of neoplasia (IPOD) analysis of
genomic DNA from AspECT and BOSS clinical
trial
The establishment of a new generation
azathioprine metabolite monitoring test based on
white cells
A randomised controlled trial of eicosapentaenoic
acid (EPA) and/or aspirin for colorectal adenoma
Gastroenterology
31
Total
Number of
Patients
Recruited
2014/15
79
84
36
58
7
5
5
2
Topic/
Specialty Group
Cancer
Cardiology
Dermatology
Health Services
Research
Hepatology
Injuries and
Emergencies
Primary Care
Study Title
Total
Number of
Patients
Recruited
2014/15
(or polyp) prevention during colonoscopic
surveillance in the NHS Bowel Cancer Screening
Programme: The seAFOod (Systematic
Evaluation of Aspirin and Fish Oil) polyp
prevention trial
Predicting serious drug side effects in
gastroenterology
Investigation of the clinical, serological and
genetic factors that determine primary nonresponse, loss of response and adverse drug
reactions to Anti-TNF drugs in patients with active
luminal Crohn's Disease
A Randomized Active-Controlled Double-Blind
and Open Extension Study to Evaluate the
Efficacy, Long-term Safety and Tolerability of
TP05 3.2 g/day for the Treatment of Active
Ulcerative Colitis (UC)
Lungcast
Stampede
Cantalk
GLORIA - AF: Global Registry on Long-Term Oral
Anti-thrombotic TReatment In Patients with Atrial
Fibrillation (Phase II/III – EU/EEA Member States)
Pressure 2
Early evaluation of the Integrated Care and
Support ‘Pioneers’ in the context of the Better
Care Fund and the Integrated Care Policy
Programme
Investigation of the Genetic and Molecular
Pathogenesis of Primary Biliary Cirrhosis
The Effect of Exercise on Liver Lipid in People
with Fatty Liver with Moderate Alcohol Intake
A UK Collaborative Study to Determine the
Genetic Basis of Primary Sclerosing Cholangitis
(UK-PSC)
Tranexamic Acid for the Treatment of
Gastrointestinal Haemorrhage: An International
Randomised, Double Blind Placebo Controlled
Trial
PCRN2761 COPD
FIRST STEPS: Randomised controlled trial of the
effectiveness of the Group Family Nurse
Partnership (gFNP) programme compared to
routine care in improving outcomes for high risk
mothers and preventing abuse
32
2
1
1
2
1
1
44
8
1
4
3
1
12
1
7
Topic/
Specialty Group
Study Title
Reproductive
Health
Effect of folic acid supplementation in pregnancy
on preeclampsia -Folic Acid Clinical Trial (FACT)
A randomized, double-blind, placebo-controlled,
Phase III, international multi-centre study of 4.0
mg of Folic Acid supplementation in pregnancy
for the prevention of preeclampsia
Spot protein creatinine ratio (SPCr) and spot
albumin creatinine ratio (SACr) in the assessment
of pre-eclampsia: A diagnostic accuracy study
with decision analytic model based economic
evaluation and acceptability analysis
Induction of labour versus expectant
management for nulliparous women over 35
years of age
A randomised, double blind, multi-center,
placebo-controlled study to evaluate the efficacy,
safety, and tolerability of NT100 in pregnant
women with a history of unexplained recurrent
pregnancy loss
A randomised, double-blind placebo controlled
trial of the effectiveness of low dose oral
theophylline as an adjunct to inhaled
corticosteroids in preventing exacerbations of
chronic obstructive pulmonary disease (TWICS)
A Multicenter, Randomized, Double-Blind,
Placebo-Controlled Study to Evaluate the Safety
and Efficacy of Pulmaquin® in the Management
of Chronic Lung Infections with Pseudomonas
aeruginosa in Subjects with Non-Cystic Fibrosis
Bronchiectasis, including 28 Day Open-Label
Extension and Pharmacokinetic Substudy (Orbit
3)
A multicentre non-blinded randomised controlled
trial to assess the impact of Regular Early
SPEcialist symptom Control Treatment on quality
of life in malignant Mesothelioma “ - RESPECTMeso”
A Phase IIa, Randomized, Double-blind, Placebocontrolled, Parallel Group Study to Assess the
Safety and Efficacy of 28 Day Oral Administration
of BAY 85-8501 in Patients with non-Cystic
Fibrosis Bronchiectasis
Extras
Respiratory
Stroke
Limbs Alive – Monitoring of Upper Limb
Rehabilitation
33
Total
Number of
Patients
Recruited
2014/15
19
5
2
1
20
4
2
1
13
3
Topic/
Specialty Group
Study Title
A Very Early Rehabilitation Trial - A Phase III,
multi-centre, randomised controlled trial of very
early rehabilitation after stroke
RATULS: Robot Assisted Training for the Upper
Limb after Stroke
Reading comprehension in aphasia: The develop
ment of a novel
assessment of reading comprehension
Total
Number of
Patients
Recruited
2014/15
1
1
1
The number of patient receiving relevant health services provided or subcontracted by
South Tyneside NHS Foundation Trust in 2014/15 that were recruited during that period
to participate in research approved by a research ethics committee 438.
34
Research Performance Metrics
In the 2011 ‘Plan for Growth’ the Government outlined the need for a dramatic and sustained improvement in the performance of
providers of NHS Services in initiating and delivering clinical research and outlined two benchmarks against which all NHS providers
would be measured
Performance in Initiating Clinical Trials
The performance in initiating clinical trials benchmark monitors 70 days from receipt of a valid research application to recruitment of
the first participant in the trial. This data has to be submitted to the NIHR on a quarterly basis. The data outlined in the table below
outlines our performance in the first three quarters of 2014/15, during this time South Tyneside opened 8 clinical trials achieving the 70
day benchmark for 6 trials. The data for the last quarter will be submitted to the NIHR on 1st May 2016.
Name of Trial
(FACT) Effect of folic acid
supplementation
in
pregnancy on preeclampsia
– Folic Acid Clinical Trial – A
randomised,
double-blind,
placebo-controlled, Phase III,
international
multi-centre
study of 0.4mg Folic Acid
supplementation
in
pregnancy
to
for
the
prevention of preeclampsia
(FIND-UC)
Endoscopic
tromdal
imaging
vs
chromoendoscopy
as
surveillance
strategy
for
neoplasia in ulcerative colitis
(CRYSTAL) A prospective,
multi-centre,
12-week,
randomised open-label study
Date of
Receipt of
Valid
Research
Application
08/04/2014
Date of NHS
Permission
First Patient
Recruited?
Date of First
Patient
Recruited
Duration
between VRA
and NHS
Permission
Duration
between
VRA and
First Patient
Comments
14
Duration
between NHS
Permission
and First
Patient
35
22/04/2014
Yes
27/05/2014
49
Benchmark
achieved
28/04/2014
07/05/2014
Yes
27/05/2014
9
20
29
Benchmark
achieved
29/05/2014
03/06/2014
Yes
16/06/2014
5
13
18
Benchmark
achieved
35
Name of Trial
to evaluate the efficacy and
safety of glycopyrronium (50
mg od) in indacterol and
glycopyrronium
bromide
fixed-dose
combination
(110/50 mg od) regarding
symptoms and health status
in patients with moderate
chronic
obstructive
pulmonary disease (COPD)
switching from treatment with
any
standard
COPD
programme.
(RESPONSE) A randomised,
double-blind,
multi-centre,
placebo-controlled study to
evaluate the efficacy, safety,
and tolerability of NT100 in
pregnant women with a
history
of
unexplained
recurrent pregnancy loss
(RPL)
(RESPECT-MESO) A multicentre,
double-blind,
randomised controlled trial to
assess the impact of Regular
Early SPecialist Symptom
Control Treatment on quality
of
life
in
malignant
Mesothelioma
(ORBIT-3) A multi-centre,
randomised,
double-blind,
placebo-controlled study to
evaluate the safety and
efficacy of Pulmaquin® in the
Date of
Receipt of
Valid
Research
Application
Date of NHS
Permission
First Patient
Recruited?
Date of First
Patient
Recruited
Duration
between VRA
and NHS
Permission
Duration
between NHS
Permission
and First
Patient
Duration
between
VRA and
First Patient
Comments
16/06/2014
19/06/2014
Yes
24/06/2014
3
5
8
Benchmark
achieved
09/06/2014
18/06/2014
No
9
147
156
17/07/2014
22/07/2014
Yes
5
105
110
Benchmark
not
achieved –
no meso
patients
st
seen. 1
patient
recruited
Benchmark
not
achieved –
patient
consented
31/07/2014
36
Name of Trial
management of chronic lung
infections with pseudomonas
aeruginosa in subjects with
non-cystic
fibrosis
bronchiectasis, including 28
day open-label extension
and pharmacokinetic substudy
SIPs Jnr RCT – Developing
and
evaluating
alcohol
screening and interventions
for
adolescents
in
emergency departments
ADENOMA
Study
–
Accuracy of Detection using
Endocuff Optimisation of
Mucosal Abnormalities
Date of
Receipt of
Valid
Research
Application
Date of NHS
Permission
First Patient
Recruited?
Date of First
Patient
Recruited
Duration
between VRA
and NHS
Permission
Duration
between NHS
Permission
and First
Patient
Duration
between
VRA and
First Patient
Comments
within 30
days but
subsequent
ly not
eligible.
14/10/2014
16/10/2014
Yes
31/10/2014
2
18/11/2014
24/11/2014
Yes
24/11/2014
6
37
15
17
Benchmark
achieved
6
Benchmark
achieved
Performance in Delivering Industry Trials
The performance in delivering clinical trials benchmark measures recruitment of the target number of patients within the agreed time
(recruitment to time and target) for all industry studies. South Tyneside recruited to 6 industry studies, 5 of which were new industry
studies. All trials are still actively recruiting so it is not yet possible to say if time and target was achieved. The data outlined in the
table below outlines our performance in the first three quarters of 2014/15 during which we opened three new industry studies.
Name of Trial
Target
number of
patients
available
Target
Number of
patients
Date Agreed
to recruit
target
number of
patients
Trial Status
8
Date Agreed
to recruit
target
number of
patients
available
Yes
A prospective, multi-centre, 12-week, randomised open-label study to
evaluate the efficacy and safety of glycopyrronium (50 mg od) in indacterol
and glycopyrronium bromide fixed-dose combination (110/50 mg od)
regarding symptoms and health status in patients with moderate chronic
obstructive pulmonary disease (COPD) switching from treatment with any
standard COPD programme (CRYSTAL).
A randomised, double-blind, multi-centre, placebo-controlled study to
evaluate the efficacy, safety, and tolerability of NT100 in pregnant women
with a history of unexplained recurrent pregnancy loss (RPL) (RESPONSE)
A multi-centre, randomised, double-blind, placebo-controlled study to
evaluate the safety and efficacy of Pulmaquin® in the management of
chronic lung infections with pseudomonas aeruginosa in subjects with noncystic fibrosis bronchiectasis, including 28 day open-label extension and
pharmacokinetic sub-study (ORBIT-3)
Yes
11/06/2015
Open
Yes
5
Yes
15/02/2015
Open
Yes
3
Yes
31/03/2015
Open
38
Research Management and Governance (approval targets)
The Research & Development Team have approved 25 portfolio studies in 2015/16, 23
studies (92%) achieved the 15 day approval target. In addition 4 non-portfolio studies
were approved and 6 service evaluations have been processed by the Research &
Development Team.
39
2.5 Commissioning for Quality and Innovation (CQUIN) Payment Framework
A proportion of South Tyneside NHS Foundation Trust’s income in 2014/15 was
conditional upon achieving quality improvement and innovation goals agreed
between South Tyneside NHS Foundation 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 goals for 2014/15 and for the following 12 month
period are available at: www.stft.nhs.uk
The monetary total for the amount of income in 2014/15 conditional upon achieving
quality improvement and innovation goals is £3,486,317. The monetary total for the
associated payment in 2013/14 was £4,151,425.
Final reconciliation shows that for the full year we will have achieved over 98% for
the scheme.
40
41
2.6
Information on Care Quality Commission (CQC) Registration
South Tyneside NHS Foundation Trust is required to register with the Care Quality
Commission and its current registration status is registration in full, with no conditions. The
Care Quality Commission has not taken any enforcement action against South Tyneside
NHS Foundation Trust during 2014/15.
Activities that the trust is registered to carry out:
•
•
•
•
•
•
•
•
•
Accommodation for persons who require nursing or personal care
Diagnostic and screening procedures
Family planning services
Maternity and midwifery services
Nursing care
Personal care
Surgical procedures
Termination of pregnancies
Treatment of disease, disorder or injury
The South Tyneside NHS Foundation Trust has participated in special reviews or
investigations by the Care Quality Commission relating to the following areas during 2014/15.
• Review of health services for Looked after Children and Safeguarding in
Gateshead. This was a focused inspection which provided a narrative outcome
report reflecting the experiences of children and young people: making
recommendations for improvement rather than giving a rating.
South Tyneside NHS Foundation trust intends to take the following action to address the
conclusions or requirements reported by CQC:
• Support the development of a multi-agency action plan
South Tyneside NHS Foundation trust has made the following progress by 31st March 2015
in taking such action:
• The action plan is now in place.
Further information about our registration status can be found at www.cqc.org.uk
42
2.7 Customer Services
In 2014/15 a total of 210 people raised formal complaints with us as indicated below:
Q1
Q2
Q3
Q4
Total
2014/15
52
65
35
58
210
2013/14
60
73
42
46
221
2012/13
71
71
68
71
281
2011/12
64
57
55
71
247
2010/11
72
55
60
48
235
2009/10
70
77
60
70
277
During 2014/15 a total of 6 complainants referred their complaints to the Parliamentary and
Health Services Ombudsman.
To date, 5 reviews have been concluded by the Ombudsman, 4 with no case to answer and 1
with further actions recommended over and above those already taken by the Trust. These
actions are currently being carried out. We are awaiting the outcome of the one remaining
case.
2.8
Information on Data Quality
Good quality information underpins sound decision making at every level in the NHS and
contributes to the improvement of health care.
South Tyneside NHS Foundation Trust submitted records during 2014/15 to the Secondary
Uses service for inclusion in the Hospital Episode Statistics which are included in the latest
published data.
The percentage of records in the published data from months April 2014 to November 2014
are:
The percentage of records which included the patient’s valid NHS number was:



99.7% for admitted patient care;
99.9% for outpatient care and
99.2% for accident and emergency care
Valid General Practitioner Registration Code was:



100% for admitted patient care;
100% for outpatient care and
100% for accident and emergency care
During the year the Trust was selected along with over 40 other Trusts to be part of the
National Referral to Treatment Waiting List Data Validation Programme. This work identified
a number of recommendations for improvement nationally, as well as operational and training
issues within the Trust. The Programme identified a number of data quality issues,
particularly within the Patient Tracking List which the Trust acted upon towards the end of the
year.
43
2.9
Information Governance Assessment Report
South Tyneside NHS Foundation Trust Information Governance Assessment Report overall
score for 2014/15 was 79% and was graded green.
To facilitate our commitment to the better sharing of patient information, we have initiated two
new programmes of work which will run for most of the next three years. These programmes
will:
•
Deploy a new Electronic Patient Record (EPR) into community healthcare, based on
EMIS Web and including mobile working for staff such that Community and GP data
will be shared, and the quality of data captured will be driven up capture occurs at
point of treatment.
•
Deliver application integration across Health and Social Care in South Tyneside to
facilitate integrated ways of working with Council staff, as well as other HealthCare
organisations such as Northumberland Tyne and Wear NHS Foundation Trust.
In addition the Trust has continued to invest in delivering its Information Technology Strategy,
continuing to extend the use of electronic whiteboards and electronic discharge solution.
In progressing actions against the data quality plan we particularly expect to see further
progress from:
•
Extending the digital referral and reporting system to cover new services currently
requested on paper. This will have both an increase in the quality of service delivery
and in the quality of data gathered and recorded.
•
The Trust will invest in mobile technology for community nursing services, which in
conjunction with the community electronic patient record will allow patient care to be
recorded at time of the event even in the patient’s home.
2.10 Information on Clinical Coding
South Tyneside NHS Foundation Trust was not subject to the Payment by Results clinical
coding audit during 2014/15 by the Audit Commission.
Audits conducted during 2014/15 have been undertaken in accordance with the HSCIC
Clinical Classifications Service Clinical Coding Audit Methodology 2014/15 Version 8.0.
During the reporting period the error rates reported in the latest audit report for that period for
diagnoses and treatments coding (clinical coding) were:
•
•
•
•
Primary Diagnoses Incorrect
Secondary Diagnoses Incorrect
Primary Procedures Incorrect
Secondary Procedures Correct
10.00%
16.80%
6.87%
9.68%
44
All episodes within the audit sample were identified from:
•
•
•
•
Ambulatory Care discharges;
General Surgery specialty;
Trauma and Orthopaedics specialty; and
Where a sign or symptom code (R code) was a primary diagnosis
The results of the coding audits should not be extrapolated further than the actual sample
audited. South Tyneside NHS Foundation Trust will be taking the following actions to
improve data quality. We have developed an action plan on the basis of the
recommendations made in the audit report. Our plan supports continuous improvement in
the accuracy of our coding. We have begun work to improve the coding of patients in the St.
Benedict’s Hospice in Sunderland; this has been identified as a contributory factor to our
“SHMI” mortality rate, and we will mirror the assurance processes that are used in the coding
within the acute hospital.
45
2.11
Reporting Against Core Quality Indicators
The value and banding of the Summary Hospital-level
Mortality Indicator (SHMI) for the Trust
Measure:
Target:
Oct 2013 – Sep
2014
STFT Value:
118.3
STFT without
Hospice:
Not Available
STFT Band:
1
Highest National:
119
Lowest National:
59.0
Band 2 “as expected”
Jul 2013 – June
Apr 2013 – Mar
2014
2014
STFT Value:
STFT Value:
115.1
115.1
STFT without
STFT without
Hospice:
Hospice:
99.3
99.2
STFT Band:
STFT Band:
1
1
Highest National:
Highest National:
119.8
119.7
Lowest National:
Lowest National:
54.1
53.9
Jan 2013 – Dec
2013
STFT Value:
110.6
STFT without
Hospice:
95.9
STFT Band:
2
Highest National:
117.6
Lowest National:
62.4
SHMI is a ratio of the observed number of deaths to the expected number of deaths
for a provider. The observed number of deaths is the total number of patient
admissions to the hospital which resulted in a death either in hospital or within 30
days post discharge from the hospital.
South Tyneside NHS Foundation Trust considers that this data is as described for
the following reasons. The table above demonstrates our SHMI values and
bandings over several reporting periods. The data shows that until recently we
have consistently been banded at level 2 which suggested that our mortality rates
were ‘as expected’.
We have identified that the SHMI value for STFT is affected by the management of
St Benedict’s Hospice in Sunderland. If the data concerning those hospice patients
was removed from the SHMI calculation, the most recent data suggests that the
Trust SHMI value is ‘99’. The deterioration to a band 1 state has been discussed
with commissioners and NHS England, and can again be linked to St Benedict’s,
specifically the increase in the number of beds in a newly built facility, and the
reduction in admissions to the acute hospital.
South Tyneside NHS Foundation Trust intends to take the following actions to
improve this indicator, and so the quality of its services. Our Mortality Review
Group is responsible for scrutinising mortality and the work of individual
departmental mortality measures. Patient deaths are reviewed to identify any
concerns or areas where care could be improved in the future. The Mortality
Review Group also regularly audits the main mortality types included with the SHMI
calculation. These audits provide assurance and form the basis for further
investigations during the year by consultants in each area.
Data
Source
•
CHKS
https://indicators.ic.nhs.uk/webview/
46
Measure:
Target:
Oct 2013 – Sep 2014
STFT Value:
Not Available
Highest National:
Not Available
Lowest National:
Not Available
The percentage of patient deaths with palliative care
coded at either diagnosis or specialty level for the Trust
Band 2 “as expected”
Jul 2013 – June
2014
STFT Value:
26.1
Highest National:
49
Lowest National:
0.0
Apr 2013 – Mar
2014
STFT Value:
27.4
Highest National:
48.5
Lowest National:
0.0
Jan 2012 – Dec
2012
STFT Value:
26.6
Highest National:
46.9
Lowest National:
1.3
South Tyneside NHS Foundation Trust considers that this data is as described for
the following reasons. Some acute Trusts including ours provide specialist
palliative care inpatient services within designated wards, or within the community.
This potentially affects the SHMI value and means that it may be difficult to
compare one Trust with another.
The South Tyneside NHS Foundation Trust intends to take the following actions to
improve this indicator, and so the quality of its services:
Our Mortality Review Group is responsible for scrutinising mortality and the work of
individual departmental mortality measures. Patient deaths are reviewed by the
group to identify any concerns or areas where care could be improved in the future.
Our mortality data and SHMI rating is affected by the fact that our trust provides
specialist palliative care to the people of Sunderland and the surrounding areas at
St Benedict’s Hospice.
Data Source
•
CHKS
•
https://indicators.ic.nhs.uk/webview/
47
Measure
Patient Reported Outcome Measures (PROMS)
Value = EQ-5D
Varicose Vein
Surgery
Hip
Replacement
Surgery
Knee
Replacement
Surgery
Groin Hernia
Surgery
2014/15
2013/14
Trust Score:
N/A
N/A
National Average:
53.8
51.8
Trust Score:
Data Censored
82.9
National Average:
90.0
89.3
Trust Score:
Data Censored
77.9
National Average:
82.2
81.4
Trust Score:
47.1
56.3
National Average:
50.2
50.6
South Tyneside NHS Foundation Trust considers that this data is as described for
the following reasons. Varicose vein procedures is not a routine operation at STFT
and none were carried out during this reporting period. The number of hip and
knee replacement questionnaire pairs returned for STFT has been censored due to
small numbers. This is to protect patient confidentiality.
South Tyneside NHS Foundation Trust intends to take the following actions to
improve PROMs performance, and so the quality of its services. We will continue
to look specifically at the actual health gains from a pre-operative to post-operative
position. In an effort to mitigate the lack of feedback from the PROMs process the
orthopaedic department is committed to implementing the EQ-5D evaluation which
is the underpinning principle behind PROMs.
This is an integral part in the planned, “Enhanced Discharge Programme”
implemented within the Department during 2014-15. Patients throughout their
journey have their outcomes assessed using the EQ 5D principle, this is a live
process which will provide accurate feedback on the progress outcomes of patients
based on their feeling of their health.
Data
Source
HSCIC: http://www.hscic.gov.uk/proms
48
The percentage of patients aged:
- 0 to 15
- 16 or over
readmitted to a hospital which forms part of the Trust within 30
days of being discharged from a hospital which forms part of
the Trust.
Measure
Age 0 to 15
Age 16+
2013/14
2014/15
Readmission Rate
5.8%
5.8%
Peer Readmission Rate
8.4%
8.3%
Readmission Rate
5.7%
5.5%
Peer Readmission Rate
7.0%
6.9%
South Tyneside NHS Foundation Trust considers that this data is as described for the
following reasons. In order to demonstrate our performance for 30 day readmissions
against the national context, we have provided a comparison with data extracted from
the CHKS database. CHKS is a healthcare intelligence provider with whom a large
number of Trusts are registered nationally. The peer group shown in the table above
includes all registered CHKS Trusts.
South Tyneside NHS Foundation Trust has taken the following actions to improve this
readmission rate, and so the quality of its services, by showing that the data has been
provided for the last two reporting periods and demonstrates that our Trust compares
favourably with the peer group readmission rates in both age groups.
We continue to work with partner organisations in improving the resilience of the
systems across South Tyneside to reduce readmissions to hospital. A number of new
projects were implemented over the winter period, including enhancing rehabilitation
services.
It should be noted that the required core indicator within the Quality Accounts is
readmission within 28 days, however, the indicator that is currently reported to the
Board and Commissioners as above is 30 days and is based upon the National Tariff
Payment System definition. The 30 day indicator is calculated where the time between
discharge from the initial admission and readmission is equal or less than 30 days and
allows for additional exclusions that are not permitted under the Quality Accounts
definition. Performance in 2014/15 on 28 day readmissions is included on page 178.
Data Source
Data source: CHKS
49
Measure
Responsiveness to Patient Need
Survey of Adult Inpatients 2014 versus 2013
The South Tyneside NHS Foundation Trust considers that this data is as described for
the following reasons. The National Inpatient Survey is part of the NHS Patient Survey
Programme. The Trust was one of 78 organisations that commissioned Picker Institute
to undertake the 2014 National Inpatient Survey. A total of 850 patients from the Trust
were sent a questionnaire. 831 patients were eligible for the survey, of which 323
returned a completed questionnaire, giving a response rate of 39%. This is a 4%
increase in response rate compared to the 2013 survey. A total of 60 questions were
used in both the 2012 and 2013 surveys. This increased to 86 questions in the 2014
survey.
The survey results have indicated that we maintained good performance in
comparison with the previous year in the majority of areas, but have identified areas
for improvement in the information we provide to patients who are being discharged
from hospital, delays in hospital discharge and opportunities for people to rate the
quality of their experience and care. It is however very encouraging to note that we
performed significantly better than other organisations in nineteen of the indicators
people rated. These included privacy, respect and dignity, confidence in staff, trust
and involvement in decision-making about people’s treatment and care.
The South Tyneside NHS Foundation Trust intends to take the following actions to
improve this indicator, and so the quality of its services. We will continue to participate
in and measure our progress via the Annual Inpatient Survey. The next steps are to
develop an action plan to promote improvement where needed and to sustain the
areas of excellent practice. This process is now established as part of our standard
operational processes and going forward, assurance will be provided via reports to our
Executive Board.
Data Source
http://www.cqc.org.uk/provider/RE9/survey/3
50
Measure
The percentage of staff employed by, or under contract to, the trust
who would recommend the Trust as a provider of care to their family
or friends
South Tyneside NHS Foundation Trust considers that this data is as described for the
following reasons. The Annual National NHS Staff Survey asked all respondents
whether they would recommend our Trust to family and friends as a provider of care.
51
The results of the survey over the last two reporting periods demonstrate that we are
in line with the national average for this indicator. The results are reported as both
percentage scores and also as ‘scale summary’. Scale summary scores are
calculated by converting staff responses to particular questions into scores. For each
of these scale summary scores, the minimum score is always 1 and the maximum
score is 5.
South Tyneside NHS Foundation Trust intends to take the following actions to
improve this score, and so the quality of its services. We will continue to work as a
team to embed a culture of leadership which is founded upon compassionate, safe
and transparent care. In 2014 we launched our Choose to Lead Strategy. This sets
out South Tyneside NHS Foundation Trust’s (STFT) leadership development strategy
for 2014 to 2016 and incorporates the clinical leadership framework.
Data
Source
Measure
http://www.nhsstaffsurveys.com/Page/1019/Latest-Results/StaffSurvey-2014-Detailed-Spreadsheets/
The percentage of patients who were admitted to hospital and who
were risk assessed for venous thromboembolism
Value
2014/15
2013/14
Trust
Score
97.6%
95.01%
National
96%
96%
Average
South Tyneside NHS Foundation Trust considers that this data is as described for the
following reasons. All Trusts are required to report the proportion of documented VTE
risk assessments being conducted as a percentage of all admitted patients. The DH
national target requires that at least 90% of all admitted patients should receive a VTE
risk assessment. In 2014/15 we exceeded the national average.
South Tyneside NHS Foundation Trust intends to take the following actions to
improve this indicator/percentage and so the quality of its services. We intend to
continue to lead nationally in terms of VTE prevention through our Choose Safer Care
programme of work
Data
Source
http://www.england.nhs.uk/statistics/statistical-work-areas/vte/vte-riskassessment-2014-15/
52
Measure
The number, and where available, rate of patient safety incidents
reported within the Trust
01-10-14 to
31-03-15
01-04-14 to
30-09-14
01-10-13 to
31-03-14
01-04-13 to
30-09-13
Number (Rate
per 1,000 Bed
Days)
Number (Rate
per 1,000 Bed
Days)
Number (Rate
per 1,000 Bed
Days )
Number (Rate
per 100
Admissions)
Trust
Not Available
2,253 (38.52)
2,249 (37)
1,748 (9.39)
National
Average
Not Available
4,196 (35.9)*
2,185 (33.3)
2,052 (8.13)
Highest
Not Available
12,020 (74.96)
3,790 (74.9)
4,301 (17.1)
Lowest
Not Available
35 (0.24)
301 (5.8)
908 (3.9)
Period
n.b. Reported against Acute non-specialist hospitals. Data for 01/10/14 to 31/03/15
expected to be available September 2015
Measure
The number, and percentage of such patient safety incidents that
resulted in severe harm or death
Trust
Not Available
10 (0.4%)
5 (0.2%)
National
Average
Not Available
Highest
Lowest
7 (0.4%)
10.18 (0.60%)
7.64 (0.4%)
Not Available
74 (74.3%)
59 (7%)
56 (3.33%)
Not Available
0 (0%)
0 (0%)
0 (0%)
7.45 (0.40%)
South Tyneside NHS Foundation Trust considers that this data is as described for the
following reasons. The Trust actively promotes a culture in which the reporting of
incidents, errors and near misses is encouraged and used as a mechanism towards
improving the safety of our patients.
South Tyneside NHS Foundation Trust has taken the following actions to improve this
indicator, and so the quality of its services. All patient safety incidents are reported
electronically via the National Reporting and Learning System (NRLS) to the National
Patient Safety Agency (NPSA) which ensures that lessons from adverse incidents in
one locality are learned across the NHS as a whole. We believe and are committed
to the delivery of health care services of the highest quality where risks to patients,
staff and visitors are minimised.
Data
Source
http://www.nrls.npsa.nhs.uk/resources
53
Maximum Waiting Time of 62 days From Urgent GP Referral to
First Treatment for All Cancers
Measure
South Tyneside NHS Foundation Trust considers that this data is as described for
the following reasons. The chart above highlights our performance in 2014/15.
National guidance on improving outcomes indicates that over 85% of patients
should receive their first definitive treatment for cancer within two months (62-days)
of an urgent referral for suspected cancer. Our results for 2014-15 demonstrate
that we have reached or exceeded the 85% national target across the year.
The South Tyneside NHS Foundation Trust has taken the following actions to
improve this indicator, and so the quality of its services. In our previous quality
reports we have highlighted the challenge faced in terms of achieving this target.
This is largely due to the low numbers of patients through the Trust who count
towards the indicator, and the fact that we work collaboratively which means that
we would share a breach with the tertiary provider if a patient begins their journey
with the Trust. This in effect means that more than two breaches per month would
likely result in failure of this target.
•
Data
Source
Connecting for Health National Cancer Waiting Times Database:
http://www.connectingforhealth.nhs.uk/nhais/cancerwaiting
•
Open Exeter database
54
Measure
The rate per 100,000 bed days of cases of C. Difficile infection
reported within the Trust amongst patients aged 2 or over
Value
2014/15
2013/14
Trust Score:
National
Average:
Highest
National:
Lowest
National
7.8
12.2
Not Available
14.7
Not Available
37.1
Not Available
0
South Tyneside NHS Foundation Trust considers that this data is as described for
the following reasons. In 2014/15 we had 9 cases of Clostridium Difficile infection
against a target of 10. To set this in context, the above chart shows that the rate of
infection reported at South Tyneside NHS Foundation Trust compares extremely
favourably with the national average. The data demonstrates that we have
consistently reported below the national average of reported cases whilst also
ranking amongst the most effective healthcare providers for this indicator.
The chart below demonstrates our progress against our targets over several
reporting periods.
South Tyneside NHS Foundation Trust intends to take the following actions to
improve infection control rates, and so the quality of its services. Our Infection
Prevention and Control Team will continue to work alongside our hospital and
community teams to provide and monitor good practice in order to achieve the
targets set in all local patches.
Data
Source
•
https://www.gov.uk/government/statistics/clostridiumdifficile-infection-annual-data
55
3
An Overview of the Quality of Care
The data set below is included in our monthly performance report to the Trust Board. The indicators have been selected by our
board and key stakeholders on the basis that any non-compliance would adversely affect patient safety, clinical effectiveness and
patient experience. Many of these indicators are also either operational standards, or national or local quality requirements of the
NHS Standard Contract. Part three contains performance against national key priorities that have not already been reported in part
two.
3.1
Quality of Care Data
Patient Safety
Indicator 1
Fractured Neck
of FemurPatients
Operated on
Within 36 Hours
of Admission
Data Source
Internal
Integrated
Performance
Dashboard
Data Standard
Average
2013-14
Target
2014-15
Quarter 1
Average
Quarter 2
Average
Quarter 3
Average
Quarter 4
Average
Average
2014-15
75.6%
> 75%
73.2%
79.9%
76.4%
82.9%
78.1%
NICE CG124
As per 2014-15
NHS Standard
Contract
National Hip
Average
fracture
71.7%
Database
This is a quality requirement within the NHS Standard Contract. Fracture neck of femur (NOF) is associated
with significant morbidity and an estimated one-year mortality of 30%.
National Data
Reason for
Selection
56
Patient Safety
Indicator 2
Ambulance
Handover Time
in A&E (%
recorded using
handover
screens)
Reason for
Selection
Patient Safety
Indicator 3
Staff
Turnover
Stability of
Turnover
Relating to
Staff with >1
year of
Service.
Reason for
Selection
Data Source
Data Standard
Average
2013-14
Target
2014-15
Quarter 1
Average
Quarter 2
Average
Quarter 3
Average
Quarter 4
Average
Average
2014-15
Internal
Integrated
Performance
Dashboard
As per 2014-15
NHS Standard
Contract
76%
>90%
76.4%
75.3%
67.7%
60.8%
70.1%
This is a quality requirement within the NHS Standard Contract. In the majority of cases handovers happen
smoothly and are well managed, but it is recognised that there are still areas where dedicated work is
needed to reduce delays and improve the service offered to patients. Handover start time is defined as the
time of arrival of the ambulance at the accident and emergency department, with the end time defined as the
time of handover of the patient to the care of accident and emergency staff. The performance of the Trust
has been validated by the commissioners, and it is recognised that the number of non-NEAS ambulances
used to transport patients to our A&E department affects the maximum possible performance. We continue
to work with commissioners to understand where performance can be improved.
Data Source
Data Standard
Average
2013-14
Target
2014-15
Average
2014-15
Internal
Workforce
Performance
Dashboard
Local HR
Strategy
90.3%
90%
89.8%
This performance indicator is presented on a monthly basis to the Executive Board. There is a nationally
accepted and growing body of evidence that patient outcomes are linked to whether or not organisations have
the right people , with the right skills, in the right place at the right time. Following the publication of the report of
the Mid-Staffordshire NHS Foundation Trust Public Inquiry and the Keogh Reviews into 14 trusts with higher
than expected mortality levels, the importance of NHS Trusts making the right decisions with regard to safe
staffing levels is coming under increasing scrutiny. Staff turnover has a direct impact on staffing levels.
‘Turnover’ includes statistics on joiners to and leavers from the Trust within a specific time period based on
headcount. There has again been a significant number of staff leave the Trust under TUPE legislation following
57
Patient Safety
Indicator 3
Clinical
Effectiveness
Indicator 1
Breastfeeding
Initiation
Reason for
Selection
Average
Target
Average
2013-14 2014-15
2014-15
the loss of contracts to other providers i.e. Minor Injury Units in Sunderland, Substance Misuse in Gateshead.
The underlying stability is above target.
Data Source
Data Standard
Data Source
Data Standard
Average
2013-14
Target
2014-15
Quarter 1
Average
Quarter 2
Average
Quarter 3
Average
Quarter 4
Average
Average
2014-15
NHS England
Statistical Work
Areas / Maternity
& Breastfeeding
55.4%
>56.8
54.7%
48.4%
47.6%
52.1%
50.7%
Internal
Integrated
Performance
Dashboard /
Vital Signs
Monitoring
Report
Average
73.5%
Min
National Data
39.3%
Max
92.2%
This is a local quality requirement within the NHS Standard Contract. Breastfeeding has many health benefits
for both the mother and infant. To reduce infant mortality and ill health, WHO recommends that mothers first
provide breast milk to their infants within one hour of birth – referred to as “early initiation of breastfeeding”. This
ensures that the infant receives the colostrum (“first milk”), which is rich in protective factors. We continue to
work with mothers in both Maternity services and Health Visiting to improve initiation and maintenance of breast
feeding rates. South Tyneside Council have continued the funding of a Public Health Midwife into 2015/16 and
this will again contribute to identifying opportunities to improve practice.
58
Clinical
Effectiveness
Indicator 2
Improving
Access to
Psychological
Therapies –
Moving to
Recovery
Data Source
Data Standard
Average
2013-14
Target
2014-15
Quarter 1
Average
Quarter 2
Average
Quarter 3
Average
Quarter 4
Average
Average
2014-15
Internal
Integrated
Performance
Dashboard
http://www.hscic.
gov.uk/iapt
52%
50%
54.5%
53.5%
54.7%
55.4%
54.6%
Jan
45.1%
This is a local quality requirement within the NHS Standard contract. Improving Access to Psychological
Therapies (IAPT) is an NHS programme rolling out services across England offering interventions approved
by the National Institute of Health and Clinical Excellence (NICE) for treating people with depression and
anxiety disorders. The IAPT programme is designed to support the NHS in delivering a number of goals
including increased health and well-being, with at least 50% of those completing treatment moving to recovery
and most experiencing a meaningful improvement in their condition. The IAPT Data Standard constitutes a
framework through which patient recovery is recorded and monitored.
Performance in both of our services - Gateshead and South Tyneside - has exceeded national targets in
2014/15 and seen both recognised nationally. Targets for waiting times and access numbers has also
exceeded their respective national targets.
National Data
Reason for
Selection
Clinical
Effectiveness
Indicator 3
Health Visitor
Numbers –
Additional
Numbers
Employed
Reason for
Selection
Data Source
Data Standard
Average
2013-14
Target
2014-15
Quarter 1
Average
Quarter 2
Average
Quarter 3
Average
Quarter 4
Average
Average
2014-15
Health Visitors
Minimum Dataset
(Health and
174.8
180.0
177.4
175.9
179.5
179.3
178.0
Social Care
Information
Centre)
The Health Visitors Minimum Data Set has been set up to help support the government's commitment to
improve the health visiting service and recruit 4,200 more health visitors nationally by 2015. Our internal data
is submitted to the Health and Social Care Information Centre (HSCIC), via the Omnibus Survey. A registered
59
Internal
Integrated
Performance
Dashboard
Health Visitor refers to a qualified nurse/midwife who is also registered on the third part of the register as a
Health Visitor.
The actual number of staff employed fluctuates as leavers and new starters occur each month. However the
underlying position was that we achieved the target.
Clinical
Effectiveness
Indicator 4
Proportion of
Patients Who
Spend More
than 90% of
Their In-patient
Stay on a Stroke
Unit.
Reason for
Selection
Data Source
Data Standard
Average
2013-14
Target
2014-15
Quarter 1
Average
Quarter 2
Average
Quarter 3
Average
Quarter 4
Average
Average
2014-15
Internal
Integrated
Performance
Dashboard
National Stroke
Strategy
NICE QS2
VSMR Guidance
85%
80%
59%
73%
80%
58%
67%
Over the last 20 years evidence has accumulated which will allow more effective primary and secondary
prevention strategies for stroke patients. We are now more able to recognise people at the highest risk and
who are most in need of active intervention. There is also now good evidence to support interventions and
care processes in stroke rehabilitation. In the UK, the National Sentinel Stroke Audits have documented
changes in secondary care provision over the last 10 years, with increasing numbers of patients being treated
in stroke units, more evidence-based practice, and reduced mortality and length of hospital stay. In addition
to other measures, Trusts are assessed by the proportion of stroke patients who spend more than 90% of
their in-patient stay on a stroke unit.
Performance in quarter 4 was particularly affected by pressures on bed availability across the wider hospital.
This restricted the ability to ensure stroke patients moved directly to the unit from A&E.
The data above has been recalculated at the year end from a revised data set. The actual performance
against target may therefore differ to what was reported to the Board during the year.
60
Patient
Experience
Indicator 1
Data Source
Cancellation of
Elective
Operations
Internal
Integrated
Performance
Dashboard /
Unify2
Data
Standard
Total
2013-14
Target
2014-15
Quarter
1
Quarter
2
Quarter
3
Quarter
4
Total
2014-15
81
0
23
13
55
105
196
National
Standard
Department
of Health
(DH)
Average 123
Min 0
Max 648
This is a national operational standard requirement within the NHS Standard Contract. Cancelled operations
are a waste of resources and time. They bring the additional administrative burden of re-scheduling
appointments or a blank theatre slot. They are distressing and inconvenient for patients, and when the
patients themselves cancel operations, they can also be problematic for the hospital. Identifying the different
type of cancellations, understanding the reasons and then tackling them appropriately, improves the
throughput of patients along the patient pathway.
Department of Health (DH) guidelines say that patients who have their operation cancelled (for a non-clinical
reason) on the day of surgery should be readmitted within 28 days. If a patient has not been treated within 28
days of a cancellation then this is recorded as a breach of the standard and the patient should be offered
treatment at the time and hospital of their choice. There were no patients at STFT who were not offered an
alternative date within 28 days during this reporting period.
Performance in quarter 3 and quarter 4 was affected by emergency admission pressures on beds; this
restricted the number of beds available for elective operations. We will continue to work to improve our winter
resilience, in partnership with all other stakeholders in the urgent care pathways, and to improve our
emergency planning for winter.
National
Data
Reason for
Selection
61
Patient
Experience
Indicator 2
Percentage of
Women who
have Seen a
Midwife by 12
Weeks and 6
Days of
Pregnancy
Reason for
Selection
Data Source
Data
Standard
Average
2013-14
Target
2014-15
Quarter
1
Average
Quarter
2
Average
Quarter
3
Average
Quarter 4
Average
Average
2013-14
Internal
Integrated
Performance
National
Dashboard /
Standard
90.1%
>90%
92.1%
89.6%
91.8%
89.6%
90.7%
https://indicat
(DH)
ors.ic.nhs.uk/
webview/
National Data
94.2%
This is a local quality requirement within the NHS Standard contract. All women should access maternity
services for a full health and social care assessment of needs, risks and choices by 12 weeks and 6 days of
their pregnancy to give them the full benefit of personalised maternity care and improve outcomes and
experience for mother and baby. Reducing the percentage of women who access maternity services late
through targeted outreach work for vulnerable and socially excluded groups will provide a focus on reducing
the health inequalities these groups face whilst also guaranteeing choice to all pregnant women.
Patient
Experience
Indicator 3
Data Source
Choose and
Book Slot
Utilisation
Issues
Internal
Integrated
Performance
Dashboard/
Choose and Book
National System
and Reports
Reason for
Selection
This is a quality requirement within the NHS Standard Contract with a target of < 4%.
Patients should always be able to book an appointment at their chosen provider using the Choose and Book
system when the service is a directly bookable service. In order to support this the Trust has a target to
ensure sufficient appointment slots available on choose & book at least 96% of the time. Performance is
measured through data collection relating to slot utilisation issues against a 4% or less target.
Performance was adversely affected by availability of consultants in a small number of clinical specialties.
Additional clinics were put in place and recruitment of medical staff continued.
Data
Average
Standard 2013-14
Choose
and Book
Best
Practice
Guidance
5.2%
Target
2014-15
Quarter
1
Average
Quarter
2
Average
Quarter 3
Average
Quarter
4
Average
Average
2014-15
<4.0%
12.2%
21.3%
14.4%
6.2%
13.7%
62
3.2
Key National Priorities 2014/15
The Risk Assessment Framework from Monitor includes key national targets and
thresholds for achievement. The Trust’s performance in 2014-15 against those not
covered elsewhere in this Quality Report is shown below.
Risk Assessment Framework Indicator
A&E: maximum waiting time of four hours from
arrival to admission/ transfer/ discharge
Maximum time of 18 weeks from point of referral
to treatment in aggregate - admitted
Maximum time of 18 weeks from point of referral
to treatment in aggregate – non admitted
Maximum time of 18 weeks from point of referral
to treatment in aggregate – patients on an
incomplete pathway
Cancer: 62-day wait for first treatment from NHS
Cancer Screening service referral
Cancer: 62-day wait for treatment from urgent
GP referral
Cancer:31-day wait for second or subsequent
treatment, comprising surgery
Cancer:31-day wait for second or subsequent
treatment, comprising anti-cancer drug
treatments
Cancer:31-day wait for second or subsequent
treatment, comprising radiotherapy
Cancer: 31-day wait from diagnosis to first
treatment
Cancer: two week wait from referral to date first
seen - all urgent cancer referrals (cancer
suspected)
Cancer: two week wait from referral to date first
seen – for symptomatic breast patients (cancer
not initially suspected)
Certification against compliance with
requirements regarding access to health care for
people with a learning disability
Data completeness: community services –
referral to treatment information
Data completeness: community services –
referral information
Data completeness: community services –
treatment activity information
Target
95%
Actual
94.5%
90%
95.6%
95%
98.7%
92%
95.1%
90%
Comments
See below
Not
Applicable
85%
88.9%
94%
100%
98%
100%
94%
Not
Applicable
96%
100%
93%
95.9%
93%
Not
Applicable
N/A
Compliant
50%
60.8%
50%
75.9%
50%
65.0%
As a result of exceptional winter emergency pressures experienced across all of the
NHS the Trust breached the A&E target in Q3 and Q4 of 2014/15. As a response to
this pressure, the Trust operated on a command and control basis for much of
January and February to ensure patient safety and experience was appropriately
63
maintained. The performance at the start of Q1 has significantly improved and the
Board is confident that the target will be met during 2015/16.
As noted in section 2.8 the National Referral to Treatment Waiting List Data
Validation Programme identified some data quality issues with Referral to Treatment
data. Whilst those identified have been addressed and not all will impact on the
above reported performance the Trust’s External Auditors are unable to provide
assurance on these figures.
The Trust’s performance in 2014-15 on other national indicators not covered
elsewhere in this Quality Report is shown below.
Other National Indicators
Emergency readmissions within 28 days of discharge from
hospital
Actual
12.76%
The above performance is based upon the Quality Accounts definition for emergency
readmissions within 28 days of discharge from hospital. This differs from the
indicator of 30 days reported monthly to the Board of Directors and Commissioners
included on page 163 which is based upon the National Tariff Payment System
definition. The National Tariff Payment System definition is calculated where the
time between discharge from the initial admission and readmission is equal or less
than 30 days and allows for additional exclusions that are not permitted under the
Quality Accounts definition.
64
Annex 1: Statements from commissioners, local Healthwatch
organisations and Oversight and Scrutiny Committees
Where 50% or more of the relevant health services that the NHS Foundation Trust
directly provides or sub-contracts during the reporting period are provided under
contracts, agreements or arrangements with NHS England, the Trust must provide a
draft copy of its quality accounts/report to NHS England for comment prior to
publication
Where this is not the case, a copy must be provided to the clinical commissioning
group (CCG) which has responsibility for the largest number of people to whom the
trust has provided relevant health services during the reporting period for comment
prior to publication and should include any comments made in its published report.
NHS foundation trusts must also send draft copies of their quality accounts/report to
their local Healthwatch organisation and oversight and scrutiny committee for
comment prior to publication.
The commissioners have a legal obligation to review and comment, while local
Healthwatch organisations and OSCs are offered the opportunity on a voluntary
basis.
South Tyneside NHS Foundation Trust made copies of its draft quality account
report available to South Tyneside CCG (as lead commissioner for local CCGs), and
to the OSCs and Healthwatch organisations in South Tyneside, Sunderland and
Gateshead.
65
Feedback on Our 2014/15 Quality Report
Statement from the Commissioners: South Tyneside Clinical Commissioning
Group, Sunderland Clinical Commissioning Group and Gateshead Clinical
Commissioning Group.
Thank you for sharing the Trust’s quality report. The Clinical Commissioning Groups
welcome the opportunity to review and provide commentary on the Quality Account
for 2014/15.
As commissioners, South Tyneside (STCCG), Gateshead (GCCG) and Sunderland
Clinical Commissioning Group (SCCG) are committed to commissioning high quality
services from South Tyneside Foundation Trust (STFT) and take seriously their
responsibility to ensure that patients’ needs are met by the provision of safe, high
quality services and that the views and expectations of patients and the public are
listened to and acted upon.
Throughout 2014/15, the CCGs held bi-monthly clinical quality review group
meetings with the Trust; these meetings were well attended and provided positive
engagement for the monitoring, review and discussion of quality issues. STCCG is
participating in the joint board visits with the Trust, to gain assurance on the quality
of services provided, and is working with the Trust to implement commissioner-led
unannounced assurance visits to monitor the quality of the services provided and to
encourage continuous quality improvement.
The report provides a comprehensive description of quality improvement work within
the Trust and an open account of where improvements in priorities have been made.
We appreciate the amount of work involved in producing this report however it is an
important step in improving public accountability in relation to quality.
The CCGs recognise the work the Trust has achieved to date in the delivery of the
2014/15 priorities and in the on-going delivery of the quality measures. We would like
to congratulate the Trust on its achievement in 2014 in being named as one of the
best places to work in the NHS by the Heath Service Journal, and its positive
leadership strategy in making leadership part of everyone’s role alongside the Board
recommitment to the ‘Hello my name is…’ campaign.
We would like to thank the Trust for working collaboratively with the CCGs regarding
mortality, and acknowledge their open and honest sharing of work carried out to
date, as well as on-going work streams.
The CCGs would like to draw attention to the innovative use of technology across
the Trust, for example the use of e-Rostering and the Safer Care Nursing Tool to
ensure optimum staffing and capability, improving visibility of staffing levels and the
implementation of Key Performance Indicators to ensure nursing establishment
reflects the patient’s needs in terms of acuity and dependency. In addition to this, we
note the investment and commitment by the Trust, to improve data quality and data
sharing between primary and community care as well as Health and Social Care.
66
We recognise the improvements in efforts to engage with staff using a variety of
social media and look forward to receiving further information around outcomes, as
this approach develops. In addition to this it is encouraging to see that staff have
been increasingly involved in the development and delivery of key metrics showing
that the Trust has adopted a ‘Board to Ward’ approach, as well as staff involvement
in Continuous Improvement projects with the resulting benefits shared across the
organisation.
The CCGs acknowledge the assurance provided by the Trust of the robust
processes in place for the investigation of serious incidents and sharing of lessons
learned at team, ward and organisational level, and recognise the improvements
made in key areas as a result of contributory factors in these incidents. It was
disappointing that the report did not also detail improvements made or lessons
learned as a result of patient feedback through complaints, which we note have seen
a year on year reduction since 2012/13.
We would like to congratulate the Trust on the work done to date to improve
transparency and availability of information in the public arena with the publication of
‘Open and Honest Care’, and the use of visibility walls to display safer staffing data
and patient safety metrics across the Trust. The CCGs look forward to receiving the
outcomes of the North East Patient Safety Collaborative initiative to decrease the
number of pressure ulcers by 50%.
The CCGs recognise the improvements made to increase patient engagement within
the Trust in an effort to gather feedback on services, with the introduction of the
CAPI facilitator, although it was disappointing that the report did not highlight any
outcomes or interventions as a result of patient feedback.
South Tyneside, Gateshead and Sunderland CCGs welcome the Trusts specific
priorities for 2015/16 and consider that these are appropriate areas to target for
continued improvements which link to the CCGs commissioning priorities. It was of
particular interest to note that these quality priorities reflect a focus on patient safety,
continuous improvement and transparency. It is also noted that the number of
priorities have been reduced to 4 compared to 10 in 2014/15, which will ensure that
resources will be more focused upon meaningful achievement. The CCGs are
assured that these priorities were developed in conjunction with key stakeholders,
including staff and patients.
Overall the report is well written and presented and is reflective of quality activity
across the organisation. As required under the Quality Report Regulations, staff
within the CCGs have checked the accuracy of data relevant to the contract. In so far
as we have been able to check the factual details, the CCGs view is that the report is
materially accurate. It is clearly presented in the format required by NHS England
and the information it contains accurately represents the Trust’s quality profile.
67
The CCGs look forward to continuing to work in partnership with the Trust to assure
the quality of services commissioned in 2015/16.
Yours sincerely
Ann Fox
Director of Nursing Quality and Safety
South Tyneside CCG
68
Response from Healthwatch Gateshead - 12-05-15
Healthwatch Gateshead – Response to South Tyneside NHS
Foundation Trust Quality Accounts 2014/15
Healthwatch Gateshead welcome the opportunity to comment on the Quality report
for South Tyneside NHS Foundation trust 2014/15.
As a consumer champion we are always looking to see how our local healthcare
providers can learn, improve and build upon patient experience. We are particularly
pleased to see and acknowledge the work undertaken to improve patient feedback
and how the trust is using that feedback to learn and improve its services, with a
clear emphasis on safety.
We acknowledge progress as reported by the trust under many of its priorities. We
are pleased to see that the trust has signed up to the ‘sign up to safety’ campaign
and reports a good track record already of achieving against the five key pledges.
We also acknowledge and support the work being undertaken under priority 10
where key information about safety quality and experience is shared across bedded
areas and community teams.
Overall we are pleased to see how the trust is clearly making good progress in
learning from the experience of their patients and that they have made a
commitment to fully implementing the Duty of Candour requirements under its
priorities for 2015/16
Healthwatch Gateshead
69
Response from Healthwatch South Tyneside 14-05-15
South Tyneside NHS Foundation Trust (the Trust) Quality Report 14/15
Healthwatch South Tyneside (HWST) Response
HWST has noted the introduction of e-rostering and the SCNT tool kit in relation to
safer staffing levels. HWST acknowledges the achievement of the Trust on being
identified as one of the best places to work in the NHS in 2014. HWST welcomes
that the Trust signed up to the “My Name is...” campaign and that its staff embraced
this initiative; HWST considers this will personalise and improve the patient
experience of provision.
HWST is pleased to note that the use of the Safety Thermometer is becoming further
embedded within the Trust’s clinical provision. HWST will be interested to see how
the patient safety dashboard develops and any outcomes from its implementation.
HWST notes the progress in terms of continuous improvement and the ASSURED
methodology that was shared with other Trusts as an NHS innovation.
HWST consider that the Trust investing in new technology will improve information
access for the public and look forward to downloading the Trust App. However
HWST hopes that there will still be “Friends and Family” alternatives available for
those people who are not comfortable with technology.
HWST applaud the inroads the Trust has made with improving staff awareness of
Dementia through “Barbara’s Story”. NHS Change Day sounds like a good
motivational tool and appears to have enhanced staff involvement and development.
HWST is pleased that the Trust has put in place the Fallsafe and SKKIN care
bundles to reduce falls and pressure ulcers respectively as these are highlighted in
the Serious Incidents. HWST hopes to see a corresponding reduction in these as
these become embedded in clinical culture.
HWST note that the Trust has introduced the Care Certificate training and that this
year 20 new starters have been trained.
HWST will be contacting the Trust’s Carer and Patient Involvement Team to look at
how we tie in with them in terms of patient and carer stories. We are also interested
in further looking at how and where the Trust uses assistive technology for patient
feedback.
HWST is disappointed that the training for staff around carer support and awareness
was put on hold this year, even though we appreciate that the LA are producing
training in relation to this.
We are pleased to see that the community safety metrics are now available to
people on line. HWST has noted the research and clinical trials data. The Trust
appears to have performed well against the CQUIN targets.
HWST is unable to comment on: rates of patient safety incidents and rates of patient
safety incidents that resulted in severe harm or death as the figures are not yet
available. The Trust appears to have performed above the key national priorities.
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HWST looks forward to working with the Trust to continue to improve services for the
people of South Tyneside in 2015/16.
Jan Pyrke, Development Officer, 14th May 2015
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Response from South Tyneside Council Oversight & Scrutiny Committee
Dear Lorraine
Thank you for giving us the opportunity to comment on your Quality report for
2014/15.
We realise that it has been an extremely difficult year for the Trust, in common with
many others around the country, in dealing with the high numbers of admissions
during the winter. The transfer of specialist palliative care to ward 22 to enable staff
to be seconded to help cope with an increase in emergency admissions illustrated
how difficult it has been to cope with rising demand in busy winter periods. We do
hope that temporary measures such as this do not become more frequent and a
more robust contingency is possible.
We are very excited about the construction of the Integrated Care Hub on the South
Tyneside General Hospital site. This will be a hugely needed focal point for the care
of older people in the Borough, particularly those with Dementia.
However, coupled with plans to move the Walk-in Centre from Jarrow to the General
Hospital site, we are concerned that the extra volume of cars on site will overwhelm
the sites car parks. We would welcome representation from the Trust to our People
Select Committee to explain how this issue is being addressed.
We continue to enjoy a very strong and honest relationship with South Tyneside
Foundation NHS Trust and hope that this continues in the future. In particular we
would like to thank yourself for the respect that you have shown for the democratic
process and wish you well in your future endeavours.
Cllr John McCabe
Response from Sunderland City Council Oversight & Scrutiny Committee
Thank you for the opportunity to comment on your 2014/15 Quality Report which
provides a good account of services and the performance achieved during the past
year.
The experience of Scrutiny Councillors is that the Trust demonstrates a strong
commitment to patient safety and high quality care.
Sunderland Scrutiny Councillors are happy to endorse the priorities set out for
2015/16 in the Trust’s draft Quality Report. In delivering those ambitions, Scrutiny
Members are keen to work with the Trust on areas of joint responsibility; particularly
where change will benefit Sunderland residents.
Overall, we would like to thank you for presenting your report and look forward to a
further year of quality and safety improvements
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Response from Gateshead Council Oversight & Scrutiny Committee
Based on Gateshead Care, Health and Wellbeing OSC’s knowledge of the work of
the Trust during 2014-15 we feel able to comment as follows:Previously the OSC has sought reassurance that the Trust’s priorities are connected
to Gateshead JSNA and reflect local need and that they receive more information
about community services being provided for Gateshead residents.
The OSC acknowledges the efforts of the Trust to provide information to the OSC
about community services in Gateshead but is disappointed that the national
approach to the format and content of Quality Accounts focuses mainly on acute
services meaning that the account provides little comparative information regarding
the provision of community services in Gateshead and other localities covered by the
Trust.
The OSC is supportive of the overall Account and the priorities outlined for 2015-16.
The OSC is pleased to note that CQC has no compliance issues in regard to the
Trust.
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Response from Governors
From: Pat Anthony [mailto:pat.anthony@blueyonder.co.uk]
Sent: 14 May 2015 16:39
To: Walker Malcolm
Subject: RE: Quality Account 2014/15
Dear Malcolm,
Thank you for your letter.
I confirm the contents to be an accurate account of our meeting. I confirm that
“Time on a Stroke Unit” is the 3rd Indicator chosen to be reviewed.
I would like to thank you for your detailed (and lengthy) explanation of the report, and
thank Mike for his contribution and explanations. It was all very informative, and
enjoyable to hear of the progress made since the last Quality Accounts/Report, and I
congratulate all those involved.
Kind Regards
Pat Anthony
From: GEORGE SCOTT [mailto:tomscott@blueyonder.co.uk]
Sent: 13 May 2015 23:30
To: Walker Malcolm
Cc: pat.anthony@blueyonder.co.uk; Burn Diane
Subject: Re: Quality Account 2014/15
Hi Malcolm,
Thank you for a very interesting and informative meeting today in which we went
through the Quality Account for 2014/15 in detail and with much discussion. Thank
you for receiving the comments made by Pat and myself with patience and for
adding to the document where necessary as a result of with those comments.
Following your explanation regarding the third indicator to be reviewed in the Quality
Account I can confirm our acceptance this should be the “Time on a Stroke Unit”
which is an important and challenging issue to address.
Regards, Tom Scott
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Annex 2: Statement of Directors’ responsibilities for the quality
report
The Directors are required under the Health Act 2009 and the National Health
Service (Quality Accounts) Regulations to prepare Quality Accounts for each
financial year.
Monitor has issued guidance to NHS foundation trust boards on the form and content
of annual quality reports (which incorporate the above legal requirements) and on
the arrangements that NHS foundation trust boards should put in place to support
the data quality for the preparation of the quality report.
In preparing the Quality Report, directors are required to take steps to satisfy
themselves that:
•
•
the content of the Quality Report meets the requirements set out in the NHS
Foundation trust Annual Reporting Manual 2014/15 and supporting guidance
the content of the Quality Report is not inconsistent with internal and external
sources of information including:
o board minutes and papers for the period April 2014 to 21st May 2015
o papers relating to Quality reported to the the board over the period
April 2014 to 21st May 2015
o feedback from commissioners dated 13/05/2015
o feedback from governors dated 13/05/2014
o feedback from local Healthwatch organisations dated 14/05/2015
o Feedback from Overview and Scrutiny Committee dated 14/05/2015
o The trusts complaints report published under regulation 18 of the Local
Authority Social Services and NHS Complaints Regulations 2009,
dated 04/06/2015
o The 2014 national patient survey 21/05/2015
o The 2014 national staff survey 16/04/2015
o The Head of Internal Audit’s annual opinion over the trust’s control
environment dated 21/05/2015
o CQC Intelligent Monitoring Report dated 25/11/2014
o The Quality Report presents a balanced picture of the NHS foundation
trust’s performance over the period covered
o The performance information reported in the Quality Report is reliable
and accurate
o There are proper internal controls over the collection and reporting of
the measures of performance included in the Quality Report, and these
controls are subject to review to confirm that they are working
effectively in practice
o The data underpinning the measures of performance reported in the
Quality report is robust and reliable, conforms to specified data quality
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standards and prescribed definitions, is subject to appropriate scrutiny
and review and
o The Quality report has been prepared in accordance with Monitor’s
annual reporting guidance (which incorporates the Quality Accounts
regulations) (published at at www.monitor.gov.uk/annualreportingmanual)
as well as the standards to support data quality for the preparation of
the Quality Report (available at
www.monitor.gov.uk/annualreportingmanual).
The Directors confirm to the best of their knowledge and belief they have complied
with the above requirements in preparing the Quality Report.
By order of the board
P Davidson
Chairman
Date: 21 May 2015
L B Lambert
Chief Executive
Date: 21 May 2015
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Glossary of Terms
Board of Directors
A board of directors is a body of elected or appointed members who jointly oversee
the activities of an organisation.
Care Quality Commission (CQC)
The CQC is the independent regulator of all health and adult social care in England.
The primary role of the CQC is to ensure that hospitals, care homes and care
services are meeting national standards.
Commissioning for Quality and Innovation (CQUIN)
The CQUIN framework is an incentive scheme which enables commissioners to
reward excellence by linking a proportion of English healthcare provider’s income to
achievement of local quality improvement goals.
Commissioners / Clinical Commissioning Groups (CCGs)
Clinical Commissioning Groups (CCGs) in each local area are made up of doctors,
nurses and other professionals coming together to use their knowledge of local
health needs to commission the best available services for patients. They have the
freedom to innovate and commission services for their local community from any
service provider which meets NHS standards and costs – these could be NHS
hospitals, social enterprises, voluntary organisations or private sector providers.
Clinical Audit
Clinical audit is a process that aims to improve patient care and outcomes through
systematic review of care against agreed standards implementation of identified
improvements.
Clostridium Difficile (C.Diff)
Clostridium Difficile is is a species of Gram-positive bacteria that occurs naturally in
the gut. Approximately two-thirds of children and 3% of adults test positive for C Diff.
The bacteria are harmless in healthy people but can cause severe diarrhoea and
other intestinal disease when competing bacteria in the gut flora have been wiped
out by antibiotics.
Datix
Datix is an electronic risk management software system which allows incident forms
to be completed electronically by all staff. The use of this technology allows greater
transparency and trend analysis in addition to improving access to the reporting
system
Department of Health (DH)
The Department of Health is a department of the UK government with responsibility
for government policy in England on health, social care and the NHS.
Foundation Trust (FT)
A Foundation Trust is a type of NHS organisation which have a significant amount of
managerial and financial freedom when compared to NHS hospital trusts. Although
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still part of the wider NHS, they have greater level of autonomy in setting strategic
goals. Similar to the concept of ‘co-operatives’ local people, patients and staff can
become members and governors and hold the Trust to account.
Healthcare- acquired infection (HCAI)
This is an infection that occurs as a result of the healthcare that a person receives.
Meticillin- Resistant Staphylococcus Aureus (MRSA)
MRSA is a bacterium which has developed resistance to a range of antibiotics
including penicillin. MRSA is therefore responsible for several difficult to treat
infections in humans. MRSA is often associated with clinical care as patients with
invasive devices such as central lines, open wounds and reduced immunity are more
at risk of infection than the general public.
Monitor
Monitor is the independent regulator of NHS Foundation Trusts. It is independent of
central government and directly accountable to parliament.
National Institute for Health and Care Excellence (NICE)
Previously known as the National Institute for Health and Clinical Excellence,
following the Health and Social Care Act 2012, NICE was renamed the National
Institute for Health and Care Excellence on 1 April 2013 and changed from a special
health authority to a non-departmental public body. The primary role if NICE is to
provide guidance and quality standards. NICE makes recommendations to the NHS
on clinical treatments and medicines and also makes recommendations to the NHS,
local authorities and other organisations involved in healthcare on how to improve
people’s health and prevent illness.
National Patient Survey
The NHS patient survey programme systematically gathers the views of patients
about the care they have recently received because listening to patients' views is
essential to providing a patient-centred health service.
National Patient Safety Agency (NPSA)
The National Patient Safety Agency is an arm’s length body of the Department of
Health which promotes improved, safe patient care by informing, supporting and
influencing the health sector.
Overview and Scrutiny Committee
Overview and Scrutiny Committees are local authority bodies with statutory roles and
powers to review local health services. They help to plan services and implement
change to make the NHS more responsive to local communities.
Pressure Ulcers / Pressure Sores
Pressure ulcers are also known bed sores. They occur when the skin and underlying
tissue becomes damaged as a result of reduced mobility combined with pressure
applied to soft tissue so that blood flow to the soft tissue is completely or partially
obstructed. Most commonly pressure ulcers occur to the sacrum, coccyx, heels or
the hips, but other sites such as the elbows, knees, ankles or the back of the
cranium can also be affected.
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Risk Assessment
This is a methodology used to protect patients and staff from harm. It is a systematic
examination of what could cause harm to allow us to weigh up if we have taken
enough precautions or should do more to prevent harm.
Root Cause Analysis (RCA)
RCA is a method used to solve problems by attempting to identify and correct the
root causes of events, as opposed to simply addressing their symptoms. RCA is
generally used in a learning culture to drive continuous improvement. By focusing
correction on root causes, problem recurrence can be prevented. Following RCA we
share learning with staff across the hospital to inform our practice and help prevent
further reoccurrence.
Safety Thermometer
The NHS Safety Thermometer is a local improvement tool for measuring, monitoring
and analysing patient harms and 'harm free' care. The tool provides a quick and
simple method for surveying patient harms and analysing results so that we can
measure and monitor local improvement and harm free care over time.
The “6C’s”
The Chief Nursing Officer's “6 Cs” are Care, Compassion, Competence,
Communication, Courage and Commitment
Venous Thromboembolism (VTE)
A venous thrombosis is a blood clot (thrombus) that forms within a vein. Thrombosis
is a term for a blood clot occurring inside a blood vessel. A typical venous
thrombosis is deep vein thrombosis (DVT), which can break off (or embolise), and
become a life-threatening pulmonary embolism (PE).
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