Quality Account
2014/15
RNOH Patient Video Guide: a new
approach to patient information
Over the past year, the Trust has produced and published a series of short information videos to
give patients and families a quick and easy guide to our services. Each film is approximately two
minutes long and is aimed at providing patients with the core information about what to expect
when they come to the RNOH. The videos are available via the Trust website and YouTube.
The areas so far covered by the films include:
• An introduction to the RNOH presented by Chief Executive Rob Hurd
• Foot and Ankle service and team
• Diagnostic services such as CT, X-Ray, Fluoroscopy and MRI
• Outpatients at Stanmore and Bolsover Street
Another set of films will be produced in 2015/16, covering clinical services such as pain
management, sarcoma, upper limb and spinal. Once completed, there will be 30 video guides in
total.
The RNOH Patient Video Guide can be accessed at http://guide.rnoh.nhs.uk/#/
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The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
Contents
Part 1: Statement on quality from the Chief Executive .......................................................5
1.1 Statement from the Chief Executive .........................................................................................5
1.2 About the Trust ........................................................................................................................8
1.3 About the Quality Account 2014-15 ......................................................................................12
1.3.1 What is the Quality Account? .....................................................................................12
1.3.2 Who has been involved in producing the Quality Account?.........................................13
Part 2: Priorities for improvement and statements of assurance from the Board ...........14
2.1 Quality Priorities in 2015/16 ...................................................................................................14
2.1.1 Priority 1 - Reduction of pressure ulcers ......................................................................15
2.1.2 Priority 2 – Reduction of surgical site infections...........................................................15
2.1.3 Priority 3 – Robust processes for learning from incidents and complaints ....................16
2.1.4 Priority 4 – Reduction in serious incidents and never events ........................................16
2.1.5 Priority 5 – Focus on staff culture, values and behaviours ............................................16
2.2 Statements of assurance ........................................................................................................17
2.2.1 Review of services.......................................................................................................17
2.2.2 Participation in clinical audits ......................................................................................18
2.2.3 Participation in clinical research...................................................................................20
2.2.4 Use of the CQUIN payment framework.......................................................................22
2.2.5 CQC registration and compliance ...............................................................................24
2.2.6 Data quality and information governance ...................................................................25
Part 3: Review of quality performance .......................................................................................27
3.1 Progress on delivering Quality Priorities in 2014/15.................................................................27
3.1.1 Priority 1: To strengthen and embed good, robust safeguarding practices ...................27
3.1.2 Priority 2: Implementation of the 6 Cs Nursing Strategy ..............................................28
3.1.3 Priority 3: To strengthen senior nursing leadership ......................................................29
3.2 Patient safety measures ..........................................................................................................30
3.2.1 Venous thromboembolism (VTE) .................................................................................30
3.2.2 Clostridium Difficile (C. difficile) infection....................................................................32
3.2.3 Patient safety incidents ...............................................................................................34
3.2.4 Pressure ulcers ............................................................................................................36
3.2.5 Medication errors .......................................................................................................36
3.2.6 Nutritional assessments ..............................................................................................38
3.3 Clinical effectiveness measures ...............................................................................................40
3.3.1 Summary Hospital-level Mortality Indicator (SHMI) ......................................................40
3.3.2 Patient Reported Outcome Measures (PROMs) ............................................................40
3.3.3 Emergency readmissions within 28 days .....................................................................42
Continued
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
3
Contents
3.4 Patient experience measures...................................................................................................43
3.4.1 Friends and Family Test ...............................................................................................43
3.4.2 Responsiveness to personal needs...............................................................................50
3.4.3 Complaints and Patient Advisory Liaison Service (PALS) ...............................................52
3.5 Maintaining continuous quality improvement at RNOH ........................................................54
3.5.1 Specialist Orthopaedic Alliance ...................................................................................54
3.5.2 Organisational Development Programme ....................................................................54
3.5.3 Nursing Strategy.........................................................................................................55
3.5.4 Quality Strategy..........................................................................................................56
3.5.5. Collaborative working with academic partners and contribution to the Academic
Health Sciences Network ...........................................................................................56
3.5.6 Continuing focus on quality improvement in operational performance .......................57
3.6 Statements from external stakeholders ................................................................................58
3.6.1 Statement of assurance from Barnet Clinical Commissioning Group (CCG) .................58
3.6.2 Statement of assurance from Healthwatch Harrow .....................................................60
Glossary
...........................................................................................................................................61
Appendix 1: Statement of directors’ responsibilities in respect of the Quality Accounts ..........................63
Appendix 2: External auditor’s assurance report .....................................................................................64
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The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
Part 1: Statement on quality from the Chief Executive
Statement on
quality from the
Chief Executive
1.1 Statement from the Chief
Executive
Rob Hurd
Chief Executive
The Quality Account provides evidence of the
Trust’s continued efforts and achievements in
2014/15 to improve the quality and safety of care
provided to our patients, maintaining world-class
standards and driving forward improvements in all
aspects of care.
In May 2014, the Royal National Orthopaedic
Hospital (RNOH) was one of the first specialist
trusts to be inspected under the Care Quality
Commission’s (CQC) newly revised inspection
approach. The inspection report (published August
2014) rated the Trust as ‘requiring improvement’
and we have worked hard to deliver improvements
where there were areas of concern identified.
These have included:
• Continuing to address the quality of our
hospital estate at Stanmore, including building
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
5
Part 1: Statement on quality from the Chief Executive
a new theatre and essential maintenance
work. The Trust’s outline business case for
redevelopment of the Stanmore site was
approved by the NHS Trust Development
Authority (TDA) in March 2015, enabling the
Trust to push forward with our plans for
developing 21st century standard facilities for
our patients.
• Reducing the number of late starts in
Outpatient clinic times and introducing robust
performance indicators for monitoring this.
• Development of a new clinical risk
management structure across the Trust, and
refreshed process for learning from incidents.
• Improved compliance with the World Health
Organization (WHO) Safety Checklist for
Radiology and Surgery.
• Improved processes in place to ensure children
are scheduled first for operations.
• Improved frequency and robustness of
equipment checking, including paediatric
resuscitation equipment.
• Continued work on improving our Trust culture
and behaviours through the organisational
development programme.
In addition to these areas, we have demonstrated
significant progress in delivering our Quality
Priorities for 2014/15, which included
strengthening and embedding more robust
safeguarding practices; implementation of the 6Cs
Nursing Strategy and strengthening senior nursing
leadership.
The Trust continues to work hard to sustain these
improvements and we are committed to continue
6
to deliver further improvements in the year
ahead. We have made a commitment to place a
particular focus on a number of areas which are
described in our Quality Priorities for 2015/16.
These are:
• Focus on staff culture, values and behaviours
• Reduction of pressure ulcers
• Reduction of surgical site infections
• Robust processes for learning from incidents
and complaints
• Reduction in serious incidents and never
events
In addition, the Trust will continue to place a
strategic focus on driving continuous quality
improvement. We will continue to build our
reputation as a world-class leader in specialist
orthopaedics and contribute to the Specialist
Orthopaedic Alliance; we will focus heavily on
supporting, engaging and developing our
workforce through our organisational development
programme, and we will refresh our Trust Nursing
Strategy and Quality Strategy.
The Trust’s performance in key national
performance indicators has remained high,
demonstrating the excellent quality of care
provided. Key achievements include:
• Increasing our compliance with Venous
Thromboembolism (VTE) assessment to 99.6%
• Significantly reducing the incidence of
Clostridium difficile (C. difficile) infection from
9 cases in 2013/14 to 3 cases in 2014/15 - a
threefold reduction. We are now into our 6th
year of no surgical site MRSA infections.
• Significantly reducing the number of pressure
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
Part 1: Statement on quality from the Chief Executive
ulcers and improving our processes for
reviewing pressure ulcers quickly to
understand the causes.
We have continued to proactively seek the views
and opinions from our patients on the quality of
care they receive including further developing the
Friends and Family Test in Inpatient, Outpatient and
Paediatric services. The feedback we have received
on patient experience is consistently positive,
which is testament to excellent dedication, hard
work and clinical expertise of our staff. For
2014/15, 96% of patients who responded to the
question on adult inpatient wards said that they
would recommend the hospital to their Friends and
Family.
The Trust has also performed very highly in the
national survey of adult inpatients (2014), scoring
within the Top 20% of Trusts in the survey for
areas including patients’ overall view of care and
services and overall experience. The Trust is
committed to continuing to provide an excellent
patient experience alongside the world-class
quality and safety of services.
Patient video guide: About the RNOH
Patient video guide: Outpatients Stanmore
The Trust is proud of its achievements over the past
year in providing high quality and safe care for our
patients, and we are confident that we will to do
this in 2015/16 through our Quality Priorities and
continuous improvement initiatives.
I confirm to the best of my knowledge that the
information contained in this report is accurate.
Rob Hurd
Chief Executive
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
7
1.2 About the Trust
patients
were
assessed for
life-threatening
blood clots
and Local Health Boards
across England, Wales,
Scotland and Ireland
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The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
1.2 About the Trust
1.2 About the Trust
The RNOH is the UK’s leading specialist
orthopaedic hospital. We provide a comprehensive
and unique range of neuro-musculoskeletal
healthcare, ranging from acute spinal injuries to
orthopaedic medicine and specialist rehabilitation
for chronic back sufferers.
The Trust also plays a major role in teaching. Over
20% of all UK orthopaedic surgeons receive
training at the RNOH. Our patients benefit from a
team of highly specialised consultants, many of
whom are nationally and internationally recognised
for their expertise.
We enhance our clinical effectiveness by working
in partnership with University College London
(UCL) and in particular UCL’s Institute of
Orthopaedic and Musculoskeletal Science (IOMS),
based on the Stanmore campus. The IOMS,
together with the RNOH, has a long track record of
innovative research leading to new devices and
treatments for some of the most complex
orthopaedic and musculoskeletal conditions.
Patient video guide: Outpatients Bolsover
2. Expanding the evidence base that we deliver
high quality clinical services – providing clinical
activity to a standard that demonstrates
services are safe, effective and provide the
best possible experience. This includes timely
referral to treatment, access to services and
transport accessibility to our sites for patients,
many of whom will have significant mobility
impairment.
3. Building academic strength – working in
partnership with UCL, a world leading
university and the UCL Partners Academic
Health Sciences Network.
Our strategic aims & objectives:
1. Maintaining and developing orthopaedic
specialisation - providing the scale and range
of tertiary sub-specialist orthopaedic clinical
activity befitting an international orthopaedic
centre of excellence.
4. Expanding our external profile and focus –
building an international reputation for
clinical, operational and academic expertise
supported by working in partnership with
other NHS and independent health care
providers.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
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1.2 About the Trust
Our Trust Values guide us in
delivering the highest
standards in patient care. They
underpin our behaviours and
strengthen our relationships
with each other.
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The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
1.2 About the Trust
Patients first, always
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Protecting patients’ rights to courtesy and
dignity
Treating patients as individuals and with
compassion
Responding to patients’ needs and expectations
Providing a clinically safe environment
Achieving positive clinical outcomes
Rigorous monitoring and maintenance of high
standard
Trust, honesty and
respect, for each other
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l
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Challenging inappropriate behaviour from
patients or colleagues
Being transparent and open with each other
Asking for help when we need to
Contributing to the team
Being constructive rather than blaming
Listening more than telling
Maintaining confidentiality for patients and
colleagues
Speaking well of, and supporting each other
Empowering staff to achieve their potential
Excellence, in all we do
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Practice based on evidence, education and
research
Working across departments and professional
boundaries to achieve Trust-wide goals and
targets
Rewarding and celebrating excellence
Maximising the benefits of partnerships
Paying attention to detail
Striving for excellence through collaboration
and research
Equality, for all
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Reaping the benefits of diversity
Ensuring equitable care for all our patients
Designing services to meet the needs of all our
patient groups
Challenging prejudice and discrimination
Valuing the diversity of ideas, roles and
backgrounds
Ensuring fair and consistent employment
practice
Celebrating difference and achievement at all
levels of the Trust
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
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1.3 About the Quality Account 2014-15
About the Quality Account 2014-15
1.3.1 What is the Quality Account?
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A Quality Account is a report about the quality of
services by an NHS healthcare provider. Each year,
NHS healthcare providers are required to publish a
Quality Account. The report is an important way
for local NHS services to report on the quality of
care provided and demonstrate improvements in
care to local communities and stakeholders.
RNOH is committed to continuously improve the
quality of the services we provide to patients.
Within the Quality Account, we aim to make the
following information available to patients, public
and stakeholders:
• Our quality priorities for the next year
(2015/16);
• How we have performed against our quality
priorities for the current year (2014/15);
• How we have performed against national
quality indicators for patient safety, clinical
effectiveness and patient experience;
• How we have performed against local quality
measures and targets, as agreed with local
commissioners;
• How we will ensure that RNOH maintains
continuous quality improvements
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
1.3 About the Quality Account 2014-15
1.3.2 Who has been involved in
producing the Quality Account?
The Quality Account has been developed by the
Trust with input and involvement from a range of
stakeholders, patients and the public. This has
included:
• Consultation on the Trust website, seeking
views on proposed quality priorities;
• Presentation and discussion of draft quality
priorities and Quality Account narrative with
the RNOH Patient Group;
• Discussion of our quality priorities with
commissioners through the Clinical Quality
Review Group (CQRG) and Barnet Clinical
Commissioning Group (CCG) Clinical Quality
Committee.
• Presentation of draft and final Quality Account
to our local Healthwatch
and Local Health Boards
across England, Wales,
Scotland and Ireland
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
13
Part 2: Priorities for improvement and statements of assurance from the Board
Priorities for
improvement
and statements
of assurance from
the Board
2.1 Quality Priorities in 2015/16
The quality priorities set by the Trust for 2015/16
focuses on continuous improvement in some key
areas. The development and agreement of the
priorities have been informed by staff, patients and
the public.
The table right summarises the areas of focus for
2015/16 and the alignment to the 3 domains of
Quality:
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The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
Part 2: Priorities for improvement and statements of assurance from the Board
Clinical
Effectiveness
Quality Priority
Reduction of pressure ulcers
Reduction of surgical site infections
3
Robust processes for learning from
incidents and complaints
Reduction in serious incidents
and never events
Focus on staff culture, values
and behaviours
3
Patient
Safety
Patient
Experience
3
3
3
3
3
3
3
3
3
3
2.1.1 Priority 1 - Reduction of pressure
ulcers
2.1.2 Priority 2 – Reduction of surgical
site infections
To reduce hospital acquired pressure ulcers (HAPUs)
to below the benchmark of specialist acute
providers by March 2016.
To reduce surgical site infections to below the
national average, for all types of surgical procedure
undertaken at the RNOH by March 2016.
Why
Pressure ulcers, which are often preventable, have
a significant impact on the recovery of patients,
may lead to prolonged periods of unnecessary
treatment either in hospital or the community and
cause anxiety and distress for the patients involved.
Why
Infections following surgery lead to delays in
recovery for patients, extended length of stay in
hospital, additional use of antibiotics and cause
anxiety for the patients involved.
How we will monitor this
We will benchmark the number of HAPUs in
specialist hospitals that treat similar types of
patients to the RNOH and will aim to reduce the
number of pressure ulcers acquired within the trust
to below this number. Actions will be coordinated
through a task force and progress will be
monitored via the trust balanced scorecard at the
Board of Directors on a monthly basis.
How we will monitor this
We will extend our surgical site infection
monitoring to beyond what is expected of us to
include all surgical procedures undertaken within
the trust. We will benchmark infection rates
nationally and will aim to reduce the number of
infections acquired within the trust to below this
number. Progress will be monitored via the trust
balanced scorecard at the Board of Directors on a
monthly basis.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
15
Part 2: Priorities for improvement and statements of assurance from the Board
2.1.3 Priority 3 – Robust processes for
learning from incidents and
complaints
To embed robust processes for learning from
incidents and complaints.
Why
RNOH is committed to working towards being the
safest specialist provider in the NHS. A key element
of this commitment is learning from feedback we
receive from patients and their families and incidents
where harm has occurred. Such learning is essential
for improvement in care processes and prevention of
similar issues occurring in the future.
How will be monitor this
We will commission an internal audit to review our
current processes and use this as a baseline to
measure improvement against. Progress with
improvement will be monitored via the trusts Clinical
Quality and Governance Committee, which will
include a re-audit of progress in March 2016.
2.1.4 Priority 4 – Reduction in serious
incidents and never events
To reduce the number of serious incidents and never
events that occur within the Trust to below the
benchmark of specialist acute providers by March
2016.
Why
Incidents of harm have a significant impact on
patients across the NHS. Patients often have
extended hospital stays, unnecessary treatment and
increased anxiety when harm occurs.
16
How we will monitor this
We will benchmark the number of harm events in
comparable specialist providers and aim to reduce
the number of events within the trust to below this
level by March 2016. Progress with this metric will be
monitored via the trusts balanced scorecard at the
Board of Directors meeting on a monthly basis.
2.1.5 Priority 5 – Focus on staff culture,
values and behaviours
To focus on culture, values and behaviours for all
staff.
Why
The quality of care that we provide for our patients is
dependent upon the staff who provide it. We are
committed to developing a culture in which staff
communicate effectively with patients and each
other, are supported and feel empowered to speak
up when things go wrong and where the values of
the Trust are evident in everything we do.
How we will monitor this
We will develop a report that will be presented
quarterly to the Workforce and Organisational
Development Committee and will monitor this
priority using the following information:
• National Staff Survey data
• Staff ‘Pulse’ Surveys
• Staff Engagement Action Plan
• Exit Interview data
• Speak In Confidence data
• Value-based Game data
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
Part 2: Priorities for improvement and statements of assurance from the Board
2.2 Statements of assurance
2.2.1 Review of services
During 2014/15, the RNOH provided 21 NHS
services. The RNOH has reviewed all the data
available to them on the quality of care in all of these
NHS services.
The 21 clinical services provided by the RNOH are:
• Anaesthesia
• Bone Infection Unit
• Clinical Neurophysiology
• Foot and Ankle
• Functional Assessment and Restoration (FARs)
• Histopathology and Pathology
• Integrated Back Unit
• Joint Reconstruction
• London Sarcoma Unit
• London Spinal Cord Injury Centre
• Orthopaedic Medicine
• Orthotics and Prosthetics
• Paediatric and Adolescents
• Pain Management Services
• Peripheral Nerve Injury Unit
• Plastics
• Radiology
• Rehabilitation and Therapy
• Shoulder and Upper Limb
• Spinal Surgical Unit
• Urology
Patient video guide: Diagnostics - MRI
Patient video guide: Diagnostics - CT
Patient video guide: Diagnostics - Ultrasound
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
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Part 2: Priorities for improvement and statements of assurance from the Board
2.2.2 Participation in clinical audits
During 2014/15, there was one national clinical audit
and three national confidential enquiries that were
applicable to the NHS services provided by the
RNOH. The Trust participated in all (100%) of these.
The national clinical audits and national confidential
enquiries that RNOH participated in are listed in the
table below. Where relevant, the data submitted
from the Trust is also detailed.
The Trust continues to contribute to the National
Joint Registry (NJR). The compliance rate for
submission of Hip and Knee operations was 79% (to
September 2014). Further work is being undertaken
to ensure that this is improved retrospectively for
year-ending 2014/15 with a revised process to be
developed to ensure future compliance is in
alignment with the benchmark figure of 95%.
The Trust reviewed the report from the National
Confidential Enquiry into tracheostomy care
(NCEPOD, Tracheostomy Care: On the Right Trach?,
2014). As a result, a policy and training programme
for tracheostomy care developed and appointment
of a nominated tracheostomy nurse within the High
Dependency Unit.
In 2014/15, the Trust has also continued its
programme for local clinical audit. The Trust’s Clinical
Quality & Governance Committee is responsible for
reviewing audits of clinical areas and for ensuring
that risks are managed through implementation of
agreed actions to maintain high quality care. Areas
of care delivery where clinical audit has been used as
National clinical audits and
National Confidential Enquiries
Number of cases
required by
the audit
Percentage
submitted
National Joint Registry: Hip, Knee
and Ankle Replacements
Benchmark figure
of 95% of activity
79%
(October 2013
- September 2014)1
National Confidential Enquiry
- SEPSIS
N/a – An organisational questionnaire
was submitted
National Confidential Enquiry
- Gastrointestinal Haemorrhage
N/a – An organisational questionnaire
was submitted
National Confidential Enquiry
- Tracheostomy Care
N/a – An organisational questionnaire
was submitted
(as reported on HES)
National Joint Registry. As at May 2015, the Trust is retrospectively submitting data to NJR
to improve the compliance.
1
18
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
Part 2: Priorities for improvement and statements of assurance from the Board
a quality improvement tool in the Trust are detailed
in the table below:
In 2015/16, the Trust will continue to deploy clinical
audits to identify and deliver quality improvement
opportunities. In particular, there will be a focus on
nursing-led audits to highlight accurate completion
of national patient safety issues including; pressure
ulcers, nutrition, urinary catheters and fall
assessments.
Audit
Recommendations for quality improvement
World Health Organisation
(WHO) Surgical Safety
Checklist Audit
To perform monthly audits to ensure correct
documentation completed at point of surgery and to
combine/revise the checklist for imaging interventional
procedures and theatre procedures.
Flagging of Vulnerable
Children Audit
Safeguarding Children Co-ordinators post developed,
central database maintained, flagging of vulnerable
children policy and procedure developed and weekly
safeguarding Multi-Disciplinary team meeting to discuss
vulnerable children implemented.
Transport of Medical Records
to Imaging Audit
Monthly monitoring to ensure medical records are
available at point of intervention within Imaging
Department.
Resuscitation Equipment Audit
Monthly checking of resuscitation equipment audit,
process/procedure developed and embedded across
all inpatient wards.
Amendment of policy and risk assessment form and
equipment purchased on the wards to decrease the
chances of patients falling including a helping hand
grabber, call bell pendants and alarmed seating pads
for patient chairs.
Falls Audit
Nutritional Assessment Audit
Nutrition information folder developed for each ward,
long stay weight chart developed and training provided
for any low complying results.
“Hello My Name Is” Audit
Display visible named nurse photo boards across
inpatient wards and within outpatients.
National Early Warning System
(NEWS) Audit
NEWs audit assessment form reviewed and implemented
across wards and training program provided for staff.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
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Part 2: Priorities for improvement and statements of assurance from the Board
2.2.3 Participation in clinical research
The number of patients receiving NHS services
provided or sub-contracted by The Royal National
Orthopaedic NHS Trust in 2014/15 that were
recruited during that period to participate in research
approved by a research ethics committee was 481
into National Institute for Health Research (NIHR)
Portfolio studies, and 175 into non-Portfolio studies.
Our NIHR Portfolio recruitment exceeded our target
agreed with the North Thames Local Clinical
Research Network (LCRN).
Participation in clinical research demonstrates The
Royal National Orthopaedic Hospital NHS Trust’s
commitment to improving the quality of care we
offer and to making our contribution to wider health
improvement. Our clinical staff stay abreast of the
latest possible treatment possibilities and active
participation in research leads to successful patient
outcomes.
The Royal National Orthopaedic Hospital NHS Trust
was involved in conducting 63 clinical research
studies of which 26 were initiated in 2014/15 in the
neuro- musculoskeletal specialities.
The improvement in patient health outcomes in The
Royal National Orthopaedic Hospital NHS Trust
demonstrates that a commitment to clinical research
leads to better treatments for patients.
There were over 100 members of clinical staff
participating in research approved by a national
research ethics committee at The Royal National
Orthopaedic Hospital NHS Trust. These staff
participated in research covering neuro-
20
musculoskeletal specialities, across different aspects
of care provided to our patients.
Our engagement with clinical research also
demonstrates The Royal National Orthopaedic
Hospital NHS Trust commitment to testing the latest
medical treatments and techniques.
The Royal National Orthopaedic Hospital NHS Trust
continues to work with academic as well as industry
partners on developing novel ideas for diagnostics
and treatment of neuro-musculoskeletal conditions.
Several successful collaborative grants were received
during the past year, which further demonstrate our
commitment to our aims.
Case study 1: TARVA trial
TARVA - Total Ankle Replacement Versus
Arthrodesis trial is being led from the RNOH.
The study compares total ankle replacement
(TAR) and arthrodesis (fusion) surgery in NHS
patients aged 50-85 with end-stage ankle
arthritis.
The trial aims to establish, which treatment is
better for patients and more cost effective.
The results will provide high quality evidence
to help patients and their surgeons to choose
between the two procedures, and inform
commissioning decisions in the NHS.
The trial is funded by the NIHR the Health
Technology Assessment (HTA) and aims to
recruit 238 patients across more than 15 sites
across the UK. 3 centres are now opened to
recruitment.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
Part 2: Priorities for improvement and statements of assurance from the Board
Case study 2: DAISY Project
The DAISY Project is being sponsored jointly
by RNOH and University College London.
For many people with a cervical spinal cord
injury, eating and drinking is an added
challenge to their recovery. The DAISY Project
aims to highlight these problems by
developing a screening tool that improves the
identification and management of
swallowing problems, ensuring a successful
return to eating and drinking. The project will
contribute to improvement in clinical practice
as well as delivering improved outcomes for
patients.
Patient video guide: Diagnostics - Foot and ankle
The planned completion date for developing
the screening tool is February 2017.
Patient video guide: Diagnostics - Foot and ankle pathway
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
21
Part 2: Priorities for improvement and statements of assurance from the Board
2.2.4 Use of the CQUIN payment
framework
Commissioning for Quality and Innovation (CQUIN)
is a payment framework, which allows
commissioners to agree payments to hospitals based
on agreed improvement work. Through discussions
with our commissioners – Barnet CCG (acting as
host commissioner on behalf of all CCGs) and NHS
England - we agreed a number of improvement
goals for 2014/15, which reflect areas of
improvement for the Trust.
A proportion of the RNOH’s income in 2014/15 was
conditional on achieving quality improvement and
innovation goals as described in the CQUINs. For
2014/15, this figure was £2.6m which represented
2.3% of the Trust’s total income from NHS provided
services.
The table right shows the agreed CQUIN objectives
and associated financial incentives for 2014/15:
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The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
Part 2: Priorities for improvement and statements of assurance from the Board
CQUIN
Value (£)
Objectives
Implementation of the Friends
& Family Test
Increased response rate to the
Friends & Family Test
Implementation of the Friends
& Family Test for staff
3
l
Reduction of Urinary Tract
Infections (UTIs), in line with
national guidance
3
l
Strengthened clinical
leadership of dementia
training across the Trust
Supporting carers with
Dementia
3
l
Reduction in the rate of
infections post-surgery
3
l
Reduce the number of falls
with and without harms within
the inpatient areas of hospital
3
l
Reduction in number of
grade 2 pressure ulcers
acquired within RNOH
inpatient areas
l
Friends and
Family Test
£570,000
l
l
NHS Safety
Thermometer
£304,000
£176,000
Dementia
l
Reduction in
Surgical Site
Infections
Reduction in falls
£237,000
£276,000
Reduction in
grade 2 pressure
ulcers
£237,000
Prevention
including smoking
and alcohol
£316,000
Primary malignant
bone tumour
£98,000
Patient held records
£98,000
for cancer
Development of
orthopaedic
network
£147,000
Spinal Cord Injury
dashboard
£98,000
Met/Not Met
Partially met*
l
Signposting information on
smoking and alcohol
prevention
3
l
Audit and workshop for
primary malignant bone
tumour
3
l
Audit of patient records
3
l
Development of network as a
result of Getting it Right First
Time (GIRFT)
3
l
Embedding and using a clinical
dashboard for spinal cord
injuries
3
Total CQUIN payments as agreed with commissioners: £2.6m
*The Trust met its targets to reduce grade 2 pressure ulcers in the first half of the year. There is
continuing work to ensure that further improvements are made in 2015/16
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
23
Part 2: Priorities for improvement and statements of assurance from the Board
2.2.5 CQC registration and compliance
The Care Quality Commission (CQC) monitors,
inspects and regulates health and social care services
in England to ensure they meet fundamental
standards of quality and safety. Performance ratings
and findings from the CQC on the quality and safety
of services are published regularly. The CQC ask a
number of key questions to inform their view on the
quality and safety of services:
• Are they safe?
• Are they effective?
• Are they caring?
• Are they responsive to people’s needs?
• Are they well-led?
All NHS hospitals are required to be registered with
the CQC in order to provide services and are
required to maintain high quality care in order to
retain their registration. RNOH is required to register
with the CQC and its current registration status is
‘without conditions’.
RNOH was inspected by the CQC in May 2014, with
subsequent inspection report published in August
2014. RNOH was one of the first specialist Trusts to
be inspected under CQC’s new inspection approach.
Overall, the Trust was rated as ‘Requires
improvement’. The ratings for each of the Trust’s
service areas are shown below.
In response to the CQC inspection report, the Trust
has had in place an action plan to address the
conclusions reported by the CQC. This includes the
following:
• Addressing the layout and design of the
Stanmore site, ensuring it is suitable for all
service users;
• Reducing late starts in clinic times within the
Outpatients department;
• Implementing improved processes and
governance systems for managing risk and
patient safety;
• Ensuring there are increased and improved
mechanisms for learning from incidents;
• Focusing on shifting culture, values and
behaviours of all staff;
• Improving compliance with the WHO surgical
safety checklist for surgery and radiology;
Overall rating for this hospital
Medical care
24
Requires improvement
Outstanding
Surgery
Good
Critical care
Good
Services for children and young people
Requires improvement
Outpatients
Requires improvement
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
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l
l
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Part 2: Priorities for improvement and statements of assurance from the Board
• Ensuring that paediatric resuscitation equipment
is checked regularly;
• Ensuring that staff who treat children are up to
date with safeguarding training;
• Ensuring that the needs of children and young
people are considered in scheduling of
operations.
RNOH has made good progress in implementing the
actions to address these issues. The major
achievements and outcomes are as follows:
• Remedial works to the site at Stanmore have
continued throughout 2014/15, this includes
building of a new theatre and addressing
backlog maintenance. The outline business case
for the next major phase of the rebuild of the
hospital at Stanmore has been unconditionally
approved by the Trust Development Authority
(TDA) in March 2015. This means that the Trust
is now able to take plans to a final stage for a
hospital in which we continue to deliver high
quality clinical care in wards and buildings that
are fit for purpose.
• Late starts in Outpatient clinic times have been
reduced. Since the inspection, an average of
94.05% of clinics have started on time
compared to 91% in May 2014. New key
performance indicators (KPIs) relating to the
start times of clinics have been introduced and
are monitored as part of the overall performance
for the Outpatient department.
• Development of a new risk management
structure across the Trust.
• Continued work to improve learning from
incidents across the Trust.
• Continued work on organisational development
programme to improve the culture and values
across all staff.
• Compliance with the WHO surgical safety
checklist has improved since the time of CQC
inspection with current WHO checklist
compliance at 99% as at March 2015.
• Regular audits on paediatric resuscitation
equipment have shown improved frequency and
compliance of equipment checking. Trust-wide
resus trolley checking procedure in place.
• Increased percentage of staff up to date with
safeguarding children training.
• Improved processes in place to ensure children
are scheduled first for operations, significantly
decreased occasions where children are not
scheduled first.
2.2.6 Data quality and information
governance
NHS Number and General Medical Practice
Code Validity
RNOH submitted records during 2014/15 to the
Secondary Uses service for inclusion in the Hospital
Episode Statistics which are included in the latest
published data. The percentage of records in the
published data which included the patient’s valid
NHS number was:
• 98.8% for admitted patient care
• 99.3% for outpatient care.
The percentage of records in the published data
which included the patient’s valid general medical
practice code was:
• 100% for admitted patient care
• 100% for outpatient care
Information Governance Toolkit attainment levels
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
25
Part 2: Priorities for improvement and statements of assurance from the Board
Information Governance (IG) assesses the way
organisations ‘process’ or handle information. It
covers personal information (i.e. that relates to
patients/service users and employees) and corporate
information (e.g. financial records). IG provides a
way for employees to deal consistently with the
many different rules about how information is
handled, including those set out in:
• The Data Protection Act 1998
• The common law duty of confidentiality
• The Confidentiality NHS Code of Practice
• The NHS Care Record Guarantee for England
• The Social Care Record Guarantee for England
• The international information security standard:
ISO/IEC 27002: 2005
• The Information Security NHS Code of Practice
• The Records Management NHS Code of Practice
• The Freedom of Information Act 2000
The Information Governance Assessment overall
score for 2014/15 was 73% and was graded
“Satisfactory – Green”. The Trust scored level 2 or
above for all 45 requirements.
Clinical coding error rate
RNOH commissioned an independent clinical coding
audit in December 2014. The aim of this audit was
to assess the quality and consistency of clinical
coding at the Trust and make any necessary
recommendations for improvement of quality and
processes.
The results of the audit are included in the table
below. The number in brackets refers to the results
of the previous year.
The quality and consistency of the coding in this
sample (of 200 Finished Consultant Episodes) was
found to be excellent. In the case of the primary and
secondary diagnosis and primary procedure an
improvement was shown on the previous year,
clearly demonstrating the Trust’s on-going
commitment to supporting the Clinical Coding
Department and Data Quality.
Number
of
FCEs
Primary
Diagnosis
Accuracy
Secondary
Diagnosis
Accuracy
Primary
Procedure
Accuracy
Secondary
Procedure
Accuracy
Episodes
Changing
HRG
200
(180)
99.5%
(98.3%)
97.3%
(95.6%)
100.0%
(99.4%)
99.5%
(99.5%)
1.7%
(1.7%)
Source: RNOH, Information Governance Clinical Coding Audit Report, December 2014
26
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
Part 3: Review of quality performance
Review of quality
performance
3.1 Progress on delivering Quality
Priorities in 2014/15
3.1.1 Priority 1: To strengthen and embed
good, robust safeguarding practices
During 2014/15, the CQC identified areas in adult
safeguarding for improvement across the Trust.
Work in this area has also been informed by the
Orchid View and the Winterbourne View serious
case reviews.
• A new pathway for the admission of people
with learning disabilities
• An increased number of Adult Safeguarding
training days and updates delivered by the
Adult Safeguarding Clinical Nurse Specialist
• Development of a comprehensive safeguarding
annual audit plan to provide ongoing
monitoring.
Improvements and outcomes for safeguarding that
have been delivered include:
• The profile of adult safeguarding has been
raised which has led to an increase in the
number of complex adult safeguarding cases
which have been identified.
• An increased number of staff at all levels being
trained in adult safeguarding
• Staff have reported that they are feeling more
confident in raising adult safeguarding
concerns.
"
Key areas of focus to embed more robust
safeguarding practices across the Trust have
included:
• The establishment of Safeguarding
Committees for children and adults with new
terms of reference, functions and purpose.
• An updated adult safeguarding policy and flow
chart displayed in all clinical areas,
accompanied with training sessions from the
Trust’s Safeguarding nurse.
• Updated policies in Children’s Safeguarding,
Mental Capacity Act (MCA) and Deprivation of
Liberties Safeguarding (DoLS), reflecting best
practice.
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The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
27
Part 3: Review of quality performance
3.1.2 Priority 2: Implementation of the
6Cs Nursing Strategy
In 2014/15 we have continued to implement the 6C’s
National Nursing Strategy to give our patients the
assurance that not only nurses within the Trust but all
staff employed by us will provide safe, compassionate
care to all our patients with the aim of improving
their experience when accessing our services.
Patient video guide: The 6C’s
Following a planned programme of engagement and
representation from a wide variety of departments in
the Trust we celebrated the official Launch of the 6C’s
on October 2014. We welcomed our guest speaker
Marie Batey from NHS England.
We have now entered Phase two embedding the
6C’s process within the organisation. We are
working with areas such as HR, Recruitment,
Complaints & Patient Advice Liaison Service (PALS)
to embed the 6C’s into our everyday working.
Examples of how this is exhibited in practice are
• Having key questions which reflect the 6C’s
in practice incorporated in the appraisal system
• Addressing core themes within complaints,
such as communication, by incorporating into
customer care training and monitoring by way
of an action plan
• Incorporating the value based game which has
been developed by Human Resources into the
recruitment process which reflects the
fundamental aspects of the Trust values and
the 6C’s
• The 15 Step Challenge proved very positive
and the feedback to areas will be incorporated
in each area with a view to repeat within the
forthcoming year.
28
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
Part 3: Review of quality performance
• The Friends and Family test feedback is very
positive, going forward a more specific
question in relation to the 6C’s will be
incorporated.
The continued roll out of phase two will continue
to be monitored through audit and the Senior
Nursing Leadership Committee.
3.1.3 Priority 3: To strengthen senior
nursing leadership
In 2014/2015 the senior nursing leadership has
been strengthened in the organisation by:
• The establishment of senior nursing leadership
committee with the formation of terms of
reference function and purpose. Chaired by
the Director of Nursing, the membership of the
committee included senior nurse at 8a and
above as well as a ward manager.
• Ensure that senior nurses completed a
programme of leadership development and
training either internal or external to the
organisation.
• Review of job roles and responsibilities
• Increased presence supporting staff in the
clinical areas through visible leadership days
Outcomes delivered in this area include:
• Increased lines of communication amongst
senior nurses in the organisation working in
different specialities
• Increased support for staff in the clinical areas
with more effective and confident leadership
styles
• Improved patient outcomes through leading by
example in the clinical areas
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
29
Part 3: Review of quality performance
3.2 Patient safety measures
3.2.1 Venous thromboembolism (VTE)
The Royal National Orthopaedic Hospital NHS Trust
has a multidisciplinary VTE Group which works to:
• Ensure that the hospital follows national
guidance on VTE and meets the requirements of
the All Party Parliamentary Thrombosis Group
• Keep VTE related policies and processes up to
date
• Implement and review mechanisms for VTE
related clinical audits
• Complete Root Cause Analysis (RCA)
investigations on all cases of VTE as nationally
recommended
• Collate and analyse data on VTE risk assessment,
prophylaxis and events including in-depth trend
analysis using RCAs findings
• Set up training and education for staff including
medical doctors, pharmacists and ward staff on
VTE prevention, recognition and treatment.
National Institute for Health and Care Excellence
(NICE) Quality Standards advise that all adult
inpatients should receive a risk assessment for VTE
on admission to hospital. Expected compliance level
nationally is 95%. In 2014/15, the Trust set itself the
target of 100% compliance. Our overall
performance in 2014/15 is 99.1%, with year on year
improvement over the last 3 years as shown below.
The graph below also shows that the incidence of
VTE has dropped at RNOH since 2012 despite
greater overall awareness of the problem and greater
case complexity. There is no evidence that we are
under-diagnosing VTE and the change is likely to
represent a real reduction in incidence.
VTE compliance and incidence
1.00%
100.00
98.00
97.00
0.60%
96.00
95.00
0.40%
94.00
93.00
0.20%
92.00
91.00
0.00%
90.00
2012-2013
2013-2014
Incidence of total VTE
% inpatients risk assessed for VTE
30
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
2014-Ongoing
Percentage of complete
VTE risk assessments
Incidence of total VTE
90.00
0.80%
Part 3: Review of quality performance
NHS Outcomes Framework Domain 5: Treating and caring for people in safe environment
and protecting them from avoidable harm
Year
2012/13
2013/14
2014/15
% patients admitted who were risk
assessed for VTE (1)
97.02
98.32
99.6
0.37%
0.23%
0.28%
Incidence in admissions with acute
spinal injury only (2)
Not
calculated
4.22%
0%
Incidence in hips & knee surgery only (2)
Not
calculated
0.48%
0.32%
VTE incidence in adults having surgical
procedures
(total VTEs in surgical cases / all surgical
admissions, excluding acute spinal injury)(2)
Data source: (1) Trust data; (2)Internal data, RNOH VTE audit, as of October 2014. There is no change in incidence
of VTE for the remaining months of 2014/15 therefore it is assumed that the incidence rate can be taken as
representative for the year.
patients
were
assessed for
life-threatening
blood clots
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
31
Part 3: Review of quality performance
3.2.2 Clostridium Difficile (C. difficile)
infection
The Royal National Orthopaedic Hospital NHS Trust
considers that the rate per 100,000 bed days of
cases of C. difficile infection is as described for the
following reasons:
• The Trust complies with Department of Health
guidance against which we report positive cases
of C diff. We submitted our data to Public Health
England and are benchmarked nationally against
other Trusts. C. difficile data is subject to external
audit for assurance purposes.
The Royal National Orthopaedic Hospital NHS Trust
has taken the following actions to reduce the
incidence of cases of C. difficile infection to improve
the quality of its services by:
• Maintaining and monitoring good infection
control practice including hand hygiene and
taking action to improve.
• Maintaining and monitoring standards of
cleanliness and taking actions to improve.
• Designated ward rounds to ensure best practice
in antibiotic prescribing and assessment and
management of patient with or at risk of C.
difficile infection
• Root cause analysis of patients who develop C
difficile in hospital to learn and improve.
The Royal National Orthopaedic Hospital NHS Trust
intends to take the following actions to reduce the
rate of incidence of C. difficile infection and to
improve the quality of its services by continued
vigilance through the above actions.
The indicator for the rate of C. difficile infection per
100,000 bed days is not applicable to specialist trusts
as outlined by NHS England in the C difficile
objectives guidance 2014/15
(http://www.england.nhs.uk/wpcontent/uploads/2014/06/c-diff-guidance-1415.pdf).
Therefore the Trust measures the number of cases
against an annual objective which is agreed with
NHS England.
The table and graph belowand right shows for the
last 3 years, the actual number of cases, the target
(“objective”) as agreed between the Trust and NHS
England.
NHS Outcomes Framework Domain 5: Treating and caring for people in safe environment
and protecting them from avoidable harm
Indicator
Number of cases
Objective
2012/13
2013/14
2014/15
11
9
3
3
3
13
Source: HSCIC
32
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
Part 3: Review of quality performance
C.diff 2012/2013 - 2014/2015
14
12
10
C.diff Infections
8
6
4
2
0
2012/2013
(T 3) (C.d 11)
2013/2014
(t 3) (C.d 9)
2014 - 2015
(t 13) (C.d 3)
Financial Year
Target
C.diff
There has been a threefold reduction in clostridium
difficile infection numbers in 2014/15 compared to
the previous two years. Ongoing actions are in place
to prevent all avoidable cases of C. difficile infection.
There has been significant work through the Trust to
embed more robust infection control around the
management of C. difficile through strengthened
staff education and training, improved monitoring of
antibiotic use, improved identification and risk
management relating to infection control, including
actions and learning from incidences of C. difficile
infection.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
33
Part 3: Review of quality performance
3.2.3 Patient safety incidents
The Royal National Orthopaedic Hospital NHS Trust
considers that the rate of patient safety incidents
reported and the number and percentage of such
incidents that resulted in severe harm or death are as
described for the following reasons:
• The Trust actively promotes an open and fair
culture that encourages the honest and timely
reporting of adverse events and near misses to
ensure learning and improvement actions are
taken.
• The Trust submits patient safety incident data to
the National Reporting Learning System (NRLS).
We are ranked against other Trusts in respect of
the rate of reporting and category of harm.
• Each incident is classified by risk from low to
high. Trends are then identified within each
category. The majority of incidents are graded as
acceptable risks, either due to the rarity of their
occurrence, the minimal harm experienced or
the control measures already in place.
• Serious incidents are investigated by a
nominated multidisciplinary team using the root
cause analysis process and action plans are
monitored via the Clinical Quality Governance
Committee and our quality review meeting with
NHS England (North Central & East London).
The Royal National Orthopaedic Hospital NHS Trust
has taken the following actions to reduce the rate of
patient safety incidents and the number and
percentage of such incidents that have resulted in
severe harm or death to improve the quality of its
services by:
• Investigating clinical incidents and serious
incidents and sharing the lessons learnt across
the Trust and ensuring recommendations are
implemented through the Directorate quality
performance meetings.
The Royal National Orthopaedic Hospital NHS Trust
intends to take the following actions to reduce the
rate of patient safety incidents and the number and
percentage of such incidents that resulted in severe
harm or death to improve the quality of its services
by:
• Continuing to actively promote reporting,
investigation of clinical incidents and serious
incidents, sharing learning across the Trust and
with our commissioners to ensure improvement
in the Trust and outside the organisation.
The graph right shows the annual trend for patient
safety incidents over the last three years.
34
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
Part 3: Review of quality performance
NHS Outcomes Framework Domain 5: Treating and caring for people in safe environment
and protecting them from avoidable harm
Indicator
Number of patient safety incidents reported1
Rate of patient safety incidents reported,
per 100 admissions (as of 14/15 per 1000
bed days)2
% incidents that resulted in severe harm or
death3
2012/13
2013/14
2014/15
812
918
1402
22.15
5.1
5.8
This indicator has
now changed to
rate of incidents
reported per 1000
bed days
0.06%
0.18%
Not
available
Source: (1) NRLS interactive analysis tool; 2014/15 figures are Trust data. (2) NRLS interactive analysis tool. 2014/15
figures are drawn from National Reporting Learning System (NRLS) Organisational Patient Safety Incident
Reports, April 2015 covering April-September 2014 only. Not available for full year 2014/15. (3) NRLS interactive
analysis tool. Not available for full year 2014/15.
Incidents reported vs % of incidents
resulting in severe harm or death
1800
10.00%
1600
8.00%
1400
1200
6.00%
1000
800
4.00%
600
400
2.00%
200
0
0.00%
2012-2013
2013-2014
2014-2015
Incidents reported
% of incidents that resulted in severe harm or death
Source: (1) Trust data; (2) NRLS
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
35
Part 3: Review of quality performance
In 2014/15, the RNOH has continued to improve its
processes for managing patient safety risks. Each
incident is classified by risk from low to high. Trends
are then identified within each category. The
majority of incidents are graded as acceptable risks,
either due to the rarity of their occurrence, the
minimal harm experienced or the control measures
already in place.
Serious incidents are investigated by a nominated
multidisciplinary team using the root cause analysis
process and action plans are monitored via the
Divisional Quality and Safety Board, the Clinical
Quality Governance Committee and the trust’s
quality review meeting with NHS North Central &
East London. The trust is currently developing new
processes to enable all staff to learn from patient
safety incidents and to ensure that the learning
results in improved risk management practices across
the trust.
In 2015/16, there will be further work undertaken to
increase the rate of incidents being reported as well
as improving the robustness and accuracy of
reporting both the volume and severity of incidents.
3.2.4 Pressure ulcers
In 2014/15, and over the last 3 years, RNOH has
seen a gradual decrease in the number of hospital
acquired pressure ulcers. There were 16 occurrences
of hospital-acquired pressure ulcers (grade 3 and 4)
reported by the Trust in 2014/15, compared to a
previous figure of 53 of all pressure ulcers in
2013/14. Although this figure represents a dramatic
reduction in hospital-acquired ulcers compared to
previous years, the reduction is also due, in part, to
36
the recent changes to the trust’s incident reporting
system to differentiate between hospital and nonhospital acquired pressure ulcers. The Trust is
continuing to work towards reducing the level of
harm associated with some of these pressure ulcers,
as well as improving the accuracy of reporting.
As of February 2015, the Trust has introduced a
Pressure Ulcer Rapid Review which looks to highlight
the cause of a pressure ulcer within 48 hours. This is
to ensure that the causes of pressure ulcers are
quickly understood and that learning can be shared
across clinical staff.
The graph right shows the monthly trend for
pressure ulcers over the last three years.
3.2.5 Medication errors
In 2014/15, there has been a significant reduction in
the number of reported medication errors. None of
the incidents reported in 2014/15 resulted in serious
harm.
A multidisciplinary medications group meets every
week to review all medication errors and make
recommendations for future practice. Where a
serious harm “near miss” incident has been
reported, a root cause analysis investigation is
undertaken.
The graph right shows the monthly trend for
medication errors over the last three years.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
Part 3: Review of quality performance
Incident of reported Pressure Ulcers
Number of Grade 3-4 Pressure Ulcers
70
60
50
40
30
20
10
0
Total
2012-2013
2013-2014
2014-2015
65
53
16
Source: Trust data
Incident of reported Medication Errors
Number of medication errors
250
200
150
100
50
0
Total
2012-2013
2013-2014
2014-2015
162
190
205
Source: Trust data
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
37
Part 3: Review of quality performance
3.2.6 Nutritional assessments
Nutritional assessments are used to monitor for the
risk of malnutrition, in this case as defined by the
NICE Quality Standard 24 ‘Quality Standard for
Nutritional Support in Adults’. At RNOH, a
malnutrition monitoring tool has been developed,
which is line with NICE recommendations. The
completion of this assessment is audited on all wards
by their management leads on a monthly basis,
below is the compliance data from the RNOH over
the last year.
To support monitoring there has been the
introduction of a “Long Stay” weight monitoring
chart to give an at-a-glance representation to
observing weight changes.
The graph right shows the compliance rate for
nutritional assessments for 2014/15:
Overall Trust wide compliance has remained
reasonably steady with each month recording scores
of over 90% compliance. The Trust overall score for
the second half of the year is 94% up from 92% in
the previous 6 months.
The Trust has also introduced the practice of the
“Red Tray” system to highlight those in need of
feeding support and also the use of an indication
magnet with the “Patient Status at a Glance”
boards. There has also been the addition of a
Diabetic Dietician post to help maintain standards of
care at ward level.
Following on from local audits performed in 2014
there has been the introduction of a Nutrition Folder
– this is a ward based folder with lots of nutrition
information, charts and the revised Malnutrition
Screening tool that also has a How to Guide on how
to complete it. This is to ensure there is education at
the ward level always available.
38
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
Part 3: Review of quality performance
Nutritional Assessment: Overall Trust Score 2014/15
100
90
80
70
Percentage
60
50
40
30
20
10
0
April
May
June
July
August
September
October
November
December
January
February
March
Month
Percentage
Trust Target
Source: Trust data, Clinical Audit Department
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
39
Part 3: Review of quality performance
3.3 Clinical effectiveness measures
3.3.1 Summary Hospital-level Mortality
Indicator (SHMI)
The measure for Summary Hospital-level Mortality
Indicator (SHMI) is not applicable to the Trust.
3.3.2 Patient Reported Outcome Measures
(PROMs)
The Royal National Orthopaedic Hospital NHS Trust
considers that the Patient Reported Outcomes
Measures (PROMs) are as described for the following
reasons:
• We introduced PROMs in 2010 for patients who
had hip and knee replacement surgery. These
measure a patient’s health gain after surgery.
The information is gathered from the patient
who completes a questionnaire before and after
surgery. The responses are analysed by an
independent company and benchmarked
against other Trusts.
The Royal National Orthopaedic Hospital NHS Trust
has taken the following actions to improve the
health gain of patient’s having hip and knee surgery
to improve the quality of its services by
• Reviewed the data with the Department of
health to compare case mix and complexity
against other specialist orthopaedic trusts.
• Implemented an electronic capture system,
Patient Outcomes Data to expand on the
PROMs questionnaire.
40
The Royal National Orthopaedic Hospital NHS Trust
has invested in an electronic Patient Outcomes Data
(POD) capture system. There is a dedicated team of
administrators collecting data from patients and
consultants on each patient visit. Currently the
following teams have data collected using the EQ5D5 Index as well as unit specific values; Foot and
Ankle, JRU- Surgical, JRU-Physio, Shoulder,
Rheumatology, Sarcoma and Pain management. This
will provide local complexity measures data in
relation to the highly specialist patients that have
their care provided by the Trust.
The Royal National Orthopaedic Hospital NHS Trust
intends to take the following actions to improve the
health gain of patient’s having hip and knee surgery
to improve the quality of its services by:
• Continuing to review and benchmark PROMs
data against other specialist orthopaedic trusts.
• Local data collection measures to set
benchmarking for levels of complexity.
Data is still under collection for 2014/15 with currently
only published data from April-September available.
The PROMs outcome data shows a marked
improvement in hip revision and primary knees year
on year. Data collection has improved and the POD
system is starting to be used to collect more data
from more departments. The Trust has begun work
on developing measures of complexity of surgery
performed by the RNOH. Going forward, there will
be a drive to have these complexity measures
collected by all surgical teams and the reporting of
PROMs within all surgical teams at a local level. This
will allow the setting of benchmarks against other
trusts as a measure of complexity.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
Part 3: Review of quality performance
NHS Outcomes Framework Domain 3: helping people to recover from episodes of ill health
or following injury
Indicator
Patient reported outcome scores (PROMs) of total health gain as
2014/15
2012/13
2013/14
(April-September
only)
Primary
0.449
0.388
0.438
Revision
0.173
0.229
0.430
Primary
0.251
0.311
0.448
Revision
0.178
0.268
Not
available
assessed by patients for elective surgical procedures
Average health gain where full health = 1
Hip replacements
Knee replacements
Patient reported outcomes for hip and knee surgery
Patient health gain measure
where 1 is full health
0.5
0.4
0.3
0.2
0.1
0
2012/13
2013/14
2014/15
Hip Primary
Hip Revision
Knee Primary
Knee Revision
0.449
0.388
0.438
0.173
0.229
0.43
0.251
0.311
0.448
0.178
0.268
Source: HSCIC. Data for 2014/15 is only available up to September 2014
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
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Part 3: Review of quality performance
3.3.3 Emergency readmissions within 28
days
The Royal National Orthopaedic Hospital NHS Trust
admitted 16318 NHS patients in 2014/15 of these
89 were emergency readmissions within 28 days of
discharge.
The Royal National Orthopaedic Hospital NHS Trust
considers that the percentage of emergency readmissions within 28 days of discharge from hospital
is as described for the following reasons:
• Every time a patient is discharged and
readmitted to hospital, staff code the episode of
care. The Information team continually monitors
and audits data quality locally and we
participate in external audit which enables the
Trust to benchmark its performance against
other Trusts.
The Royal National Orthopaedic Hospital NHS Trust
intends to take the following actions to reduce
readmissions to improve the quality of its services by:
• We will work with commissioners to put in
routine monitoring systems to monitor those
patients discharged from the Royal National
Orthopaedic Hospital NHS Trust and readmitted
to other hospitals to ensure accurate
readmission rates and appropriate clinical review
of any readmissions within 28 days.
Indicator
Percentage of emergency readmissions within
28 days of discharge from hospital of patients
i)
0 to 14 year olds
ii) 15 or over
2012/13
2013/14
2014/15
0.29%
0.20%
0.04%
0.05%
0.04%
0.50%
Source: Trust data. Does not include patients discharged from the RNOH and readmitted to other hospitals
42
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
Part 3: Review of quality performance
3.4 Patient experience measures
3.4.1 Friends and Family Test
Patient Friends & Family Test
The Friends and Family Test (FFT) is a single question
survey which asks patients whether they would
recommend the NHS service they have received to
friends and family who need similar treatment or care.
It highlights the importance of listening to patients to
ensure the delivery of safe, high quality services.
In 2014/15, RNOH has continued to implement the
FFT across clinical services. In addition to adult
inpatient services, the Trust has focussed on
implementing the FFT in Outpatients and Paediatrics.
The focus has been on embedding the process and
empowering patients to provide their responses.
The Trust has consistently achieved high response
rates and high scores in the ‘Extremely likely’ and
‘Likely’ categories for patients who would
recommend the care they have received at RNOH.
Each clinical service area reviews patient feedback
comments on a monthly basis which are made
available via the Trust’s Insight system.
The chart below shows the responses across all adult
inpatient wards of patients for the year 2014/15. The
overwhelming majority reported that they would be
‘extremely likely’ to recommend the Trust to their
friends and family. This is based on a response rate
of 50% of patients. The feedback received from the
Friends and Family Test are made available to all
wards and where negative feedback is received, this
is regularly reviewed to highlight areas of
improvement.
Recommend RNOH Wards
Extremely likely
Likely
Neither likely
or unlikely
78.8%
17.4%
2.4%
Unlikely
0.9%
Extremely unlikely 0.4%
Don’t know
0.2%
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
Source: Trust data, Clinical Audit Department
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Part 3: Review of quality performance
“
A sample of the patient feedback received through
the Friends and Family Test are included below.
“The staff are absolutely excellent. They go above and beyond, are totally
professional. the staff are very caring and always take time to ensure you are
comfortable and doing well”
“I have had 3 back operations within 2 years and I found my experience at this
hospital with staff, doctors, the surgeon and all concerned to be very polite and
helpful they go out of their way to make your stay a very good one”
“I think, even though the buildings are old looking. I really think your members of
staff give great customer service. They really take it on themselves to try and
make you feel better”
“
“I have felt very well cared for during my hip replacement, the staff were all
professional, friendly and supportive the beds were all clean very comfortable
and easily adjusted. The ward and bathrooms were clean and bright. From
admission to being discharged, the whole process was professional and caring; I
felt safe and was treated as an individual”.
44
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
Part 3: Review of quality performance
The Trust has also implemented the FFT in Paediatric
wards, alongside additional patient experience
questions. The graphs below show the responses to
these questions for the year 2014/15.
.
In 2015/16, the Trust will continue its work to ensure
that all patients are provided with the opportunity to
provide feedback on the care that they receive. The
Trust will continue to roll out the FFT to other clinical
services, in line with national guidance. This includes
extension to patient transport service.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
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Part 3: Review of quality performance
Staff Friends & Family Test
The NHS Trust considers that the percentage of staff
who would recommend the hospital to friends and
family needing care is as described for the following
reasons:
• Each year the Trust participates in the National
Staff Survey. Staff are sent a nationally agreed
questionnaire by an independent company. The
results are analysed by the Staff Survey Co
ordination Centre.
NHS Outcomes Framework Domain 4: ensuring that people have a positive experience of
care
Indicator
Staff Friends &
Family Test
Percentage of staff who
would recommend the
hospital to friends or
family needing care1
2012/13
2013/14
2014/15
National
average
in
2014/152
89%
90%
98%
76%
Highest
average
other
Trusts
2014/15
Lowest
average
other
Trusts
2014/15
99%
44%
Source: 1 Trust data from Insight; 2 NHS England, based on Q1 and Q2 2014/15 available data
In 2014/15, the staff element of the FFT was
expanded to include the question to staff “How
likely are you to recommend RNOH to friends and
family as a place to work?”. All staff are provided
with the opportunity to answer this question and
provide free-text comments at any time through the
Trust’s staff intranet. This is to ensure that, in
addition to the Annual NHS Staff Survey, the Trust is
able to gain a ‘temperature check’ of staff
satisfaction and engagement which are important
factors linked with delivery of high quality and safe
care. The results are captured and monitored
through the Trust’s internal Insight system. The chart
46
right shows the current percentages of staff who
would recommend that Trust as a place of work.
Further work will be underway in 2015/16 to ensure
that the Trust is proactively learning from feedback
from staff. The staff FFT will align with the existing
Staff Survey as a critical mechanism for
understanding the views of staff. The Trust will
regularly review the feedback, identify themes and
agree actions to be undertaken from the feedback.
Actions will be regularly monitored to ensure
improvement in the areas of concern.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
Part 3: Review of quality performance
% of staff who would recommend the hospital as a place of work
Extremely likely
Likely
Neither likely
or unlikely
58.0%
25.4%
7.1%
Unlikely
5.2%
Extremely unlikely 3.2%
Don’t know
1.0%
Source: Trust data, as at May 2015
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
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Part 3: Review of quality performance
3.4.2 Responsiveness to personal needs
The Royal National Orthopaedic Hospital NHS Trust
considers that the mean score of responsiveness to
inpatient personal needs is as described for the
following reasons:
• Each year the Trust participates in the National
Inpatient Survey. A random sample of 850
patients are sent a nationally agreed
questionnaire and the results are analysed
independently by The Patient Survey
Co-ordination Centre.
In the National Survey of Adult Inpatients (2014), the
RNOH scored ‘better’ compared with most other
hospitals, in 6 out of 10 of the applicable indicators
sections, including overall views of care and services
and overall experience. The RNOH achieved a
response rate of 54% which is above the national
average of all trusts of 47%. Right is the summary of
the section scores the RNOH achieved.
The Royal National Orthopaedic Hospital NHS Trust
has taken the following actions to improve
responsiveness to inpatient personal needs and
improve the quality of its services by:
• Training on Customer Care for all nurses
• Introduction of card with admission and
discharge information for patients.
• Displayed posters on wards displaying the
management team saying who to contact if you
need help and advice.
The Royal National Orthopaedic Hospital NHS Trust
intends to take the following actions to improve
responsiveness to inpatient personal needs and
improve the quality of its services by:
• Acuity tool, Safer Nursing Care Tool (SNCT),
being introduced.
• Introduction of Intentional Rounding in all ward
areas.
• Ensure discharge medications are prescribed well
in advance of discharge.
• Include a question on cleanliness in the Real
Time Patient Feedback
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The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
Part 3: Review of quality performance
Survey of adult inpatients 2014
Royal National Orthopaedic Hospital NHS Trust
Sections Scores
S1. The Emergency/A&E
Department (answered by
emergency patients only
S2. Waiting list and planned
admissions (answered by
those referred to hospital)
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
Better
S3. Waiting to get to a bed on
a ward
S4. The hospital and ward
Better
S5. Doctors
S6. Nurses
S8. Operations and procedures
(answered by patients who
had an operation or procedure)
Better
S7. Care and treatment
Better
S9. Leaving hospital
Better
S10. Overall views of care
and services
Better
S11. Overall experience
Source: CQC National NHS patient survey programme, Inpatient Survey 2014
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
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Part 3: Review of quality performance
3.4.3 Complaints and Patient Advisory
Liaison Service (PALS)
Complaints
During 2014/15 the Trust has received 92 formal
complaints. This is a marginal increase compared
with 2013/14 but overall a steady decrease since
2012/13, as shown in the table top right.
In 2014/15, the Trust has continued to review its
processes for responding to complaints. As a result
of the Francis Report and the Clwyd Hart Review of
the NHS Hospitals Complaints System, the Trust’s
Complaints Policy and process was reviewed. The
Clwyd-Hart report contained 38 points for action for
Trusts and other bodies. From the 38
recommendations, the Trust identified with 26 of
these. An action plan has been put in place and 13
recommendations from the 26 have been delivered.
13 recommendations are in active progress and
within the timescale set.
responsive and accessible service through email,
telephone contact and face-to-face interaction,
providing patients, relatives and carers with
information about the hospital services. Contacts
through PALS are not necessarily a concern or
problem but can be an enquiry. Each contact is
assessed individually and proactive measures are
taken to assist as efficiently and effectively as
possible.
The PALS team started recording type of contact
from August 2014 in order to monitor usage of the
service. The majority of contacts are concerns which
are managed efficiently and within a short timescale.
The breakdown of the type of contacts received is
shown in the graph bottom right.
The Complaints department continues to manage
incoming complaints in a pro-active manner. Time
scales for investigations vary depending on the
complexity of the complaint. We continue to aim for
resolution in 25 working days; however local
resolution meetings at an earlier stage in the
complaint process have shown to be effective. The
Trust follows the Principles of Remedy - getting it
right, being customer focussed, being open and
accountable, acting fairly and proportionately,
putting things right and seeking continuous
improvement.
In 2014/15, the Trust has continued to provide a
responsive PALS service which seeks to provide a
50
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Complaints received
by the Trust, 2014/15
Total number of complaints
2012/13
2013/14
2014/15
135
91
92
Clinical Treatment (24%)
Appointment, Admission
& Discharge (20%)
Staff Attitude (17%)
Top Three Categories for complaints – 2014/15
Patient Advisory Liaison Service (PALS)
PALS contacts received
by the Trust
2012/13
2013/14
2014/15
Total number of PALS contacts
1229
1367
1497
PALS contacts by type -2014/15
80
60
40
20
0
August
2014
September
2014
October
2014
Concern
Positive Comment
External Enquiry
Service User Enquiry
November
2014
December
2014
January
2015
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
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Part 3: Review of quality performance
3.5 Maintaining continuous
quality improvement at RNOH
3.5.1 Specialist Orthopaedic Alliance
The Specialist Orthopaedic Alliance has been formed
by a group of specialist centres dedicated to
providing orthopaedic services, ranging from the
straightforward to the highly specialised, to patients
across the UK. These centres, based at Trusts around
the country, are at the leading edge of best practice
in medicine and conduct internationally recognised
training and research. They not only provide services
to patients, but are also responsible for training
many of the UK’s orthopaedic surgeons and other
specialist staff including, for example,
physiotherapists. They provide essential clinical
training, leadership and research.
Their reputation means they take referrals from
across the UK and also receive private referrals from
across the world. Specialist orthopaedic centres have
developed a high degree of competence and clinical
effectiveness for routine orthopaedic treatments and
highly specialised complex procedures.
The nature of the specialist centres brings together
some key components that enable development of
procedures which other hospitals are unable to
undertake.
These Trusts provide specialist services not routinely
provided elsewhere, including:
• The treatment of primary malignant bone
52
tumours and chronic bone infections for which
the only other option would be amputation
• Complex disorders such as spinal deformity and
developmental dysplasia of the hip
• Each of the centres undertakes more than 1,000
hip and knee procedures every year and they
specialise in joint replacement
• Specialist paediatric rheumatology services
3.5.2 Organisational Development
Programme
The RNOH continues to maintain its reputation for
recruiting and developing high quality, specialist staff.
To support this, the RNOH’s organisation
development strategy was agreed by the
organisation in 2012/13 and the strategy has just
completed its second year of implementation. The
strategy is a planned and systematic approach to
enabling sustained organisational performance
through the development, involvement and
engagement of staff. Examples of the strategy that
are already in practice are:
• A range of projects that ensure sustainable
improvements in the staff culture and behaviour
by embedding the Trust’s values including:
• Value-based Game
• Value-based Staff Achievement Awards
• Value-based Induction
• Value-based Appraisals
• Tackling concerns regarding bullying and
harassment head on with projects including:
• Bullying and harassment guidance for all
staff
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
Part 3: Review of quality performance
• Bullying and harassment training for all staff
• Updated Exit Interview processes
• Develop metrics that will enable the Trust and
more specifically the Board to monitor the
culture of the organisation and behaviours of
staff going forwards:
• Staff ‘Pulse’ Surveys
• Staff Engagement Action Plan
• Exit Interview data
• Value-based Game data
The group oversees the development of a Trustwide and Trust-owned action plan and delivery is
also monitored via that forum.
92% of staff agreed that their role makes a
difference to patients while 84% felt satisfied with
the quality of work and patient care they are able to
deliver. These results reflect the commitment of
RNOH staff to the high quality care our in-patient
survey reflects we deliver.
Staff turnover was 15%. The Trust remains
committed to reducing this in the coming year
through the use of exit interview data and staff
surveys to develop effective retention initiatives. The
Trust’s sickness absence target is 3%. The Trust’s
average sickness absence rate was 2.59%. The Trust
will be seeking to maintain a sickness absence rate
of below 3% in the coming year.
Whilst seeing improvements in areas such as training
received and appraisals undertaken by staff
(including equality and diversity training), the Trust
continues to remain significantly concerned about
the level of bullying and harassment experienced by
staff. This is an area we have focussed significantly
on in the last year and we will continue to focus on
to deliver improvements in the coming years.
The Trust’s vacancy rate is currently 10.6%. The
continuing focus on vacancy rates indicates a
stabilised position of approximately 10% which has
been a steady reduction in vacancy rate in 2014/15
to-date. This is a positive performance when
compared with other London trusts. The Trust is also
part of the ‘Streamlining Recruitment Programme’
and this has enabled the reduction in the time it
takes to recruit considerably in the last few months.
3.5.3 Nursing Strategy
Listening to our staff
The annual NHS staff survey provides a wealth of
information about staff views on working at the
Trust. The results are used to develop genuine
improvements in staff experience. As a result the
results are considered by a range of managers and
staff through the Trust’s Listening Into Action group.
The trust will develop a new nursing strategy in 2015
that will outline the trusts ambitions for the
profession through until 2018. Key stakeholders
meet in May to develop the outline plans with
publication of the strategy expected in July. Areas
that are expected to feature in the strategy include:
• A focus on improving safety and experience
for patients through nursing practice
• Development of the Centre for Orthopaedic
Nursing Research and Education in collaboration
with London Southbank University
• Developing the clinical leaders of today and for
the future
• Enhancing professional practice
• Introduction of a ward accreditation system
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
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Part 3: Review of quality performance
• Developing advanced practice roles and patient
pathways that enhance the care of patients
• Eliminating waste and working together to
achieve financial stability
3.5.4 Quality Strategy
The Trust launched the Quality Strategy and Quality
Ambitions in 2013/14. Work has continued
throughout 2014/15 to deliver against the Quality
ambitions and goals as listed below.
Our Quality Ambitions:
• To deliver safe and appropriate evidence based
care to all our patients, to ensure the best
possible clinical outcomes and overall patient
experience. The partnerships between those
delivering services and patients and carers will
respect individual needs and values and
demonstrate compassion continuity, clear
communication and shared decision-making.
• A zero harm culture for the healthcare patients
receive, and that they are cared for in an
appropriate, clean and safe environment at all
times.
• The most appropriate treatments, interventions,
support and services will be provided at the right
time to everyone who will benefit, with no
wasteful or harmful variation.
Our Quality Goals
• Staff, patients and public are confident that the
Royal National Orthopaedic Hospital NHS Trust is
reliably and consistently safe, effective and
responsive to their needs.
• Everyone working at the Royal National
Orthopaedic Hospital NHS Trust is confident that
they are supported to do what they came in to
54
the NHS to do, and that they are valued for
doing that.
• To have a shared pride in the Royal National
Orthopaedic Hospital NHS Trust and recognition
that it is amongst the best providers of
healthcare in the world.
Further work will be undertaken in 2015/16 to
refresh the Trust’s Quality Strategy and this will align
to the new Nursing Strategy. The RNOH will remain
ambitious in continually improving the excellent and
world-class care that is provided. This includes
setting of internal targets for continuous
improvement as well as further work to understand
and improve the effectiveness and efficiency of
management of patients with highly complex needs.
3.5.5. Collaborative working with
academic partners and contribution
to the Academic Health Sciences
Network
The RNOH has agreed to develop, in partnership
with London Southbank University, the Centre for
Orthopaedic Nursing Research and Education. The
centre will be the first of its type in the UK and the
vision of the partners will be for it to make a major
contribution to post graduate nursing education and
be a centre of excellence for orthopaedic nursing
research. 2015/16 will see further development of
the centre and the development of an integrated
nursing research and education strategy.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
Part 3: Review of quality performance
3.5.6 Continuing focus on quality
improvement in operational
performance
In line with national guidance the Trust is committed
to improving quality and to this end agreed a series
of CQUIN schemes in conjunction with
Commissioners during 2014/15.
Once agreed the schemes are cascaded down form
Directors to operational and clinical leads who are
responsible for the delivery of the CQUIN schemes.
Progress towards achievement of the schemes is
monitored quarterly at the appropriate subcommittee of the Trust Board and discussed and
agreed with commissioners at monthly contract
review meetings.
The Trust also has an agreed set of Clinical
performance indicators which form the basis of its
contracts with commissioners and are monitored at
monthly contract review meetings. The Trust’s
internal Balanced Scorecard includes additional KPIs
and is reviewed monthly by the RNOH Trust Board
sub-committee.
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
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Part 3: Review of quality performance
3.6 Statements from external
stakeholders
3.6.1 Statement of assurance from Barnet
Clinical Commissioning Group (CCG)
Barnet CCG has been the lead commissioner of services from The Royal National Orthopaedic Hospital
(RNOH) in Stanmore, Middlesex during 2014/15. Lead commissioning arrangements were handed over
to NHS England at the end of 2014/15 and a quality assurance process around clinical due diligence
was completed by the CCG in preparation for this and accepted by NHS England. Barnet CCG remains
the lead for non-specialised commissioning on behalf of the London boroughs.
Barnet CCG supported by North East London Commissioning Support Unit has reviewed and is pleased
to assure the 2014/15 Quality Account for The Royal National Orthopaedic Hospital. The Quality
Account was discussed and presented by the trust at Barnet CCGs’ Clinical Quality and Risk Committee
Meeting in April 2015 and the trust have redrafted the Quality Account based on initial feedback from
the CCG.
The Accounts provides a comprehensive summary of the work done by the Trust in 2014/15 to
enhance and improve their services to patients.
Following a Care Quality Commission (CQC) inspection in 2014, the trust implemented an action plan
to address the key areas that were found to require improvement as a result of the inspection and
these are clearly defined in the Quality Account. Barnet CCG acknowledged and supported the
comments made by the CQC, regarding the excellent standard of care provided by the trust in its
specialist clinical services.
There have been four never events reported by the Trust in interventional radiology since July 2013,
two of which occurred during 2014/15 but we recognise the ongoing work to ensure that learning
from these events is widely disseminated among clinical and medical staff, with the review of internal
processes and external support to eliminate these. In response to the ‘never events’ Barnet CCG quality
leads have worked closely with trust leads and the Trust Development Authority, to support the
required improvements to quality, conducting walkthroughs the radiology service to gain further
assurance on the safety of patients.
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The CCG acknowledges the work that trust has undertaken during the year to reduce their challenges
around infection control, specifically in the reduction of Clostridium difficile and surgical site infections.
The CCG support the planned changes to further improve outcomes for infection control.
The CCG support the Quality Priorities the trust has set for 2015/16 in the following areas:
• Reduction of pressure ulcers
• Reduction of surgical site infections
• Robust process for learning from incident and complaints
• Reduction in serious incident and never events
• Focus on staff culture, values and behaviour
Commissioners were pleased to see the planned developments and priorities for 2015/16 continue to
build on the improvement work that is currently in place to improve quality, whilst being aware of
further improvements required. The improvement priorities have been clearly described and linked to
each domain for quality.
The quality priorities are relevant and meaningful for the Trust with clear outcomes identified. These
have been identified through consultation with staff and patients and key stakeholders including
Healthwatch. The CCG feel that the method for measurement and reporting of the five identified
priorities is clearly stated within the Accounts and would recommend that these continue to be
monitored through the Clinical Quality Review Group which is managed by NHS England.
Barnet CCG have enjoyed working with and supporting the trust on their continued journey to
improve patient care.
NHS Barnet Clinical Commissioning Group
June 2015
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Part 3: Review of quality performance
3.6.2 Statement of assurance from
!
Healthwatch Harrow
10th June 2015
Maggie Lam
Assistant Director of Quality Assurance & External Compliance
Royal National Orthopaedic Hospital NHS Trust
Brockley Hill
Stanmore
Middlesex
HA7 4LP
Re: RNOH Quality Accounts 2014/15
Dear Maggie
Thank you for inviting Healthwatch Harrow to make a response to RNOH QA for 2014/15.
We appreciate that Quality Account reports is an important mechanism in making sure that
RNOH is focussed continually on assessing the quality of its provision and outcomes for the
patients and communities it serves. We also welcome RNOH’s commitment to ensuring that they
are accountable to patients and the public about the quality of service they provide.
I am pleased to record that during the last year I participated and contributed to RNOH’s CQC
Action Planning meetings. This group considered and developed appropriate strategies and
action plans in response to CQC’s findings and the trust own self-assessment on areas which
would benefit from improvement. It is pleasing to note that RNOH QA is consistent and
complimentary with the strategies and operational interventions identified by the RNOH CQC
Action Planning working group. This demonstrates that RNOH has a consistent approach in its
self-assessment and in turn developing appropriate strategies for building on its strengths and
addressing areas that require improvement. Healthwatch Harrow has been invited to further add
to this process by acting as a critical friend in reviewing and assessing progress.
I am pleased to note that RNOH QA for 2014/15 shares similar levels of high quality and rigour in
identifying areas for improvement. At Healthwatch Harrow we are also pleased to note the high
ambitions you have for patient experience and care and the wider community in which you
operate.
I also found RNOH QA document to be an open and honest, acknowledging where services are
working well and where there is room for improvement and impressed with the high level of
professionalism and rigour which colleagues from RNOH have managed and developed this
process.
We look forward to working together in reviewing the preparation and assisting in assessing the
effectiveness of implementing your quality plan and the preparation of RNOH Quality Accounts in
the coming year and making sure that the voice and experience of patients and the public form
an integral part of these processes.
If you need further information please do not hesitate to contact me.
Yours sincerely
Arvind Sharma
Chair
Healthwatch Harrow
Healthwatch Harrow, Harrow in Business Advice Centre, Stanmore Place,
Howard Road (off Honeypot Lane), Stanmore, Middlesex HA7 1BT
Telephone: 020 3432 2889 info@healthwatchharrow.co.uk
www.healthwatchharrow.co.uk
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The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
Glossary
Term
Definition
AHP
Allied Healthcare Professionals
C. difficile
Clostridium difficile
CCG
Clinical Commissioning Group
CQC
Care Quality Commission
CQRG
Clinical Quality Review Group
CQUIN
Commissioning for Quality and Innovation
DoLS
Deprivation of Liberties Safeguarding
EQ5D
A standardised measure of patient reported health outcome for hip and knee operations
FARs
Functional Assessment and Restoration
FFT
Friends and Family Test
GIRFT
Getting it Right First Time programme
HAPU
Hospital Acquired Pressure Ulcers
HES
Hospital Episode Statistics
IG
Information Governance
IOMS
Institute of Orthopaedic and Musculoskeletal Science
KPI
Key performance indicators
LCRN
Local Clinical Research Network
MCA
Mental Capacity Act
MRSA
Methicillin-resistant Staphylococcus aureus
NEWS
National Early Warning System
NICE
National Institute for Health and Clinical Excellence
NIHR
National Institute for Health Research
NJR
National Joint Registry
PALS
Patient Advice Liaison Service
POD
Patient Outcomes Data
PROMs
Patient Reported Outcome Measures
RCA
Root Cause Analysis
RNOH
Royal National Orthopaedic Hospital NHS Trust
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
59
Glossary
Term
Definition
SHMI
Summary Hospital-level Mortality Indicator
SNCT
Safer Nursing Care Tool
TDA
NHS Trust Development Authority
UCL
University College London
UTI
Urinary Tract Infections
VTE
Venous Thromboembolism
WHO
World Health Organization
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The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
Appendix 1
Appendix 1: Statement of directors’
responsibilities in respect of the
Quality Accounts
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 the annual Quality Account (which
incorporates the legal requirements in the Health Act 2009 and the National Health Service (Quality Account)
Regulations 2010 (as amended by the National Health Service (Quality Account) Amendment Regulations 2011).
The Quality Account presents a balanced picture of the Trust’s performance over the period covered:
• The performance information reported in the Quality Account is reliable and accurate
• There are proper internal controls over the collection and reporting of the measures of performance
included in the Quality Account and these controls are subject to review to confirm that they are working
effectively in practice
• The data underpinning the measures of performance reported in the Quality Account is robust and reliable,
conforms to specified data quality standards and prescribed definitions, and is subject to appropriate
scrutiny and review;
• The Quality Account has been prepared in accordance with 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.
Professor Anthony Goldstone CBE
Chairman
Rob Hurd
Chief Executive Officer
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
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Appendix 2
Appendix 2: External auditor’s
assurance report
Independent Auditor's Limited Assurance Report to the Directors of Royal National
Orthopaedic Hospital NHS Trust on the Annual Quality Account
We are required to perform an independent assurance engagement in respect of Royal National Orthopaedic
Hospital NHS Trust’s Quality Account for the year ended 31 March 2015 (“the Quality Account”) and certain
performance indicators contained therein as part of our work. NHS trusts are required by section 8 of the Health
Act 2009 to publish a quality account which must include prescribed information set out in The National Health
Service (Quality Account) Regulations 2010, the National Health Service (Quality Account) Amendment
Regulations 2011 and the National Health Service (Quality Account) Amendment Regulations 2012 (“the
Regulations”).
Scope and subject matter
The indicators for the year ended 31 March 2015 subject to limited assurance consist of the following indicators:
• Percentage of patients risk-assessed for venous thromboembolism (VTE)
• Rate of Clostridium difficile infections (“CDIs”)
We refer to these two indicators collectively as “the indicators”.
Respective responsibilities of directors and auditors
The Directors are required under the Health Act 2009 to prepare a Quality Account for each financial year. The
Department of Health has issued guidance on the form and content of annual Quality Accounts (which
incorporates the legal requirements in the Health Act 2009 and the Regulations).
In preparing the Quality Account, the directors are required to take steps to satisfy themselves that:
• the Quality Account presents a balanced picture of the Trust’s performance over the period covered;
• the performance information reported in the Quality Account is reliable and accurate;
• there are proper internal controls over the collection and reporting of the measures of performance included
in the Quality Account, and these controls are subject to review to confirm that they are working effectively
in practice;
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The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
Appendix 2
• the data underpinning the measures of performance reported in the Quality Account is robust and reliable,
conforms to specified data quality standards and prescribed definitions, and is subject to appropriate
scrutiny and review; and
• the Quality Account has been prepared in accordance with Department of Health guidance.
The Directors are required to confirm compliance with these requirements in a statement of directors’
responsibilities within the Quality Account.
Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything has
come to our attention that causes us to believe that:
• the Quality Account is not prepared in all material respects in line with the criteria set out in the Regulations;
• the Quality Account is not consistent in all material respects with the sources specified in the NHS Quality
Accounts Auditor Guidance 2014-15 issued by DH in March 2015 (“the Guidance”); and
• the indicators in the Quality Account identified as having been the subject of limited assurance in the
Quality Account are not reasonably stated in all material respects in accordance with the Regulations and
the six dimensions of data quality set out in the Guidance.
We read the Quality Account and conclude whether it is consistent with the requirements of the Regulations
and to consider the implications for our report if we become aware of any material omissions.
We read the other information contained in the Quality Account and consider whether it is materially
inconsistent with:
• Board minutes for the period April 2014 to June 2015;
• papers relating to quality reported to the Board over the period April 2014 to June 2015;
• feedback from the Commissioners dated 5 June 2015;
• feedback from Local Healthwatch dated 10 June 2015;
• the Trust’s complaints report published under regulation 18 of the Local Authority, Social Services and NHS
Complaints (England) Regulations 2009, dated 2014/15;
• feedback from other named stakeholder(s) involved in the sign off of the Quality Account;
• the latest national patient survey dated 21 May 2015;
• the latest national staff survey dated 2014;
• the Head of Internal Audit’s annual opinion over the trust’s control environment dated 2 June 2015;
• the annual governance statement dated 2 June 2015;
• the Care Quality Commission’s Intelligent Monitoring Report dated May 2015;
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
63
Appendix 2
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 Royal National Orthopaedic
Hospital NHS Trust.
We permit the disclosure of this report to enable the Board of Directors to demonstrate that they have
discharged their governance responsibilities by commissioning an independent assurance report in connection
with the indicators. To the fullest extent permissible by law, we do not accept or assume responsibility to anyone
other than the Board of Directors as a body and Royal National Orthopaedic Hospital NHS Trust for our work or
this report save where terms are expressly agreed and with our prior consent in writing.
Assurance work performed
We conducted this limited assurance engagement under the terms of the guidance. Our limited assurance
procedures included:
• evaluating the design and implementation of the key processes and controls for managing and reporting
the indicators;
• making enquiries of management;
• testing key management controls;
• analytical procedures;
• limited testing, on a selective basis, of the data used to calculate the indicator back to supporting
documentation;
• comparing the content of the Quality Account to the requirements of the Regulations; and
• reading the documents.
A limited assurance engagement is narrower in scope than a reasonable assurance engagement. The nature,
timing and extent of procedures for gathering sufficient appropriate evidence are deliberately limited relative to
a reasonable assurance engagement.
Limitations
Non-financial performance information is subject to more inherent limitations than financial information, given
the characteristics of the subject matter and the methods used for determining such information.
The absence of a significant body of established practice on which to draw allows for the selection of different
but acceptable measurement techniques which can result in materially different measurements and can impact
comparability. The precision of different measurement techniques may also vary. Furthermore, the nature and
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The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
Appendix 2
methods used to determine such information, as well as the measurement criteria and the precision thereof,
may change over time. It is important to read the Quality Account in the context of the criteria set out in the
Regulations.
The nature, form and content required of Quality Accounts are determined by the Department of Health. This
may result in the omission of information relevant to other users, for example for the purpose of comparing the
results of different NHS organisations.
In addition, the scope of our assurance work has not included governance over quality or non-mandated
indicators which have been determined locally by Royal National Orthopaedic Hospital 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 indicators in the Quality Account subject to limited assurance have not been reasonably stated in all
material respects in accordance with the Regulations and the six dimensions of data quality set out in the
Guidance.
Grant Thornton UK LLP
Grant Thornton House
Melton Street
Euston Square
London |
NW1 2EP
24 June 2015
The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
65
Notes
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The Royal National Orthopaedic Hospital NHS Trust Quality Account 2014/15
If you have any comments about this document
or would like it translated into another language/large print,
please contact the Clinical Governance Department
on 020 8909 5439/5717.
15-15 © RNOH June 2015
Royal National Orthopaedic Hospital NHS Trust
Brockley Hill, Stanmore, Middlesex HA7 4LP
www.rnoh.nhs.uk