QUALITY REPORT
Quality Report 2012/2013
Improving your local hospitals
– our report to you
QUALITY REPORT: CONTENTS
Page
About this report
2
Introduction
3
Summary of 2012/2013 Quality Report
4
Looking back
6
Looking forward
18
Statement of assurance from the Board
23
Annexe
31
1
Quality report
ABOUT THIS REPORT
This Quality Report confirms the Trust’s
commitment to put the patient and the
quality of care at the heart of everything
that we do. The report is the result
of consultation with a wide group of
stakeholders, including our Governors,
commissioners, People in Partnership, and
our Local Involvement Network (LINk – now
known as Health Watch).
Within North West London the “Shaping
a Healthier Future” programme has been
approved by the Joint Committee of Primary
Care Trusts. This programme places The
Hillingdon Hospitals NHS Foundation Trust as
one of the five major hospitals for providing
a full range of 24/7 emergency care in the
region. The programme also places an
emphasis on the provision of a wider range
of out-of-hours primary and urgent care,
and we are working closely with our GP
commissioners and other providers to ensure
that across the healthcare community patient
care is provided in the right place at the right
time.
The project plans for a new Emergency
Care Department, incorporating a rebuilt
Urgent Care Centre, have been approved,
and building work on the first phase of the
project (due to be completed in 18 months)
has already commenced. This year we have
also been successful with a Department
of Health capital funding bid for a large
maternity refurbishment, the second highest
amount awarded by the NHS in London,
which will improve the birthing environment
for women and their partners. We have
also secured NHS centrally funded money
for dementia which will provide a better
environment for patients with this condition
during their hospital stay.
steps to a seven day hospital. This forms one
of our main priorities in the “Look Forward”
section of the report.
This year has also seen the publication of
the Francis Report which highlights the
failings of a hospital where quality was not
the first priority and which did not listen
to its patients or frontline staff. Our care
priorities, which form one part of a range
of measures of patient care, will continue to
be refined and extended in the coming year.
Along with using Communication, Attitude,
Responsibility, Equity, Safety (CARES) as
our values we will develop a framework
for providing compassionate care, as well
as monitoring the improvements made in
delivering patient care.
I hope you find this report well presented,
and that it gives you useful information
about the Trust. I would be very interested
in your views on the style or content of the
report. If you wish to comment please write
to me via the e-mail address below.
Yours sincerely
Shane Degaris
Chief Executive
shane.degaris@thh.nhs.uk
I confirm that to the best of my knowledge
the information in this document is accurate.
This year has seen the publication of
a London-wide set of emergency care
standards which include more senior decision
making on a seven day a week basis to
reduce weekend mortality and take the first
Quality report
2
INTRODUCTION
This Quality Report, which looks back at our
achievements in 2012/13 and summarises our
key quality objectives for the coming year,
will be available on the NHS Choices website
and our own website – (www.thh.nhs.uk).
Each of the priorities is aligned to the
three domains of quality – safety, clinical
effectiveness and patient experience.
What do we mean when we talk
about patient safety?
“Treating and caring for people in a safe
environment and protecting them from
avoidable harm”, (National Patient Safety
Agency), for example, ensuring that
medicines are managed safely.
What do we mean when we talk
about clinical effectiveness?
Clinical effectiveness is about whether or not
a patient’s care or treatment was successful.
In other words, did it have the impact that
it was supposed to have? And did it achieve
the best possible result for the patient?
This may include improvement in specific
medical or health conditions, but in the
community we also have a strong focus
on improving quality of life, for example,
independence, mobility, activities of daily
living and social participation.
What do we mean when we talk
about patient experience?
Patient experience is about ensuring
patients, relatives and carers have as
positive experience as possible at every
stage of the care or treatment that is being
provided. Patient experience refers to the
overall experience throughout the course of
treatment, and not just the results that were
achieved at the end.
For example, a patient’s experience could
be strongly influenced by whether they felt
3
Quality report
they were treated with dignity and respect,
or whether they found it easy to access the
service.
What is CQUIN?
CQUIN is a scheme to encourage NHS Trusts
to improve quality and patient safety by
setting targets and rewarding achievement
of those targets financially. These targets are
set with local, regional and national bodies.
SUMMARY OF 2012/2013
QUALITY REPORT
was a significant increase of 7% between Q3
and Q4 result. We are continuing to focus on
improving nursing record keeping across the
Trust.
Looking back at quality
improvement
Priority 4 was The Leaving Hospital
Project where we have achieved some of
Our priorities during 2012/2013
Priority 1 was the further embedding
of the First Contact Project – Improving
the Outpatient Experience where we
fully achieved two of the four targets;
implementing the Call Management
System (CMS), and introducing a document
scanning referral system for all cancer
and symptomatic breast referrals. We
partially achieved our plans to centralise
all appointment bookings; the one target
we did not achieve was introducing the
electronic letters from the hospital clinics to
the GP which is currently being piloted in
four specialties.
Priority 2 was about making Changes in
Maternity where we achieved the majority
of our targets (other than breastfeeding);
improving the patient experience by
2% from 86% to 88%; and reduced our
caesarean section rates from 30.1% in
2011/2012 to 26.9% for 2012/2013. Whilst
breast feeding figures have increased to
82.9%, we did not quite meet the target of
85%. We have recruited women from ethnic
minorities to work in clinical and non-clinical
public facing roles. We have refurbished
public areas which included a new layout in
maternity triage and we were successful in
securing significant funds to modernise the
ten delivery rooms, where work is due to
commence in June 2013.
Priority 3 was Care Priorities where we
achieved the target of 90% at year end for
patients having the correct identification
bands and staff following the correct
process for confirming identification and
for hydration/fluid balance. We did not
achieve the 90% target for record keeping;
achieving 79% at year end; although there
the targets to date such as an increased
positive patient experience for when patients
leave hospital; ensuring patients have the
appropriate discharge documentation and
keeping the Visual Management System
(our colour coded system for where a
patient is on their pathway) up to date.
Several of the other standards are close to
their target such as receiving a copy of your
patient journey; 90% of patients are going
home with their medication. We narrowly
missed the 80% target for the proportion
of patients being discharged home before
8pm in the evening. We aim to discharge
patients before 6pm wherever possible,
but they may be discharged later where it
is clinically appropriate and safe to do so,
taking the patient’s home circumstances into
consideration. Although we did not achieve
the target of 85% of GPs receiving a copy of
the patient’s discharge summary within 24
hours, there has been an improvement from
the 2011/2012 baseline figure.
Priority 5 was CQUINs (Commissioning
for Quality and Innovation). Of the nine
CQUIN schemes for 2012/2013 we have fully
achieved four in Q3: preventing blood clots;
collecting the data for the Patient Safety
Thermometer (a local improvement tool
for measuring, monitoring and analysing
patient harm and ‘harm free’ care which
includes assessment for blood clots, urinary
catheter related infections, falls and pressure
ulcers); using the North West London Drug
Formulary and improving the care for
patients with the complications of diabetes.
We partially achieved four remaining CQUINs
in Q3: an improvement of the patient
experience; providing real time information
about our patients for GPs; ensuring we have
Consultant assessments within 12 hours of an
Quality report
4
emergency admission and achieving all the
milestones for end of life care. We predict
that we will not achieve our target for the
dementia screening and risk assessment
process for this year. Confirmed figures for
the full year will be available in mid June.
Looking forward at quality
improvement
Our priorities for 2013/2014
The following five priorities have been
identified for 2013/2014:
1. Continuing with the First Contact
Project which will further embed
the way patients are contacted and
reminded about their appointments
and to further centralise bookings. The
Call Management System needs further
development to ensure we are getting
our messages right for patients. There
will be significant resources allocated to
establish an Electronic Document Record
System which will allow easier clinician
access to full healthcare records and to
relevant referral forms, enhancing clinical
decision making.
2. Continuing with the Leaving Hospital
Project to include work with external
experts regarding Improving Inpatient
Care and Discharge, to enhance early
assessments for elderly people and
reduce any unnecessary lengths of stay in
hospital, as well as reducing readmissions.
We will be improving the discharge
process by better co-ordination of teams
and working closer together with doctors,
nurses, pharmacists and therapists when
reviewing a patient’s needs before they
leave hospital.
3. Improving Emergency Care taking into
account the Acute Emergency Care
Standards that have been set across
London and an analysis of the Hospital
Standardised Mortality Ratio (HSMR).
There will be a focus on early consultant
review of patients requiring admission
5
Quality report
on a seven day a week basis to enhance
early senior clinical decision making
and eliminate the difference between
weekday and weekend mortality.
4. Using CARES as our values. These were
launched in May last year and are
supported by a framework that sets out
the standard in terms of attitude and
behaviours we expect from our staff.
5. CQUINs (Commissioning for Quality and
Innovation): we will continue efforts
to prevent blood clots however, we
will be expected to achieve a higher
percentage of patient assessment.
The patient experience CQUIN will be
based on the new “Friends and Family
Test”. The dementia risk assessment will
be continued and the Patient Safety
Thermometer will be based on reductions
in pressure sores and not just on data
submission. Regional CQUINs are not
confirmed but may include supporting
care outside hospital, 12 hour consultant
assessment and GP direct access to
diagnostics and pathology. Local CQUINs
may include the colorectal cancer
pathway and improved communication
between GPs and consultants for effective
patient management.
Our priorities will be monitored by the
individual teams, through their Divisional
Reviews and quarterly through reports to the
Board or Board Committee and the results
will be reported in the 2013/2014 Trust
Annual Report.
LOOKING BACK…
This section starts by looking at key measurements in a dashboard format. These are derived
from some mandatory requirements, our consultation with our stakeholders, and those of
national importance that patients will want to know about.
Dashboard of key quality measures
ACHIEVED TARGET
NARROWLY MISSING TARGET
SIGNIFICANTLY MISSING TARGET
Latest data
available to
benchmark
Domain:
Patient Safety (PS)/
Clinical
Effectiveness (CE)/
Patient
Experience (PE)
2011/12
Performance
2012/13
Target
2012/13
Performance
How
London
Trusts
Perform
National
Performance
1a: In Hospital
Standardised
Mortality Ratio
(HSMR)
Apr-2012 to
Dec-2012
[Dr Foster]
PS
107.2
(99.2 - 115.6)
<100
89.5
(81.7 - 97.9)*
84
(82.7 85.4)
100
1b: Standardised
Hospital
Mortality Index
(SHMI)
Jul-2011 to
Jun-2012
[Dr Foster]
1c: the
percentage of
patient deaths
with palliative
care coded at
diagnosis
2a:
Readmissions to
hospital within
28 days
2b: Emergency
readmissions
to hospital
within 28 days
of discharge
from hospital:
0-15 years
(Standardised)
Lowest
Performing
1.2559
(Blackpool
Teaching NHS
FT)
Highest
Performing
0.7108
(The
Whittington
Hospital NHS
Trust)
National =
18.2%
Lowest = 0.3%
(Royal Devon
& Exeter NHS
Foundation
Trust)
Highest =
46.3% (Kings
College
Hospital NHS
Foundation
Trust)
PS
0.8878
(As Expected)
As Expected
or Lower
Than
Expected
0.8936
(As Expected)*
n/a
Jul-2011 to
Jun-2012
[Dr Foster]
PS
n/a
n/a
(Contextual
Indicator)
5.2%*
n/a
Apr-2012 to
Sep-2012
[Dr Foster]
CE/PS
104.2
(101 - 107.4)
<100
108.3
(103.8 113.1)*
99.4
(98.7 100.1)
100
Apr-2011 to
Mar-2012
[HSCIC
Indicator
Portal]
(Local)
[9.41%*]
[8.04%]
[10.15%]
CE/PS
6.38%
n/a
(5.6%)
(n/a)
(n/a)
Quality report
6
Latest data
available to
benchmark
Domain:
Patient Safety (PS)/
Clinical
Effectiveness (CE)/
Patient
Experience (PE)
2011/12
Performance
2012/13
Target
2c: Emergency
readmissions
to hospital
within 28 days
of discharge
from hospital:
16+ years
(Standardised)
Apr-2011 to
Mar-2012
[HSCIC
Indicator
Portal]
(Local)
CE/PS
12.09%
n/a
3: Non clinically
justified
single sex
accommodation
breach, rate per
1,000 finished
consultant
episodes
Apr-2012 to
Dec-2012
[Unify2/DH]
PE
0.11
4: Cancer: Two
week wait from
GP referral
to seeing
a specialist
(suspected
cancer)/(breast
symptoms)
Apr-2012 to
Dec-2012
[OpenExeter/
DH]
5: Cancer: 31
day maximum
wait from
diagnosis to first
treatment
6: Cancer: 31
day maximum
wait from
diagnosis to
subsequent
treatment, drug
or surgery
2012/13
Performance
How
London
Trusts
Perform
National
Performance
[11.86%*]
[11.95%]
[11.42%]
(7.5%)
(n/a)
(n/a)
0
0.06*
0.73
0.21
CE/PS
Suspected:
98.3%
Breast
Symptom:
96.4%
93%
93%
97.9%”
98.0%”
95.3%
95.1%
95.5%
95.4%
Apr-2012 to
Dec-2012
[OpenExeter/
DH]
CE/PS
97.9%
96%
99.2%”
98.1%
98.4%
Apr-2012 to
Dec-2012
[OpenExeter/
DH]
CE/PS
Drug: 100.0%
Surgery:
100.0%
98%
94%
100.0%”
100.0%”
99.6%
97.2%
99.7%
97.4%
85%
90%
85%
93.3%”
93.9%”
98.6%”
86.1%
92.1%
94.2%
87.5%
95.1%
93.4%
7: Cancer: 62day maximum
wait from
referral by
GP/screening
service/
consultant
upgrade to
treatment
Apr-2012 to
Dec-2012
[OpenExeter/
DH]
CE/PS
8: Referral
to treatment
waiting times admitted
Dec-2012
[Unify2/DH]
CE/PS
95.9%
90%
96.7%^
92.4%
93.1%
9: Referral
to treatment
waiting times non admitted
Dec-2012
[Unify2/DH]
CE/PS
98.9%
95%
98.6%^
97.9%
97.7%
7
Quality report
GP/GDP:
92.6%
Screening:
68.6%
Upgrade:
98.3%
Latest data
available to
benchmark
Domain:
Patient Safety (PS)/
Clinical
Effectiveness (CE)/
Patient
Experience (PE)
2011/12
Performance
2012/13
Target
2012/13
Performance
How
London
Trusts
Perform
National
Performance
Dec-2012
[Unify2/DH]
CE/PS
96.9%
92%
97.6%^
93.4%
94.5%
Apr-2011 to
Mar 2012
NHF Database
CE/PS
79.1%
90%
90.8%
n/a n/a Apr-2012 to
Jan-2013
[Unify2/DH]
PE
97.9%
95%
96.7%
96.4%
96.2%
Apr-Dec 2012
[Unify2/DH]
CE/PS
3.4%
0%
6.0%
2.8%
4.6%
Apr-Dec 2012
[Unify2/DH]
PE/CE
90.2%
90%
93.3%
(Excluding
Late Referrals)
80.4%
86.9%
15: Stroke
patients:
Percentage of
patients that
have spent at
least 90% of
their time on
the stroke unit
Oct-2012 to
Dec-2012
[Unify2/DH]
CE
99%
80%
99.6%
93.8%
85.0%
16: Stroke
patients:
Percentage of
high risk TIA/
mini stroke
patients who
are treated
within 24 hours
Oct-2012 to
Dec-2012
[Unify2/DH]
CE
100%
75%
100%
84.6%
75.9%
10: Referral
to treatment
waiting times Incomplete1
11: Fractured
neck of femur
emergency
patients in
theatre within
36 hours
12: Total time
in A&E: 4 hours
or less
13: Percentage
of patients
not treated
within 28 days
of having
operation
cancelled for
non-clinical
reasons
14: Percentage
of women in
the relevant
PCT population
who have seen
a midwife or
a maternity
healthcare
professional,
for health and
social care
assessment of
needs, risks
and choices
by 12 weeks
and 6 days of
pregnancy
Quality report
8
Latest data
available to
benchmark
17: MRSA
Apr-2011 to
Mar-2012
[HPA]
18: Cdiff cases
reported
within the
Trust amongst
patients aged 2
and over during
the reporting
period
Apr-2011 to
Mar-2012
[HPA]
19: Percentage
of patients who
were admitted
to hospital
and who were
risk assessed
for Venous
Thrombo
Embolism (VTE)
20a: Patient
Reported
Outcome
Measures
(PROMs) scores
(Health Gain),
Groin Hernia,
EQ-5D Index/
VAS
20b: PROMS
(Health
Gain), Hip
Replacement,
EQ-5D Index/
VAS
20c: PROMS
(Health
Gain), Knee
Replacement,
EQ-5D Index/
VAS
21: Inpatient
Experience
Programme
(local survey
results)
9
Domain:
Patient Safety (PS)/
Clinical
Effectiveness (CE)/
Patient
Experience (PE)
2011/12
Performance
PS
4 Cases
2.9 Cases per
100,000 bed
days
National
Performance
3
1 Case
0.77 Cases per
100,000 bed
days
114 Cases
2.0 Cases
per
100,000
bed days
471 Cases
1.3 Cases per
100,000 bed
days
7,670
21.8 Cases per
100,000 bed
days
Lowest
Performing
82 Cases,
51.6 Cases
per 100,000
bed days
(Tameside FT)
Highest
Performing
0 Cases
(Birmingham
Women’s)
94.1%
Lowest
Performing
84.6%
(Croydon
Health
Services NHS
Trust)
Highest
Perfoming
100%
(South Essex
Partnership
University FT)
24
87.5%
90%
91.9%+
93.10%
CE/PS
n/a
n/a
0.123 / 0.667*
n/a
0.091 / -0.603
(i)
CE/PS
n/a
n/a
0.4 / 12.105*
n/a
0.437 / 10.863
(ii)
CE/PS
n/a
n/a
0.262 / 18.2*
n/a
0.312 / 5 (iii)
PE
87% >87%
88%
n/a
n/a
Oct-2012 to
Dec-2012
[Unify2/DH]
PS
Apr-2012 to
Sep-2012
[HES]
Apr-2012 to
Sep-2012
[HES]
Quality report
How
London
Trusts
Perform
1,154
21.1
Cases per
100,000
bed days
PS
88% YTD
[Local Survey]
2012/13
Performance
23
16.2 Cases per
100,000 bed
days
25 Cases
19.3 Cases per
100,000 bed
days
Apr-2012 to
Sep-2012
[HES]
2012/13
Target
Latest data
available to
benchmark
Domain:
Patient Safety (PS)/
Clinical
Effectiveness (CE)/
Patient
Experience (PE)
2011/12
Performance
2012/13
Target
2012/13
Performance
How
London
Trusts
Perform
National
Performance
22: Outpatient
Experience
Programme
(local survey
results)
87% YTD
[Local Survey]
PE
86% >86%
87%
n/a
n/a
23: Maternity
Experience
Programme
(local survey
results)
86%YTD
[Local Survey]
PE
85% >85%
86%
n/a
n/a
88% YTD
PE
92% >87%
87%
n/a
n/a
25: Percentage
of complaints
responded to
within agreed
timescale
n/a PE
84%
90%
74.5%
n/a n/a
26: Trust’s
responsiveness
to personal
needs of our
patients
Apr 2012 to
March 2013
[National
Patient
Survey]
PE
62.9%
72%
65%
n/a
67.4%
3.70
3.57 average
Lowest
Performing
2.90 (North
Cumbria
University
Hospital)
Highest
Performing
4.08 (Guy’s &
St Thomas’)
1.3
0.9
24: Independent
assessment of
cleanliness of
hospital
27: Percentage
of staff
who would
recommend
the Trust as a
provider of care
to their family
and friends
28: Patient
safety incidents/
percentage
resulted in
severe harm or
death
2012 Survey
[National
Staff Survey]
Apr 2012 to
March 2013
[Datix]
PE
3.53
n/a
3.66
0.75% (41)
PS
1% (45)NRLS
n/a
(0.75 per 100
admissions)
Notes: 2012/2013 Performance is for Apr-2012 to Mar-2013 unless:
* Same as Benchmark Period
+ Apr -2012 to Jan-2013
“ Apr-2012 to Feb-2013
^ Mar-2013
Quality report
10
EQ-5D INDEX
EQ-5D VAS
Lowest
performing
Highest
performing
Lowest
performing
Highest
performing
(i) Groin
Warrington And
Halton Hospitals NHS
Foundation Trust
(-0.062)
University Hospitals
Bristol NHS
Foundation Trust
(0.227)
The Whittington
Hospital NHS Trust
(-10.667)
Guy’s And St
Thomas’ NHS
Foundation Trust
(11.4)
(ii) Hip
Replacement
Yeovil District Hospital
NHS Foundation Trust
(0.155)
The Queen Elizabeth
Hospital, King’s Lynn,
NHS Foundation Trust
(0.69)
Brighton And
Sussex University
Hospitals NHS Trust
(-10.571)
Barts And The
London NHS Trust
(30.6)
(iii) Knee
Replacement
Royal National
Orthopaedic Hospital
NHS Trust (0.031)
Mid Cheshire Hospitals
NHS Foundation Trust
(0.527)
Imperial College
Healthcare NHS
Trust (-10.667)
Barnsley Hospital
NHS Foundation
Trust (24.842)
Supporting information about the
indicators required in accordance with
the Quality Account regulations
Indicator 1b
The Hillingdon Hospitals NHS Foundation
Trust considers that this data is as described
for the following reasons - national reporting
shows a stable ratio over the past two years.
The Trust is working on improving the
variation between weekdays and weekends
and will examine any outliers.
Indicator 1c
The Hillingdon Hospitals NHS Foundation
Trust considers that this data is as described
for the following reasons – not all patients
who are receiving palliative care are
on the Liverpool Care Pathway. Clearer
identification of these patients will improve
the palliative care coding.
Indicator 2a, 2b and 2c
The Hillingdon Hospitals NHS Foundation
Trust considers that these percentages are
as described for the following reasons – the
Trust is aware from a variety of data sources
that the figures are higher than expected.
Several initiatives to improve these figures
include strengthening our care pathways and
the Improving Inpatient Care initiative. Refer
11
Quality report
to priority 2 for 2013/2014 on page 19.
Indicator 18
The Hillingdon Hospitals NHS Foundation
Trust considers that this rate is described for
the following reasons – the Trust achieved a
target of 23 out of 24 for 2012/2013 and has
shown a year on year improvement. The Trust
will continue with all current initiatives. The
Trust hosted a multidisciplinary workshop in
May chaired by a national expert in infection
control which will inform our measures to
improve our targets for 2013/2014 of 14 for C
Diff and 0 for MRSA.
Indicator 19
The Hillingdon Hospitals NHS Foundation
Trust considers that this percentage is as
described for the following reasons – the
Trust has shown an improvement over the
last two years. This is a CQUIN for 2013/14
and work will be taken forward to bring
about further improvement.
Indicator 20a, 20b and 20c
The Hillingdon Hospitals NHS Foundation
Trust considers that the outcome scores are
as described for the following reasons – Data
shows that the five domains that this score
refers to are hospital outcome measures (EQ
– 5D index VAS). The Trust performs better
than average for hernias, but worse than
average for hip and knee replacements, and
better than average for all three procedures
from the patient’s perspective (EQ -5 index
VAS).
Indicator 26
The Hillingdon Hospitals NHS Foundation
Trust considers that this data is as described
for the following reasons – there has been
a slow improvement but still below target.
Further work is being undertaken to improve
the situation through our customer care
programme, our CARES values initiative and
the Improving Inpatient Care initiative.
Indicator 27
The Hillingdon Hospitals NHS Foundation
Trust considers that this data is as described
for the following reasons – there has been
a steady improvement but further work is
being undertaken through our CARES values
initiative.
Indicator 28
The Hillingdon Hospitals NHS Foundation
Trust considers that this data is as described
for the following reasons - whilst the Trust
has a lower than average rate of severe
harm / death patient safety incidents, there
is not a nationally established and regulated
approach to reporting and categorising
patient safety incidents. The approach
taken to determine the classification of each
incident, such as those ‘resulting in severe
harm or death’, will often rely on clinical
judgement. In addition, the classification of
the impact of an incident may be subject to a
potentially lengthy investigation which may
result in the classification being changed.
This change may not be reported externally
and the data held by a Trust may not be the
same as that held by the NRLS.
Definitions of the two mandated
indicators
Indicator 7
Percentage of patients receiving first
definitive treatment for cancer within 62
days of an urgent GP referral for suspected
cancer.
Indicator 2a
Percentage of emergency admissions to any
hospital in England within 28 days of the last
previous discharge from hospital.
Priority 1: The First Contact Project –
improving the outpatient experience
We said:
We would centralise all outpatient
appointment bookings to ensure that calls
are answered more quickly; provide more
telephone lines; patients won’t have to wait
so long to be attended to; the system would
also have an interactive element where
patients will receive a phone call and text as
a reminder of their appointment.
We also said we would introduce a document
scanning referral system and introduce the
electronic transfer of outpatient clinic letters
from the hospital clinicians to the GP.
The changes would be measured for
impact by reviewing the data from the Call
Management System (CMS) detailing the
average call waiting time and abandonment
rate, appointment non-attendance (DNA)
rate and the number of complaints.
Quality report
12
We did:
a
PARTIALLY ACHIEVED
Booking centralisation
During 2012 staff that make new and follow
up appointments have been centralised to
one location. We recognise that this is the
first step towards centralising all bookings
and that further work to train staff and
equip them with the skills to deal with
queries about any outpatient appointment
related query is necessary.
a
ACHIEVED
Call Management System (CMS)
The CMS was implemented in June 2012 with
an appointment reminder function going live
in August 2012.
The CMS has changed the way The
Hillingdon Hospital deals with telephone
calls from patients about their outpatient
appointments. Now patients are given one
telephone number, they then choose from a
list of options which ensures their call is dealt
with by the correct member of staff (agent).
If all agents are busy the patient is held in
a queue and informed that their call will be
answered.
The system provides staff with comprehensive
reports and real time information about call
activity, response times, abandonment rates
and call resolution. Managers are able to
adjust resources to meet the volume of calls.
There has also been a reduction in Patient
Advice and Liaison Services (PALs) concerns
and complaints from 129 in 2011/2012 to 77
in 2012/2013.
The CMS has an optional appointment
reminder functionality (called Remind+)
which contacts patients by telephone seven
days before their appointment to confirm
their attendance. This is then further
supplemented with a text messaging service
which sends a reminder to a mobile number
48 hrs before the appointment.
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Quality report
a
ACHIEVED
Introduce a document scanning referral
system
Document scanning has been implemented
for all cancer and symptomatic breast
referrals. The new process allows outpatient
appointment centre staff, Multi Disciplinary
Team (MDT) coordinators and Health
Care Assistants (HCAs) in outpatients to
access the documents electronically which
eliminates the risk of paper letters getting
lost and subsequent delays. GPs are also
increasingly making referrals and outpatient
appointments via an electronic system called
Choose and Book.
r NOT ACHIEVED
Electronic outpatient letters to GPs
From January 2013 the Trust is piloting the
electronic delivery of outpatient letters to
GPs in Hillingdon in the following specialities:
Care of the Elderly, Stroke, Paediatrics and
breast surgery.
There is much more to do particularly in
relation to the centralisation of booking
appointments and implementation of
the electronic document and records
management.
Priority 2: Maternity
We said:
As part of our ongoing maternity strategy
for improving quality of care we said that
we would like to see an improvement in our
patient experience survey by at least 1%
and respond to shortfalls identified by both
staff and comments made within the patient
survey. We look forward to the rich source of
information from the patient diary exercise,
which commenced in November 2012. As a
response to a survey undertaken by the Local
Involvement Network (LINk) survey we have
engaged more with hard to reach groups
including Somali and Afghan support groups.
We also said we would improve the Labour
Ward environment; reduce caesarean section
rates to 27.6% and increase breastfeeding
rates.
We also aimed to increase the number of
non-obstetric deliveries – including an aim to
increase the number of women having their
babies at home.
We also said that we would reconfigure
our community services to improve the
experience.
a
We did:
a
ACHIEVED
Patient experience in maternity is improving.
The patient experience rate is 86% and by
Q4 the figure is 88%; an increase so far this
year of 2%. We continue to monitor this on a
monthly basis.
a
ACHIEVED
We have now managed to recruit women
from a variety of cultural backgrounds
(representative of the population we
serve) to work in the reception area of the
Maternity main foyer and Maternity helpers
(now called maternity mates) on the wards,
depending on language.
Some of these women have a National
Vocational Qualification (NVQ) in health and
social care and are looking to continue their
education into nursing and midwifery.
In June we will be meeting with women
from the Afghan community to identify any
specific needs to improve their experience
of our service and staff. Key learning points
identified from these informative meetings
are shared with staff through relevant
forums and training sessions.
a
The “Improving Birth Environments” bid,
a Department of Health funding project
to improve the physical environment of
Maternity units in England, has been
successful and will allow us to modernise 10
delivery rooms which will include en-suite
facilities in each room and restructure the
Labour Ward reception area. This work is due
to commence in June 2013.
ACHIEVED
General refurbishment of the maternity unit,
such as painting the stairwell and public
areas, and the layout of the maternity triage
area have been completed.
ACHIEVED
The current year to date figure for caesarean
sections is 26.9% for the year compared
with the 2011/2012 full year figure of 30.1%
showing an improvement to date from last
year.
The multifaceted action plan for caesarean
reduction continues to be monitored and
implemented to drive forward appropriate
and safe changes in practice to allow for
reduction in the overall rates of caesarean
section, both elective and emergency.
A three month trial of mixing ante and
postnatal women on both maternity wards
is currently underway to increase Consultant
presence to each area, to enable more
confident decision making with junior staff.
This will shortly end and be audited to
review its impact on care provision.
r NOT ACHIEVED
Breastfeeding initiation rates are improving;
the year to date figure is 82.9% for the
year compared to 81.6% for last year,
however, we did not reach our target of
85%. Breastfeeding initiation stickers have
helped to highlight information sharing and
training. There is still work to be done on
improving these figures.
With the appointment of a Breastfeeding
Health Visitor, working with public health,
we hope that the restructuring of our
community services will strengthen the joint
education and training of all staff with a
view to improving rates further.
Quality report
14
Priority 3: Care priorities
We said we would:
•Ensure every patient is wearing a correctly
labelled identiband
•Improve record keeping
•Improve hydration and fluid balance of
our patients during their stay in hospital.
Priority 4: Leaving hospital –
improving the patient experience
We did:
a
PARTIALLY ACHIEVED
CARE PRIORITY
TARGET
2012/2013
RESULT
2012/2013
Patient
identification
90%
91%
Record keeping
90%
79%
Hydration/ fluid
balance
90%
90%
We have achieved the target of 90% in two
of our care priorities, patient identification
and hydration/fluid balance. Record
keeping is short of the target, achieving
79% at year end. We did see a significant
improvement of 8% between Q3 and Q4
and we will continue to focus our attention
on record keeping throughout 2013/2014
to achieve our 90% target even though it is
not included as a priority in the 2013/2014
Quality Account. A number of initiatives to
support improved record keeping were put
into place in 2012/2013, these include:
•A Nursing Documentation Working
Group has been set up. This group is
made up of frontline staff and has been
working to develop core care plans and to
standardise some of the many charts that
are used across the Trust.
•The group will also be developing chart
specific guidance to support accurate and
effective record keeping.
•A new approach to the regular assessment
and assurance of the quality of nursing
care was developed. Peer review of the
nursing documentation is an integral
15
Quality report
part of this monthly assessment across all
inpatient wards.
•Matrons and/or senior sisters reviewed the
nursing record of all patients on the ward
as part of the monthly Patient Safety
Thermometer survey. This provided an
opportunity for immediate feedback to
staff with clarification of the standard of
record keeping required.
We said we would:
Work to improve the information patients
are given when they leave hospital to
include the purpose and side effects of any
medication that they will be taking when
they get home and who to contact if they are
worried after leaving hospital.
We did:
TARGET FOR
2012/2013
RESULT
2012/2013
Patient’s experience
of leaving hospital is
positive
72%
82%
Patient receive
a copy of ‘Your
Hospital Journey’
100%
93%
Discharge
documentation is
completed as per
policy
80%
93%
Patients understand
where they are on
their care pathway
90%
88%
The Visual
Management
System (VMS) is kept
updated
90%
95%
Patient goes
home with their
medication
90%
89%
GP receives copy of
discharge summary
within 24 hrs
85%
73%
25%
60%
80%
15.8%
42.3%
79.5%
STANDARD
Patients discharged
in a timely manner:
Before 12pm
Before 4pm
Before 8pm
We saw an improvement in the patient
experience of leaving hospital as measured
by our follow up phone call. Additionally,
many patients have commented that the
follow up call is useful to check out any
concerns that they may have. We continue
to revise our processes so going forward
into 2013/2014 our revised and simplified
discharge checklist will be integrated into a
new electronic tool that supports safe and
planned discharges.
Key learning from this project such as the
use of the coloured magnets to display key
steps in the discharge process have now been
incorporated into the electronic whiteboard.
This is part of the Improving Inpatient Care
Project that features in Looking Forward
Priority 2 (see page 19).
Our monthly Observations of Care visits
to wards which began in February include
asking patients key questions about their
understanding of their care, current
treatment and ongoing plans towards
discharge.
We are now looking at integrating
information about who to contact if worried
following discharge with an existing patient
information leaflet.
Quality report
16
Priority 5: CQUINs – Commissioning for quality & innovation (subject to
confirmation)
Looking back:
CQUIN TARGETS FOR 2012/2013
WHAT WE DID
National
Preventing blood clots
100% full year result
Patient experience (patient survey)
20% predicted full year result
Dementia risk assessment (scoring tool to identify clinical risks)
Not achieved
Collection of data for the Patient Safety Thermometer (see page 4
for definition)
100% full year result
Regional schemes
Real time GP information (information for GPs about admission
treatment and discharge of patients)
84% predicted full year result
Use of the North West London Formulary (a list of all medicines
that are agreed for use across North West London between hospital
and primary care services)
100% full year result
Local schemes
Consultant Assessments within 12 hours of emergency admission
50% predicted full year result
Patients with complications of diabetes
100% predicted full year result
End of life care (a structured pathway to ensure patients receive
high quality patient focused care)
92% predicted full year result
Exact percentages to be confirmed in mid
June.
Patient experience – The Trust achieved
20% of the targets which was a steady
improvement over 2 years.
Dementia risk assessment – This depends
on electronic recording of assessments, the
system required to do this was not available
at the time.
Real time GP information – The IT
system required to achieve this has been
implemented for patients who attend
A&E, and patients who are admitted as
an emergency and inpatient discharge
summaries. However, an electronic solution
for sending outpatients letters was not
available.
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Quality report
Consultant assessments within 12 hours
of emergency admission – The Trust has
successfully achieved 55% of emergency
admitted patients having a consultant
assessment within 12 hours. It will continue
to strive to achieve a higher percentage
during 2013/14.
End of life care – The drop in percentage
points is due to a very high level of staff
needing to be trained.
LOOKING FORWARD…
Our priorities for 2013/2014
NO.
PRIORITY
SAFETY
CLINICAL
EFFECTIVENESS
PATIENT
EXPERIENCE
ü
ü
1
First contact – Continuing to improve the
outpatient experience
2
Continuing with the leaving hospital Project to
include work regarding Improving inpatient care
and discharge
ü
ü
ü
3
Emergency care
ü
ü
4
CARES
ü
ü
5
CQUINs
ü
ü
ü
In arriving at these priorities, agreed by the
Trust Board, we had a systematic process
of stakeholder involvement, as in previous
years. This included our public, in the form
of our People in Partnership (PiP) which
included a series of focus groups, our
Governors, LINKs (which included difficult to
reach groups) and our Commissioners. There
was a strong opinion from our stakeholders
that we should continue with projects started
in previous years where further outcomes
needed to be set and achieved to fulfil
their potential. Hence the projects relating
to an effective outpatient experience and
high quality inpatient care with efficient
discharge planning have been retained.
During 2012/2013 a review of inpatient care
on one ward showed that the balance of
nurses to healthcare assistants on the ward
was not always at the planned level; multiprofessional communication was sometimes
fragmented and nursing leadership on the
ward needed to improve. We undertook a
number of actions to address these issues
and this work continues to inform our
quality priorities, notably through the CARES
and Improving Inpatient Care priorities
outlined below. We will also be performing
a detailed review of our ward staffing levels.
During the later stages of the consultation,
the Francis Report was released and we
have incorporated a number of its key
recommendations in this document. The
“Emergency Care” priority will have targets
related to improving mortality, and a full
participation in the “Friends and Family” test
which preliminary data from most Hospitals
has found to be difficult to implement in
A&E. The priority related to implementing
our CARES framework of staff values goes to
the heart of the Francis report by acting as
the framework for providing patient-focused
high quality, responsive and compassionate
care.
PRIORITY 1: First Contact –
continuing to improve the
outpatient experience
Why is this one of our priorities?
We recognise that we have made some
changes to the way patients are contacted
and are reminded about their outpatient
appointments and these changes have now
been made. Furthermore we have more work
to do to centralise bookings and implement
a new electronic document records
management system; this work remains a
priority because the changes have a clear
impact on quality and patients’ experience.
Quality report
18
Our aims for 2013/2014:
Call Management System (CMS)
Implementation of the CMS has significantly
changed the way we handle calls and remind
people about their outpatient appointments.
This year we will set up a focus group to
gain feedback from our patients and users
about their experience in navigating the
system so we can establish what further work
is needed and take the appropriate action.
Some of the things we will be discussing at
the focus group are the opening times of
the outpatient appointments centre and
communication with patients about times
when we know the call volume will be high.
We continue to provide staff training on
customer care including telephone handling
skills which reflects the CARES strategy
(see Priority 4 on page 21). We use random
call listening to support staff training and
development. Furthermore staff are being
trained to deal with a variety of patients’
queries with the aim to improve first call
resolution.
Electronic document records management
This year the Trust is undertaking a
major change to the way medical records
are accessed and stored. The Electronic
Document Records System is being proposed
as a key infrastructure for the Trust in
order to enhance the quality and efficiency
of healthcare provided to our patients.
The underlying vision for this case is to
ensure that the best and most up to date
information should be readily available to
enable professional staff to offer appropriate
care and treatment.
It will also increase productivity and
improve quality of care provided through
the facilitation of electronic forms and
workflows. Scanned documents e.g. referral
letters will be used in workflow processes,
allowing the conversion of paper form-
19
Quality report
centric processes into paperless ones with
electronic forms being stored directly into
patient records to support clinical decision
making and administrative functions.
Booking centralisation
During 2013/2014 further work will take
place to centralise the booking of new
and follow up outpatient appointments
across the Trust. We have already achieved
the first stage of centralising where the
Outpatient Appointments Centre now takes
all telephone queries for Mount Vernon
Hospital outpatient appointments.
The performance targets we will use to
measure the impact of the changes and new
initiatives are:
•Call abandonment rate - we aim to
keep this below 10% (currently 28% for
January-March 2013)
•95% of calls to be answered within 60
seconds
•First contact resolution – aim to resolve
more than 90% of the queries in the first
contact (less than 10% of calls transferred
to other departments)
•Reduction in ‘did not attend’ rates (DNA)
for outpatient appointments (to be
agreed in quarter 1).
PRIORITY 2: Continuing to improve
the Leaving Hospital Project –
improving inpatient care
Why is this one of our priorities?
Following the success of implementing our
leaving hospital principles across all of our
wards, we reviewed our goals and priorities
and re-launched the project as “Improving
Inpatient Care”. The overall objective of
this programme of work is to ensure we
provide high quality of care to all inpatients
by improving the patient journey and
thereby decreasing length of stay.
How are we doing so far?
Length of stay for inpatients at Hillingdon
Hospital has been a priority service
improvement goal for a number of years. We
know that the longer patients are in hospital,
the more risks there are to the patient, and
fundamentally, we know people do not
want to be in hospital. We want to support
our patients to return to their homes and
be supported in the community as soon as
clinically appropriate. We want to remove all
unnecessary waits in hospital, and provide a
better service, particularly for those patients
with greater need, such as those who may
need social care support or ongoing care in
the community.
Successful changes have been made gradually
through individual teams and Trust wide
initiatives which have enabled more effective
working and as a result, more efficient, high
quality care. Almost 50% of our emergency
patients are discharged within 72 hours.
The average length of stay for the Trust has
reduced by 0.8 days over the past 12 months;
we are heading in the right direction.
Our aims for 2013/2014 are:
The Improving Inpatient Care programme,
initiated in December 2012, is putting in
place a series of changes across the Trust to
continue to reduce the length of stay, by
eliminating delays and improving the overall
experience patients receive whilst in hospital.
Examples of this work include:
•Developing an enhanced service for frail
and elderly patients who are admitted as
an emergency. The full details are being
developed and tested during the early
part of 2013, but will aim to involve an
enhanced comprehensive assessment
completed by a specialist Care of the
Elderly Consultant and a team of specialist
occupational and physiotherapists on
day one of admission. This will then
mean the hospital can start putting in
place everything the patient will need
to get home, as soon as they are better.
For example, for patients who might be
unsteady on their feet, fitting rails in their
home so they can manage stairs without
coming to harm.
•Improving how we set discharge dates,
with better co-ordination of teams
through doctors’ rounds, and supporting
nurses, doctors, pharmacists and
therapists to work together better when
reviewing a patient’s needs.
•Implementing new electronic whiteboards
to provide reminders of all patients’
next steps for all teams who work on the
wards.
•Improving the clarity of information we
provide to nursing and residential homes,
in order to support them in looking
after patients when they are discharged
from hospital. This aims to reduce the
likelihood of that person needing to come
back into hospital, as their care teams
will know how to manage their needs
appropriately.
Specific goals for this project are:
•Reduce length of stay to become one of
the top 25% of Trusts nationally
•Achieve 40% of all discharges leaving
before 12pm
•Earlier therapy and specialist review for
complex elderly patients, supporting up
to an additional 400 patients per year
•Reduce the rate of readmissions aiming to
prevent up to 230 avoidable readmissions
per year
PRIORITY 3: Improving emergency
care
Why is this one of our priorities?
There is national and London evidence to
show that there are significant differences
in the mortality rates for patients admitted
as an emergency during the week compared
with patients admitted as an emergency
at the weekend. Reduced service provision
Quality report
20
at weekends has been associated with this
higher mortality rate.
In response to the data, NHS London have
developed commissioning standards for
emergency care with the aim of ensuring
that consultants have early and continued
involvement in the care of all patients
admitted as an emergency.
How are we doing so far?
As a Trust we are committed to achieving the
emergency care standards and have invested
in additional senior doctor time, out of hours
Monday to Friday and also at the weekends.
Notably we have provided Consultant
ward rounds twice a day on our medical
Emergency Assessment Unit. This has ensured
that our patients continue to receive care
from our most senior doctors irrespective of
the day of the week.
We have also ensured that in Medicine,
Surgery and Paediatrics, all Consultants
covering A&E are freed from all other clinical
commitments.
Further investment has allowed for an
increase in therapy provision at weekends
which has facilitated patients with complex
needs having access to a multi-disciplinary
team assessment.
In 2012 a detailed review of our hospital
mortality data was carried out, specifically
the measure of mortality known as the
Hospital Standardised Mortality Ratio
(HSMR).
This review concluded that the Trust had a
lower than average palliative care and comorbidity coding which may falsely elevate
the HSMR, but that some specialties had a
higher than expected HSMR.
In response to the findings of the report a
great deal of work has been undertaken to
improve coding for palliative care and comorbidity which are at a national average
and now monitored monthly. Specialties
that were identified to have a higher
21
Quality report
than expected HSMR have been or are in
the process of being reviewed through
clinical workshops. These workshops have
provided the opportunity for clinical staff
to come together to identify areas of care
for improvement and also to ascertain the
suitability of utilising a care bundle approach
(a group of several clinical interventions).
These approaches together have reduced the
HSMR to 89.8 (up to and including January
2013) but there is still some weekday versus
weekend variability.
Our aims for 2013/2014 are
•To invest in evening and weekend
Consultant emergency presence in
Medicine, Surgery, A&E and Paediatrics.
•Implement NHS London emergency care
standards in relation to Consultant review
within 12 hours of decision to admit:
number of patients being seen within
target time 2013/2014 is 90%, and to
ensure that there is no weekday versus
weekend variability.
•To reduce HSMR to London average in
2013/2014 and ensure no difference in
weekday vs. weekend mortality.
•Seven day access to pharmacy and all
therapies (physiotherapy, respiratory, and
occupational therapy).
•Full participation in the Friends
and Family test (more than 15% of
all attending patients) in the A&E
Department where participation so
far has been disappointing, running at
around 5.7% for 2011/2012.
PRIORITY 4: CARES
Why is this one of our priorities?
There continues to be an increased focus
nationally on the patient/staff experience
and engagement of these groups. It is
essential that we see more significant
changes in attitude and behaviour from
our staff to improve the experience of our
patients. Through analysing information
captured from key sources such as the
National Patient Survey, Inpatient Survey,
National Staff Survey and incidents and
complaints locally, we recognise that we can
make improvements to the experience of our
patients and staff.
Our goal is to deliver the best possible
experience to our patients and to our
staff. In May 2012 we formally launched
Communication Attitude Responsibility
Equity Safety (CARES), which is our set of
values supported by a framework that sets
out the standard, in terms of attitude and
behaviours we expect from our staff. This
will support our staff to deliver care with
compassion as well as ensuring it is also safe
and effective.
Our aims for 2013/2014 are:
•Complaints – We will ensure that all
complaints are addressed using the CARES
framework. We will make the framework
an integral part of the investigation
process to identify behavioural and
attitudinal issues as well as the technical
aspects so that we can learn from them.
•Performance and Personal Development
Reviews (PDR) – All staff are expected to
undertake a PDR annually with their line
manager so they can ensure individual
performance is linked to the achievement
of Trust and departmental objectives.
It is also essential to see how they are
progressing in terms of their performance
and provides an opportunity to discuss
personal and professional development.
We have introduced a CARES behavioural
scale into the PDR paperwork to help
initiate discussions around staff attitude
and behaviours so that agreements can be
reached on any developmental areas in an
open manner.
•Customer Care Training – We want all
staff to recognise how their behaviours
and attitudes can have a negative or
positive impact on the experience of
patients and colleagues. Through the
delivery of a tailored Customer Care
training programme we will support
staff to understand how by adopting the
CARES behaviours they can enhance that
experience.
•CARES plays a large part in the work
programme we are developing in relation
to the Engagement and Experience
Strategy.
•Some Key Performance indicators for
2013/2014 are presented in the table
above; others are being developed in
quarter 1.
PERFORMANCE INDICATOR
TARGET
2012/13
Communication, involvement and
information – using the cluster of
questions in the patient survey
Improve result
by 2%
Compassionate Care – using
the cluster of questions in the
questionnaire from the Improving
Patient Care initiative.
Achieve 85%
PRIORITY 5: CQUINs
The National CQUINs for the next financial
year will still include the prevention of blood
clots, but we will be expected to achieve a
higher percentage of patient assessment. The
patient experience CQUIN will be based on
the new “Friends and Family Test” and the
dementia risk assessment will be continued.
The Patient Safety Thermometer will be
based on reductions in pressure sores and not
just on data submission.
Regional and local CQUINs are still to be
agreed.
Quality report
22
STATEMENTS OF ASSURANCE
FROM THE BOARD
Information for our regulators
Our regulators need to understand how
we are working to improve quality so the
following pages are specific messages they
have asked us to provide:
Services
During 2012/2013 The Hillingdon Hospitals
NHS Foundation Trust provided medicine,
surgery, clinical support services and
women’s and children’s NHS services. The
Hillingdon Hospitals NHS Foundation Trust
has reviewed all the data available to them
on the quality of care in all of these NHS
services. The income generated by the NHS
services reviewed in 2012/2013 represents
100% of the total income generated
from the provision of NHS services by the
Hillingdon Hospitals NHS Foundation Trust
for 2012/2013.
Audit
National audits
During 2012/2013, 38 national clinical audits
and two national confidential enquiries
covered NHS services that The Hillingdon
Hospitals NHS Foundation Trust provides.
During that period The Hillingdon Hospitals
NHS Foundation Trust participated in 82% of
national clinical audits and 100% of national
confidential enquiries for which it was
eligible to participate in. The national clinical
audits and national confidential enquiries
that The Hillingdon Hospital NHS Foundation
Trust was eligible to participate in during
2012/2013 are listed 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.
23
Quality report
AUDIT
PARTICIPATED
CASES SUBMITTED
Child Health Programme (CHR-UK)
Perinatal Mortality (MBRRACE-UK)
Neonatal Intensive and Special Care (NNAP)
Paediatric Pneumonia (British Thoracic Society)
Paediatric Asthma (British Thoracic Society)
Paediatric Fever (College of Emergency Medicine)
Yes
Yes
Yes
Yes
Yes
No
Epilepsy 12 Audit (RCPH National Childhood Epilepsy Audit)
Yes
0% (only 1 patient applicable)
100%
100%
100%
100%
N/A
Data entry commenced 1st March 2013
and continues throughout 2013/14 –
Trust participating
WOMENS AND CHILDRENS HEALTH
ACUTE CARE
Emergency Use of Oxygen (British Thoracic Society BTS)
Adult Community Acquired Pneumonia (BTS)
Non-invasive Ventilation (BTS)
Renal Colic (College Emergency Medicine)
Yes
Yes
Yes
Yes
100%
100%
85%
100%
Hip, Knee and Ankle Replacements (National Joint Registry)
Yes
Hillingdon 71%
Mount Vernon Treatment Centre 93%
Adult Critical Care (ICNARC CMPD)
Alcohol Related Liver Disease (National Confidential Enquiry
NCEPOD)
Subarachnoid Haemorrhage (NCEPOD)
Severe Trauma (Trauma Audit & Research Network, TARN)
No
N/A
Yes
100%
Yes
Yes
Data submission ongoing
81%
Diabetes (National Audit Diabetes Audit)
Diabetes (RCPH National Paediatric Diabetes Audit)
National Review of Asthma Deaths
Chronic Pain (National Pain Audit)
No
Yes
Yes
Yes
Inflammatory Bowel Disease (IBD)
Yes
Adult Asthma (BTS)
Adult Bronchiectasis (BTS)
Paediatric Bronchiectasis (BTS)
Yes
No
No
N/A
100%
No applicable cases
34.7%
Data submission commenced Jan
2013, 100% patients included to date
88%
N/A
N/A
LONG TERM CONDITIONS
OTHER
Yes
Percentages unavailable, numbers are:
Hip replacements: 249; knee
replacements: 312; groin hernia: 167;
varicose veins: 7.
Acute Myocardial Infarction & other ACS (MINAP)
Yes
100%
Heart Failure (Heart Failure Audit)
Yes
59% due to staff changeover our
participation is lower than previous
years - this has now been resolved
Cardiac Arrest (National Cardiac Arrest Audit)
No
N/A, Trust will be submitting data
from July 2013
Head and Neck Oncology (DAHNO)
Lung Cancer (National Lung Cancer Audit)
Bowel Cancer (National Bowel Cancer Audit Programme)
Yes
Yes
Yes
Oesophago-gastric Cancer (National O-G Cancer Audit)
Yes
100%
Expected 100%
100%
Deadline for submission October 2013
- expected 100%
Yes
Yes
No
Yes
Yes
70%
100%
N/A
100%
100%
Blood Sample Labelling (National Comparative Audit of
Blood Transfusion)
Yes
100%
Potential Donor Audit (NHS Blood and Transplant)
Yes
100%
Medical use of Blood (National Comparative Audit of Blood
Transfusion)
Yes
100%
Elective Surgery (National PROMS programme)
CARDIOVASCULAR DISEASE
CANCER
OLDER PEOPLE
Fractured Neck of Femur (College of Emergency Medicine)
National Audit of Dementia (NAD)
Parkinson’s Disease (National Parkinson’s Audit)
Sentinel Stroke National Audit Programme (SSNAP)
Hip Fracture (National Hip Fracture Database)
BLOOD AND TRANSPLANT
Quality report
24
Taking actions
The reports of 13 national clinical audits were reviewed by the provider in 2012/2013 and The
Hillingdon Hospitals NHS Foundation Trust intends to take the following actions to improve
the quality of healthcare provided.
AUDIT
ACTIONS
Neonatal intensive and special care (NNAP)
The Trust performs well in the majority of the standards for this audit. We
have not been submitting data for whether babies have an encephalopathy
(neurological assessment) to allow us to review clinical practice, this has
now been addressed and data will be available within future reports.
Diabetes (RCPH) national paediatric
diabetes audit
The Trust now uses the Twinkle database which records all of the
requirements for the national paediatric diabetes audit. Use of this
database prompts awareness of diabetes clinical indicators to team
members, improves the quality of data collection and will allow for a more
automated submission to this national audit.
To reduce admissions for diabetic ketoacidosis and to raise awareness for
early diagnosis of diabetes, we are using the diabetes UK 4Ts campaign
(toilet, thirsty, tired, thinner) in all our clinic letters sent to GPs and schools.
Pain management in children (College of
Emergency Medicine)
A pain rating scale document is in development. This document can help us
to assess pain severity quickly so we will be able to manage a child’s pain as
soon as possible.
Epilepsy 12 audit (RCPH national childhood
epilepsy audit)
A ‘transitional clinic’ to transfer from paediatric to adult epilepsy care has
been set up. The first clinic ran in July 2012 and we plan to run 3 to 4 clinics
per year.
Paediatric asthma (British Thoracic Society)
Emergency use of oxygen (British Thoracic
Society)
A Trust paediatric asthma guideline has been produced and was published
for use in the hospital in December 2012. Two new A&E Paediatric
Consultants started in December 2012, which will support implementation
of this guideline and improve paediatric asthma standards.
Improvements will be made, relating to documentation of prescribing of
oxygen, as a result of an oxygen prescribing policy being published within
the Trust. A new prescription chart is in development for the hospital,
which includes a section on oxygen prescribing.
Non-invasive ventilation (British Thoracic
Society)
The lead respiratory Consultants are using existing training sessions to reiterate the need to document a clear non invasive ventilation (NIV) plan.
Severe sepsis & septic shock (College Of
Emergency Medicine)
A clinical guideline specific to the emergency department is being agreed,
this will be used in conjunction with the sepsis care bundle.
Cardiac arrest procedures – time to
intervene (NCEPOD)
The Trust has signed up to join the national cardiac arrest audit and will
start submitting data from July 2013.
Written information leaflets for surgical inflammatory bowel disease (IBD)
patients now provided. Meetings with x-ray and gastroenterology have
been restructured to discuss IBD patients, surgeons are present to discuss to
relevant patients.
The national lung cancer audit has been improved for the 2012 submissions. The development of closer links with the Royal Brompton and Harefield
NHS Foundation Trust and locally between our clinical nurse specialist and
lung team co-ordinator has greatly facilitated a more streamlined reporting
process.
Inflammatory bowel disease (IBD)
Lung cancer (National Lung Cancer Audit)
Oesophago-gastric cancer (National O-G
Cancer Audit)
Patients within this audit are included as part of a review of emergency
admission & re-admission rates of palliative care patients captured at
local level. All patients are identified with a pall alert tag on the patient
administration system. The Co-Ordinate My Care (CMC) system is a recent
strategy to identify patients with their consent to reduce emergency
admissions and re-admissions into hospital and guide community resources
to them with appropriate care identified in the community.
Hip fracture (National Hip Fracture
Database)
Following the introduction of the “assessment and protocol document
for hip fragility fractures” compliance with hip fracture standards has
improved, including falls assessment and both abbreviated mental tests.
A separate audit of this document is now taking place and any identified
improvements will be made.
25
Quality report
Local audits
The reports of 84 local clinical audits were reviewed by the provider in 2012/13 and
examples of The Hillingdon Hospitals NHS Foundation Trust actions to improve the quality of
healthcare provided are detailed below.
Audit of inpatient pathways and day of
discharge processes
This audit was part of the improving inpatient care project and will
roll out the new PAS+ system which will help streamline processes
on the ward to the introduction of electronic white boards and real
time bed management. This should support better discharge planning
and recording of estimated dates of discharge.
Quality of inpatient care (treatment) plans
To improve quality of care plans we are working with each Division
to devise ward round standards, which will include increased multidisciplinary input into care planning. We are also looking at ways to set
and record estimated discharge dates consistently e.g. prompt stickers on
ward rounds.
Audit of Deep Vein Thrombosis pathway
Revised Deep Vein Thrombosis Pathway is under development in
consultation with the Clinical Commissioning Group.
Re-audit - Staff survey of caring for
vulnerable patients including those with a
learning difficulty
This re-audit identified a general positive increase in awareness of caring
for vulnerable patients. The use of the vulnerable adults action card
and patient passport is continually re-inforced to staff, for example, at
mandatory training and induction. The documents are available on the
Trust Intranet.
Survey of staff to evaluate the
implementation of the mental capacity act
2005 and DOLS - re-audit
The re-audit identified the need for further training for staff on the
Mental Capacity Act. Local training sessions have been provided within
the Trust. In March 2013 a training session was delivered by Central
North West London NHS Foundation Trust.
Staff taking blood cultures using best practice
The blood culture audit has demonstrated a significant increase in
blood culture training provided by the Trust from 16% in 2009 to 83%
in 2012. We have standardised blood culture equipment and all new
medical staff receive blood culture theoretical training including a copy
of the blood culture guidelines on induction. The Foundation Year 1 &
2 doctors receive clinical skills & competency checks within 6 weeks of
commencement in the Trust.
Measures of care nursing audits: Falls,
hydration and fluid balance, medicines
management, record keeping, privacy and
dignity, pressure ulcer prevention, food
and nutrition, failure to rescue & patient
identification
During 2012/13 there has been an overall improvement with some
areas sustaining well above target scores. To achieve this, the Nursing
Performance Unit undertook bespoke teaching, one to one working,
role modelling and observation feedback. This together with staff
motivation, commitment, and engagement in undertaking audits and
hard work resulted in improvement.
Audit of children who Do Not Attend (DNA)
Children’s Outpatients (Wendy Ward)
All clinic staff have been reminded of the need to document, in the
patient notes, the process followed when a child does not attend their
appointment. Each consulting room has a copy of the DNA process
flowchart on the desk for staff to refer to.
Audit of records of women with safeguarding
concerns in Maternity Department
A postnatal communication sheet, to aid information sharing, has been
developed and introduced. This document identifies the lead midwife,
confirms the health visitor has been contacted and specifies the plan of
action for individual safeguarding cases.
Quality report
26
Research
Commitment to research as a driver for
improving the quality of care and patient
experience
The number of patients receiving NHS
services provided by The Hillingdon Hospitals
NHS Foundation Trust, that were recruited
during the period to participate in research
approved by a research ethics committee was
547.
The Hillingdon Hospitals NHS Foundation
Trust has a good research track record for
a hospital of its size. We are continuing
with our strategy to broaden our research
portfolio and this has enabled us to offer a
greater number of patients, from different
clinical areas the opportunity to participate
in research. This year we invested in a
research nurse to support our Cardiologists
and Diabetes Consultants as a means of
increasing commercially funded and portfolio
adopted research activity in these areas.
It is projected that within two years the
commercial income generated should sustain
this post thereafter.
Participation in clinical research demonstrates
The Hillingdon Hospitals NHS Foundation
Trust‘s commitment to improving the
quality of care we offer and to making our
contribution to wider health improvement.
This allows our clinical staff to stay abreast
of the latest treatment possibilities and
active participation in research allows our
patient’s access to new treatments that
they otherwise would not have. With this
in mind we aim to offer our patients the
opportunity to participate in a wide range of
clinical research projects. These studies are
both funded by the pharmaceutical industry
and by the Department of Health via the
North West London Comprehensive Research
Network (CLRN); for this work we received
£524,911 from the CLRN.
The money generated from this research
activity funds research nurses and data
managers to support the clinicians in this
27
Quality report
work. The majority of our studies are
National Institute for Health Research (NIHR)
portfolio adopted multi-centre studies where
we are acting as a recruiting site on behalf
of the lead centre. Our research portfolio is
a balance of observational and treatment
studies across many clinical areas in the Trust
including cancer, stroke, and haematology,
many of the general medicine and surgical
specialities and paediatrics. We also support
PhD and Masters students from the local
universities giving them access to our
patients for their projects.
During 2012/2013 we had 66 open or followup studies. We recruited 505 patients into
30 NIHR Portfolio Studies, supported the
repatriation of 20 patients recruited into
treatment studies at other hospitals and
supported four Masters or PhD student
studies.
Our research management processes reflect
the Research Support Services nationally
and have a setup time that meets the NIHR
national targets. On average our research
governance review is undertaken in less than
10 days which is well below the national
target of 30 days.
Summary of lessons learned from serious
incidents
During 2012/2013, the Trust reported
nine Serious Incidents where panel
investigations were conducted. There were
two Serious Incidents reported as ‘Never
Events’; one of these was investigated by
a panel. Never Events are serious grade
2, largely preventable patient safety
incidents that should never occur if the
available preventable measures have been
implemented by healthcare providers (NPSA
2010). It is a legal requirement under CQC
regulations to report them. Protecting
patients from avoidable harm is something
to which there is universal agreement and
the Trust has clearly defined processes and
procedures to follow to help avoid these
events occurring.
Lessons learnt as a result of the serious incidents include:
AREA
DIVISION
SUMMARY
CT scans
Cancer and Clinical
Support Services
(CCSS)
The investigation led to the requirement for more radiology
staff.
Deteriorating patients
All divisions
Record keeping
All divisions
Administration of medicine for
patients that are nil by mouth
Medicine
Reminder to staff regarding using alternative routes of
medicine administration.
Medicine
Review undertaken and new pathway being implemented.
All medical staff
Refresher training provided and access for doctors to the e
learning module for DVT.
Review the Deep Vein
Thrombosis (DVT) clinical
pathway
Refresher training for DVT and
Venous Thrombo Embolysis
(VTE)
Translation for non-English
speaking patients
Maternity
Maternal sepsis
Maternity
Recognition and management
of diabetes in the sick patient
Sharing the learning from
serious incidents
Training and use of an established structured communication
tool (SBAR) for the deteriorating patient.
Training and audit programme in place.
Memo sent out to remind all staff to provide the Trust
translation service when required.
Reminder sent to all staff regarding the use of the centre for
maternal and child enquiries (cmace) guidelines and inclusion
of giving antibiotics to cover listeria.
Medical staff
Clinical training reviewed and updated.
Medical staff
Conducted at the divisional clinical governance forums
Now included in the regular skills and drills programme.
(Skills and drills are practice clinical scenarios undertaken
both formally, through mandatory training and informally
through mock assessments (spontaneous and unexpected
scenarios, practicing specific emergency situations, usually
led by the practice development team and a Consultant).
These are undertaken to ensure that staff are prepared for
all emergency situations, and where shortfalls are identified,
then further training implemented).
Refresher training in place using the regular skills and drills
programme (as above).
Policy reinforced, ongoing monitoring of compliance being
undertaken.
Skills and drills training in the
maternity triage area
Maternity
Neonatal resuscitation training
Paediatrics
Maternity escalation policy
Maternity
Supernumerary status for the
maternity bleep holder
Maternity
Under review, all co-ordinators reminded about their
supernumerary status.
CTG training and CTG ‘buddy’
system
Maternity
Reviewed and competencies being monitored, spot audits in
place.
Security of documents in transit
Corporate
Use of security envelopes across the Trust.
Corporate
Monitored on the incident reporting system.
CCSS
Scanning now in place.
WHO surgical patient safety
checklist
Surgical
Implemented and audit being undertaken. Reminder to use
checklist sent out to staff.
Safe sedation
Surgical
Reminder of safe sedation practice sent out to staff and audit
being undertaken to ensure compliance.
Pain procedure lists and shifts
Surgical
Review of workload undertaken, number, skill mix and
duration of lists.
Escalation of missing patient
communication
Scanning cancer referral
documents
Quality report
28
Goals agreed with commissioners
(CQUINs)
A proportion, 2.5%, of out turn value of
The Hillingdon Hospitals NHS Foundation
Trust’s income in 2012/2013 was conditional
on achieving quality improvement and
innovation goals agreed between The
Hillingdon Hospitals NHS Foundation Trust
and any body they entered into a contract,
agreement or arrangement with for the
provision of NHS services, through the
Commissioning for Quality and Innovation
payment framework. The monetary total for
the associated payments was £3.3 million.
Further details of the agreed goals for
2012/2013 and for the following 12 month
period are available on request from the
Financial Planning Department, The Furze,
The Hillingdon Hospitals NHS Foundation
Trust, Pield Heath Road, Uxbridge, Middlesex.
UB8 3NN or from the Trust website www.thh.
nhs.uk.
Care Quality Commission
The Trust is required to register with the Care
Quality Commission and is registered without
conditions. The CQC paid an unannounced
visit in December 2012 as part of their
planned review of the Trust. The report
issued from this visit stated the Trust is fully
compliant with the Essential Standards of
Quality and Safety.
The Trust received notification on 15th
February 2013 that it was an outlier for
puerperal sepsis (maternal infection)
following delivery and an update was
also requested on maternal emergency
readmission rates. Coding issues and clinical
issues mostly relating to urinary catheters
and infections were identified and a
comprehensive action plan was put in place
which enabled the readmission rate to
reduce to less than 1% bringing us within the
expected range and well below the national
average.
29
Quality report
Data quality
The Hillingdon Hospitals NHS Foundation
Trust submitted records during April –
January for 2012/2013 to the Secondary
User’s Service (SUS) for inclusion in the
Hospital Episode Statistics (HES) which
included the patient’s valid NHS number (to
month 10:)
•98.5% for admitted patient care
•99.8% for outpatients care
•96.4% for accident and emergency care.
The percentage records in the published data
which included the patient’s valid General
Medical Practitioner Code was:
•100% for admitted patient care
•100% for outpatient care
•100% for accident and emergency care.
The Hillingdon Hospitals NHS Foundation
Trust will be taking forward the following
actions to improve data quality:
•continue to review and action data
quality issues at the Trust’s data quality
meetings
•daily data quality reports are published
on the Trust’s web based management
information system for action and
rectification.
Information Governance Toolkit
The Hillingdon Hospitals NHS Foundation
Trust’s Information Governance Assessment
report overall score for 2012/2013 was 81%
and termed as unsatisfactory as one of 44
requirements remains at level 1; all the other
scores are at level 2 or 3.
Clinical coding error rate
The Hillingdon Hospitals NHS Foundation
Trust was subject to the Payment by Results
Clinical Coding Audit during the reporting
period by the Audit Commission. However,
the final 2012/2013 report is yet to be
published and so the latest published report
is from 2011/2012.
The Audit Commission sampled Finished
Consultant Episodes (FCEs) and the overall
average Health Resource Group (HRG) error
rate was 6.5% at episode level compared to
a National average of 9.1% in 2009/2010.
The error rates reported in that audit for
diagnoses and treatment coding (clinical
coding) was:
•Primary diagnosis incorrect 4.0%
•Secondary diagnosis incorrect 5.1%
•Primary procedure incorrect 3.6%
•Secondary procedure incorrect 16.2%.
The results were not extrapolated further
than the actual sample audited. The sample
covered 100 case notes from Respiratory
Medicine and 100 randomly selected case
notes across all specialties.
Quality report
30
ANNEXE
Commissioner statement from
Hillingdon Clinical Commissioning
Group (CCG)
Hillingdon CCG is pleased to receive The
Hillingdon Hospitals Foundation Trust
2012/13 Quality Account. We note that the
involvement of your patients in identification
of priorities for 2013/14 and that you have
included reference to the Francis Report.
2012/13 priorities
We share the Trust’s disappointment that
not all the 2012/13 priorities were achieved;
in particular those relating to information
to GPs following discharge and discharging
patients early in the day as these support
effective and safe discharge from hospital
for patients and reduces the likelihood
of readmission. We would hope to see
a strong patient voice in future work to
improve discharge processes. We note
the very positive steps taken as part of
priority 4 Leaving Hospital – Improving the
Patient Experience; especially the follow up
telephone call and monthly observations of
care visits. Priority 2 – Changes in Maternity
also demonstrated well if not 100%
achievement of targets set. It would be
helpful to see more detail on the steps that
will be taken to increase breast feeding rates.
Quality measures
Quality Measure 4: Independent measure of
cleanliness was 88% and rated green. The
National Inpatient Survey (CQC) indicated
that the Trust scored below the national
average for cleanliness of the toilets and
bathrooms as well as the hospital ward.
There is some discrepancy between the
scores.
Linking to our previous comment on
discharge processes, there is a need to
continue focus on reducing admissions.
31
Quality report
We notice that many of the performance
achievements have been achieved by the
Trust.
2013/14 priorities
Broadly speaking the CCG supports the
priorities identified for 2013/14. It is
reassuring to see a continued focus on
patient experience through continuation
of the CARES priority. We recognise it is
important enough to be a stand-alone
priority but would anticipate that these
values underpin all other priorities.
We were surprised that reference to the
Emergency Care Intensive Support Team
(ECIST) was not made in relation to the
emergency care priority but pleased to see it
identified as an area of focus in 2013/14.
Information for regulators
It would be useful in future reports to
have a better understanding of the impact
of actions where the action has been for
example “reviews” or “memos”.
The overall score for the Information
Governance Toolkit was 81% and termed
“unsatisfactory”. It would have been helpful
if actions planned to improve the score had
been included in the Quality Account.
Hillingdon CCG can confirm that the review
of the 2012/13 performance is consistent
with the SLA monitoring information it has
received in 2012/13.
Hillingdon Health Watch response
to The Hillingdon Hospitals NHS
Foundation Trust Annual Quality
Report
Introduction
Although Health Watch Hillingdon was only
established under The Health and Social Care
Act 2012 on 1st April 2013, it feels qualified
to respond to The Hillingdon Hospitals
NHS Foundation Trust (THH) Quality Report
2012-2013, due to the transfer of staff and
volunteers from Hillingdon Link who have
been involved in working with THH in this
and the previous year’s quality accounts
programme.
Health Watch Hillingdon wishes to thank
THH for the opportunity to comment on the
Trust’s Quality Report for the year 2012-2013.
We would also like to acknowledge the
Trust’s continued commitment to engage
with Hillingdon LINk during the last year. This
has seen an open working relationship, in
which the Trust has embraced the LINk as a
critical friend, encouraging positive challenge
for the improvement of service quality.
The Chief Executive Officer, Chair and
Director of Nursing of the Trust met regularly
with LINk representatives and LINk were
invited to sit on a number of important
groups to monitor patient experience
and quality, such as the Experience and
Engagement Group, the Maternity Liaison
Group, and The Leaving Hospital Project
Group.
Quality report
Health Watch Hillingdon found this year’s
Quality Report easy to read, with clear
explanation throughout the document,
making it accessible to the general public.
Written in a similar style to the 2011/12
report, this year’s report is more focused
on quantitative outcomes, and although
subjective, we have a preference for the
qualitative touches from last year which
quoted patients feedback.
From the Quality Report and the work
LINk has been doing with the Trust it is
self-evident that the Trust is committed to
improving the quality of the services they
provide.
Health Watch Hillingdon found the Quality
Report to be an honest assessment of the
Trust’s performance and provided a balanced
report on the quality of their services.
The Trust should be congratulated on
achieving many of its targets and in making
significant progress in many other areas. It
was especially good to see the recruiting
of women in Maternity reception and as
Maternity Mates to meet the diverse cultural
needs of the women in Hillingdon.
We are pleased that the Trust has been
candid in acknowledging the areas which
require improvement and in recognising
shortfalls that the Trust has made
commitments to improve in these areas. We
particularly feel that for patients, further
improvements around record keeping, and
discharge information given to GP’s and
community health services within 24 hours,
will be specifically beneficial.
We are in agreement with and support THH
in their choice of 2013/14 quality priorities
which has taken into account the views of
LINk and the wider public.
The First Contact Project has now been a
Trust priority for four years and CARES is a
long term programme. It would be helpful
for the general public, where completion of
a project is planned over a long period of
time, for this to be indicated in the report,
setting out the long term goals in addition
to the short term. If this is not the case and a
priority extends due to complexities, it would
be useful if the reasons for this are reported.
The Trust has also indicated in its future
priorities for 2013/14 that it intends to
Quality report
32
increase those people discharged before
12pm from 15.8% to 40% and that the
number of patients being seen by a
consultant within 12 hours of the decision
to admit them will increase from 55% to
90%. We very much welcome these areas as
priorities, with improvements of this scale
and the positive affect this will have on the
patient experience. We are cautious of the
effect these targets may have on patient
expectation, especially around discharge.
Health Watch Hillingdon look forward to
continuing the relationship THH has had
with LINk and working with THH in a joint
commitment to monitor and improve quality.
External Services Scrutiny
Committee Statement
Response on behalf of the External Services
Scrutiny Committee at the London Borough
of Hillingdon
The External Services Scrutiny Committee
welcomes the opportunity to comment on
the Trust’s 2012/2013 Quality Report and
acknowledges the Trust’s commitment to
attend its meetings when requested.
The Committee is pleased to note that the
mortality rate is lower than the national
average expected in hospitals. The Trust has
met the year’s targets for infection control.
The Committee has noted that the Trust has
had only one incident of MRSA in the last
year; and notes the target for next year is
zero. The patient bed days are also below
the national average and London average.
The Trust has also met the 4 hour average
waiting time at A&E.
The Committee is mindful of the imminent
closure of Ealing Hospital’s A & E department
and whether this will have a big impact on
Hillingdon Hospital. The Committee has
noted that in theory rather than the numbers
increasing at Hillingdon, people should
be directed to the appropriate care. The
Committee has noted the challenging times
33
Quality report
within the NHS and the planning involved in
this. The Trust will be spending £12million
in the next few years to start to gear up for
this change. The Committee would like to be
kept up to date on these changes and how
they will affect the residents of Hillingdon
for better or worse.
The Committee is aware that improving
patient care and discharge continues to be
a priority for the Trust. Complaints with
regard to discharge have been identified
as a problem that needs to be addressed;
in particular with regard to when patients
receive their medication. It has been
recognised that this is a problem and the
aim is to have patient’s papers ready on
discharge. The Committee has noted that
the targets for complaints response had
not been met and suggested improvement
in this area. There are some issues with
the turnaround time for complaints which
needed addressing. The Committee has
noted that the Trust is still using a paper
based system but there are plans for
improvements to this.
It is noted that the Trust has formulated 5
priorities for the forthcoming year which are
broadly similar to last years. These priorities
are: First Contact Project; Improving Inpatient
Care and Discharge; Improving Emergency
Care; CARES and CQUINs.
Overall, the Committee is pleased with
the continued progress that the Trust has
made over the last year but notes that
there are a number of areas where further
improvements still need to be made. We
look forward to being informed of how the
priorities outlined in the Quality Report are
implemented over the course of 2013/14.
The Hillingdon Hospitals NHS
Foundation Trust response to the
consultation
to be articulated rather than just a one year
strategy, and we will share these plans in the
coming year.
The Hillingdon Hospitals NHS Foundation
Trust thanks all its stakeholders for their
comments about the 2012-13 Quality Report.
The Trust would like to reassure our
Commissioners that there is a clear action
plan to improve Information Governance
training to achieve Level 2. This plan includes
full training to all new staff on induction,
more regular refresher sessions, bespoke
training where needed, an up to date
training record, and clear escalation for nonattendance. There is also a more detailed
action plan to increase breastfeeding rates.
The External Services Scrutiny Committee
comment on the potential impact of the
implementation of Shaping a Healthier
Future, and the Trust will involve all
stakeholders, including the residents of
Hillingdon, to ensure that a high quality
service will be provided. A merging of the
PALS and complaints teams, as well as our
plan to deal with issues as they arise at
the bedside, should lead to a reduction in
complaints and a prompter turnaround.
Our Commissioners are right in noting the
importance of the 2012 Emergency Care
Intensive Support Team (ECIST) report
and the NHS England: Improving A&E
Performance report (Gateway reference
00062, released April 2013), which both
support our stated aims for improving
emergency care. They also offer other best
practice and operational recommendations
many of which have been, or are being,
implemented.
Our Commissioners have rightly pointed out
the difference between our independent
measure of cleanliness (an audit of
cleanliness standards) being higher than the
National Inpatient Survey for the cleanliness
of toilets and bathrooms as well as the
hospital ward (a measure of the patients
perception of cleanliness). The results of the
National Inpatient Survey has historically
been lower and is difficult to reconcile
because they are asking different questions
and measuring different things.
Health Watch note the need for the Trust to
continue to be candid, balanced, and honest,
qualities we agree are essential. We agree
that a clear plan for long term project needs
Quality report
34
Independent Auditor’s Report to
the Council of Governors of The
Hillingdon Hospitals NHS Foundation
Trust on the Quality Report
We refer to these national priority indicators
collectively as the “indicators”.
We have been engaged by the Council of
Governors of The Hillingdon Hospitals NHS
Foundation Trust to perform an independent
assurance engagement in respect of The
Hillingdon Hospitals NHS Foundation Trust’s
Quality Report for the year ended 31 March
2013 (the “Quality Report”) and certain
performance indicators contained therein.
The Directors are responsible for the content
and the preparation of the Quality Report
in accordance with the criteria set out in
the NHS Foundation Trust Annual Reporting
Manual issued by Monitor. Our responsibility
is to form a conclusion, based on limited
assurance procedures, on whether anything
has come to our attention that causes us to
believe that:
This report, including the conclusion, has
been prepared solely for the Council of
Governors of The Hillingdon Hospitals
NHS Foundation Trust as a body, to assist
the Council of Governors in reporting
The Hillingdon Hospitals NHS Foundation
Trust’s quality agenda, performance and
activities. We permit the disclosure of this
report within the Annual Report for the year
ended 31 March 2013, to enable the Council
of Governors to demonstrate they have
discharged their governance responsibilities
by commissioning an independent assurance
report in connection with the indicators.
To the fullest extent permitted by law, we
do not accept or assume responsibility to
anyone other than the Council of Governors
as a body and The Hillingdon Hospitals NHS
Foundation Trust for our work or this report
save where terms are expressly agreed and
with our prior consent in writing.
Scope and subject matter
The indicators for the year ended 31 March
2013 subject to limited assurance consist of
the national priority indicators as mandated
by Monitor:
• Maximum 62 day waiting time from
urgent GP referral to treatment for all
cancers;
• Emergency readmissions within 28
days of discharge from hospital.
35
Quality report
Respective responsibilities of the
Directors and auditors
• the Quality Report is not prepared in
all material respects in line with the
criteria set out in the NHS Foundation
Trust Annual Reporting Manual;
• the Quality Report is not consistent in
all material respects with the sources
specified in the guidance; and
• the indicators in the Quality Report
identified as having been the subject
of limited assurance in the Quality
Report are not reasonably stated in
all material respects in accordance
with the NHS Foundation Trust
Annual Reporting Manual and the six
dimensions of data quality set out in
the Detailed Guidance for External
Assurance on Quality Reports.
We read the Quality Report and consider
whether it addresses the content
requirements of the NHS Foundation Trust
Annual Reporting Manual, and consider the
implications for our report if we become
aware of any material omissions.
We read the other information contained in
the Quality Report and consider whether it is
materially inconsistent with the documents
specified within the detailed guidance. We
consider the implications for our report
if we become aware of any apparent
misstatements or material inconsistencies
with those documents (collectively the
“documents”). Our responsibilities do not
extend to any other information.
We are in compliance with the applicable
independence and competency requirements
of the Institute of Chartered Accountants in
England and Wales (ICAEW) Code of Ethics.
Our team comprised assurance practitioners
and relevant subject matter experts.
Assurance work performed
We conducted this limited assurance
engagement in accordance with
International Standard on Assurance
Engagements 3000 (Revised) – “Assurance
Engagements other than Audits or Reviews
of Historical Financial Information” issued
by the International Auditing and Assurance
Standards Board (“ISAE 3000”). Our limited
assurance procedures included:
• Evaluating the design and
implementation of the key processes
and controls for managing and
reporting the indicators.
• Making enquiries of management.
• Testing key management controls.
• Limited testing, on a selective basis, of
the data used to calculate the indicator
back to supporting documentation.
• Comparing the content requirements
of the NHS Foundation Trust Annual
Reporting Manual to the categories
reported in the Quality Report.
• Reading the documents.
A limited assurance engagement is smaller
in scope than a reasonable assurance
engagement. The nature, timing and extent
of procedures for gathering sufficient
appropriate evidence are deliberately
limited relative to a reasonable assurance
engagement.
Limitations
the methods used for determining such
information. The absence of a significant
body of established practice on which to
draw allows for the selection of different
but acceptable measurement techniques
which can result in materially different
measurements and can impact comparability.
The precision of different measurement
techniques may also vary. Furthermore, the
nature and methods used to determine such
information, as well as the measurement
criteria and the precision thereof, may
change over time. It is important to read the
Quality Report in the context of the criteria
set out in the NHS Foundation Trust Annual
Reporting Manual.
The scope of our assurance work has not
included governance over quality or nonmandated indicators which have been
determined locally by The Hillingdon
Hospitals NHS Foundation Trust.
Conclusion
Based on the results of our procedures,
nothing has come to our attention that
causes us to believe that, for the year ended
31 March 2013:
• the Quality Report is not prepared in
all material respects in line with the
criteria set out in the NHS Foundation
Trust Annual Reporting Manual;
• the Quality Report is not consistent in
all material respects with the sources
specified in the guidance; and
• the indicators in the Quality Report
subject to limited assurance have not
been reasonably stated in all material
respects in accordance with the NHS
Foundation Trust Annual Reporting
Manual.
Deloitte LLP
Chartered Accountants
St Albans
29 May 2013
Non-financial performance information
is subject to more inherent limitations
than financial information, given the
characteristics of the subject matter and
Quality report
36
Statement of Directors’
responsibilities in respect of the
Quality Report
The Directors are required under the Health
Act 2009 and the National Health Service
(Quality Accounts) Regulations 2010 as
amended 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 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 2012/2013;
•the content of the Quality Report is not
inconsistent with internal and external
sources of information including:
° Board minutes and papers for the
period April 2012 to May 2013
° Papers relating to quality reported to
the Board over the period April 2012 to
May 2013
° Feedback from the Commissioners
dated 22/5/2013
° Feedback from the Governors dated
25/4/2013
° Feedback from LINks dated 7/5/2013
° The Trust’s Complaints Report
published under Regulation 18 of the
Local Authority Social Services and
NHS Complaints Regulations 2009,
17/5/2013;
37
Quality report
° The latest national patient survey
published 16/4/2013
° The latest national staff survey
28/2/2013
° The Head of Internal Audit’s annual
opinion over the Trust’s control
environment dated 8/5/2013
° CQC Quality and Risk Profiles dated
from 1 April 2012 to 31 March 2013
•The Quality Report presents a balanced
picture of the NHS Foundation Trust’s
performance over the period covered;
•The performance information reported in
the Quality Report is reliable and accurate;
•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;
•The data underpinning the measures
of performance reported in the Quality
Report is robust and reliable, conforms
to specified data quality standards and
prescribed definitions, is subject to
appropriate scrutiny and review; and
the Quality Report has been prepared
in accordance with Monitor’s annual
reporting guidance (which incorporates
the Quality Accounts Regulations)
(published at www.monitor-NHSft.gov.
uk/annualreportingmanual) as well as
the standards to support data quality for
the preparation of the Quality Report
(available at www.monitor-NHSft.gov.uk/
annualreportingmanual).
The Directors confirm to the best of their
knowledge and belief they have complied
with the above requirement in preparing the
Quality Report.
LANGUAGES/ ALTERNATIVE FORMATS
Quality report
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