Our Quality Account
2014-15
CONTENTS
1. Statement on quality from our CEO
3
2. Introduction
2.1 ‘Unlocking our Potential’ and the Care Quality Commission
2.2 Are we safe?
2.3 Are we caring?
2.4 Are we effective?
2.5 Are we responsive?
2.6 Are we well-led?
5
6
7
10
12
15
17
3. Looking back
3.1 Review of our performance against 2014/15 priorities
3.2 Mortality
3.3 Patient reported outcome measures
3.4 Readmissions
3.5 Venous thromboembolism
3.6 Staff experience
3.7 Infection prevention and control
3.8 Serious incidents
3.9 Responsiveness to personal needs
3.10 Friends and Family Test (FTT)
3.11 Participation in clinical research
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19
25
26
27
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29
31
33
35
35
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4. Looking forward
4.1 Priorities for improvement
4.2 Priority one: Patient safety
4.3 Priority two: Clinical effectiveness
4.4 Priority three: Patient experience
4.5 Priority four: Timely
4.6 Priority five: Efficient
4.7 Priority six: Equitable
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39
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5. Quality Account appendices
5.1 Contracted services
5.2 Quality of services
5.3 Generated income
5.4 Audit
5.5 CQUINS
5.6 CQC Registration and compliance
5.7 Data Quality
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45
46
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54
56
57
6. Statements of assurance and closing statement
59
7. Partner commentaries
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Quality Account 2014-15
Barking, Havering and Redbridge University Hospitals NHS Trust
2
1.
STATEMENT ON QUALITY FROM OUR CHIEF EXECUTIVE, MATTHEW HOPKINS
Welcome to our Quality Account. This year we have developed strong working relationships with our
partners to deliver on our commitment to provide outstanding healthcare for our community –
delivered with pride. In just over a year since we were placed in special measures following a visit
from the Care Quality Commission (CQC), we have started to address the issues raised to improve
the care we provide for our patients, and in June last year we published our Improvement Plan
Unlocking our Potential.
We are well underway in implementing that plan and each month we publish our progress report on
our website. This explains where we have improved, what we have put in place, and what more
needs to be done to ensure our patients receive the quality care they deserve every day.
Now that our Trust Board is complete we are in a much stronger position to achieve this – we have
the right people in place with the right expertise to drive further sustainable improvements and
provide the necessary support and challenge to our staff. We are now working on areas of
improvement that were highlighted during the more recent CQC inspection in March 2015, and a
report will be available for the public from the CQC in the summer.
This year, we have also reviewed our clinical leadership to make sure we have the right structure to
deliver the changes, and one that is fit for the future. By ensuring our leadership and our structure
are sound, we can get a much tighter grip of our organisation. The divisional leadership teams that
are now in place will continue to deliver our improvement plan and can place a dedicated focus on
improving our quality, addressing our performance and stabilising our finances.
Delivering improvements and improving our quality is also about continuing to embed our values of
passion, responsibility, innovation, drive and empowerment – PRIDE. We have increased the
visibility of our leadership team, and implemented new channels to encourage open and honest
discussion that helps ensure that the decisions we make put our patients first.
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Barking, Havering and Redbridge University Hospitals NHS Trust
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I believe the information provided in this report demonstrates our continuing commitment to
providing the highest quality clinical care as we aspire to provide outstanding services to our local
community. I confirm that, to the best of my knowledge, the information provided in this document
is accurate.
Matthew Hopkins
Chief Executive
11 May 2015
Contact us
If you would like any further information about our hospitals, please contact us:
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www.bhrhospitals.nhs.uk
Tweet us at @bhr_hospitals
Call 01708 435 000
Email communications@bhrhospitals.nhs.uk
If you or someone you know cannot read this document, please let us know and we will do our best
to provide the information in a suitable format or language.
To contact our Patient Advice and Liaison team please:
 call 01708 435 454
 email pals@bhrhospitals.nhs.uk
 visit the main receptions at Queen’s or King George hospitals:
Queen’s Hospital
Rom Valley Way
Romford
Essex RM7 0AG
King George Hospital
Barley Lane
Goodmayes
Ilford IG3 8YB
These are the main hospitals we run our services from. Our teams also provide services at other
clinics and sites across our community.
Quality Account 2014-15
Barking, Havering and Redbridge University Hospitals NHS Trust
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2.
INTRODUCTION
Dr Nadeem Moghal, Medical Director and
Wendy Matthews, Interim Chief Nurse
Our quality vision is simple: we place excellence in patient care at the centre of all we do in caring
for our community. This means a relentless focus on patient safety, experience and clinical
outcomes. Each year our Quality Account looks back at our progress over the year and looks forward
to our ambitions for the year ahead. Some years ago, the US Institute of Medicine outlined six
dimensions of quality. Over the past few years we have set our improvement priorities against three
of those – safe, effective and person-centred care. This year, to embed quality even further into our
improvement plans, we have added the other three further dimensions to complete the full
definition of what constitutes quality in healthcare: that care should be timely, efficient, and
equitable. We firmly believe that people deserve our utmost effort to reduce harm and improve
quality for all our patients.
Over the next year, we will continue to work closely with our partners locally: with our
commissioners to provide better, more coordinated integrated services; with our local authorities to
make sure that we provide services for patients identified through the Joint Strategic Needs
Assessment (an assessment of the health and wellbeing of our local community) as needing our
support, help and treatment the most; and with our community and voluntary sector partners, who
provide much needed care and support in the community and at home.
We recognise that culture plays a large part in this and that cultural change and continual
improvement come from the commitment and encouragement of leaders. During the year we have
continued to reinforce our clinical leadership at all levels and to invest in our leadership
development. We have more to do and will focus on this into the coming year. Our values of PRIDE
– passion, responsibility, innovation, drive and empowerment – have become embedded within the
Trust and provide a way to reinforce the behaviours we need and the ethos our patients deserve.
All of our staff and volunteers, including doctors, nurses, midwives and managers, will lead the
delivery of our objectives over the next year, developing us further to become the resilient, reliable
and sustainable provider of health and healthcare for the large, fantastically diverse, growing
population we serve.
Quality Account 2014-15
Barking, Havering and Redbridge University Hospitals NHS Trust
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2.1
UNLOCKING OUR POTENTIAL AND THE CARE QUALITY COMMISSION (CQC)
In December 2013, the Care Quality Commission (CQC) put our Trust into special measures. In June
2014, we published our improvement plan Unlocking our Potential. It was developed with input from
staff, Clinical Commissioning Groups, Local Authorities, and North East London NHS Foundation
Trust, to address the issues the CQC raised. The plan gave us an opportunity to look at how we
improve our services, with a clear focus on partnership working, as we need a whole-system
approach to ensure our local residents receive the best care possible.
We began the year with a new Chair, Dr Maureen Dalziel, and over the course of the year, new nonexecutive directors were appointed to our Board. We brought in a new leadership team led by
Matthew Hopkins, who was appointed permanently as Chief Executive in July 2014. Additionally,
since last July we have published a monthly progress report, reflecting the key achievements in our
improvement plan. These are available on our website – About Us: Our Improvement Plan.
The CQC monitor the quality of our care against five domains. The questions they ask are:
Are we safe?
Are we caring?
Are we effective?
Are we responsive?
Are we well-led?
During their inspections the CQC looked at these five key areas and provided a report with
recommendations about where we needed to improve. To deliver the necessary actions to improve
patient care, we developed a comprehensive improvement plan with five key work streams:
1. Leadership and organisational development – led by Deborah Tarrant, Director of People
and Organisational Development
2. Outpatients – led by Steve Russell, Deputy Chief Executive
3. Patient care and clinical governance – led by Jason Seez, Director of Planning and
Governance
4. Patient flow and emergency pathway – led by Sarah Tedford, Chief Operating Officer
5. Workforce – led by Deborah Tarrant, Director of People and Organisational Development
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2.2
ARE WE SAFE?
The CQC assess whether or not the people we care for are protected from abuse and avoidable
harm. When they inspected our services in 2013 they found that many of the services at our Trust
were safe, however, the Emergency Departments at both hospitals were at times unsafe because of
the lack of full-time consultants and middle-grade doctors. They found there was an over-reliance on
locum doctors with long waiting times for patients to be assessed by specialist doctors.
How do we assure ourselves that our services are safe?
We have put in place a number of changes and improvements that help to keep our patients safe.
We review national and local quality and safety indicators via our governance committee structure.
These are shared through the performance dashboard which goes to our Trust Board.
This year we have improved our clinical management structure and we now have six clinical
divisions. These divisions have an integrated performance review process where they review quality
and safety indicators at divisional level. The divisions set targets for improvement in addition to their
activity and financial performance.
We reviewed divisional level quality performance through an assurance review process, this means
that we reviewed information submitted by divisions and compared this against centrally-held
information on quality performance. Guidance was then provided on how the divisions can make
improvements; and their progress is monitored as part of their performance meetings. The quality
and safety on our wards is also regularly reviewed via the weekly quality of care and daily safe to fly
checks, plus deep dive quality road maps which we are currently updating. Executive and nonexecutive walkabouts seek to identify safety issues at ward and department level and a log of actions
is held by the Chief Nurse to monitor progress.
Our staff have a vital role in ensuring our services are safe and we have sought to embed a culture
where they are comfortable in raising issues and concerns. They are encouraged to do this through
their line management route; however if this does not work they have a number of open forums, for
example Meet the Chief Executive, where they are encouraged to be open and honest about the
challenges we face. We have also implemented a pioneering Guardian Service1 which is an
1
Guardian Service. This is an independent and confidential service, which is the first of its kind in the country, which offers our
staff the opportunity to confidentially and openly raise their concerns. Confidential surgeries are held weekly offering one-to-one
appointments with monthly slots available for staff that work evening and weekend shifts.
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independent service that has been used by over 200 staff, where they can report concerns
anonymously.
Additional assurances include:
An electronic incident reporting system; incident and harm analysis features in specific reports
throughout the governance committee structure
A new learning lessons group which has established a number of communication networks to
disseminate key lessons learned
All Serious Incident (SI) reports are published on the intranet. There are specific review groups
for high risk areas such as falls, medicines, pressure ulcers, maternity and emergency care
A programme of education and comprehensive committee structure for Safeguarding of Adults
and Children; with attendance at external groups to share and compare practice
Safety thermometer data is reviewed and analysed at the Nursing Midwifery and Allied Health
Professionals Steering Group
Our Trust Board reviews the Safer Staffing report from the Chief Nurse on a monthly basis to
ensure our staffing levels remain consistent with the organisational staffing standards
Improved systems for reporting and escalating risks; we have begun a comprehensive training
needs analysis for risk management with the aim of preventing incidents and harm.
What improvements have we made?
Recruiting and retaining high-quality permanent staff is one of the key priorities in our improvement
plan that will help to improve the safety of our patients. We are running focused recruitment
campaigns, both nationally and internationally, and we are working with partner organisations to
help ensure the Trust is an attractive place to work.
Our performance against the emergency access target has also significantly improved in recent
months. We have met the local target agreed with the NHS Trust Development Authority - at the
end of March 2015, 91% of our patients were seen and treated within four hours - and we are
continuing to improve our performance further to meet the national standard of seeing, treating and
discharging 95% of patients within four hours.
Quality Account 2014-15
Barking, Havering and Redbridge University Hospitals NHS Trust
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Additional improvements include:
Reduction in grade three and four pressure ulcers
Web-based live risk management system and exposure of high level risks requiring action
New maternity triage system for assessing level of risks in women presenting to the Maternity
unit unannounced
Dedicated pharmacist for Maternity supporting the new Maternity Awareness Group to improve
safety in this area
Re-modelled Board level committee responsible for oversight of quality and safety which
includes all members of the Executive Management Team, demonstrating a collective
responsibility for ensuring quality and safety within the organisation
We have improved the availability and reporting of safety indicators through divisional quality
governance reports and integrated performance review process. As the new divisional structure
is embedded, this will help to provide further assurance of the level of quality and safe care that
we provide and help to identify areas of concern.
What are our key challenges and next steps?
We have joined the national programme, Sign up for Safety, which was launched in June 2014 aimed
at halving avoidable harm over the next three years. Our pledges include:
Improving the prevention and management of patient falls
Utilising key medication error data to develop robust actions that will ensure greater patient
safety
Monitoring and identifying mortality outliers to recognise and take action where deaths may
be prevented
Improving awareness, recognition and management of sepsis
Improving monitoring of women in labour.
We are working hard to demonstrate that we put patients’ safety first, that we continually learn,
that we are transparent and honest, and that we collaborate across agencies to ensure we can give
high levels of care and support.
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Barking, Havering and Redbridge University Hospitals NHS Trust
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A key focus of our work to improve safety is in our Emergency departments. We are continuing to
work with our partners to help manage demand and improve patient flow. This requires initiatives
across the health system, with the focus on providing as much care as possible closer to home by
working effectively with Community Treatment Teams and the Intensive Rehabilitation Service.
We continue to improve our governance across our hospitals and we are working with the Good
Governance Institute to improve our corporate and clinical governance and to help ensure that our
Quality and Safety Committee provides the right level of assurance to our Board on these issues.
Workforce is also a key area of focus. We need to get the right staff, doing the right job and
providing the right quality of care for our patients. We are strengthening the clinical leadership in
our Emergency departments, and enhancing our trustwide recruitment and attraction strategy.
We have made some good progress in our efforts to improve the sharing of lessons learned as a
result of serious incidents and now monitor the levels of feedback sent to staff via the Ulysses IT
system. There is now a learning lessons intranet2 web page, quarterly newsletter and presentation
at our Senior Team Brief, and we continue to make available all serious incident investigation reports
to our staff via our intranet.
2.3
ARE WE CARING?
The CQC assess how we involve and treat people with compassion, respect and dignity, and tailor
care to meet their individual needs. Their last report acknowledged that significant work has been
undertaken to improve patient care and many patients and relatives were complimentary about
their care. Inspectors observed that staff treated patients with dignity and respect; however, more
work is required to ensure improvements are reflected in national patient surveys.
How do we assure ourselves that we are caring?
We collect feedback about patient experience in a number of ways, including speaking directly with
our patients, comment cards, and thank you letters. Our patient experience team triangulates
information and feedback that we receive from patients including:
Online reviews, NHS Choices reviews and Patient Opinion
2
The intranet is the Trust’s own internal electronic resource for staff that holds the latest information as well as historic
documents such as policies, strategies and minutes of meetings.
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Barking, Havering and Redbridge University Hospitals NHS Trust
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Friends and Family Test and patient surveys
Patient Advice and Liaison Service (PALS) enquiries
Formal complaints.
We work hard to involve patients and our communities in our work. Patient representatives are
involved in key meetings and we have an Improving Patient Experience Group, where patient
representatives can get involved and talk to us about issues that matter to them. We also regularly
attend the Clinical Commissioning Groups’ (CCGs) patient representative forums.
What improvements have we made?
This year as part of our improvement programme we launched new listening events to help us
engage patients and our communities in our service improvements. We worked in partnership with
four of our local Healthwatch organisations: Barking and Dagenham, Havering, Redbridge and Essex.
Our frontline teams attended and heard first-hand the feedback from the public on their thoughts
about our progress against the CQC’s five domains. The key themes they raised included: issues
around communication with patients, for example by letter and text message; patient experience,
for example access to entertainment and being treated with dignity and respect; and treatment of
patients with specific needs, such as those with learning disabilities, mental health conditions or
sensory impairments. This feedback has been integrated into our improvement plan and is being
actioned by our frontline teams.
We have also improved the way we get feedback from our local representatives such as MPs and
councillors, through introducing a regular Local Representatives Panel. This forum is an opportunity
for those who represent local groups, areas or sections of the population to provide our hospitals
with feedback and an opportunity for our teams to involve them and talk to them about our
improvement initiatives. This year we also introduced a Mystery Shopper scheme, which provides us
with invaluable insights into our services.
It is important for us that our patients and their families feel able to raise concerns and have the
right information to do so. We have therefore introduced ‘Welcome’ and ‘It’s good to talk’ boards
across our wards and departments. To ensure all patients are able to feedback and to improve
equality and accessibility, we have also translated patient surveys into the top 10 most requested
languages. We have also made them available in braille, a child-friendly format and an easy-read
version.
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Barking, Havering and Redbridge University Hospitals NHS Trust
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Nutrition was a key issue raised by our patients. We have therefore created a nutrition action plan to
improve our food and meal services in the coming year and take on board their feedback.
What are our key challenges and next steps?
•
Ensuring changes are being made as a result of patient feedback
•
Ensuring high response rates to patient surveys when wards are busy
•
Ensuring feedback is given to the right people, in a timely manner
•
Improving our patient experience ratings
•
Providing better information for patients
•
Implementing better discharge processes
•
Introducing a laminated inpatient handbook on every ward
•
Introducing welcome packs on the wards
•
Reviewing the specific needs and requirements for patients who are severely deaf and blind
•
Looking at new ways to respond to patient concerns and complaints.
2.4
ARE WE EFFECTIVE?
The CQC also assess whether the care, treatment and support we provide to patients achieves good
outcomes, promotes a good quality of life, and is based on the best available evidence. Following
their last report they assessed that while we had some arrangements in place to manage quality and
ensure effective care; more work was needed in Medicine, children’s care, end of life care and
Outpatients. Long waiting times in the Emergency Department have meant that some patients have
had to wait longer than ideal to see a specialist.
What assurances do we have in place that we are effective?
Our Quality and Safety Committee, which is a sub-committee of the Trust Board, monitors the
effectiveness of our services, ensuring feedback through to the Board. The work we are now
undertaking with the Good Governance Institute (GGI) will strengthen our governance processes.
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A number of other groups and committees also help to provide assurance:
Evidence-based Practice Committee which reviews all new practices against best available
evidence
Safe Medicines Practice Group, which is overseen by our Drugs and Therapeutic Committee - a
multi-provider group with our Clinical Commissioning Groups (CCGs)3 to provide an assurance
process for new treatments
NICE Guidance Assurance Group which monitors compliance with NICE guidelines.
Our audit processes and systems also help to ensure we provide effective care. Our Clinical Audit
Group meets every two months to ensure all divisions have a planned audit programme.
We also participate in national audits, including all College of Emergency Medicine audits, which
enable us to benchmark ourselves against other trusts. Our eHandover system, which won an NHS
Innovation award, enables effective and auditable patient care between shifts. Regarding mortality,
we ensure we hold ‘deep dive’ investigations into areas with a higher than national mortality;
findings are then reviewed through our monthly assurance review process.
Participation in peer reviews with other organisations such as acute providers. Recent examples
include haemoglobinopathy services and inflammatory bowel services
Mandatory training in mental health and the ongoing monitoring of compliance with the Mental
Health Act 2005, which is reported to our Safeguarding operational boards
What improvements have we made?
Adopted the Sepsis Six - a best practice tool to help manage and treat sepsis. More than 3,000
staff have been trained in its use. Regular audits take place in our Emergency departments (EDs)
and are being rolled out in other areas across the Trust.
Rolled out the National Early Warning Score (NEWS). This enables earlier detection of
deteriorating/likely to deteriorate patients. This work has been further supported by the
establishment of the Critical Care Outreach team across both sites, which has led to a reduction
in cardiac arrests outside of the Critical Care department.
3
Clinical Commissioning Groups are groups of GP Practices that are responsible for commissioning most health and care
services for their patients as set out in the Health & Social Care Act 2012. They are formed in largely co-terminus groups that
mirror the local authority boundaries.
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Barking, Havering and Redbridge University Hospitals NHS Trust
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Purchased the HED database which helps to investigate mortality and flag areas of concern
Widened the audience for mandatory training to include all clinical staff, and made mandatory
training more accessible. For example, over 80 per cent of clinical staff are now trained in basic
life support.
Developed an antibiotic guidance app for smart phones and tablets, giving clinicians access to
crucial information without leaving the patient’s bedside.
Introduced the LACE Index scoring system which assesses the risk of a patient’s readmission by
looking at length of stay, acute admission through the EDs, co-morbidities4, and the number of
times an individual patient has visited the ED in the past six months, to help reduce future
readmissions.
What are our key next steps?
Strengthen clinical governance within the new divisional structure
Review our dementia strategy and monitor effectiveness
Improve specialty input to the emergency pathway
Improve the way we review each death and gain assurance about avoidance of harm to patients
Implement an inquisitive improvement culture, driven by data and ward to board dashboards
Improve uptake of mandatory training in weaker areas
Switch to our new nursing documentation booklet – this is quicker and easier to complete,
leaving more time to spend with patients
Ensure all patients have a treatment escalation plan
Roll out an eLearning module on ‘Do Not Attempt Resuscitation’ decisions.
4
Co-morbidities refer to the presence of one or more additional disorders (or diseases) co-occurring with a primary disease or
disorder, or the effect of such additional disorders or diseases.
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Barking, Havering and Redbridge University Hospitals NHS Trust
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2.5
ARE WE RESPONSIVE?
The CQC assess whether or not our services are organised so that they meet people's needs. Their
last report highlighted the longstanding issue of waiting times in our Emergency department at
Queen’s Hospital. They stated that poor discharge planning and capacity planning was putting
patients at risk of receiving unsafe care and causing unnecessary pressure in some departments.
What assurances do we have in place that we are responsive?
In recent months there has been considerable improvement to our flow of patients through our
hospitals and the timeliness of care in our Emergency departments. We have been working closely
with our partners to provide our patients with the services they need in a flexible, accessible way.
On our emergency pathway we identified areas for improvement and have a resilience plan that is
closely scrutinised to ensure we are delivering the best care in the right environment.
We have completely reconfigured our ‘front door of care’5 to ensure that patients are treated by
specialist, dedicated teams with a particular focus on our most at-risk patients. We listen carefully to
the views of our patients and closely monitor complaints to ensure that we respond to people’s
concerns and incorporate their opinions into the redesign of services.
What improvements have we made?
This year we are particularly proud of our Emergency department teams, our ward teams and
partners in the community who, together, have started to improve the flow of patients through our
hospitals. By discharging patients earlier in the day through better coordination internally and with
support from our community partners, we are now beginning to see real improvements in the
timeliness of the care we provide and therefore improved experience for our patients. This
demonstrates that future improvement is dependent on strong partnerships with our colleagues
beyond our hospital boundaries.
5
We have considered how our patients require our hospitals’ services and have been working with local GPs, CCGs
community services and councils to identify ways to help avoid hospital admissions. Our internal procedures once patients do
arrive have also been reviewed to ensure the care and treatment we provide is as effective and timely as we can make it.
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We have also been recognised for the work we are doing to support our elderly patients. We have
one of the highest elderly populations in London and are working closely with our partners in the
community to help ensure the right services are in place for our frail patients, so they are not
brought into hospital unnecessarily. We have also launched our 30-bed Elders’ Receiving Unit at
Queen’s Hospital to help reduce the number of unnecessary admissions by assessing patients
quickly, treating them and getting them back into the comfort of their own homes as soon as
possible.
Improvements have also focused in our Outpatient areas. Around 650,000 people visit our
Outpatient Departments every year. We also receive up to 6,000 telephone calls to our call centre
each week. Improving our Outpatient departments has been a key part of our improvement plan.
We want to make sure that the right patient is in the right clinic with the right consultant and
paperwork to give them the best possible care. Listening to feedback from our patients and our GP
community, we know that we need to work hard to improve the outpatient service we provide.
Many patients have experienced problems, including clarity of the letters we have sent them,
appointment cancellations and sometimes at appointments because their case note have not been
available. They have also had difficulties in contacting us when they needed to. A major piece of
work needed to be done to address these long-standing issues. To improve the care and service our
patients receive, we appointed a dedicated Improvement Manager for Outpatients. The project to
improve outpatients was a challenging one – covering everything from the décor of the waiting
areas to the processes used by our Appointments booking team. Significant improvements have
been made and are highlighted in this report.
What are our key challenges and next steps?
Our key challenge is to ensure that the improvements we have made are sustainable and that, whilst
we are meeting our agreed local trajectory, we also need to do more to ensure we consistently meet
the national standard across our hospitals. We need to continue to work with our community
partners to ensure that provision of care in the community is effective in helping to ensure flow
through our hospitals. Recruitment and retention of our workforce will also be a key focus for the
future.
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2.6
ARE WE WELL-LED?
Following their last report the Care Quality Commission found examples of good clinical leadership
at every service level and staff were positive about their immediate line managers. They stated that
the Trust Executive Team needed to be more visible and greater focus was needed at Board level to
resolve longstanding quality and patient safety issues. Since then we have made significant
improvements to our leadership as we strive to lead our organisation to deliver high quality, patientcentred care. The leadership supports learning and innovation and promotes an open and fair
culture. We are governed by a new Board and we have put in place a new management structure to
ensure we improve our focus on the delivery of care.
What assurances do we have in place to ensure we are well led?
Our Trust Board and its supporting committees, including the Audit and Quality and Safety
Committees - reviews our performance, holds the Executive and all staff to account, and gains
assurance that we are delivering high quality, patient-centred care
Our performance monitoring and service improvement capability – helps drive improvement
and identifies areas requiring attention
Our corporate risk register - covers all key risks to the organisation and how we will mitigate
them
Local risk registers - cover all key risks to each service’s delivery, and plans to address them,
escalated to senior management as appropriate
Regular team meetings, one-to-ones with each staff member and annual appraisals are held so
that each staff member feels supported and held to account
A programme of both desk-based and face-to-face training for all staff, complemented by an IT
system, Wired, to enable managers to ensure their staff have up-to-date training
‘Speak up for a healthy Trust’6 policy, with a Guardian Service, so all staff feel confident to raise
concerns.
6
Speak up for a Healthy Trust is the title of the Trust’s whistle-blowing policy.
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What improvements have we made?
Appointed a new Chair, Chief Executive, and a full Board and Executive team, to helps us match
the scale of the challenges we face as an organisation
Undertaken a restructure to create six strong clinical divisions each led by a triumvirate of a
clinician, a nurse or therapist, and a manager
Created a new role of Deputy Chief Executive to strengthen the leadership team
Created a new role of Director of Planning and Governance to focus on strengthening planning,
business development and corporate governance
Given the Board more focus on quality and patient safety issues and introduced a Board
development programme
Introduced a programme of activity to help make the Executive Team more visible and to listen
to staff concerns, including monthly Meet the Chief Executive sessions for all staff, and health
and safety walk-rounds across the hospitals
Implemented a programme to embed our PRIDE values and behaviours with all our staff and our
work with over 5,000 staff going through the PRIDE programme
Improved the leadership focus of King George Hospital, with the Executive Team (normally
based at Queen’s Hospital) spending at least one day a week there, Board meetings alternating
between King George and Queen’s, and a senior doctor and nurse lead
Introduced a new programme of Senior Team Brief, with face-to-face briefings for the top 150
leaders across the organisation to cascade to their teams each month
Introduced a programme of staff engagement and encouragement of staff feedback, including
promotion of the ‘Speak up for a healthy trust’ policy, so all staff feel able to contribute towards
improvement.
What are our key next steps?
Structure ourselves for success – Phase two of our management restructure, so that our new
divisional directors, managers and nurses/therapists are supported by an excellent team of
matrons, general managers, and clinical leads
Further develop clinical leadership across the organisation and embed the new divisional
structure
Review the team meeting process and the role of Senior Team Brief cascade throughout the
organisation and develop how our managers engage with their teams
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Improve the management of staff across the organisation, so every member of staff is clear
about their role, supported in their development and held to account for delivery.
Continue to build on our PRIDE programme and instil a culture of intolerance of mediocrity
Lever the expertise of our Non-Executive Directors to ensure challenge of Executive directors
Confident, unitary board instilling internal and external confidence
3.
LOOKING BACK
3.1
REVIEW OF PERFORMANCE AGAINST OUR 2014/15 IMPROVEMENT PRIORITIES
The quality priorities we set last year were incorporated into our Improvement Plan and Operating
Plan. They covered a wide range of initiatives that supplemented our five year Quality Strategy
aimed at driving up the quality of care and helped to focus our attention on reducing harm,
improving our patient experience and delivering high quality clinical outcomes.
The table below shows how we performed against our improvement priorities in 2014/15:
Achieved
Partially achieved
Not achieved
PRIORITY 1: PATIENT SAFETY
Avoiding injuries to patients from care that is intended to help them
Objective
Our plan
Progress
2013-14 CQUIN target for reduction in overall falls by 5%
Reducing
the
number of
patient
falls
2013-14 CQUIN target reduction in preventable moderate/severe harm falls by
30%
Improved attendance at quarterly Falls Champions workshops
Improved attendance at mandatory training and Registered Nurse induction
Monthly Quality of Care Audits show continuous incremental improvement
Overall there has been a 17% reduction in falls this year.
There has been a significant programme of work to help prevent falls across our hospitals. This includes
the simplification of the falls documentation, engagement of the Falls Champions and weekly mandatory
training.
There has been improved scrutiny of investigations into severe and moderate harm falls resulting in the
CQUIN target not being met. Work continues with our community partners to develop frailty pathways.
The Generic Falls action plan sets out how we will further reduce inpatient falls, including harm from
falls, and ensure our processes are robust.
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PRIORITY 1: PATIENT SAFETY
Avoiding injuries to patients from care that is intended to help them
Objective
Our plan
Progress
Wards and departments issued with Unavailable Medicines Flowchart,
detailing actions to be taken when medicine is not available
Reducing
harm
associated
with
medication
errors
Medication Error posters supplied to ward areas: highlighting risk areas
such as nut allergy, penicillin sensitivity and inpatient medication
labelling
Improved communication with staff including the use of desktop screen
savers to raise awareness of key medication issues
Establishment of e-learning module for doctors and nurses on medicines
management
Revision of medicines governance framework and reporting
arrangements
Audit evidence that doctors are using their GMC numbers
There is audit data to show that compliance with GMC numbers has increased from around 20% to over
80% and regular audits are continuing. Named GMC stamps are also now being implemented and
distributed for all doctors.
Medicines governance and reporting arrangements have been revised in line with NHS England and the
NHS Trust Development Agency requirements. We now have a named Executive lead, a full time
Medication Safety Officer (MSO) and a Nursing Executive lead for medicines.
The Safe Medicines Practice Group and Drugs and Therapeutic Group now have clearer reporting and
escalation process on Medicines Safety issues to the Integrated Governance Group as reflected in their
terms of reference. These will improve the profile of medicines safety especially at Divisional level. We
continue working to improve medical and nursing input from the Divisions and with clinical engagement
for the task and finish groups to address specific medicines risks.
Medicines issues have been communicated on a regular basis via our internal communication channels,
including The Link (our electronic staff newsletter), doctors’ e-handover, desktop screensavers.
PRIORITY 1: PATIENT SAFETY
Avoiding injuries to patients from care that is intended to help them
Objective
Our plan
Progress
Establishment and effective functioning of a Mortality Review Group
At least 95% of Consultants re-trained on the use of CHKS data
Better use of
mortality data
to improve
patient safety
Introduction of a ward based flagging system
Recommendation for improvement following review of the London
Cancer audit
Recommendations made and implemented to improve clinical coding
practice
Prompt and accurate response to all identified mortality outlier data
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We are transferring mortality data from CHKS to Healthcare Evaluation Data (HED); therefore consultant
training on CHKS has not been progressed. The Mortality Assurance Review Group will ensure the focus
on training for the new system is maintained. Training consultants on HED began in April 2015. Use of
HED software now enables us to identify mortality outlier data and to undertake ‘deep dive’
investigations.
We investigated the recommendation to introduce a ward based flagging system for safe nurse staffing
levels, and will implement elements of this in early 2015/16.
We are pilot sites for London Cancer and Cancer Research UK initiatives to develop ‘straight to test’
pathways for lower GI cancer investigations, and a pilot site for a new upper GI cancer pathway. Both are
in development.
PRIORITY 2: CLINICAL EFFECTIVENESS
Providing services based on scientific knowledge to all who could benefit
Objective
Our plan
Progress
Successful appointment of an appropriately qualified radiology manager
Benchmark current processes and performance against ISAS standards
Develop and implement a plan to apply for and attain ISAS accreditation in
2015-16
Improving
Radiology
standards
Introduce audit programme to review radiological reports
Develop radiology performance dashboard of key performance indicators
Our new Medical Director has initiated a comprehensive review of our Radiology services aimed at
making improvements over the next year. The overall objective of improving Radiology remains a high
priority and has been included, in a revised format, in our 2015-16 improvement priorities. The
Radiology issues are complex and long-standing; improving reporting time performance requires a
holistic approach to developing the team requiring an investment in expertise and time. The Trust
remains sighted on delivering an improved outcome.
PRIORITY 2: CLINICAL EFFECTIVENESS
Providing services based on scientific knowledge to all who could benefit
Objective
Our plan
Progress
Establish Medical Retina Working Group
Improving
Ophthalmology
standards
Reconfigure medical retina service and resolve capacity issues
Implement robust systems to track patient referrals and appointments
Develop capacity for 75% of patients to be seen within 5 weeks of their
previous visit
Reconfiguration of the medical retina service is well underway following the appointment of a Medical
Retinal Consultant and the establishment of a Medical Retina Steering Group. A new database now helps
track and monitor patients’ progress and a number of Medical Retina Fellows have been introduced to
ensure 75% of patients are seen within the expected five week period for follow up appointments;
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this work is ongoing.
Capacity has been increased by two additional Band 5 nurses, and Band 6 and Band 7 nurses have been
recruited and are currently being trained and supervised to carry out ophthalmic injections. In addition
new ophthalmic equipment has been purchased for both King George and Queen’s Hospitals.
PRIORITY 2: CLINICAL EFFECTIVENESS
Providing services based on scientific knowledge to all who could benefit
Objective
Our plan
Progress
Identify sepsis promptly through the use of the Sepsis Six care bundle in
the Emergency Department and inpatient areas
Introduce redesigned observation charts that prompt staff to screen for
sepsis in medicine, surgery and maternity areas
Improving
sepsis
management
Establish sepsis trolleys and a sepsis cupboard in the Emergency
Departments
Antibiotic nurse available on every shift in the Emergency Department
Introduce the antibiotic app to all medical staff
Patients to have three investigations and three treatments within the first
hour
Mortality from sepsis decreases
We have achieved significant improvement in the management of sepsis. We have adopted the Sepsis Six
- a best practice tool to help manage and treat sepsis. Following a successful communication campaign,
delivered in partnership with the UK Sepsis Trust, over 3,000 staff have been trained in its use. Regular
audits take place in ED and are being rolled out in other areas across the Trust. We have also rolled out
the National Early Warning Score (NEWS). This enables earlier detection of deteriorating/likely to
deteriorate patients. This work has been further supported by the rollout of the Critical Care Outreach
Team across both sites, which has led to a reduction in cardiac arrests outside of Critical Care.
Purchase of the HED database which helps to investigate mortality and flag areas of concern.
Over the next two to three years we will fully embed the Sepsis Six care bundle effectively. Going
forward we need to ensure the consistent measurement of urine and prescribing of oxygen within the
first hour. We will continually monitor the use of our new observation charts and ensure health care
records are accurately completed.
PRIORITY 3: PATIENT EXPERIENCE
Providing care that is respectful of and responsive to individual patient preferences, needs and values.
Objective
Our plan
Progress
Pain relief training for Band 6 nurses and above
Understanding
patients’
Emergency
Department
experience
Emergency Department pain management audits
Snap-shot audits of proposed verbal hourly waiting time updates in main
waiting areas
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Log sheet review of half-hourly waiting room checks for paediatric
waiting rooms
At least 80% of reception staff attending customer training sessions
FFT score of 45% and above
The target was not met because of capacity issues relative to demand. Improvements within existing
resources are being made, resulting in significantly reduced numbers of complaints and negative
feedback from patients relating to pain relief. The paediatric waiting room log sheets are in use, and
being rolled out and embedded in use. We are also trialling having a Paediatric Nurse ‘streamer’ to view
the waiting room between 10am and 10pm to improve patient flow.
The FFT scores for February was 34 and for March, 32. Work is taking place to review patients’
comments in order to focus on specific issues that will generate improvement. With the increase in our
nursing establishment and planned recruitment days it is anticipated more time can be devoted to
embedding the Friends and Family Test in the department.
PRIORITY 3: PATIENT EXPERIENCE
Providing care that is respectful of and responsive to individual patient preferences, needs and values.
Objective
Our plan
Progress
Outpatient feedback survey completed and returned
Consultant job plans adapted to revised Outpatient Clinics
Reduction in short notice clinic cancellations by 50%
Improving our
outpatient
department
Choose and Book referrals accepted or rejected within 48-72 hours of
receipt
Booking criteria developed to ensure patients are directed to the right
clinic and right doctor
Outpatient letters that are clear to understand and accurate
Increasing the number of answered calls to Outpatients by 25%
Outpatient Department user forum established
Patient Experience Lead for Outpatients role filled on a part-time basis
In June last year our Call Centre staff only managed to answer 48% of incoming calls before people rang
off. We looked carefully at the time of day that most calls came in, and reorganised staffing to make sure
we could meet that demand. 95% of calls are now answered, with an average time to answer of 46
seconds.
At any one time we can have 200 different outpatient clinics running, and hold around 1,800 a year. We
were cancelling too many clinics and not giving our patients enough notice. In May last year, 117 clinics
were cancelled with less than six weeks’ notice. That has now been reduced to no more than 15. Clinics
are now only cancelled due to staff sickness, and we have worked with our consultants to raise
awareness of the impact of rearranging people’s appointments. If clinics do have to be cancelled, we
always try to find alternative cover so that we don’t have to rearrange patients’ appointments.
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This has led to a vast reduction in the number of multiple appointment changes. Since April last year it
has dropped by 80%
A GP Liaison Manager started work in April 2015 and is developing a programme of activity, including
events, visits and newsletters. They will work with our GPs to listen to and act on any concerns and will
be the point of contact for any enquiries or issues. They will also keep GPs up-to-date with our services
and plans.
Our outpatient staff will soon be wearing new uniforms. The new outfits will make the departments look
more professional and give our staff pride in their work. We are running a pilot project, giving patients a
pager if their clinics are running late. They can then go for a walk, get some air or grab some
refreshments, knowing that we will page them as soon as the doctor is available to see them. If the pilot
is successful, we will look to roll this out across our hospitals. We are making progress accepting or
rejecting Choose and Book referrals within 48-72 hrs. Since January 2015, we reviewed over 50% of
Choose and Book referrals and work continues.
PRIORITY 3: PATIENT EXPERIENCE
Providing care that is respectful of and responsive to individual patient preferences, needs and values.
Objective
Our plan
Progress
Completion of advertising campaign
Introducing
‘Mystery
Shoppers’
A pool of ‘Mystery Shoppers’ engaged and trained
Feedback reports received from ‘Mystery Shopper’ visits or interactions
with the Trust
Analysis of feedback included in regular reports
The Mystery Shopper initiative allows patients, relatives and carers to comment on the aspects of their
experience of our services that are most important to them. Mystery Shoppers are encouraged to tell us
what they think was important about their visit and how well we catered for these needs. Ultimately this
feedback helps staff to see through the patient’s eyes, we start to understand what our patients think
and feel about our services and care.
This approach results in a broad range of valuable qualitative and quantitative data, often from feedback
that touches on the whole patient journey, not just what we have asked for feedback on, e.g. staff handwashing.
Mystery shopper questionnaire templates are widely available to complete, and the patient should
always be offered a standard patient survey where they were treated. Outcomes range from passing on
positive feedback to boost staff morale, to more specific actions which can be addressed immediately or
in more depth by Matrons or Service Managers. When Mystery Shopper feedback is received it is shared
with the appropriate Matron/General Manager to review and action as necessary. A quarterly report is
produced and shared with the Trust’s Patient Experience and Engagement Group.
A recent example of a positive outcome is the introduction of specific deaf awareness initiatives in our
Ear, Nose and Throat and Audiology Outpatients Departments. Mystery Shoppers who were carers of
deaf patients reported that staff were not trained on how to communicate with deaf patients. As a result
of this feedback, a number of receptionists have now been on deaf awareness courses and we have
piloted restaurant style buzzers which vibrate and flash when instructed via a system operated by the
receptionists. A total of 20 Mystery Shoppers were in place by the end of March 2015 and that number
has subsequently increased to 26, with plans to recruit more.
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.3.2
MORTALITY
The Summary Hospital-Level Mortality Indicator (SHMI) is used across the country to measure death
rates associated with hospital admissions in England. The SHMI measures how many deaths would
be expected to occur if each hospital was conforming to the national average. It takes account of
factors such as age, sex, diagnosis, type of admission and other conditions a patient may have –
these are sometimes referred to as co-morbidities. This figure is compared with the number of
deaths that actually occurred in the hospital, and is shown as a ratio of the two figures. If the same
number of deaths occurred as expected the ratio would be one; although to make the figures easier
to understand this is referred to as 100. The expectation is therefore that each hospital should have
a SHMI of 100. If it is greater than 100 it indicates that more deaths have occurred than expected
and if it is lower, fewer deaths have occurred.
The latest verified SHMI result for our Trust for the year October 2013 to September 2014 is 95.51.
This means there were fewer deaths than were expected and the Health and Social Care Information
Centre (HSCIC) has confirmed that our mortality rate is as expected; we remain at Band 2.
The percentage of patient deaths with palliative care coded at either diagnosis or specialty level for
our Trust in 2014/15 is 15.7 % (in any coding position) and for 2013-14 (October 2013 to September
2014) it was 13.20 %. This data is the latest data available from the Health and Social Care
Information Centre. We continue to target the management of avoidable deaths.
The SHMI results reflect a significantly lower number of expected deaths in a number of clinical
conditions but remains within the expected range overall, as for some conditions such as sepsis and
pneumonia, we continue to have higher numbers of deaths.
The increase in patients with palliative care coded reflect the significant work carried out by the
Palliative Care Team in this period increasing patient access to formal palliative care services within
the Trust.
Mortality is an area we are focusing on in 2015/16 to generate improvements and how we intend to
do this is shown in section 4.2, as it is one of our improvement priority areas.
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3.3
PATIENT REPORTED OUTCOME MEASURES
For certain conditions patient reported outcome measure (PROM) questionnaires are given to
patients so that they can describe how they felt before and after their surgery. This allows us to test
whether patients feel they have improved after their surgery. Higher scores represent better
reported outcomes – scores range from -100, 0 is the middle, to +100 - which is the best score in
terms of improved outcomes.
Table 3.31 PROMS Data
Hip replacement surgery
Knee replacement surgery
Varicose Vein surgery
Groin Hernia surgery
Net scores
BHRUT
Lowest
performing Trust
Best performing
Trust
EQ-5D
85.9
67.7
100.0
EQ-VAS
59.5
46.4
76.6
EQ-5D
79.5
60.0
89.3
EQ-VAS
38.5
38.5
68.4
EQ-5D
51.7
22.2
85.7
EQ-VAS
39.3
13.0
75.0
EQ-5D
33.3
20.8
75.0
EQ-VAS
39.3
14.3
57.4
The 2013/14 data in the table above is the latest data available from the Health and Social Care
Information Centre and was published in February 2015.
The PROMS data shows we are a negative outlier for improvement in post-operative hip and knee
scores. Our priority is to improve the participation and linkage rates to ensure all of our patients are
targeted and responses received, and to assure the quality of our service delivery.
Actions to address this include
An appointed Consultant Lead for PROMS with access to the Health and Social Care
Information Centre data and who will have greater oversight of the PROMS process. This will
enable us to see which of our patients are being missed and to establish if our patients are
more severely affected pre-operatively
An audit of how the questionnaires are delivered, collated and dispatched at pre-assessment
clinic
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We have established a complex case meeting, to assure quality of major joint replacement
with participation of all consultant teams.
We hold a weekly arthroplasty meeting where all pre-operative patients are discussed and
post-operative patients are critiqued
There is a meeting scheduled for November 2015 where we will discuss the type of implants
we are using
3.4
READMISSIONS
Emergency readmission data helps us to understand why patients are being readmitted following their
hospital stay. By targeting attention on those cases where readmission could have been avoided we
aim to improve patient care and ensure lessons are being learned.
Table 3.41 Readmissions data
0-14 years
BHRUT
England
Worst performing
Best performing
2010/11
6.84%
1.38%
16.05%
0%
2011/12
8.10%
1.35%
14.94%
0%
15+
BHRUT
England
Worst performing
Best performing
2010/11
12.28%
11.43%
22.76%
0%
2011/12
12.54%
11.45%
41.65%
0%
This data, as described, is the latest data available from the Trust’s HED data as no information was
available on the Health and Social Care Information Centre website (Latest published data is
2011/12).
We have introduced the LACE scoring system which assesses the risk of readmission by looking at
length of stay, acute admission through the Emergency Department, co-morbidities, the number of
times an individual patient has visited the ED n the past six months, to help reduce future
readmissions.
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3.5
VENOUS THROMBOEMBOLISM
Our venous thromboembolism (VTE) data demonstrates the percentage of patients who were
admitted to our hospitals and who were risk assessed for VTE during 2014/15. We carry out risk
assessments to ensure patients are treated appropriately with preventative medication, in a timely
way in order to significantly reduce rates of mortality associated with blood clots.
The VTE data for 2014/15 is shown below shows the proportion of patients risk assessed during their
stay.
3.51 VTE Data
Quarter
Q1 2014/15
BHRUT
England (Acute
and Independent
Sector Providers)
VTE risk assessed admissions
27,189
3,382,542
Total admissions
27,785
3,518,110
98%
96%
VTE risk assessed admissions
32,443
3,440,213
Total admissions
33,199
3,575,719
98%
96%
VTE risk assessed admissions
31,014
3,430,353
Total admissions
31,977
3,574,611
97%
96%
VTE risk assessed admissions
26,004
3,405,121
Total admissions
29,958
3,548,037
87%
96%
Percentage of admitted patients risk-assessed for VTE
Q2 2014/15
Percentage of admitted patients risk-assessed for VTE
Q3 2014/15
Percentage of admitted patients risk-assessed for VTE
Q4 2014/15
Percentage of admitted patients risk-assessed for VTE
Following review of last year’s Quality Account (2013/14), our external Auditors identified
where we needed to improve our data collection for VTE. The introduction of the Medway
PAS system earlier that year had triggered some data capture anomalies, and previously did
not capture the date of assessment. The data for Q1 - Q3 is of the period during which the
date of assessment was not captured and therefore the data did not reflect true
compliance. This was rectified, but due to the change in process, we predicted and found a
significant deterioration in results in Q4. Subsequently, we have provided improved
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guidance and training for staff, improved the data capture in line with national guidance and
weekly reports are now submitted to clinical Divisions. Current data is showing progressive
improvement in compliance as per national guidance.
3.6
STAFF EXPERIENCE
In April 2014, NHS England introduced the Staff Friends and Family Test (FFT) across all NHS trusts,
to gather feedback from staff about their organisation and whether they would recommend care
and working to friends and family. Throughout 2014/15 we gave all staff the opportunity to respond
to the Test and reported these to the Health & Social Care Information Centre.
In all 1,130 staff responded, a response rate of 19%. A total of 66% would strongly agree and agree
they would recommend the Trust to family and friends, with 10% saying they would not. A total of
54% would strongly agree and agree they would recommend the Trust as a place to work, compared
with 22% who would not.
Findings have been shared locally throughout the year including with staff. Some but not all areas
have used these proactively to develop local actions plans to improve responses. The Friends and
Family test is also part of the annual NHS Staff Survey. We had a better response rate, 33%, to this
survey and the following table shows responses:
Table 3.61 Staff Friends and Family Test recommend the Trust as a place to receive treatment
Question
2013
%
2014
%
All Trusts
2014 %
Strongly Agree
14
13
18
Agree
40
42
47
Neither agree or disagree
31
30
24
Disagree
10
10
8
Strongly disagree
5
5
3
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Table 3.62 Staff Friends and Family Test recommend the Trust as a place to work
Question
2013
%
2014
%
All Trusts
2014 %
Strongly Agree
14
13
15
Agree
37
36
40
Neither agree or disagree
31
33
28
Disagree
12
12
11
Strongly disagree
6
7
6
One of the other key measures in the national survey is overall staff engagement as this is linked to
providing high quality patient care. This measure is derived from questions relating to staffs’ ability
to contribute towards improvements at work, their recommendation of the Trust as a place to work
or receive treatment and motivation at work. Our score in the 2014 survey was 3.69 which
compares to the national average for acute trusts of 3.74. Our score for staff recommending the
organisation as a place to work has also remained fairly static at 3.56 compared to the national
average of 3.67.
The following tables show our best and worst scores:
Table 3.63 Top five scores 2014 Staff Survey
Question
2014
2013
% of staff having equality and diversity training
77
66
63
% of staff agreeing the feedback from patients/service
users informs decisions in their directorate/department
63
56
56
3.90
3.92
% of staff reporting errors, near misses or incidents in the
last month
92
89
% of staff experiencing physical violence from patients,
relatives or the public in last 12 months
13
13
Staff motivation at work
Quality Account 2014-15
Trend
__
Average
acute
trusts
3.86
90
__
14
Barking, Havering and Redbridge University Hospitals NHS Trust
30
Table 3.64 Key areas for improvement 2014 Staff Survey
Question
2014
2013
% of staff experiencing harassment, bullying or abuse from
staff in last 12 months.
31
29
23
% of staff working extra hours
77
77
71
% of staff suffering work-related stress in last 12 months
44
42
37
% of staff believing Trust provides equal opportunities for
career progression/promotion
78
80
87
3.21
3.12
3.07
Work pressure felt by staff
Trend
Average
acute
trusts
We have considered this data, as described, because we applied NHS England guidance to the
2014/15 FFT that was administered by an experienced external provider. Our annual Staff Survey
findings have been reported to the Board and a robust action plan programme is being put in place.
This starts with an action plan that will translate into a ‘You said, we did’ campaign to support an
improvement in the number of staff completing the survey and responding. We will continue to
invest in the ‘You said, we did’ initiative to identify and deliver improved patient experience
outcomes.
3.7
INFECTION PREVENTION AND CONTROL
Clostridium difficile (C.diff)
C.diff is an infection that can cause diarrhoea and illness to patients. Our staff work hard to ensure
that the number of cases at our hospitals is minimised. We have consistently had fewer cases than
our trajectory, the performance agreed for our Trust.
We have undertaken a thematic review of all cases for the last year and have identified key themes
to help pull together an action plan for next year, for example key themes include antibiotic
stewardship. Following a review of our reported cases of C.diff in 2013-14, we are now improving
our processes to ensure we are reporting in line with national guidance. We are currently
undertaking a review of our previous reporting. This data is from our laboratory reporting system,
reported centrally to Public Health England.
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Table 3.71 C.diff data - 1 April - 31 March
Note: The ‘reported’ figure contains the number of cases that were clinically significant and were
reported to meet regulatory requirements. The ‘actual’ figure includes additional cases which were
not clinically significant, such as samples testing positive where the patient has no symptoms.
C.diff
Trajectory
Actual
Reported
2013-14
40
38
24
2014-15
37
39
33
Table 3.72 C.diff data by 1,000 bed days - 1 April - 31 March
BHRUT
England
Best performing
Worst
performing
2012/13
18.2
17.4
0
31.2
2013/14
6.9
14.7
0
37.4
MRSA
The prevention of MRSA and other avoidable infections is a very high priority for us. We have a zero
tolerance approach to MRSA and our staff continue to work hard to ensure no cases occur. In year
we reported six cases in total, two of which were contaminants – this is a term used to explain
where bacteria is found in the blood culture but does not reflect true blood stream infection.
Table 3.73 MRSA data - 1 April - 31 March
Target
True
Contaminants
2014-15
Zero tolerance
4
2
2013-14
Zero tolerance
0
2
We have undertaken a thematic review of all cases for last year, and we have identified
opportunities to improve trust-wide including cannula technology and management.
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3.8
SERIOUS INCIDENTS
Data on the rate of patient safety incidents is regularly reviewed via the Trust committee structure.
The data below looks at the rates of patient safety incidents reported within the Trust in the periods
from April to September 2014. During that period the Trust reported 3,928 incidents of which 0.4%
resulted in severe harm or death.
The Trust uses data sourced from the Healthcare Evaluation Data (HED) database, which combines
statistics on hospital activity with Office of National Statistics (ONS) data sets on Mortality.
Table 3.81 Serious Incidents 2014-15
BHRUT
% of incidents resulting severe
harm
England
0.40%
% of incidents resulting in death
Rate of incidents per 100
admissions
Source: HED data
Worst
performing
Best
performing
74.30%
0%
0%
0.10%
9%
0%
23.41
21.8
74.96
0.24
In 2014/15 there were two never events, both related to retention of swabs. Each was investigated
in considerable detail, resulting in system changes to make care resilient.
The rate of incidents per 100 admissions is better than for poorer performing trusts, but there is an
acknowledgment that further improvement is possible to meet the standards achieved for best
scoring trusts.
Improvement has been hampered by a number of factors, namely reduced internal resources
available to investigate incidents and large scale changes in operational management arrangements.
This, combined with increased scrutiny and quality standards for investigation and closure of
incidents, has increased pressure internally and has led to a backlog in the completion of incident
investigations, particularly for serious incidents. We have put in place a recovery plan, working with
partners, to address this backlog. By the time this Quality Account was finalised, substantial progress
had been made in clearing this backlog.
In line with our commissioners, we have identified the management and closure of outstanding
serious incidents as a top priority for 2015/16 and as an important method by which we can improve
the quality of our services. Key actions identified are as follows:
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We have increased internal resources to ensure a fully operational clinical governance
corporate function and divisional support to ensure timely dialogue, action planning and
monitoring of serious incidents, clearing the outstanding backlog and ensuring that
emerging serious incidents are dealt with appropriately.
We are strengthening the processes and management arrangements for managing serious
incidents to set out clear expectations and quality standards and to reinforce the roles and
responsibilities set out for the divisions and corporate function. This is being supported by a
review of an external organisation, the Good Governance Institute.
Training is being provided to equip staff to investigate serious incidents via Root Cause
Analysis (RCA). This will ensure a wider group of staff is available to manage serious
incidents and will also help with alleviating the current backlog.
All incidents are recorded on a database which enables incidents to be easily reported and
for feedback to be provided to incident managers. Training has been provided to support
administrative tasks and to use the database to extract and create reports which identify
actions to be taken to prevent future incidents.
We are improving our processes for capturing and sharing lessons learned as a result of
serious incidents and we now monitor the levels of feedback sent to staff via the database
system. We have implemented a quarterly ‘Lessons Learnt’ panel meeting for summarising
and the learning from key incidents or events across the organisation. This is supplemented
by a ‘Learning Lessons’ intranet web page, newsletter and presentation at the Chief
Executive’s Senior Team Brief. We also continue to make available all serious incident
investigation reports via the Trust intranet.
Finally, we are committed to sustaining a culture of openness and transparency throughout the
organisation and are signed up to the Duty of Candour obligations to be open with people when
things go wrong. In response to this commitment, we have updated our reporting systems to
ensure that patients and carers are notified of incidents as soon as possible, with a formal letter
sent within 10 days. Outcomes from investigations will also be shared in accordance with the
patient's (or carer's) wishes, although this part of the process is proving more challenging to
implement. Through all of this, we are working hard to improve our compliance in this important
part of the process so that patients, families and carers receive feedback in a timely way.
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3.9
RESPONSIVENESS TO PERSONAL NEEDS
A key indicator of the quality of patient experience is compiled using the scores to five questions
posed as part of the National Inpatient Survey. We continually strive to improve its responsiveness
to the needs of patients who use our services. The questions asked are shown below:
Table 3.91 Inpatient Survey 2014
Inpatient questions
2014
BHRUT 2013
Out of 10
BHRUT 2014
Out of 10
Worst
performing
Out of 10
Best
performing
Out of 10
Were you involved as much as
wanted to be in decisions about
your care and treatment?
6.7
6.8
6.1
9.2
Did you find someone on the
hospital staff to talk to about
your worries and fears?
4.9
5.3
4.3
8.2
Were you given enough privacy
when discussing your condition
or treatment?
8.5
8.2
7.5
9.4
Did a member of staff tell you
about medication side effects to
watch for when you went home?
4.4
4.8
3.7
7.6
Did hospital staff tell you who to
contact if you were worried
about your condition or
treatment after you left hospital?
6.4
7.1
6.4
9.7
3.10
INPATIENT FAMILY AND FRIENDS TEST AND A&E FFT
Our Adult Inpatients annual FFT score in 2013/14 was 53, in 2014/15 this improved to 69. This score
is higher than the London average (66) but lower than the national average (74). Areas which we
score lower on relate to food and communication. We undertook a number of actions in 2013/14,
particularly relating to these areas, which helped improve our score, these include:
the trial and expansion of a course by course meal service on all wards at Queen’s Hospital
conducting a pilot of a Nutrition Board on Japonica ward which resulted in a +29%
improvement in food scores since the pilot began
reinvigorated the Trust’s Nutrition Champion network
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improved awareness of the Trust’s 24 hour meal protocol
introduced a range of patient safety, care and communication magnets for patient bedside
headboards, which also include information such as the name of the nurse looking after the
patient
introduced patient surveys in the top ten most requested languages and two easy-read
versions
continued to roll-out Welcome Boards and It’s Good to Talk Boards in more areas across the
Trust
Our Emergency Department annual FFT score in 2013/14 was 26, in 2014/15 this increased to 27.
This score is lower than the London average (52) and the national average (55). Our below average
position is likely due to the extremely high number of attenders to the Emergency Department, we
are the busiest in London and the number of vacancies in nursing and medical staffing which means
that we rely more on temporary staffing. This has resulted in longer waits for patients.
Actions to address these issues are included in the Emergency Department Improvement Plan which
includes improving the four hour wait target from 80% of patients seen within four hours to 93% in
recent months; during 2013/14 we have also:
produced an Emergency Department Patient Handbook which is given to all patients as they
check in on arrival, and details what patients should expect whilst being in the Department
and general information about the hospital and department
rolled out Welcome and It’s Good To Talk Boards, in the department, similar to the wards
purchased Monkey Wellbeing activity books to entertain children in the waiting area, and
also provided information about what to expect in a child-friendly manner
ran community sessions in Havering, in conjunction with Havering CCG, to teach parents
self-care skills and when it is appropriate to bring their child to the Emergency Department
held open recruitment days for nursing staff
Improving our FFT remains on our agenda, we are continuing to look for innovative ways to improve
our score. Section 4.4 of this report provides more details of priorities we have identified for
2015/16.
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3.11
PARTICIPATION IN CLINICAL RESEARCH
As well as providing our patients with the best possible care today, we want to ensure that we are
also investing in improvements for care in the future. We have a programme of research to provide
cutting edge treatments which will benefit our patients. Over the last year, we recruited 6,850
patients into research studies. We are currently the third best performing NHS Trust within UCL
Partners, spanning 25 NHS trusts.
We are also involved in a number of high profile research studies:
In maternity we hosted the Non-Invasive Prenatal Testing study. This offered our expecting
mothers a foetal DNA test not normally available in the NHS to test for conditions like Down’s
syndrome without the risk of miscarriage that traditional testing involves.
Life Study is a unique and world-leading study which will track the growth, development, health
and well-being of more than 80,000 UK babies and their parents as they grow up. This year the
country’s first Life Study centre, one of only two in the country, was opened at King George
Hospital in March. Over the course of the study, around 20,000 babies and their families from
Barking, Dagenham, Havering and Redbridge will play a crucial part. It will create the largest UK
collection of information that will support research and policies aimed at giving children the best
possible start in life.
Within stroke services, we now offer our patients the chance to take part in the Robot Assisted
Training for the Upper Limb after Stroke study, which looks at the use of a leading-edge robotic
device in aiding stroke rehabilitation.
We undertake research into many different types of cancer, and over the last year we have
expanded this to include trials into brain cancer treatments. We have also made ophthalmology
research available to our eye patients.
This year, we have also seen a significant increase in the number of commercially-funded research
studies we host. This brings to our patients some of the latest treatments that will not be widely
available to NHS patients for another five to 10 years, and helps gather evidence for their wider use.
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4.
LOOKING FORWARD
4.1
PRIORITIES FOR IMPROVEMENT IN 2015/16
In June we anticipate the next report from the Care Quality Commission following their inspection of
our hospitals in March. We are not waiting until then to act on the themes they raised during their
visit; however the report will be important in helping to define further our priorities for
improvement going forward.
Our operational business plan sets out our objectives under five banners:
Delivering high quality care
Working in partnership
Becoming an employer of choice
Efficiently running our hospitals
Managing our finances.
It demonstrates how, working with our partners, we will improve quality, proving we are clinically
effective, safe, and offering our patients a positive experience.
Over the next 12 months, we are concentrating on being a stable and resilient organisation,
providing safe, clinically effective and high quality care, working with our partners, and offering a
positive experience of our care.
Our quality priorities for 2015/16 are:
Priority one
Safe
Priority two
Effective
Priority three
Person-centred
Priority four
Priority five
Priority six
Timely
Efficient
Equitable
Quality Account 2014-15
Avoiding harm to patients from care that is intended to help
them.
Providing services based on scientific knowledge of which
produce a clear benefit.
Providing care that is respectful and responsive to
individuals’ needs and values.
Reducing waits and where possible, harmful delays
Avoiding waste
Providing care that does not vary in quality because of a
person’s characteristics.
Barking, Havering and Redbridge University Hospitals NHS Trust
38
This year we introduced a Local Representatives Panel. Every 6-8 weeks we invite local councillors,
chairs of our local scrutiny committees and other local representatives into our hospitals to share
feedback from their communities and the people they represent, and to hear about improvements
and initiatives in our hospitals. Our Medical Director consulted the Panel on our planned priorities
for improvement at the February meeting and they were in agreement.
4.2
PRIORITY ONE: PATIENT SAFETY
Providing safe care is fundamental to delivering high quality care. Preventing avoidable harm
requires everyone to understand their responsibility in delivering safe care and, where errors occur,
to work immediately to make safe that care, extract and share the necessary learning and, where
necessary, redesign the pathways of care to prevent a recurrence. In 2015/16 we aim to improve on
two key systems to help provide increasingly safe care.
Mortality
Mortality remains a significant focus for our hospitals to ensure safe care. Our ambition is to be
better than the national average for mortality as measured against the Hospital Standardised
Mortality Ratios (HSMR) and SHMI scores. We aim to protect our patients by developing a robust
Mortality Strategy that will facilitate systematic reviews of deaths, reduce avoidable harm to
patients and which functions within an open and transparent framework.
We will develop
7
procedures and processes aimed at reducing external ‘outlier’ alerts; initially focusing on avoidable
deaths from sepsis and pneumonia, but broadening to include other potential conditions that may
be identified by the Mortality Assurance Review Group which reports through the Quality and Safety
Committee, by exception, to the Trust Board. The maturing data analysis capability will also allow
for greater divisional, service and consultant level ownership, responsibility and accountability for
clinical outcomes.
Serious incidents
We have carried out a review of our serious incidents and recognise that we need to rebuild and
improve our systems and processes, particularly strengthening our ability to learn lessons and
thereby change systems of care. We will do this by appointing additional clinical governance
resources to our Divisions and restructuring and supporting the corporate governance team. We
7
Outliers are when the data indicates the Trust’s performance sits outside the expected ranges and is therefore a possible
indicator of problems requiring attention.
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have pledged to improve our performance against serious incident key performance indicators
substantially by the end of March 2016. We plan to further upgrade our Ulysses risk management
database system which enables the process of logging, and learning from incidents. We aim to
extend training on its use to a wider range of staff to improve weekly tracking and reporting, making
our data more robust. In addition we will strengthen the culture for the delivery of our duty of
candour responsibilities. Serious incidents are reported through the Integrated Governance Group,
Quality and Safety Committee and Trust Board. Information on serious incident management is
regularly shared with our commissioners following discussion at the Trust Executive Committee.
4.3
PRIORITY TWO: CLINICAL EFFECTIVENESS
Effective care means using the latest scientific evidence that has been tested and recognised to
deliver the best care, be it the right medicine or the right technology. The National Institute for
Health Care Excellence (NICE) generates guidance as well as the opportunity to have constructive
evidenced debates to narrow the variation in care that we know contributes to ineffective care
which also wastes resources. The development of care bundles with proven value have become
increasingly standard and expected to be evidenced in performance indicators.
NICE Compliance
We need to improve our monitoring and reporting on compliance with NICE guidance. We will
establish a permanent NICE Compliance Group with membership from each of our Divisions and
other key staff groups. We will update the NICE Policy and provide clear guidance for staff on the
use of the NICE Quality Standards. We will establish a rigorous monitoring, assurance and reporting
function between the NICE Compliance Group and the Clinical Risk Management Group. Summary
updates are reported by exception to the Integrated Governance Group, which feeds into the
Quality and Safety Committee.
Sepsis bundle8
We have significantly improved our ability to apply the sepsis bundle by training over 3,000 clinical
staff in 2014/15. Sepsis as a source for preventable deaths, evidenced by the HSMR mortality
indicator, has also improved towards the end of 2014/15. As a cause for mortality and morbidity this
8
An international body formed from 18 professional bodies from Europe, North America, Australasia and Japan issued the
Surviving Sepsis Campaign (SSC) Guidelines for the management of severe sepsis and septic shock. These led to the
development of the Sepsis Resuscitation Bundle, of measures to be taken within six hours following the onset of sepsis,
including monitoring various bodily functions and delivering antibiotics for example.
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remains a key focus to deliver safe care. The aim is to improve the effective application of the sepsis
bundle within the first hour of identifying sepsis as a cause for critical illness.
4.4
PRIORITY THREE: PATIENT EXPERIENCE
A fundamental outcome measure of quality is the description that patients, families and carers give
about their experiences of the care we provide. That experience starts from when the patient
receives a letter to attend an outpatient clinic and has an appointment with the consultant, right
through to recovering and returning home after a period of inpatient care, as well as those who
need care in their final year of life. We have increased the number of ways we seek feedback from
patients and generated a number of improvement initiatives as a result of that learning.
Friends and Family Test (FFT)
In order to streamline and ensure there is uniformity in the way patient feedback data is collected,
analysed and displayed, we will ensure our internal processes are robust enough to:
Report and publish inpatient, maternity, paediatric and Emergency Department FFT results
monthly
Recruit and train volunteers to undertake FFT in inpatient areas
Undertake deep-dive reviews of wards with an FFT below 42
Introduce the FFT into our Outpatient areas.
Quarterly updates on the Friends and Family Test results are shared via Patient Experience Reports
to the Quality and Safety Committee, with clinical staff receiving regular reports on the findings of
the FFT in their own areas.
We will seek ways to make it easier for patients, families and carers to provide feedback, including
their experience of clinical consultations. We will aim to appoint a medical clinician to join the
Patient Experience Team to develop the clinical engagement strategy.
Frail Elderly Patients
We have extensive plans to address the increased demand and focus on this vulnerable group of
patients, especially those with dementia. We will do this by engaging with other health care
providers to streamline the patient’s pathways. This will involve working closely with the London
Ambulance Service, the Community Treatment Team, Integrated Care Management and other
voluntary agencies such as Age UK. Our Elders Receiving Unit will continue to play a crucial role as
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will the development of a Geriatric Ambulatory Care service and Hot Clinics in 2015/16. We intend
to appoint a Senior Frailty Nurse and to ensure a Geriatrician is based within our Emergency
Department to offer prompt assessment and treatment. Progress with work on frail elderly patients
is monitored via the monthly Divisional Performance Meetings, with updates on any risk elements
escalated via the Clinical Risk Management Group to the Integrated Governance Group.
Dementia strategy
The executive lead for dementia is our Medical Director. We will establish a dementia strategy that
will be recognised by the CCGs as focused on the care and support needed by the patients and
carers and provided in partnership with services in our community. We will increase the number of
staff from all disciplines for them to be able to assess for dementia and thereby be better able to
identify the timely support and care needed.
4.5
PRIORITY FOUR: TIMELY
Timely care is not about targets, but targets have served a useful purpose in establishing minimum
standards to ensure that harm that might arise from delay in care is avoided. This explains why
timely care is a quality domain. Where delay is identified we have established a monitoring system
to detect any potential harm.
Referral to Treatment times (RTT)
A huge amount of work has taken place this year to treat patients who have been waiting too long
for their care. A new reporting system identified a number of issues with our Referral to Treatment
reporting, meaning that a large number of patients had been waiting longer than 18 weeks for
treatment. This was not an acceptable position for our patients, and we took action to improve. A
recovery plan was put in place to ensure we could treat more patients, more quickly, to clear the
backlog. Extra theatre capacity was put in place, additional clinics held and some operations were
outsourced to the private sector to make sure patients got the care they needed.
We are also carrying out reviews to check that no patients who have waited longer than they should
for an appointment have experienced any harm as a result of the delay in their treatment. Now we
are concentrating on verifying the data so that we can treat those patients who are waiting for nonadmitted treatment – care which can be delivered in an outpatient setting. It was agreed by the NHS
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Trust Development Authority that we should not report our performance against the RTT standard
until the data had been verified.
We aim to achieve national cancer standard as we improve our RTT position.
Radiology
Following an internal review and close monitoring of radiology data it is clear that we need to make
improvements to our radiology service. We therefore intend to initiate a peer-to-peer review to
evaluate the service as a whole, including the team culture, resources and leadership in order to
transform the existing culture and practice. We intend by the end of March 2016 to have delivered
improved leadership of the service and improved performance against defined key performance
indicators. The strategic management of Radiology is monitored by our Medical Director and Chief
Operating Office, and is reported to the Trust Executive Committee and monthly divisional
performance meetings.
4.6
PRIORITY FIVE: EFFICIENT
Pathways of care where resources such as time, equipment and money are not well or optimally
used means that we are less able to meet the needs of the current and growing demand for care in
an equitable way. We also have a duty to the taxpayer to be guardians of the investment they make
to the public services, including the NHS.
Workforce
Our priority is to get the right staff, doing the right job, with the right skills. We intend to prioritise
this for the coming year by developing strategies that will allow us to over-fill Registered Nursing
posts by 10% to take account of those that leave the organisation, are on maternity or on long term
leave. We also intend to enhance our in-house Bank arrangements that allow our own staff to work
additional hours and reduce our reliance on expensive agency staff. Our human resource processes
are being reviewed to improve the time it takes to hire new staff, preventing the loss of some
applicants and enabling managers to fill gaps more easily.
This measure will sit alongside implementation of an improved sickness management policy and
reinforcing and promoting the benefits of working at the Trust, including new career development
opportunities.
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We will establish a strategy to improve how we recruit and retain the consultant workforce across all
the specialities. A number of initiatives are being developed, including one for appointing academic
staff, shared across external partners. Our Workforce and People Committee is a sub-committee of
the Board with a remit to focus on how we recruit our staff.
Digital by design
Our new information management and technology (IM&T) strategy has been developed, working
with our staff across the Trust. Major changes are being made to the way we use technology across
our hospitals, to support the work of our staff and improve the care we provide to our patients.
The strategy sets our three key areas which will be delivered over the next five years:
Information – It should be accurate, meaningful and available—when and where it is needed
Systems – These need to be fast, intuitive and integrated
Infrastructure – It should be modern, highly-available and robust.
The IM&T strategy is backed by major investment as we work towards providing 24/7 access to
support, wifi and mobile working and faster and more efficient access to systems.
4.7
PRIORITY SIX: EQUITABLE
Diversity of our population
We have a diverse population and we are increasingly working with our partners across the region to
understand local needs and how they will develop in the future.
For instance, we need to understand the age, ethnicity and health issues of the 750,000 people that
form the community that we serve. We also need to understand what access issues they may have.
To do this, we intend to work jointly with our Public Health partners to investigate these topics
further and to engage more with our local community and partners with a view to providing the
right services, at the right time and in the right place. Appreciating that this is a new initiative and
one that depends on strong partnership working, it is expected that the measurable outcomes will
take several years to materialise. In 2015/16, the aim is first to agree how in partnership we can
begin to understand the diversity of the populations we serve.
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5.
QUALITY ACCOUNT APPENDICES
5.1
HEALTH SERVICES PROVIDED OR SUB-CONTRACTED IN 2014-2015
We provided and sub-contracted a number of different types of relevant health services in 2014-15,
as determined in accordance with the categorisation of services:
a. specified under the contracts, agreements or arrangements under which those services are
provided; or
b. in the case of an NHS body providing services other than under a contract, agreement or
arrangements, adopted by the provider.
During 2014-15, BHRUT provided and/or subcontracted the following NHS services for the provision
of:
General health services to NHS Barnet CCG
General health services to NHS Barking and Dagenham CCG
General health services to NHS Basildon and Brentwood CCG
General health services to NHS Camden CCG
General health services to NHS Castle Point and Rochford CCG
General health services to NHS City and Hackney CCG
General Health services to NHS Enfield CCG
General health services to NHS Haringey CCG
General health services to NHS Havering CCG
General health services to NHS Mid Essex CCG
General health services to NHS Newham CCG
General health services to NHS North East Essex CCG
General health services to NHS Redbridge CCG
General health services to NHS Thurrock CCG
General health services to NHS Tower Hamlets CCG
General health services to NHS Waltham Forest CCG
General health services to NHS West Essex CCG
General health services to London Specialist Commissioning and NHS England
Sexual health services to London Boroughs of Barking and Dagenham, Havering, and
Redbridge
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5.2
REVIEW OF DATA ON QUALITY OF CARE FOR THESE SERVICES IN 2014-2015
We have reviewed all the data available to us on the quality of care for the above NHS services.
5.3
INCOME GENERATED BY THESE SERVICES AS A PERCENTAGE OF TOTAL INCOME IN 2014-15
The income generated by the NHS services reviewed in 2014-15 represents the total income
generated from the provision of NHS services by Barking, Havering and Redbridge University
Hospitals NHS Trust as shown in the following table:
Contract
Contract bodies
Essex Clinical Commissioning
Groups and Clinical Support
Unit
2014-15 Total outturn
£30,467,846
Local Authority – Sexual Health
Contracts
London Boroughs of Barking
and Dagenham, Havering, and
Redbridge
London Specialist
Commissioning Group
NHS England
£4,376,048
£62,846,344
North and East London
Commissioning Support Unit
£304,258,026
Non contract activity
£3,918,641
Contract totals
5.4
£405,866,905
PUBLISHED NATIONAL CLINICAL AUDITS AND CONFIDENTIAL ENQUIRY REPORTS
Clinical audit is an important tool used for evaluating services to ensure they meet expected or
prescribed quality standards. Where audits indicate that a service is not meeting the agreed
standard, the audit provides a framework for suggesting improvements.
National audits are conducted by third party organisations and participating in these gives the Trust
the ability to compare how well it is delivering a given standard against other organisations.
Local audits are conducted by the Trust and evaluated in-house; they are foremost audits of issues
that the Trust considers to be priority areas for improving patients’ care, outcomes or experiences
and where more information is needed, or indeed, to allow the organisation to utilise its resources
better by ‘working smarter’.
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During 2014/15 the Trust participated in 88% of national clinical audits (35/40) and 100% national
confidential enquiries (2/2) which the Trust was eligible to participate in. The required National
Diabetes Audits are listed as three separate programmes i.e. adult, foot care and pregnancy
The following table provides details on national clinical audits and national confidential enquiries
that the Trust was eligible for and participated in, and for which data collection was completed
during 2014/15. The table includes the number of cases submitted to each audit or enquiry as a
percentage of the number of registered cases required by the terms of that audit or enquiry. The
audit strategy for 2015/16 aims to focus resources on delivering national over local audits.
National Clinical Audit
Target sample
size
Cases
submitted (%)
1. Acute coronary syndrome or Acute myocardial infarction
(MINAP)
All cases
32%
2. British Society for Clinical Neurophysiology (BSCN) and
Association of Neurophysiological Scientists (ANS) Standards for
Ulnar Neuropathy at Elbow (UNE) testing
All cases
100%
290
95%
4. Cardiac Rhythm Management (CRM)
All cases
100%
5. Case Mix Programme (CMP)
All cases
100%
6c. Diabetes Care in Pregnancy
All cases
100%
7. Diabetes (Paediatric) (NPDA)
All cases
85%
8. Elective surgery (National PROMs Programme)
Participation
confirmed
Not known
9. Epilepsy 12 audit Round 2 (Childhood Epilepsy)
All cases
100%
10b. Falls and Fragility Fractures Audit Programme – National Hip
Fracture Database (FFFAP) Part 2
All cases
100%
11. Fitting child (care in emergency departments)
50 cases
82%
12. Head and neck oncology (DAHNO) - 10th round
All cases
100%
13. Inflammatory bowel disease (IBD)
All Cases
data
incomplete
14. Lung cancer (NLCA)
All cases
95%
15. Maternal, Newborn and Infant Clinical Outcome Review
Programme (MBRRACE-UK)
All cases
100%
16. Mental health (care in emergency departments)
50 cases
100%
Participated ( 35 )
3. Bowel cancer (NBOCAP)
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National Clinical Audit
Target sample
size
Cases
submitted (%)
17. National Chronic Obstructive Pulmonary Disease (COPD) Audit
All cases
100%
18. National Comparative Audit of Blood Transfusion programme
All cases
100%
19. National Emergency Laparotomy audit (NELA)
All cases
98%
20. National Heart Failure Audit
All cases
75.1%
21. National Joint Registry (NJR)
All cases
87%
22. National Vascular Registry
All cases
100%
23. Neonatal intensive and special care (NNAP)
All cases
100%
24. Oesophago-gastric cancer (NAOGC)
All cases
100%
25. Older people (care in emergency departments)
100 cases
81%
26. Pleural procedures
All cases
100%
Participation
confirmed
Low
All cases
100%
174
70%
Target sample
size
Cases
submitted (%)
All Cases
100%
2. Determining universal processes related to best outcome in
emergency abdominal surgery
29
100%
3. National Lung Cancer Audit LUCADA
280
95%
4. National Vestibular Schwannoma
All Cases
100%
5. UK Perioperative Pain Study
All Cases
100%
6. STARSurg UK - Defining Surgical Complications in the Overweight
All Cases
100%
27. Rheumatoid and early inflammatory arthritis
28. Sentinel Stroke National Audit Programme (SSNAP)
29. Severe trauma (Trauma Audit & Research Network, TARN)
Non-HQIP National Clinical Audits
1. National Neurosurgery Audit Programme NNAP
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For the five audits where the Trust did not participate, the reasons are set out below:
National Clinical Audit
Reason for Non-Participation
6a. Diabetes (Adult) ND(A), includes National Diabetes Inpatient
Audit (NADIA)
Lack of resources
6b. Diabetes (Adult) ND(A) Diabetes Footcare
Lack of Resources
10a. Falls and Fragility Fractures Audit Programme (FFFAP) part 1
Lack of Resource
30. National cardiac arrest (NCAA)
Poor Data Capture
31. Non invasive ventilation
Withdrawn by British Thoracic
Society
Following the above national audits, there are actions that need to be taken in order to generate
improvement in the quality of healthcare. These are:
Conclusion and recommendations
Ulnar Neuropathy
We are adhering to national standards. No action required.
MINAP
Our mortality rates are comparable with the national average.
We need to improve data collection.
National Heart Failure Audit
Our use of secondary prevention drugs is comparable with
national levels. Manage cardiac patients on cardiac wards;
ensure patients are discharged with appropriate HF medications
Determining Universal Processes
Related to Best Outcome in
Emergency Abdominal Surgery
Queen’s Hospital Sept to Nov 2014
In this series, post-op mortality was 0% (primary outcome**), 3%
(secondary outcome**) (**at 24 hours, 30 days respectively)
compared to the 15% international rate. Queen’s Hospital data
will still be compared regionally as well as internationally, though
the values are acceptable. The data will be updated as soon as
the results from King George Hospital are available as well as the
International feedback is available.
Recommendation:
To improve upon the time between admission and surgery –
work in progress
Paediatric Diabetes - Latest report
published October 2014
There has been some improvement in mean and median HbA1c,
however, this is still higher than national median of 69
mmol/mol. The percentage of children with good control
(HbA1C<58 mmol/mol) has also improved (13.7% for King George
Hospital and 11.9% for Queen’s) but they are below national
median of 15.8%. Hence, the BHRUT paediatric diabetes team
needs to maintain the effort to improve control to make things
as per with national average.
Quality Account 2014-15
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Conclusion and recommendations
Action plan:
Target the children with HbA1c >80 mmol/mol so that limited
resources could be used effectively.
Pregnancy in Diabetes – Latest
report published October 2014
Engaging with primary care to raise awareness and enhance
pregnancy planning. Develop plans to incorporate training about
pregnancy into patient education programmes especially for
Type 2 diabetics. Focus on improving glycaemic control during
pregnancy to avoid late adverse fetal outcomes.
Action plan: The Gestational Diabetes Mellitus (GMD) clinic in
King George Hospital run by the Midwifery Service to reduce
numbers in the multidisciplinary Friday clinic, giving more time to
pre-existing diabetics – completed; Nurses/Community Diabetes
Specialist Nurses/Family Planning Nurses to increase referrals to
pre-conception clinic.
Non-invasive Ventilation – Local
report received November 2014
Recommendation: Develop a respiratory consultant-led
integrated pleural service including supervising drain insertion,
ultrasound training of (respiratory) junior staff, setting-up of
ambulatory pleural clinics to keep patients out of hospital where
possible, and develop medical thoracoscopy.
Oesophago-Gastric Cancer – Local
report received for latest published
report 2014
Recommendations:
1. For patients referred for treatment, networks should know
the proportion admitted as emergencies and develop
strategies for reducing it within the network.
2. All patients being considered for curative treatment should
undergo an endoscopic ultrasound (EUS) (if oesophageal or
upper junctional tumour) or a staging laparoscopy (if gastric
or lower junctional tumour). Cancer services should be
encouraged to monitor their use.
3. All patients with oesophageal squamous-cell carcinoma (SSC)
being considered for curative treatment should be discussed
with both a clinical oncologist who specialises in the
treatment of Upper Gastrointestinal Cancers as well as a
surgeon, to discuss the most appropriate treatment
approach.
4. Cancer Networks should monitor treatment of patients with
early cancers in particular, and consider referral of such
patients to specialist endoscopic centres where endoscopic
treatment may be an option.
5. As surgical mortality continues to fall, increased focus should
go into optimising efficacy of surgery (lymph node yield and
proportion of patients with positive longitudinal margins)
and complication rates. These should be monitored
prospectively by surgeons.
Quality Account 2014-15
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Conclusion and recommendations
6. Minimally invasive surgery should continue to be introduced
cautiously with particular focus on associated complication
rates and length of stay.
7. Networks should consider coordinating brachytherapy.
Actions:
All the items in 1-6 above have been implemented at this Trust
although Item 1 is a significant issue for our Trust compared to
the national scene and reflects our demography and the primary
care aspects of care of these patients. Action is already being
taken to improve this by communication with GPs.
Item 7 – We have employed brachytherapy for over 10 years,
however this is no longer considered an effective option and has
been discontinued.
IBD Biological Therapies
Dosing regimen for induction with adalimumab is standardised to
recommended levels. Patient reported outcome measures are
now going to be entered. 5-ASA medicines for Crohn’s patients
on biologics should be stopped.
The following table provides details the National Confidential Enquiries into Patient
Outcome and Death (NCEPOD) audits.
Gastric Haemorrhage
100%
Clinical
questionnaire
returned
100%
Sepsis
100%
100%
NCEPOD
Cases
included
Case notes
returned
100%
Organisational
questionnaire
returned
Yes
100%
Yes
The following table details the local clinical audit reports that were reviewed by the Trust
during 2014/15:
Local clinical audit
Headline results and/or actions
Participated (10)
Annual Pressure Ulcer audit
Rapid Review Tool being implemented rigorously to determine
causes of grade 2s. New equipment has been put into King
George Hospital. Additional cushions now at Queen’s Hospital.
MOHs* service audit
The number of MOHs slots for these high-risk patients has been
increased. Action undertaken to survey GPs with a view to
developing education mobile ‘app’ for them to access
information around ophthalmological treatment and diagnosis,
*Developed by Dr. Frederick Mohs in
the 1930s, Mohs micrographic surgery
is a technique used for the removal of
Quality Account 2014-15
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51
a variety of skin cancers.
and indications for referral to tertiary care.
Obesity in Pregnancy audit
Incorporate raised BMI identification into antenatal clerking
proforma. Referrals to dietician to be made during the
antenatal period.
N-terminal of the prohormone
brain natriuretic peptide (NTproBNP) assay and new patient
pathway on heart failure
diagnostic services and patient
outcome post implementation of
NICE Chronic Heart Failure
guidance in January 2014 audit
Much more rapid specialist review, diagnosis, investigation and
treatment of heart failure and exclusion of heart failure in
patients referred by GPs. Previously patients may have waited
12 weeks, however with this care pathway patients are all seen
within the NICE specified targets of 2 or 6 weeks. Over time
this is anticipated to result in improved patient care outcomes
and also increased user satisfaction.
The potential avoidance of unnecessary ECHO and specialist
referral based on normal SNP.
Neurosurgery Preoperative
Assessment Audit
(Re-Audit)
We improved the quality of pre-assessing patients admitted
electively for neurosurgical procedures. This meant reduction in
cancelling elective procedures on the day of surgery due to
medical reversible causes. As a result, we were able to achieve
a better quality of care for our patients as well as reducing the
costs that might result from cancellations.
Antimicrobial Prescribing and
patient safety: Review of five
annual point prevalence studies
2010-2014
Development and implementation of the antimicrobial app.
(This was part of the Trust Improvement Plan).
Significant improvement in documentation of indication and
duration of use of antimicrobials in patients.
Improved engagement of prescribers on antibiotic issues and
raised the profile of prudent antimicrobial prescribing within
the Trust.
Introduction of the New
Emergency Surgical Clerking
Proforma
We have introduced the new clerking proforma in emergency
surgery which is being re-audited with more number of patients
with a view to change the current practice.
Sickle Cell & Thalassaemia
Individual Care Plan Compliance
To remedy poor documentation of childhood immunisation, not
all children appear to have received Pneumovax at aged 2 years
and a poor response to booster vaccine every 5 years, patient
annual reviews not being routinely done for most patients and
Transcranial Dopplers (TCD) not being done in a timely manner
as recommended by NICE guidelines.
Actions taken ensure care pathways are developed and all staff
involved in care of patients with sickle cell and thalassaemia are
aware of follow up process.
Improve outpatient follow up and monitoring to ensure that all
care pathways are maintained/followed and
treatment/procedure provided at the scheduled time.
Ensure all staff involved in care and treatment of these patients
have easy access to their records.
Develop close working relationship with GP to ensure joint care
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provided and easy access to GP record of immunisation and
compliance with antibiotic prophylaxis.
At least one evening or weekend community clinic per month
to do TCDs and more focus to ensure patient annual reviews
updated and completed.
End of Life Care
End of life communication and documentation with patients
and carers has decreased since the withdrawal of the Liverpool
Care Pathway (LCP). The audit results have reinforced that a
plan of care is required to support the staff to deliver the best
quality of end of life care for patients. We are piloting an
individualised end of life care plan to ensure best practice in
end of life care for patients and support for staff and carers.
This will include a robust programme of training and evaluation
to prevent the failings of implementation and interpretation
that caused the LCP to be withdrawn from use in the UK.
Muscle Biopsy - Correlating
technique with quality of histology
and diagnosis
Separating individual sections (‘serial sections’) on a slide to
avoid excessive folding. Using height-adjustable chair at the
cryostat to reduce static effects and ‘flying off’ of sections to
reduce folds/overlap. Reviewing protocols used at external labs
to compare handling practices, freezing techniques and
cryostat sectioning (RLH). Reviewing freezing and staining
protocols locally
Quality Account 2014-15
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5.5
USE OF THE COMMISSIONING FOR QUALITY AND INNOVATION (CQUIN)
FRAMEWORK
The CQUIN payment framework enables commissioners of services to reward excellence by linking a
proportion of the income they provide to organisations such as BHRUT, to the achievement of
national and local quality improvement goals.
A proportion of the Trust’s income in 2014/15 was conditional on achieving quality improvement
and innovation goals agreed between the Trust and our commissioners through the CQUIN payment
framework. The total amount of CQUIN income possible in 2014/15 was £7,067,892 as shown in the
table below. Each goal has been colour-coded to indicate whether the goal was achieved or not and
where the milestone was not achieved during the year, or the outturn contract value was lower than
the baseline contract, then a proportion of the CQUIN monies were withheld. The actual CQUIN
income attributable to CQUIN targets was £5,391,602 which equates to 76% of total CQUIN
achievement.
Further details of the agreed goals for the reporting period and for the following 12 month period,
are available on request from:
Director of Finance, Barking, Havering & Redbridge University Hospitals NHS Trust,
Queen’s Hospital, Rom Valley Way, Romford, RM7 0AG
National
Friend & Family Test (FTT)
Key: Achieved
Partially Achieved
Not achieved
Description of Goal
Approx.
Value
Implement and generate a 10% improvement with staff
FFT
Action plan to be developed and bi-annual staff survey
£104,605
Early implementation of FFT in Day Surgery and
Outpatients
£104,605
Improve cancer patient experience by improving FFT
scores, response rates and developing an action plan
£76,333
Increase response rate for inpatients and A&E areas as
prescribed nationally
£53,716
Increase inpatient response rate of 47% or more for the
month of March 2015
£141.358
Quality Account 2014-15
Status
Barking, Havering and Redbridge University Hospitals NHS Trust
54
£183,765
Clinical leadership, appropriate training and evaluation
of training for staff, including use of Health Analytics to
enter on ‘This is Me’ documentation.
£104,605
Supporting carers of people with dementia and with
appropriate onward referral
£169,629
Notification and communication of admission to
Community Treatment Team between 8am and 10 pm
£79,160
Data sharing and information flows – Health Analytics,
flagging patients.
£240,308
Identification of high risk patients, admissions, writing
care plans on Health Analytics
£141,358
Discharge planning, weekly MDT pilot Havering, roll out
in other boroughs Q3 & Q4
£424,074
Stratification criteria and process (breast prostate,
colorectal), data management system, audit, prepare
Health & Well Being event
£240,308
Outcome measures: reduction in admission, LOS,
readmission and A&E attendances
£1,130,863
Falls handbook, staff training, creation of falls risk
register on Health Analytics
£565,431
Reduction in preventable moderate / severe falls by Q4
to not more than 30%.
5% reduction in all falls by end Qtr.4
£282,716
£349,437
Staffing
in ED
Hours of Consultant cover within ED
Ratio of temporary versus permanent staff
Number of unfilled shifts in ED
Ambulatory
Care
Local
Find, assess, investigate and refer patients 75+ and
targeted 65+ patients on specific dementia clinic
Local
Safety
Thermom
eter
Dementia
Integrated Care
£480,617
Creation of dedicated GP number
Direct access to GP slots
8am to 8pm - 20 patients per day / 8am to 4pm
weekends
Paediatric
A&E
pathway
Falls
Work with NELFT to develop a joint action plan to
reduce pressure ulcers across health economy for
Commissioner agreement.
Increase paediatric UCC utilisation
Production of advice leaflets for parents
Increase in utilisation of Paediatric Hot clinics for ED
TOTAL
Quality Account 2014-15
£1,639,751
£555,254
£7,067,892
£5,391,602
Barking, Havering and Redbridge University Hospitals NHS Trust
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5.6
CARE QUALITY COMMISSION REGISTRATION AND COMPLIANCE
Our Trust is registered with the Care Quality Commission under section 10 of the Health and Social
Care Act 2008 and has no conditions on its registration.
During 2014/15 we took part in the CQC ‘Review of health services for Children Looked After and
Safeguarding in Redbridge’. Whilst the primary focus of the review was not on the Trust, our
organisation’s processes and procedures when coordinating services for Redbridge children was
considered and a number of recommendations were made. An action plan was developed which
was monitored by the Deputy Director of Nursing with progress reported quarterly to the
Safeguarding Strategic and Assurance Group. All identified actions pertaining to this inspection have
been completed within agreed timescales.
The CQC visited our hospitals between 2-6 March 2015 to carry out a re-inspection of our core
services of Urgent and Emergency Services, Medical Care including older peoples’ care, Surgery,
Critical Care, Maternity and Gynaecology, Children and Young People, End of Life Care and
Outpatients. Each of these areas provided a range of data on topics such as the number of incidents
or complaints, its performance data on audit, staffing levels and training, infection control and
environment and plans for the future. The information from the core service was supplemented by
a wide range of additional information about how we are organised and managed.
The CQC will use this information to help determine whether sufficient progress had been made to
take the Trust out of ‘special measures’.
Their view on progress will also be influenced by
observation visits to clinical areas, meeting with a wide range of clinical and non-clinical staff from
across the whole organisation and from both sites and talking to patients and their relatives and
carers. In addition, a number of unannounced visits took place out-of-hours to enable the CQC to
gather a true view of our patients’ experience.
The final report is expected to be published in the summer and therefore does not form part of this
Quality Account. Work is already underway to take account of the brief verbal feedback received at
the end of the visit.
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5.7
DATA QUALITY
Payment by results
We were not subject to the Payment by Results clinical coding audit during 2014/15; however a
clinical coding audit was carried out as part of the Information Governance requirements for the
Trust. The error rates reported for clinical diagnosis coding and clinical treatment coding were:
Primary Diagnosis Correct
91.0%
Secondary Diagnosis Correct
92.6%
Primary Procedure Correct
93.1%
Secondary Procedures Correct
97.0%
The Trust has taken the following actions to improve clinical coding data quality:
The Training Manager/Head of Clinical Coding and Data Quality to organise a session with all
coders to feedback the errors and refresh their knowledge in clinical coding standards, rules,
conventions and guidance leading to the errors. Special emphasis should be put on the Primary
Diagnosis definition in general and choice of primary diagnosis in multiple episodes spells in
particular and how the main condition may change from one episode to another. The training
sessions should include coding of co-morbidities, what constitutes an episode in terms of
documentation to be examined and where to find relevant documents.
The Head of Clinical Coding and Data Quality to continue to work with clinicians to improve the
quality of clinical information and discharge summaries to secure the Trust income before the
implementation of paper-lite patient record.
Key Performance Indicators
The Trust is dependent on good quality data from clinical systems in order to deliver appropriate
care and treatment to our patients. The data must be accurate and accessible when required and
must effectively support the safe and effective delivery of patient care.
However, internal audit identified significant weaknesses in the mechanisms in place for data
collection; validation and reporting for a number of key mandatory data return indicators such as
that for serious incidents and referral to treatment times mentioned earlier in the report. We have
introduced an information assurance framework, supported by the introduction of a data assurance
framework for each data indicator. A further audit of data quality has resulted in an increased level
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57
of assurance being provided and has shown that whilst areas for improvement still exist, we have
continued to take required actions to address data quality issues.
Our Audit Committee also highlighted weaknesses in our system of governance risk management
and internal control and the need to develop an improved Board Assurance Framework (BAF); the
work to develop a more rigorous BAF is underway.
Hospital Episode Statistics
We have submitted records relating to admitted patient care to the Secondary Uses Service for
inclusion in the Hospital Episode Statistics, which are included in the latest validated Hospital
Episode Statistics data. The percentage of records in the published data are:
Admitted patient care
Outpatient care
Accident and
Emergency Care
Valid NHS number
97.4%
98.2%
85.5%
General Medical
Practice Code
100%
100%
99.3%
Note: Data Quality report of the percentage valid for BHRUT from month 10 / January 2015 for
Outpatient attendances from SUS data
Information Governance
The information governance toolkit is an online system which allows the NHS to assess itself against
Department of Health Information policies and standards.
Barking, Havering and Redbridge
University Hospitals NHS Trust score overall for 2014/15 was 74% and was graded ‘satisfactory’.
Monthly monitoring is now taking place, with staff whose training has lapsed being sent a reminder.
Failure to refresh their training within 2 weeks results in non-compliant staff network accounts being
disabled.
The 20% improvement (54% score in 2013-14) has been achieved by the development of an
Information Governance Work Programme and Improvement Plan covering the full range of
information governance elements to ensure appropriate policies and management arrangements
are in place. The Work Programme and Improvement Plan were regularly monitored by the
Information Governance Steering Group.
A focus for 2015-16 will be to see the Trust become increasingly paper-lite, thereby releasing
physical space and minimising the risks to patient confidentiality. The Information Governance Team
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will continue to promote the use of NHS Mail, assist in office reviews of existing business practices
and flows with a view to reducing the Trust’s reliance on using fax and other insecure means to send
patient confidential data.
6.
CLOSING STATEMENTS
Comments and recommendations for improvement and/or clarification received from our Auditors
and Stakeholders have been incorporated into the final report where possible. We extend our
thanks to them for helping to ensure this report provides clear and understandable information for
our readers.
The following organisations were sent the draft Quality Account but did not provide any feedback:
London Borough of Havering Health Overview and Scrutiny Committee
Healthwatch Redbridge
Healthwatch Essex
This report will be sent to the Secretary of State as required under the Quality Account Regulations
by the 30 June and a copy will be uploaded to our Trust’s and NHS Choices’ websites.
Any comments from the public can be sent to the Trust Communications and Marketing Directorate
at communications.department@bhrhospitals.nhs.uK or via telephone on 01708 435000 Ext.3980.
Written comments can be sent to the Communications and Marketing Directorate at Trust
Headquarters, Queen’s Hospital, Rom Valley Way, Romford, RM7 0AG.
Quality Account 2014-15
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6.1
STATEMENTS OF ASSURANCE
The Directors are required under the Health Act 2009 to prepare a Quality Account for each financial
year. The Department of Health has issued guidance on the form and content of annual Quality
Accounts (in line with requirements set out in Quality Accounts legislation).
In preparing the Quality Account, directors should take steps to assure themselves that:
The Quality Account presents a balanced picture of the Trust’s performance over the reporting
period.
There are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Account, and these controls are subject to review to
confirm they are working effectively in practice.
The data underpinning the measure of performance reported in the Quality Account is robust
and reliable, conforms to specified data quality standards and prescribed definitions, and is
subject to appropriate scrutiny and review.
The Quality Account has been prepared in accordance with any Department of Health guidance.
The directors confirm to the best of their knowledge and belief that they have complied with the
above requirements in preparing the Quality Account.
By order of the Board
Chair
Chief Executive
Signed 29 June 2015
Signed 29 June 2015
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6.2
AUDITOR’S LIMITED ASSURANCE REPORT
INDEPENDENT AUDITORS’ LIMITED ASSURANCE REPORT TO THE DIRECTORS OF BARKING, HAVERING
AND REDBRIDGE UNIVERSITY NHS TRUST ON THE ANNUAL QUALITY ACCOUNT
We are required to perform an independent assurance engagement in respect of Barking,
Havering Redbridge University Hospitals NHS Trusts Quality Account for the year ended 31
March 2015 (the Quality Account) and certain performance indicators contained therein as
part of our work. NHS trusts are required by section 8 of the Health Act 2009 to publish a
Quality Account which must include prescribed information set out in The National Health
Service (Quality Account) Regulations 2010, the National Health Service (Quality Account)
Amendment Regulations 2011 and the National Health Service (Quality Account)
Amendment Regulations 2012 (the Regulations).
Scope and subject matter
The indicators for the year ended 31 March 2015 subject to limited assurance consist of the
following indicators:
• Rate of clostridium difficile infections
• FFT patient element score
During 2014/15 the management did not have reliable data to use in order to calculate the
Trusts performance for this indicator for 2014/15 period. We have been unable to perform
sufficient testing in relation to this indicator and have excluded the provision of assurance in
relation to FFT patient element score from the scope of our work.
In this opinion all references to the indicator" refer to rate of clostridium difficile infections
indicator.
Respective responsibilities of the Directors and the auditor
The Directors are required under the Health Act 2009 to prepare a Quality Account for each
financial year. The Department of Health has issued guidance on the form and content of
annual Quality Accounts (which incorporates the legal requirements in the Health Act 2009
and the Regulations).
In preparing the Quality Account, the Directors are required to take steps to satisfy
themselves that:
• the Quality Account presents a balanced picture of the trusts performance over the period
covered;
• the performance information reported in the Quality Account is reliable and accurate;
Quality Account 2014-15
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61
• there are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Account, and these controls are subject to review to
confirm that they are working effectively in practice;
• the data underpinning the measures of performance reported in the Quality Account is
robust and reliable, conforms to specified data quality standards and prescribed definitions,
and is subject to appropriate scrutiny and review; and
• the Quality Account has been prepared in accordance with Department of Health
guidance.
The Directors are required to confirm compliance with these requirements in a statement of
directors responsibilities within the Quality Account.
Our responsibility is to form a conclusion, based on limited assurance procedures, on
whether anything has come to our attention that causes us to believe that
• the Quality Account is not prepared in all material respects in line with the criteria set out
in the Regulations;
• the Quality Account is not consistent in all material respects with the sources specified in
the NHS Quality Accounts Auditor Guidance 2014-15 (the Guidance); and
• the indicator in the Quality Account identified as having been the subject of limited
assurance in the Quality Account are not reasonably stated in all material respects in
accordance with the Regulations and the six dimensions of data quality set out in the
Guidance.
We read the Quality Account and conclude whether it is consistent with the requirements of
the Regulations and to consider the implications for our report if we become aware of any
material Omissions.
We read the other information contained in the Quality Account and consider whether it is
materially inconsistent with:
• Board minutes for the period April 2014 to June 2015;
• papers relating to quality reported to the Board over the period April 2014 to June 2015;
• the Trusts complaints report published under regulation 18 of the Local Authority, Social
Services and NHS Complaints (England) Regulations 2009, dated May 2015;
• feedback from other named stakeholders) involved in the sign off of the Quality Account;
• the latest national patient survey dated 2014;
• the latest national staff survey dated 2014;
• the Head of Internal Audits annual opinion over the trusts control environment dated May
2015;
• the annual governance statement dated May 2015;
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We consider the implications for our report if we become aware of any apparent
misstatements or material inconsistencies with these documents (collectively the
documents). Our responsibilities do not extend to any other information.
This report, including the conclusion, is made solely to the Board of Directors of Barking,
Havering and Redbridge University Hospitals NHS Trust.
We permit the disclosure of this report to enable the Board of Directors to demonstrate that
they have discharged their governance responsibilities by commissioning an independent
assurance report in connection with the indicator. To the fullest extent permissible by law,
we do not accept or assume responsibility to anyone other than the Board of Directors as a
body and BHRUT for our work or this report save where terms are expressly agreed and with
our prior consent in writing.
Assurance work performed
We conducted this limited assurance engagement under the terms of the Guidance. Our
limited assurance procedures included:
• evaluating the design and implementation of the key processes and controls for managing
and reporting the indicator,
• 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 of the Quality Account to the requirements of the Regulations; and
• reading the documents.
A limited assurance engagement is narrower in scope than a reasonable assurance
engagement. The nature, timing and extent of procedures for gathering sufficient
appropriate evidence are deliberately limited relative to a reasonable assurance
engagement.
Limitations
Non-financial performance information is subject to more inherent limitations than financial
information, given the characteristics of the subject matter and the methods used for
determining such information.
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The absence of a significant body of established practice on which to draw allows for the
selection of different but acceptable measurement techniques which can result in materially
different measurements and can impact comparability. The precision of different
measurement techniques may also vary. Furthermore, the nature and methods used to
determine such information, as well as the measurement criteria and the precision thereof,
may change over time. It is important to read the Quality Account in the context of the
criteria set out in the Regulations.
The nature, form and content required of Quality Accounts are determined by the
Department of Health. This may result in the omission of information relevant to other
users, for example for the purpose of comparing the results of different NHS organisations.
In addition, the scope of our assurance work has not included governance over quality or
non-mandated indicator which have been determined locally by Barking, Havering and
Redbridge University Hospitals NHS 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 2015:
the Quality Account is not prepared in all material respects in line with the criteria set
out in the Regulations;
the Quality Account is not consistent in all material respects with the sources specified
in the Guidance; and
the indicator in the Quality Account subject to limited assurance have not been
reasonably stated in all material respects in accordance with the Regulations and the six
dimensions of data quality set out in the Guidance.
ΚΡΜG LLP
Chartered Accountants
15 Canada Square
Canary Wharf
London E14.5GL
3 June 2015
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6.3
ADDENDUM TO 2013-15 QUALITY ACCOUNT
On page 7 of last year’s Quality Account we said ‘Changes to the process for end of life care which
have reduced the length of time it takes to arrange discharge from an average of 5 days to 24 hours’.
This statement has since been identified as incorrect but despite an internal review it has not been
possible to identify where these figures originated. It should read “In October 2013 the time taken
from initiation of the fast track discharge process to completion was 11-12 days; this has been
reduced down to an average of 5.7 days (as of end of March 2014) and work is ongoing to generate
further reductions”. We apologise for this error.
Quality Account 2014-15
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7. PARTNER COMMENTARIES
Barking, Havering and Redbridge University Hospitals NHS Trust Commissioners’ Statement for
14/15 Quality Account
NHS Havering Clinical Commissioning Group welcomes the opportunity to review the Quality
Account (the Account) for Barking, Havering and Redbridge University Hospitals NHS Trust (the
Trust) and to provide this statement. This statement has been prepared in collaboration with
Barking and Dagenham and Redbridge CCGs and colleagues from the North and East London
Commissioning Support Unit.
We confirm that we have reviewed the information contained within the Account and checked this
against data sources where this is available to us as part of existing contract assurance and
monitoring processes and can confirm that we believe it is mostly accurate in relation to the services
provided by the Trust.
We have noted the number of examples provided within the Account which attest to the Trust’s
achievements in improving the quality of care and patient experience during 2014/15.
In particular, the End of Life Care audit describes a pilot of individualised care plans to ensure best
practice in end of life care. This will include a robust programme of training and evaluation to
prevent the failings and interpretation that caused the Liverpool Care Pathway to be withdrawn
from use.
The Trust review of clinical coding places special emphasis on the Primary Diagnosis definition and
choice of primary diagnosis in multiple episodes of care and how the main condition may change
during a patient’s episode of care. A training programme is in place to improve this. It is also noted
that the head of clinical coding and data quality will continue to work with clinicians to improve the
quality of clinical information and discharge summaries to secure the Trust income before the
introduction of paper light patient records. Improvement of the quality of discharge summaries is a
commissioner priority and we therefore welcome this.
We are pleased to note the Trust has joined up to the Sign up for Safety campaign and fully support
the pledges. The Trust has demonstrated progress in achieving these pledges.
We note the following priorities which were not fully met in 2014/15:
Targets for improving radiology standards are recorded as not yet complete, with the intention to
meet these targets by the end of 2016. It would be useful to include success criteria for meeting
these targets and to provide a date by which they will be complete.
The Account notes that targets for the pain management audit and pain relief training were not met,
but does not provide any detail of constraints preventing them from meeting these targets. It would
be useful to have this detail.
Venous Thromboembolism risk assessment figures for quarter 4 are not included. As this is one of
the Harm Free Care quality initiatives an explanation of why the quarter 4 assessment figures is not
in the Account should be included.
The staff survey shows areas of improvement for staff safety which are, bullying/abuse, staff
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suffering work-related stress and staff believing the Trust provides equal opportunities for career
progression. The Account states that the actions to improve will translate into a ‘You Say, We Did’
campaign, but this is not explicit in the 2015/16 priorities.
The Account details the Trust’s priority to establish a strategy to improve the recruitment and
retention of the consultant workforce, but it would be useful to include details of how and when this
would be achieved.
We are pleased to note that the Trust is not waiting on the next report from the Care Quality
Commission before acting on themes identified during their recent inspection, and we fully support
this approach and how this has shaped the Trust’s priorities for 2015/16, which we are in support of.
These are:
Avoiding harm to patient from care that is intended to help them
Providing services based on scientific knowledge of which produce a clear benefit
Providing care that is respectful and responsive to individuals’ needs and values
Reducing waits and sometimes harmful delays
Avoiding waste
Providing care that does not vary in quality because of a person’s characteristics.
We note that there is limited detail within the Account regarding how the Trust intends to achieve
the priorities; however the Trust has set out the expected outcomes for each of the priorities.
Commissioners are fully committed to working collaboratively with the Trust to support delivery of
the priorities and to monitor delivery through the monthly Clinical Quality Review meetings. We are
disappointed that achievement of the national cancer standards has not been specifically identified
as a Trust priority and confirm this is a commissioner priority.
We have reviewed the content of the Account against the prescribed information, form and content
as set out by the Department of Health and note that in the main this account reflects that guidance.
There are some areas where we believe further, or more detailed, information is required to meet
the guidance and the priorities of the CCGs. These areas are:
‘Better Discharge Processes’ has been identified as a key challenge but no next steps have been
identified to achieve this in 2015/16. It would be useful for the Account to include milestones and
dates for 2015/16.
Section 5.4 lists the 32 National Clinical Audits (NCAs) which BHRUT participated in and the
percentage of cases that they submitted. For completeness, it should also list which National Clinical
Audits the Trust did not participate in and reasons why. It would also be useful to include any
rationale for implementation of actions and recommendations into practice, and to link these with
2015/16 quality improvements.
Inclusion of the learning the Trust has implemented as a result of the Never Events reported during
2014-15.
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More specific reference on how the Trust will continue to implement the recommendations of the
Francis enquiry and the Morecambe Bay Investigation Report.
Providing information regarding how patients, staff and the Trust Board were involved in setting the
quality priorities.
Providing the full set of data required by the DH Quality Account Toolkit and DH Gateway Guidance
2013, letter dated 29 January 2013.
From the patient’s perspective, provide an explanation of what some of the data means to them for
example “as a patient should I be worried that mortality related to stroke has increased?”
Clear evidence of the intention to improve accessibility of the Quality Account e.g. publication on
website, translation into other languages.
We believe that the Account represents a fair, representative and balanced overview of the quality
of care delivered by the Trust and overall we welcome and support the vision described within the
Account and agree on the priority areas. We will continue to strengthen our good relationship with
the Trust to work with and fully support them to continually improve the quality of services provided
to patients.
Conor Burke
Accountable Officer, on behalf of NHS Havering Clinical Commissioning Group
Also on behalf of the collaborative commissioning arrangements for Barking, Havering and
Redbridge University Hospitals NHS Trust
Basildon and Brentwood Clinical Commissioning Group
Lisa Allen, Chief Nurse
Basildon and Brentwood Clinical Commissioning Group welcomes the opportunity to comment on
the Quality Annual Account prepared by Barking, Havering and Redbridge University Hospitals NHS
Trust (BHRT).
As an associate commissioner of services; Basildon and Brentwood CCG has the following statement
to make for inclusion in the BHRT Quality Account.
To the best of the CCGs knowledge, the information contained in the Account is accurate and
reflects a true and balanced description of the quality of the provision of services
This year has been a challenging year for patient safety and quality of care at BHRT throughout
2014/15, having been placed into Special Measures.
There have been a number of achievements since that time; and theses are a reflection of the
dedication and hard work of all staff at the Trust. The Trust acknowledges that they have a way to go
and that they need to drive continued improvements. This is of course on a background of
unprecedented demand on the health system with the need for the Trust to be also out-ward
looking in order to be part of a sustainable future NHS.
It is our observation that the governance re-structure is yielding improved accountability for patient
safety and quality throughout and across the organisation as the Trust continues to work towards
creating a positive, open and transparent culture, and an organisation which learns from its
mistakes.
The CCG agree with and support the key quality goals that the Trust has described to continually
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improve patient safety and quality of care.
Progress with the Improvement Plan has at times been slow, but plans for improvement have been
well articulated and pro-actively shared with partners. The Quality Account reports the over-arching
measures such as SHMI that have been maintained within expected ranges, and also describes
improvements that are required against other metrics such as the staff survey.
The CCG looks forward to continuing to support the Trust in its Improvement Programme.
Healthwatch Barking and Dagenham
Marie Kearns, Chief Executive
Healthwatch Barking and Dagenham welcome the BHURT’s Quality Account of 2014-15. It is pleasing
to see that the Trusts improvement plan, Unlocking our Potential had a focus on patient safety,
effectiveness and experience. Our own experience of working with the Trust reflects that this
principle was indeed made a reality. Our Enter and Views were welcomed and all our
recommendations, based on patients comments, were adopted and implemented with timed action
plans. Likewise recent work done with patients in the Accident and Emergency Units of both Queen’s
and King George’s Hospital reflects the improvement in waiting times and a high degree of patient
satisfaction with their overall experience.
We appreciate that it has been a very hard year for the Trust, with more hard work to come.
Maintaining a patient focus however by improving outcomes and experiences, must undoubtedly be
the route that will soon see the Trust out of special measures.
Healthwatch Barking and Dagenham looks forward to our continued partnership working with the
Trust to improve the patient experience for Barking and Dagenham residents.
Healthwatch Havering
Anne-Marie Dean, Chief Executive
During the past year we have evidenced a number of positive and substantial changes within
Queen’s, the attention to working with other organisations, the desire to develop clinical rigor, to
work more closely with your staff and particularly developing ways of communicating and working
with patients and carers. The open culture which now embraces working with local Councillors,
voluntary organisations and other key stakeholders, the development of media such as Twitter and
Facebook has contributed to the growing confidence in the hospital team.
The Quality Account and the new priorities are welcomed and will build on the work of 2014/2015.
The introduction by the Medical Director and the Interim Director of Nursing sets the tone for taking
a pragmatic approach which enables the previous years work to be further enhances and developed.
We particularly think that the three new initiatives - timely, efficient and equitable will considerably
enhance the overall care at the hospital, in particular areas such as medicines management and
patient discharge arrangements.
We wish the hospital team every success and looking forward to continuing our positive relationship
London Borough of Barking and Dagenham Health and Adult Services Select Committee
Councillor Eileen Keller, Chair
Leadership
The appointment of Matthew Hopkins as Chief Executive and Steve Russell as Deputy Chief
Executive, and the completion of the Trust’s Board puts the Trust in a strong and stable position to
deliver the changes identified in the Trust’s Improvement Plan.
We note the Trust’s initiative to work with the Good Governance Institute to improve corporate and
clinical governance and to help ensure that the Trust Board receives the right level of assurance on
quality and safety of BHRUT services. The improvements that you report in information governance
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practice are particularly welcome, albeit that there remains further work to do.
Partnership working
As an observer of the Health and Wellbeing Board (HWB) I noted the HWBB’s positive comments
around the Trust’s approach to communicating with the Local Authority on its improvement plan
and hope to see this relationship continue. I know that my colleague, Cllr Worby, as chair of the
Board has welcomed the contribution made by Dr Moghul as the incoming Medical Director and
representative on the Board, and looks forward to his continued input.
The implementation of the Joint Assessment and Discharge Service and the improved outcomes this
Service has brought for service users and partners involved is testament to what effective
partnership work can achieve; the Service was ‘highly commended’ in the Health Education North,
Central & East London Quality Awards, and has been viewed as a positive step in supporting the
acute services, especially in the reduction of pressures on hospital A&E departments over the winter
months. It has continued to play a key part in our operational resilience delivery over the winter
period, and is evidence of the improvement in the Trust’s approach to partnership working. This is
one of the schemes of our Better Care Fund, and whilst not explicitly referenced in the Quality
Account itself, BHRUT’s continued active participation will be important to the success of the
programme, across a range of areas. Our prevention scheme focuses on falls, and together with
dementia this appears to be an area that the Trust would like to improve for itself, so there is the
potential for some further joint work that we would like to see fully exploited.
The creation of a Local Representatives Panel has been a positive step in ensuring that the Trust is
seen to be transparent and accountable to local stakeholders. We note that the Trust has made
significant efforts in engaging with local service users holding listening events with partners such as
Barking and Dagenham HealthWatch.
I noted the HWBB’s concerns with regard to local partners’ readiness to meet the requirements of
the Care Act 2014 and hope that BHRUT’s discussions will continue with our Adult and Community
Services Department to ensure preparedness to meet the requirements brought about by further
recent reform on care. I note that BHRUT continue to play a role in the Safeguarding Adults Board
and subgroups, and expect that this will continue to be a strong partnership as it moves forward
with the statutory status conferred upon it by the Care Act. In particular, we expect new panLondon procedures for safeguarding to be issued in the late summer, and BHRUT should be gearing
up to ensure they are implemented in partnership with us.
We agree that there is a strong need for BHRUT to understand the changing age, ethnicity and
health profile of our residents to address their future needs effectively and the need for BHRUT to
work with our Public Health team to do this. We look forward to observing developments in this
regard through our health scrutiny function in 2015/16.
Financial position
From the Trust Board papers for March 2015, we note that the Trust ended the year with a deficit of
ca. £38m. We hope to see the Trust achieve a break-even position as soon as possible and without
compromising clinical effectiveness or negatively impacting on patient experience.
Reviewing the finance information, it is neither helpful nor ‘proper’ to reference the income from
North East London Commissioning Support Unit. We would expect to see represented the income
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from Barking & Dagenham Clinical Commissioning Group, on behalf of the residents of our borough.
We’d be grateful to see this amended.
As we start the year, we are aware that the allocation of winter pressures monies is currently
planned to be through the Trusts with no allocation currently identified to support social care. We
would observe that only a system-wide response to winter pressures is likely to have real success
and we trust that this will be the approach taken when the final decisions have to be made.
Emergency Department
We congratulate the Trust on the improvements in its emergency department performance for
March 2015 and we note the hard work of the emergency department teams, ward teams and
partners in the community who, together, have started to improve the flow of patients through the
Trust’s hospitals. However, there remain concerns about consistency taking into account the Winter
months of 2014 and that many patients are still waiting long periods of time to get treated. The
Trusts own A&E survey of patients treated over spring 2014 showed very disappointing results. The
Trust is some way off achieving its aim of a Friends and Family Test score of 45% and above. We
hope the work taking place to review patient’s comments, as well as the wider work to strengthen
clinical leadership in the Emergency Departments and the trust-wide recruitment and attraction
strategy will help generate further, consistent improvement.
Staffing
We note that one of the key measures in the NHS staff survey is overall staff engagement and that
the Trust’s score in this measure in the last survey was 3.69. We hope that the action plan being put
in place to address this sees the score rise to at least 3.74, the national average, by the time the next
survey is undertaken as this measure is linked to providing high quality patient care.
We note that spend on locum staff remains a concern, and that the Trust is prioritising the need to
convert this spend to permanent staff to bring quality and care benefits and reduce costs. We would
share the national concern about the cost of agency staff in the NHS, as well as seeing at first hand
the impact that this lack of continuity has on the quality of care.
We note the results of the Trust’s inpatient survey which showed that one of the top priorities for
patients was increasing the number of nurses on duty. Whilst we note that the May 2015 Inpatient
Survey Issue Brief commits to spending £5.9m to improving nursing care, the 2014/15 Quality
Account could present clearer information on the Trust’s progress against its objective in 2014/15 to
improve recruitment processes and attract more people to work at BHRUT in respect of nurses and
the impact this has had on patients.
Patient experience
We commend the Trust’s progress on improving maternity services which has led to positive reports
from external bodies such as the Care Quality Commission, and very positive feedback from women.
We feel that the Quality Account could include further information around these improvements.
We are pleased to see that the Trust is embedding a culture in which staff feel comfortable in raising
legitimate issues and concerns without fear of blame or reprisal and note references in the Account
to the systems in place to help achieve this. However, as acknowledged in the Trust’s June progress
report, more could be done, given the importance of this, as highlighted in the Francis report. We
are assured by BHRUT’s commitment to consult on its ‘Speaking Up for a Healthy Trust’ Policy in that
regard.
We note that a significant number of actions identified related to improving radiology services in the
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Improvement Plan for Priority 2, Clinical Effectiveness are rated red. Again, we would expect to see a
determined effort to improve this situation in the coming year.
Amongst a number of areas of patient experience that require improvement, we particularly note
the need to improve doctors’ communication so that they give understandable explanations, which
was highlighted during local ‘listening’ events. We feel this is a relatively low cost area to see
improvement in, which would go a long way in improving patient experience and hope that the next
Quality Account documents the steps the Trust has taken in improving communication with patients.
I am aware that you will be attending a HASSC meeting on 16 June 2015 to update the Committee
on the outcomes of the CQC re-inspection that took place in March 2015. My Elected Member
colleagues and I look forward to discussing the issues arising from the re-inspection and this
statement with the Trust directly at the meeting.
London Borough of Redbridge Health Overview and Scrutiny Committee
We welcome this opportunity to comment on the quality Account for BHRUT. The Trust has made
great improvements over the year, as reflected in this report. The Committee wishes to place on
record our thanks and congratulations to the staff for this achievement. However, as is also clear,
there is still a journey to be travelled to ensure that Redbridge residents and all the other people
who use the services provided by BHRUT will get the best possible care and achieve the best possible
outcomes.
As a ‘critical friend’ of BHRUT over the last year, both supporting and challenging when needed in
order to get the best for our residents, the Council’s Health Scrutiny Committee, and the
committee’s Health Monitoring Scrutiny Working Group, sees its role as an active partner in
achieving the improvements needed.
Over the past year we have reviewed and monitored progress on the BHRUT improvement plans;
engaged with the Trust around changes to Breast Cancer Screening services; sought assurances
around the referral to treatment waiting times (particularly when a backlog of cases had been
detected); visited maternity services at Queen’s Hospital for assurance that service improvements
has been made, and some Committee Members have participated in the Trust’s newly developed
Local Representatives Panel.
We welcome the approach of the BHRUT leadership team, and in particular its Chief Executive,
Matthew Hopkins, who has engaged with the Health Scrutiny Committee and with its Working
Group in a refreshingly open and honest manner, and we believe that this has not only enabled the
development of trust but has provided real opportunities for effective dialogue.
The changing culture resultant from this new leadership is palpable and, we believe, has significantly
contributed to the improvements the Trust has achieved to date. Our residents and other service
users deserve the best treatment and care and there is still much work to be done to achieve all of
the required improvements.
Redbridge’s Health Scrutiny Committee commits itself to continue being an active partner and
critical friend to support BHRUT to be able to deliver this ambition.
Improving Patient Experience Group
Elaine Clark, Chair
In the past year I have seen the biggest improvement within the Trust than in previous years. The
new Trust Board have shown a vast amount of interest in ‘The Patient Experience’ which is the most
important part of the patient’s journey. People can cope with most things if they are given care,
compassion and a friendly smile and not greeted by a frowning or disgruntled member of the
workforce. I have observed this change in the staff increasing month by month as they start to see
the differences in how the Trust is running.
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I have the reassuring knowledge that the staff and patients now have the opportunity to speak not
just to managers, but to the people at the top; the Chairman, the Chief Executive and other Board
members.
This is not only at the Hospital, but also at the Listening Events for the general public that the
Hospital has organised. This means a lot to people.
It is good to see staff being rewarded with the Terrific Tickets at all levels and the pride values
showing through. It is also great to hear the compliments that the patients say about the staff and
when complaints are received that they are addressed more quickly and thoroughly.
As Chair of IPEG, I have a voice at meetings and do not feel it is just a tick box exercise. I feel a
valued part of the team and am sure the members of IPEG that attend various committee meetings
also feel the same.
There obviously still a long way to go, but I personally feel that the Trust has taken some big steps
forward and are not just talking the talk, but are now starting to walk the walk!
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