Quality Report
2014/15
Quality Report
Part 1 – Statement on Quality from the Chief Executive
The vision for Dorset County Hospital Foundation Trust (DCHFT) is Delivering Safe and
Compassionate Healthcare to all those who use our services. This means delivering excellent clinical
outcomes in a caring, compassionate and safe environment. This Quality Report (also known as the
Quality Account) demonstrates the progress made in our quality priority areas in the previous year
and also details the areas of work we aim to deliver in the forthcoming year.
Achievements in 2014/15 include an overall reduction in the amount of hospital acquired pressure
ulcers, an improvement in the management of diabetes as a secondary disease to hospital admission
and a complete change in the way that medications are dispensed prior to discharge from hospital.
These are the things that you told us were important to you and the full details of progress is shown in
the following sections of this account.
The management of patients who fall whilst in hospital has been a challenging priority as the reasons
for falls are often very complex, however we recognise that this is an area that we can still further
improve upon and for this reason it has remained as a quality priority for the forthcoming year. We
also know that people aged 65 and older have the highest risk of falling, with 30% of people older
than 65 and 50% of people older than 80 falling at least once a year. To this end we will be working
with our partner agencies and commissioners to ensure that we can not only support the patients
within our care, but also those on discharge from our hospital.
We have continued to make progress on improving the measures included in the National Safety
Thermometer. These measures include the prevention of venous thrombosis (blood clots) and
catheter associated urinary tract infections. DCHFT ended the year reporting 97% harm-free care.
Our aim is to always prevent possible harm to our patients and when harm does occur we ensure that
we learn from it to improve care to others. The National Safety Thermometer has been a useful tool
to enable us to benchmark our care against others and learn from best practice.
In the forthcoming year, the Trust has also produced its pledges to the ‘Sign up to Safety’ campaign, a
National Campaign designed to reduce harm to patients, and these include areas such as:

Sepsis – The early recognition and prompt treatment of infections

Pressure Ulcers – Damage caused to the skin by any pressure

Falls – The reduction of harm caused to people who fall in hospital

Documentation and communication – Accurate passing on of information and recording it
in places that are easily accessible to others and understood by others
Acute Kidney Injury – Early recognition and reduction in the damage to kidneys that can be
caused by infections, dehydration and medications

1
Dorset County Hospital NHS Foundation Trust
Quality Report 2014/15 We have reviewed the data available on patient safety and quality and in discussion with our partners
and stakeholders have agreed the following priorities for 2015/16: (Full explanations of meanings and
how they will be measured are detailed in the following section of this report)

Zero tolerance to hospital acquired pressure ulcers

Reducing harm to patients who fall in hospital

Reducing the incidence of severe sepsis

Reducing the number of patients discharged at night

Increasing the number of electronic discharge summaries sent within 24 hours

Learning from ‘near-miss’ incidents


Friends and family test
Robust application of the duty of Candour

Timely and compassionate response to complaints
We will continue to ensure that services are developed and improved for the benefit of our patients
and without the commitment and professionalism of all our staff this would not be possible. On behalf
of the Board, I wish to thank each and every member of staff for all their commitment, hard work and
to recognise the significant contribution individuals and teams make to continually developing and
improving the services we provide to our patients and community.
I would also like to take the opportunity to thank our patients, as without their willingness to share their
views and experiences we would not be able to gain this valuable feedback to help us to continually
improve and shape the services we provide.
We are dedicated to continually learning and developing our services and I believe that the priorities
selected for the forthcoming year will make a demonstrable difference to the experience of our
patients and their families.
I confirm that to the best of my knowledge the information included in this Quality Report is accurate
and reflects the quality improvements made at Dorset County Hospital NHS Foundation Trust.
Patricia Miller
Chief Executive
26 May 2015
2
Our Approach to Quality
The Board of Directors is focused on the quality of services and is assured that quality governance is
subject to rigorous challenge. This is achieved through Non-Executive Director engagement and
chairmanship of the key Board-level committees. The Director of Nursing and Quality is supported by
the Medical Director as executive lead for quality governance. The Board receives a Patient Safety
and Quality Report monthly, in which areas of good practice, issues of concern, and performance
against quality metrics are reported.
The Board also reviews specific examples of patient feedback, both positive and negative, at each
meeting, with a view to learning from this and ensuring that appropriate action is taken to safeguard
quality and improve the patient experience. A detailed Patient Safety, Effectiveness and Experience
report is presented to the Board each quarter. The Board has revised its Quality Committee to
scrutinise clinical and quality governance across the organisation, and to provide assurance to the
Board on specifically designated areas of concern. In addition the Audit Committee will provide
assurance on both clinical and non-clinical processes.
The Quality Committee now meets each month and receives reports on compliance against the Care
Quality Commission’s (CQC) Essential Standards, including details of the evidence supporting the
stated level of compliance. The Committee is able to assure itself by scrutiny of the evidence in place
that compliance is being maintained and, where gaps have been identified, that remedial action is
being taken to attain or resume full compliance. The Committee also receives regular updates on the
Trusts’ CQC Intelligent Monitoring Report, so any movement of indicators can be tracked and
assurance provided that changes in performance are being managed appropriately. The Trust’s
Clinical Governance Committee, which is chaired by the Medical Director, reports to the Quality
Committee by exception. The Clinical Governance Committee has a robust reporting mechanism from
the key clinical committees, while maintaining a strong focus on improving clinical based services and
ensuring evidence based practice is the bedrock of clinical decision making.
The Finance and Performance Committee meets monthly and includes the detailed monitoring of all
national and local performance targets within its remit. Many of these indicators contain quality
components, for example CQUINs, Infection Control targets, the Cancer National Standards,
Emergency Department Indicators, the National Stroke Strategy indicators, and levels of cancelled
operations. In addition, the quality aspects of each cost improvement programme (CIP) savings
scheme identified are assessed by the Service Improvement Board, chaired by the Director of
Operations to ensure patient safety and service quality are not compromised by the savings
proposed.
The Board are continuously reviewing this process and identifying ways in which to strengthen it
further.
3
Dorset County Hospital NHS Foundation Trust
Quality Report 2014/15 Part 2.1 – Priorities for Improvement
How we chose our Priorities for 2015/16
The Trust has used a variety of methods to agree our quality priorities for 2015/16. To ensure we
continue to improve our services and learn as an organisation we have used incident reports and
listened to the views of our staff through our executive safety walk rounds, through both the patients
and staff friends and family test responses as well as open sessions with the Chief Executive and
Executive Directors to shape the priorities for 2015/16.
Proactive use of patient feedback, to learn from the experiences of our service users, as well as
information from national and local patient surveys, is a rich source of data which has helped us to
further identify trends and prioritise areas for improvement. In addition, our Governors’ undertake
assurance visits which provide the board with a valuable independent view on the services patients
receive and an insight from an alternative perspective on any concerns our staff may have.
The priorities have been discussed with our clinical teams as part of service planning and through
routine updates on the quality priorities to our Governors, staff and local groups such as Dorset
Health Scrutiny Committee, Dorset HealthWatch and Dorset Clinical Commissioning Group. Our
commissioners and local GPs have helped us determine our priorities through a range of discussions
held throughout the year.
The Trust has made good progress on last year’s priorities. However, further improvements can be
made and, to that end, some existing priorities will be carried forward as well as additional areas of
focus proposed for 2015/16. A number of these areas are required to achieve our CQUIN
Programme (Commissioning for Quality and Innovation), the Trust’s corporate objectives, and to
support the CQC (Care Quality Commission) standards and Trust Strategic Imperatives.
In summary, the Trust has built up its quality priorities for 2015/16, based on the quality
recommendations from national reports, commissioner and regulators requirements and its own audit
and assessment of the needs of our patients for service development. The Trust Board agreed the
nine priorities in March 2015.
4
Our Quality Priorities for 2015-16
Patient Safety
Our quality priorities and why we chose them.
What success will look like?
Zero Tolerance to Hospital Acquired Pressure Ulcers
Pressure ulcers cause patients acute discomfort and can prolong their stay
in hospital. There has been considerable work done in recent years to
reduce the incidence of hospital acquired pressure ulcers. The rationale for
keeping this priority into 2015/16 is that we believe further reduction in
harm to patients can be achieved.
We will have no hospital acquired
pressure ulcers developed due to a lapse
in the care we provide.
How will we monitor progress?
Patient Quality, Safety and
Experience Reports for Trust
Board
Ward Patient Safety Monitoring
Group
Risk Management Committee
Reducing Harm to Patients Who Fall in Hospital
Work has been undertaken to prevent patients falling in hospital, and whilst
this has led to improved awareness, patients continue to fall in hospitals.
The reasons for this are multifactorial and it is unlikely that falls can be
totally prevented. However, reducing the levels of harm experienced by
patients can be improved upon and lead to better outcomes for patients.
For this reason we have included this critically important area in our
priorities for 2015/16.
All patients identified as high risk of falls
will have an individualised plan of care to
reduce the level of harm.
Patient Quality, Safety and
Experience Reports for Trust
Board
Ward Patient Safety Monitoring
Group
Risk Management Committee
Early Recognition of Sepsis
Sepsis is a common and potentially life-threatening condition and is
recognised as a significant cause of mortality and morbidity in the NHS.
Approximately 70% of patients with sepsis will require treatment in a Critical
Care or High Dependency Unit. Consistent recognition and rapid treatment
contributes to the reduction of preventable deaths from Sepsis.
We will reduce the incidence of severe
sepsis by 50% in patients treated at
Dorset County Hospital (within 3 years
linked to our ‘Sign up to Safety Pledge)
Risk Management Committee
Safety Improvement Committee
‘Sign up to Safety’ National
Pledges
5
Dorset County Hospital NHS Foundation Trust
Quality Report 2014/15 Our Quality Priorities for 2015-16
Clinical effectiveness
Our quality priorities and why we chose them
What success will look like
How will we monitor progress?
Reducing the Number of Patients Discharged at Night
Although there are occasions when patients do not require admission
overnight, we recognise that the support for this group of patients may not
always be available back in their own homes or the community. We will
look to make decisions to discharge patients earlier in the day so that
appropriate support can be obtained and provided on their discharge.
We will reduce the number of
inappropriate discharges after 21.00 and
before 07.59
Clinical Commissioning Group
Contract Monitoring
Meetings/Quarterly Quality
Monitoring Meetings
Risk Management Committee
Quality Committee
Increase the Number of Electronic Discharge Summaries (EDS) sent
within 24 Hours
We recognise that valuable information regarding a patients hospital stay
needs to be communicated effectively with our partners in other
organisations and patients own GP’s.
We have heard from our commissioners the difficulties that GP’s in
particular face when they do not receive this information in a timely fashion
in order to enable them to make plans about the future care of their patients
back in the community setting
We will increase the number of EDS sent
within 24 hours and reduce the number of
incidents reported where this does not
occur.
Learning from ‘Near Miss’ Incidents
Although we can learn and implement changes following events that
happen in the organisation, this is too late to prevent that occurrence. As a
Trust we are committed to prioritising the learning from ‘near miss’ events
to stop these events occurring.
We will identify all near miss events as
they are reported and implement solutions
to prevent their potential to reoccur
Clinical Commissioning Group
Contract Monitoring
Meetings/Quarterly Quality
Monitoring Meetings
Risk Management Committee
Quality Committee
6
Risk Management Committee
Quality Committee
Our Quality Priorities for 2015-16
Patient experience
Our quality priorities and why we chose them
What success will look like
How will we monitor progress?
Friends and Family Test
Patient feedback is vitally important to the Trust for gaining insights to
improve services. The Trust has linked the friends and family test to the
NICE standards for patient experience, and the national NHS WoW
awards. Both have provided a platform to tell more people about patient’s
experiences. Focusing on this will further improve the engagement of
patients in sharing their experiences, and extend the audience for the Trust
to share this with.
We will retain our position within the top
20% Trusts whilst we continue to support
the National Implementation Plan and
introduce into other areas.
Learning from Patients Committee
Robust Application of the Duty of Candour
Being open and honest with our patients and their families when things go
wrong is a fundamental standard. By the robust application of the Duty of
Candour we mean that we will investigate any errors and provide a written
response to our patients or their families detailing what occurred and the
measures that have been put in place to prevent another occurrence.
We will ensure that any errors that occur
are discussed with the patient and/or their
family and that a written response of the
actions taken is supplied.
Clinical Commissioning Group
Contract Monitoring
Meetings/Quarterly Quality
Monitoring Meetings
Monthly Patient Quality, Safety
and Experience Reports and
Quarterly Patient Experience
report for Trust Board
Risk Management Committee
Quality Committee
Timely and Compassionate Response to Complaints
We believe that when our patients or their families have cause to complain,
the response they receive should be both within an agreed timescale and
also acknowledge the experience of the patient through their own eyes.
We believe that the response should cover all the concerns that are raised,
and that our patients/families should have an identified lead who will keep
them updated on the progress of any investigation.
We will contact all patients or relatives
who make a complaint and agree a
timescale in which to work. The identified
lead will be known to the patient or
relative.
We will reduce the number of complaints
that are re-opened
7
Clinical Commissioning Group
Contract Monitoring
Meetings/Quarterly Quality
Monitoring Meetings
Learning from Patients Committee
Dorset County Hospital NHS Foundation Trust Quality Report 2014/15 Progress against Priorities for 2014-15
Priority 1 – ZERO TOLERANCE TO HOSPITAL ACQUIRED
PRESSURE ULCERS
What did we set out to achieve?
To have a zero tolerance for patients developing an avoidable hospital acquired pressure ulcer due to
a lapse in care.
What was our rationale for including this as a priority?
Pressure ulcers cause patients acute discomfort, can prolong their stay in hospital and contribute to
other risks such as infection. The development of a pressure ulcer in any setting provides the patient
with a ‘life-long’ risk as the tissue from any healed pressure ulcer will only ever achieve approximately
70% of the strength of previously undamaged tissue. Therefore it is imperative that no patients are
placed at this risk from the care we provide in our Trust.
What have we done to improve?
In the year 2014/15 much work has been done to reduce the risk of developing pressure ulcers at
DCHFT.





The role of the Tissue Viability Nurse (TVN)
Education
Prevention
Treatments
Pressure Ulcer data
The role of the TVN:
The TVN has maintained a high profile on the wards to support staff in the prevention and
management of pressure ulcers. As a result the grading and reporting of pressure ulcers is more
accurate. The TVN has worked in tandem with the Risk Management Department and the Matrons to
produce a more robust reporting format . The SSKIN Bundle and Body Map within the AIRS (Adult
Inpatient Record) document have provided staff with the tools to adequately document patient care,
whilst the safety cross has allowed a mechanism for all staff on the ward to easily see ‘how they are
doing’.
8
Educatio
on:
Since Ap
pril 2014 all newly
n
appoin
nted Health Care
C
Supporrt workers receive pressu
ure ulcer prevvention
and skin
n manageme
ent training. Tissue
T
Viabiliity is taught to
t newly qua
alified nursess as part of th
he
Precepto
orship progra
amme. The TVN also acccepts studen
nts on short placements during their ttraining
to highlig
ght the importance of tisssue viability. Many educa
ation session
ns have been provided
througho
out the year both on the wards
w
and th
hrough the ANTS
A
group (Agents
(
for Nutrition
N
and Tissue
Viability..)
Preventiion:
Promotin
ng effective and
a consiste
ent evidence based care is essential when
w
manag
ging pressure
e ulcer
prevention and mana
agement.
d up to the ‘P
Pan Dorset Pressure
P
Ulccer Prevention Strategy’ in order to be
etter
The Trusst has signed
understa
and the risk factors
f
prior to hospital admission
a
and work towards an agree
ed Pan Dorse
et
prevention and treatment approa
ach. .
aff have rece
eived update
ed training on
n the correct use and trou
ubleshooting of the dynam
mic
Ward sta
mattressses.
Low air loss and gel mattresses have been trrialled consisstently over the
t year with the new con
ntract
ender. Air cusshions are allso available.
out to te
Heel pro
otectors have
e been purch
hased and prressure ulcerr prevention gel pads ma
ade available
e to all
areas th
hrough the inttroduction off a simple system in conjunction with the stores department.
Treatme
ent:
Pressure
e ulcers are wounds, and
d to that effec
ct, require a wound asse
essment plan
n. New treatm
ment
productss have been assessed byy the TVN an
nd ward stafff and evaluatted. These new
n
productss are
now ava
ailable to warrd staff to use
e following skin
s
risk asse
essment.
9
Quality Report 2014/15 Dorset County Hospital NHS Foundation Trust What has this achieved?
This has resulted in a steady decline in the number of pressure ulcers acquired in hospital. Although
we recognise that there are peaks and troughs which are equally mirrored by the number of patients
that are admitted to hospital with a pressure ulcer, the general trend has been decreasing. We have
maintained this priority into the forthcoming year as we still believe that there is more that we can do
and that a further reduction is possible.
25
Number of patients 20
15
Grade II
Grade III
10
Grade IV
5
0
*Grade II - Partial thickness skin loss involving epidermis, dermis or both. Presents clinically as an abrasion or
clear blister . Ulcer is superficial without bruising.
*Grade III - Full thickness skin loss. Subcutaneous fat may be visible but bone, tendon and muscle are not
exposed. May include undermining and tunneling. The depth varies by anatomical location (bridge of the nose,
ear, occiput and malleolus do not have (adipose) subcutaneous tissue and grade 3 ulcers can be shallow) . In
contrast area of significant adiposity can develop extremely deep grade 3 pressure ulcers . Bone/tendon is not
visible or directly palpable.
*Grade IV - Full thickness tissue loss with exposed bone (or directly palpable), tendon. Often include
undermining and tunneling. The depth varies by anatomical location (bridge of the nose, ear, occiput and
malleolus do not have (adipose) subcutaneous tissue and grade 4 ulcers can be shallow). Grade 4 ulcers can
extend into the muscle and/or supporting structures (eg fascia, tendon or joint capsule).
Priority 2 – REDUCING HARM TO PATIENTS WHO FALL IN
HOSPITAL
What did we set out to achieve?
Although the reasons for patients falling in hospital are multifactorial and it is unlikely that falls could
ever be totally prevented, reducing the level of harm that patients experience when they do fall can be
improved upon and lead to better outcomes for patients. We aimed to reduce the number of patients
experiencing moderate or severe harm by identifying those at high risk.
10
What was our rationale for including this as a priority?
Falls and fall-related injuries are a common and serious problem for older people. People aged 65
and older have the highest risk of falling, with 30% of people older than 65 and 50% of people older
than 80 falling at least once a year.
The human cost of falling includes distress, pain, injury, loss of confidence, loss of independence and
mortality. Falling also affects the family members and carers of people who fall and therefore the
entire consequences of a significant fall can be life-changing and devastating to both patients and
their families.
What have we done to improve?
Throughout the year we have been working with our clinical staff, ward leaders and matrons to
develop a risk assessment approach to identifying those patients at higher risk and then identifying
actions to implement to further reduce the risk of harm to patients.
The 1st National Audit of Inpatient Falls is planned to run in May 2015. The Trust will be participating
in this audit, having been part of the pilot process in 2014. The Trust is also joining a regional forum
“Falls Prevention – Working Together” from April 2015, a joint social care and health approach to
looking at the issue of falls proposed by our Commissioners and including primary and secondary
care providers
What has this achieved?
The risk assessment was successfully introduced into our new Adult Inpatient Record and
disseminated across all ward areas in December 2014. An initial audit in January 2015 demonstrated
compliance with the new risk assessment to be greater than 85%.
Falls Risk Indicator Presentation (Any other = 0) Agitation Cognition SCORE 1 Urinary frequency No agitation Normal Treatment – 0 – 2 Drugs Antidepressants, Sedation, Detox, Diuretics PACT Score 4 or less = Low Risk SCORE2 Reduced mobility/ neurology/mechanical falls Some Dementia/Confusion/ Delirium/Poor eyesight 3 – 4 Drugs PACT Score 5 – 6 = Medium Risk 11
SCORE 3 Repeated collapse High Severe dementia/ Confusion/Delirium
4+ Drugs PACT Score 7+ = High Risk Quality Report 2014/15 Dorset County Hospital NHS Foundation Trust 4
Number of falls 3
2
Moderate Harm
1
Severe Harm
Apr‐13
May‐13
Jun‐13
Jul‐13
Aug‐13
Sep‐13
Oct‐13
Nov‐13
Decemebr 13
Jan‐14
Feb‐14
Mar‐14
Apr‐14
May‐14
Jun‐14
Jul‐14
Aug‐14
Sep‐14
Oct‐14
Nov‐14
Dec‐14
Jan‐15
Feb‐15
Mar‐15
0
We have maintained this priority into the forthcoming year as we still believe that there is more that
we can do and that a further reduction is possible.
Priority 3 – MANAGEMENT OF DIABETES AS A CO-MORBIDITY TO
HOSPITAL ADMISSION
What did we set out to achieve?
We aimed to have no serious incidents relating to the care and management of people admitted to
DCHFT with diabetes as a secondary condition, that is, where diabetes is not the primary reason for
admission.
What was our rationale for including this priority?
Up to 20% of our in-patients at DCHFT have diabetes as a co-morbidity. In high risk areas such as
Coronary Care, Prince of Wales and the Elderly Care Unit the prevalence can be as high as 40%.
Insulin and other oral hypoglycaemic agents are often required to improve glycaemia in times of
illness. Managing glycaemia can improve outcomes for people with diabetes admitted to hospital.
However, insulin can cause hypoglycaemia and is a high risk medication and ensuring the safety of
our patients is essential.
What have we done to improve?
All people admitted to our hospital with diabetes will have their blood glucose monitored for at least 4 times a day for the first 24 hours after admission. Thereafter it will be monitored in line with their
needs, information about this can be found in the new Blood Glucose Monitoring Policy located on the
Clinical Guidelines website.
Any blood glucose readings outside of the acceptable range (4-12mmol/L) will be highlighted and
those patients will be reviewed by the Diabetes Specialist Nurse (DSN) nursing team. This enables
the safe adjustment of medication to optimise blood glucose and manage further hypo or
12
hyperglyycaemic even
nts. This also
o provides an educationa
al opportunity for people with diabete
es, where
the diab
betes nursess can discuss the manag
gement of a
an individual’’s diabetes, check injecttion sites
and also
o review the
eir practical skills.
s
The DSN
D
team ha
ave access to the diabe
etes consulta
ants who
assist in
n providing ex
xpert advice for this patie
ent group.
FT the DSN team carry out an auditt to determin
ne the staff knowledge
k
off hypoglycae
emia and
At DCHF
it’s mana
agement. Th
his is carried out each yea
ar with the Director
D
of Nu
ursing, Deputty Director off Nursing
and the matrons. Th
he results ha
ave shown continual prog
gress as sta
aff at DCHFT
T have becom
me more
oglycaemia and
a how to manage
m
it.
aware of the implicattions of hypo
ar the Diabe
etes team pu
urchased the
e Safe Use of Insulin e--learning package for alll staff at
Last yea
DCHFT in order to raise
r
awaren
ness and red
duce insulin errors
e
within
n the Trust. The
T uptake has
h been
poor an
nd therefore the Diabete
es Team arre currently working with the Pharm
macy Deparrtment to
develop our own bes
spoke e-learrning packag
ge which will be more eas
sily accessib
ble and more
e relevant
ose staff at DCHFT
D
that prescribe
p
of administer
a
in
nsulin.
to all tho
Diabeticc Ketoacidosis is an unco
ommon but liife threatenin
ng condition relating, most commonlyy, but not
exclusively to Type 1 diabetes. Blood
B
ketone
e monitoring has been carried
c
out att DCHFT for 2 years,
od ketone te
esting is a tim
mely and acccurate way to monitor problems
p
in addition to urine testing. Bloo
related to
t hyperglyca
aemia when people with diabetes are
e unwell. Blo
ood ketone meters
m
are hand held
devices that allow bedside
b
mon
nitoring. How
wever these devices
d
requ
uire quality control
c
testin
ng before
use but can be used
d without, un
nlike our bloo
od glucose monitoring
m
syystem which users canno
ot access
if a quality control te
est has not been
b
perform
med. This pro
ovided a dile
emma for the
e Diabetes Team and
the Poin
nt of Care te
eam. In orde
er to safegua
ard patients and ensure
e that clinica
al decisions could be
made ba
ased upon re
esults from th
he ketone me
eters, we wo
orked with the
e Equipmentt Library to develop
d
a
system where by a cleaned and
d quality con
ntrolled keton
ne meter is delivered
d
to key areas (ED, ITU,
Ilchesterr Integrated Assessmen
nt Unit, Ren
nal Unit and
d Kingfisherr Ward) dailly. Testing urine for
ketones remains the
e first step in this proce
ess in order to reduce th
he cost of th
his innovatio
on, whilst
ning patient safety.
s
maintain
What has this achiieved?
Systemss are in placce at DCHFT to ensure that if the blood glucosse control of people admitted to
hospital with a prima
ary or secon
ndary diagno
osis of diabettes deteriora
ate, the diabe
etes team are aware
and able
e to intervene
e. The diabetes team are
e visible and accessible.
13
Dorset County Hospital NHS Foundation Trust Quality Report 2014/15 We have had no serious incidents relating to the care and management of people admitted to our
hospital with diabetes as a secondary condition, that is, where diabetes is not their primary reason for
admission.
Priority 4 – IMPROVE THE EFFECTIVENESS OF DISCHARGE FROM
HOSPITAL
What did we set out to achieve?
Effective discharge planning is vitally important to ensure the organisation uses its resources
efficiently and ensures that patient safety continues when they leave the Trust’s direct care. A
particular focus of the Trust in 2014/15 was improving on the timely availability of take home
medications. We set out to deliver a standard that patients would not wait any longer than 2 hours for
medications to take home.
What was our rationale for including this priority?
This priority was included as responses to the Friends and Family Test had highlighted that, at times,
the whole experience of our patients and their families was diminished at the end point of waiting for
medications to take home.
What have we done to improve?
In terms of effective discharge and medications to take home, this was linked to the restructuring of
the Pharmacy service and the roll out of ‘ward based’ Pharmacy discharge teams in recent months.
The Chief Pharmacist developed a decentralisation working group and action plan to be able to
deliver this service, which the Trust has been working towards throughout the year.
The roll out of the EPMA (Electronic Prescribing and Medicines Administration) has been successfully
achieved across all inpatient ward areas (with the exception of SCBU and Maternity) and
Outpatients. The EPMA project, in conjunction with the revised pharmacy structure has improved the
discharge process significantly. It is anticipated that the time from the decision to discharge a patient
to the time that the medication is ready with the patient will be 60 minutes, compared to the previous
model where significant delays were experienced in the medical staff writing the discharge
prescription and it being received and processed by the pharmacy department.
Furthermore, all discharge prescriptions from the acute care hub are being prioritised and will
routinely be processed by Pharmacy in under one hour.
What has this achieved?
The pharmacy department have been currently piloting the new service on two surgical wards,
Abbotsbury and Lulworth, and are reporting a significant improvement in turn-around times for
discharge medicines, routinely around one hour. The service will be extended to all adult wards over
the next 6 months.
14
Lulworth
Time (mins)
300
200
Average
100
Median
Time (mins)
Abbotsbury
300
200
100
Average
0
Median
0
Pre‐Pilot
Pilot
Priority 5 – ALL PATIENTS WILL BE REVIEWED BY A
CONSULTANT WITHIN 14 HOURS OF ADMISSION TO HOSPITAL
What did we set out to achieve?
In support of 7 day services, we set out to achieve a standard whereby our patients received a
Consultant review within 14 hours of admission to hospital.
What was our rationale for including this priority?
The rationale for including this priority was from guidance from the NHS Seven Day Working Forum
who issued a set of clinical standards.
What have we done to improve?
An initial audit was conducted in May 2014 to establish whether DCHFT was compliant in providing
Consultant review within 14 hours of decision to admit (not including the initial assessment when the
decision to admit is made). After wide dissemination of the results, the audit was repeated in October
and shows a significant improvement in both Medicine and Surgery; Paediatrics was also included in
the October audit cycle.
The results of both audits were used to develop the service provided to emergency admissions; this is
being monitored through the Quality Committee. The results indicate that areas in need of
development in the first audit has raised awareness amongst clinicians, and highlighted practice in
need of change to demonstrate compliance and to provide safe and effective care to our patients.
There was a noticeable improvement in the quality of documentation of time, grade of staff and nature
of review in the second audit.
What has this achieved?
No.
1.
Standard
Division
100% of emergency patients Medicine
should have their case reviewed
by a Consultant within 14 hours of
Surgery
being admitted to Dorset County
Hospital
Paediatric
May‐14
Oct‐14
Feb‐15
Apr‐15
64%
88%
83%
96%
↑
59%
89%
45%
67%
-
92%
100%
100%
↑
↑
15
Quality Report 2014/15 Dorset County Hospital NHS Foundation Trust Review of the cases where consultant input was greater than 14 hours continues in order to seek
solutions and ensure that we comply with this standard for the benefits to our patients and their
families.
*Audits undertaken in Feb 15 and April 15 were over a 24 hour period, previous audits undertaken
took place over a week.
Priority 6 – ZERO TOLERANCE TO PREVENTABLE CANCELLED
OPERATIONS DUE TO EQUIPMENT AVAILABILITY
What did we set out to achieve?
To improve the incidence of cancelled operations performed due to lack of equipment. Establish the
root causes of any cancelled operations and work on resolving these issues to prevent reoccurrences.
What was our rationale for including this priority?
A cancelled operation on the day cause patients to have increased anxiety and compromises the care
pathway that these patients are on. When this cancellation happens on the day the patient becomes
more distressed. The Trust reputation for efficiency in Theatre operations is also compromised.
Utilisation of staff, clinicians, equipment and Theatre time is wasted.
What have we done to improve?
For 14th July 2014 until 31st March 2015 there have been 13 cancelled operations on the day due to
lack of equipment, these can be themed as below.
Cancellations April 2014 ‐ March 2015
Due to Lack of Equipment
5
2
0
0
0
Apr‐14 May‐14 Jun‐14
3
1
1
0
1
0
0
Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Mar‐15
Themes for Cancelled Operations Due to Equipment Failure
5
2
Wrong Lens Ordered
1
Xray Machine
Broken
3
2
Hole in Wrap
16
Phaco Machine
Broken
Foot Pedal Phaco
Machine Broken
The Theatre Practitioners now review their Theatre Lists the day before the operation is due and the
lists are reviewed weekly in the Theatre Scheduling.
The Orthopaedic speciality has an equipment administrator who will review all lists and order all
equipment required both in loan and consignment perspective.
The Theatre Quality Administrator has now completed a review of the maintenance contracts on all
equipment used within Theatres and monitors these for when planned maintenance needs to take
place.
From the themes identified we have learnt the following:  Wrong lens ordered – all ophthalmic lenses are now standard, they are measured at booking
any special requirements are forwarded to the theatre teams who liase with procurement to
order. This is done on a weekly basis. A cancelled operation on the day due to wrong lens
being ordered has not occurred since July 2014.

X-Ray Machine – this is an unexpected occurrence and we are informed of any planned
maintenance.

Hole in wrap – this is an ongoing issue which is experienced by Trusts throughout the
country. Equipment is often sterilised using containers metal / plastic. These are then
wrapped in paper. Due to infrequent use shelving movement and handling issues within a
confined storage space these “kits” sometimes become damaged. Theatres and SSD are
currently working on two projects:
o Trial of triple wrapping of sets
o A review of shelving within the set cupboard.
The department recognises that this is an ongoing issue.

Phaco Machine Broken – this was an unexpected episode of machine failure. This led to 5
patients being cancelled on one list on the day.

Foot Pedal on Phaco Machine broken – this was also an unexpected episode of machine
failure and this affected 3 patients being cancelled on one list on the day although 14
patients were listed. To prevent this happening in the future a replacement and a spare have
been ordered.
What has this achieved?
This has enabled the department to learn from these issues and shows a proactive approach to
Theatre planning; because of the nature of mechanical equipment within the department, failure
cannot be completely eradicated, however we have planned maintenance and a proactive review of
the equipment needed.
17
Dorse
et County Hospital
H
N
NHS
Foundation Tru
ust Quality Repo
ort 2014
4/15 Prioriity 7 – IM
MPROVE THE EXPERIENC
CE OF CARERS
C
OF PATIIENTS
WITH DEMENTIA
What did we set ou
ut to achieve
e?
To impro
ove the expe
eriences of patients
p
with
h dementia by
b understan
nding it from both the patient and
their carrers perspecttive.
What wa
as our rationale for including this priority?
The incrrease in patie
ents with dem
mentia is nattionally recog
gnised and iss a high priority in the op
perational
framewo
ork. Ensuring that patien
nts with dementia and their carers ha
ave a positive
e experience
e is often
challeng
ging but criticcally importan
nt.
What ha
ave we done
e to improve
e?
We agreed to unde
ertake an audit
a
of care
ers of peop
ple with dem
mentia to test whether they felt
supporte
ed. A list off patients wh
ho had been admitted to DCHFT from
m April 2014
4 to March 2015
2
was
obtained
d and in totall 240 carers were
w
sent ou
ut a question
nnaire and co
overing letterr.
Unfortun
nately the retturn rate for these questiionnaires wa
as much lowe
er than had been anticipated, but
of the 61
1 responses that were received:



53% off carers who
o responded
d felt that th
hey had eno
ough supportt to provide care on
discharge from hosp
pital;
elt that the hospital
h
staff listened to th
hem about th
he needs
66% of carers who responded fe
of the patient;
p
46% of carers who responded fe
elt that they were directe
ed to relevant advice to help
h
them
supportt their relative
e.
estionnaire was
w then revvised to an experience based desig
gn questionn
naire and se
ent to 20
This que
carers a month, tak
king care to ensure that carers who
o had already been asked to comp
plete the
question
nnaire were not
n asked ag
gain.
Unfortun
nately, the re
esponse rate was very po
oor with only one questio
onnaire return
ned in April. We plan,
therefore
e, to ask carers to comp
plete a shortt questionnaire whilst the
eir relatives are in patien
nts using
the ward
d iPad. and are
a in discusssion with the
e Patient and Public Enga
agement Tea
am to develo
op this.
What ha
as this achie
eved?
The responses from
m the carers have shown
n that in som
me areas th
he understan
nding of the complex
nature a
and needs of
o dementia patients requires more
e education. A dementia
a strategy has
h
been
develope
ed with mandatory trainin
ng for clinica
al staff
The ccare and info
ormation in A
A&E and on the ward
d was given w
with warmth
h and undersstanding, mum
m settled into
o the ward, aalthough the
ey were very busy they allways had tim
me to inform
m us via phone or on the ward, discharge loun
nge staff telep
weree very helpfu
ul. Oxygen arrrived in timee prior to m
my mother’s d
discharge, go
ood care and
d GP which was greeat. Always h
had visitss followed w
good
d admissionss for my mother 18
At all tim
mes without exception, the staff in each my department where m
husband has been a patient we have been given tthe utmost ccare and atteention Inform
med of the proceedure to get my husband hom
me ‐ n very helpful
again
Priority 8 – FRIENDS AND FAMILY TEST
What did we set out to achieve?
The friends and family test was introduced to capture feedback from patients as they left the hospital
(within 48 hours) by asking them a simple question:
‘How likely are you to recommend our ward / A & E Department / Maternity Service to friends and
family if they needed similar care or treatment?’
What was our rationale for including this priority?
The Friends and Family Test (FFT) is a survey which asks patients whether they would recommend
the NHS service they have received to friends and family who need similar treatment or care. The
responses to the FFT question are used to produce a score that can be aggregated to ward, site,
specialty and trust level. The scores can also be aggregated to national level.
As a nationally lead initiative, the friends and family test has been in use since April 2013 and was
undertaken in all adult in-patient wards, Emergency Department and Maternity Services. In October
2014 Dorset County Hospital NHS Foundation Trust was an earlier adopter in outpatients, further
extending this to all outpatient services (National Mandate April 2015).
The responses received provide a wealth of information and allow the Trust to monitor and review the
services it provides in real time and in relation to providing a positive experience of care.
What have we done to improve?
DCHFT uses different methodologies to collect the patient feedback. In-patients use paper surveys
and the Emergency Department and Outpatients use a text/telephone
survey.
Feedback from the Friends & Family Test is linked to staff recognition
for their outstanding contributions to patient experience and care. The
use of the WOW! Awards have been launched in the hospital and
receive many external and internal nominations each month. These
awards can be presented to individuals or teams.
What has this achieved?
The Trust won the Best Newcomer at the National WOW! Awards ceremony in November 2014,
based on our patient feedback.
We have been able to demonstrate consistency in our response rate throughout the year in all
services. Monthly reports and information are shared with the ward teams using a sample of the
comments received (the full narrative is shared if requested). These are displayed on PALS boards
throughout the Trust, with service improvement in the form of “you said, we did”.
Any negative comments received via text are automatically followed up with a request for permission
to call the patient for further information to ensure that learning can take place and a number of
service improvements have taken place as a result
19
Quality Report 2014/15 Dorset County Hospital NHS Foundation Trust NHS England changed the net promoter scoring system in Q2 and now publish the % of patients
likely to recommend the service. These have been consistently high for both Inpatient and the
Emergency Department. Q4 excludes March figures as these have not been published at the time of
the report.
Standards
Q1
Q2
Q3
Q4
Friends and Family Test Response Rate
- Inpatient
42%
37%
37%
38%
Friends and Family Test Response Rate
- Emergency Department
21%
21%
22%
22%
Friends and Family Test Response Rate Emergency Department and Inpatient Wards
(maintain a combined average response rate of
<20%)
31.5%
29%
29.5%
30%
Friends and Family Test % likely to recommend
- Inpatient
97%
97%
97%
97%
Friends and Family Test % likely to recommend
- Emergency Department
-
85%
87%
87.5%
Friends and Family Test % likely to recommend
- Emergency Department and Inpatient Wards
-
91%
92%
92%
“This has been a most wonderful experience. I have found great warmth and expertise in all members of staff. I honestly believe that nothing more could have been done to make my treatment, physically and emotionally, complete. There was also fun banter with fellow patients. The food was excellent! Thank you to all concerned” ‘Nothing was too much trouble and so glad to help
in all ways’
20
Priority 9 – IMPROVE ACCESS TO CLINICS
What did we set out to achieve?
We set ourselves a target to achieve a reduction in the percentage of clinic cancellations which were
at short notice, thereby reducing the number of patients adversely affected by the lack of notice.
What was our rationale for including this as a priority?
Patients tell us through surveys and direct feedback that cancellations of their clinic appointments at
short notice significantly impact on their experience of DCHFT services. There is acknowledgement
and understanding that notice of cancellation, that is 6 weeks or more, while inconvenient does allow
for appropriate diary planning for patients but that little or no notice is deeply inconvenient and a
cause for concern for our patients.
What have we done to improve rates of short notice clinic cancellations?
A zero tolerance approach was taken to requests for cancellations where the notice given to patients
was less than 6 weeks. The Director of Operations would only accept cancellations where actions on
alternative arrangements had been exhausted. The Divisions introduced administrative pathways
with clearly defined actions, responsible parties and timescales so as to reduce those which were
cancelled due to administrative or management delays. In addition the Divisions worked to support
cross-team working to allow for cover of clinics where clinicians were unavoidably unavailable.
This item was added to the monthly report by the Director of Operations to the Finance and
Performance Committee where reasons for cancellations and actions were consistently discussed
and challenged throughout the year. This action ensured Executive scrutiny and focus was
maintained throughout the reporting year.
What has this achieved?
The above described approach delivered demonstrable changes in the percentage of clinics
cancelled with minimal notice. In 2013/14 short notice cancellations were on average 44.5% of all
cancellations. In 2014/15 this percentage dropped to 25.5% see below:
21
Dorset County Hospital NHS Foundation Trust Quality Report 2014/15 Due to operational pressures such as unplanned absences of key personnel it has not been possible
to maintain a steady downward trend throughout the year. The reasons for cancellations however,
are now more consistently due to the unexpected rather than for reasons to do with capacity planning,
annual/study leave management and administrative errors in the process. Three of the four Divisions
have managed to maintain very low figures all year with Surgery having managed to maintain low
figures in the Quarters where specific surgeons have been absent. The peaks in cancellations are
mainly attributable to absences within the Head and Neck Directorate in year and it is expected that
recruitment into these roles in early 2015/16 will address this concern.
22
Part 2.2 – Statements of Assurance
from the Board of Directors
Review of Services
During 2014/15 Dorset County Hospital NHS Foundation Trust provided and/or sub-contracted 35
relevant health services. The Trust continually reviews the data available to it on the quality of care in
these services.
The income generated by the relevant health services reviewed in 2014/15 represents 100% of the
total income generated from the provision of relevant health services by Dorset County Hospital NHS
Foundation Trust for 2014/15.
Participation in Clinical Audits and National Confidential Enquiries
A clinical audit aims to improve patient care by reviewing services and making changes where
necessary. National Confidential Enquiries investigate an area of healthcare and recommend ways to
improve it.
During 2014/15 30 national clinical audits and 4 national confidential enquiries covered NHS services
that the Trust provides. During that period the Trust participated in 94% of national clinical audits and
100% of National Confidential Enquiries which it was eligible to participate in.
Some of the National Bodies do not recommend the use of HES data for example NELA recommend
clinical definition as opposed to coding definition to be used to identify cases.
The national clinical audits and national confidential enquiries that the Trust was eligible to participate
in during 2014/15 and the extent of its’ participation, are set out in the following tables:
National Clinical Audits 2014/15
DCH
eligible
DCH
Participation
Cases
submitted
% of
registered
cases
Acute Care
Adult critical care
(Case Mix Programme)


690
100%
Emergency use of oxygen


n/a
n/a
National Audit of Seizures in Hospitals


30
100%
National Emergency Laparotomy Audit


120
(predicted)
100%
Ankles
Hips
Knees
Shoulders
Elbows
83%
81%
74%
98%
75%
Name of audit
National Joint Registry


Adult Community Acquired Pneumonia


23
Finished
June2015
Finished
June2015
Quality Report 2014/15 Dorset County Hospital NHS Foundation Trust National Clinical Audits 2014/15
DCH
eligible
DCH
Participation
Cases
submitted
% of
registered
cases
Older People ( Care in ED)


35
100%
Severe trauma (Trauma Audit &
Research Network)


278
89%
Blood and transplant
National Comparative Audit
of Blood Transfusion programme


16
94%
Cancer
Bowel cancer (NBOCAP)


73
100%
Head and neck oncology (DAHNO)


n/a
n/a
100%
Name of audit
Lung cancer (NLCA)


109
(predicted
figure, report
period end
June 2014)
National Prostate Cancer


All patients
100%
Oesophago-gastric cancer (NAOGC)


40
95%
Heart
Acute coronary syndrome or
Acute myocardial infarction (MINAP)


31/21
155%
Cardiac Rhythm Management


2,264
100%
Congenital heart disease
(Paediatric cardiac surgery)


n/a
n/a
Coronary angioplasty


319
100%
National Adult Cardiac Surgery Audit


n/a
n/a
National Cardiac Arrest Audit


179
100%
National Heart Failure Audit


207
Data taken
from new
vascular
database
only (Aug
2014-April
2015)
National Vascular Registry
Pulmonary Hypertension Audit






(data entry
closes31.5.14)
100% AAA’s
94% IIB’s
16%
Amputations
n/a
n/a
1098
100%
Long term conditions
Diabetes (Adult), includes
24
National Clinical Audits 2014/15
DCH
eligible
DCH
Participation
Cases
submitted
% of
registered
cases
Diabetes (Paediatric) (NPDA)


96
100%
Inflammatory bowel disease


n/a
n/a
National Chronic Obstructive Pulmonary
Disease (COPD) Audit ProgrammePulmonary Rehabilitation


21
100%
Renal replacement therapy
(Renal Registry)


628
100%
Rheumatoid and early inflammatory
arthritis


n/a
n/a
Prescribing Observatory for Mental
Health


n/a
n/a
Mental Health (Care in the ED)


52/50
100%


310
98%


372
92%


12
100%


2
100%
Fitting Child (care provided in
emergency departments)


34
100%
Neonatal intensive and special care


270
100%
Paediatric intensive care


n/a
n/a

Nb: as
numbers for
hernias/VV’s
are so small,
PROMs do
not report on
these
Hips79.30%
Knees 81.5%
Groin (Hernia)
54.6%
Varicose Veins
48.30%
Name of audit
National Diabetes Inpatient Audit
Mental Health
Older people
Falls and Fragility Fractures
Audit Programme
(National Hip Fracture Database)
Sentinel Stroke National Audit
Programme
Women and children’s health
Epilepsy 12 audit (Childhood Epilepsy)
Maternal, Newborn and Infant
Clinical Outcome Review Programme
Other
Elective surgery (National PROMs
Programme)

25
Quality Report 2014/15 Dorset County Hospital NHS Foundation Trust National Confidential Enquiries 2013/14
Name of enquiry
Cases submitted
% of registered cases
Lower Limb Amputation
3
100%
Tracheostomy Care*
5
100%
Sepsis
4
100%
Gastrointestinal Haemorrhage
4
100%
* 5 cases submitted but only 2 selected for review.
The reports of 17 national clinical audits were reviewed by the provider in 2014/15 and we intend to
take the following actions to improve the quality of healthcare we provide.
Actions arising from National Clinical Audits
Name of audit
Actions required
Paediatric Asthma Audit British Thoracic Society
We have good overall results but the audit demonstrates poorer
compliance with: recording observations after giving beta-2 –
agonists, recording severity, and measurement of peak flow.
National Paediatric Diabetes
Audit
The audit shows that the paediatric diabetes team has achieved a
top quartile result for HbA1c under 58 mmol/l and also for care
processes completed. The median HbA1c results show DCHFT
achieving better than average results including after compensation
for skill mix. There are no results in the audit indicating DCHFT is a
negative outlier.
National Hip Fracture Data
Collection 2014/15
To continue to audit fracture neck of femur admissions. Audit
continues, and improvements have been made by Trauma Coordinator to ensure data completeness.
PROMs Knees (Patient
Reported Outcome Measures)
April 2013 to March 2014
No actions required
National Chronic Obstructive
Pulmonary Disease (COPD)
Audit Programme
There were a number of coding inaccuracies that affected the final
report. We have concerns that the figures do not accurately reflect
our ward experience.
Low WTE consultant staff for the clinical workload. There were 1.8
per 1000 COPD admissions compared to the national 6.1.
Absence of smoking cessation service in secondary care
Lack of designated consultant time for the COPD integrated service.
This is currently ad-hoc.
Incorrect entries
Lack of designated respiratory beds (this has since been rectified)
National Joint Registry April
2014 to March 2015
Continue to monitor trends, no immediate actions required
PROMs - Hip
No actions required, continue to audit
National Hip Fracture Data
Collection 2013/2014
No actions required
Overview of ICNARC Case
Mix Programme 2012/13
The results of this audit continue to be good. Cases are reviewed by
the Critical Care Delivery Group (CCDG) on a quarterly basis
26
Actions arising from National Clinical Audits
Name of audit
Acute coronary syndrome or
Acute myocardial infarction
(MINAP)
Actions required
DCH has the best door to balloon time for ST elevation MI in the UK
DCH has the third best Call to balloon time in the UK.
DCH is above average in all other fields except number of patients
admitted to a cardiac ward (non –stemi). This is because admitting
ward not coded as cardiac. A change of coding has now been
actioned to change coding of EMU to a cardiac ward
National Bowel Cancer Audit
2013/2014
The Trust has very good outcomes within this reporting period. In
particular, the 90 day post-operative mortality figures are excellent
and there are high rates of procedures performed laparoscopically.
From this data there are no areas of concern. The report has been
discussed within the department.
BHIVA national clinical audit
2012-13: HIV patients
retention in care
Poster with summary of results of the national audit to be displayed
in the waiting area.
Review SOPHID report every January to identify and chase up
patients who have not attended for care the previous year.
Patients to be made a follow-up appointment after each visit, to
ensure a DNA will be flagged up and acted on
Potential Donor Audit
Continuation of NHSBT National Potential Donor Audit.
Continuation of Organ Donation Teaching to acute areas.
Continuation of raising the profile of organ donation in DCHFT.
Falls and Fragility Fractures
Audit Programme (National
Hip Fracture Data Base)
To continue to audit the fractured neck of femur admissions.
To continue to enter correct data in relation to fractured neck of
femur admission to the National Database using the electronic
system and feedback results to the Trauma team.
The 2013 Report was reviewed by CAC in July 2014. We did do
well for Diabetes Specialist Nursing times, consultant & dietician
input to inpatients. The report confirms that we have twice as many
DM related admissions as the average, with twice the rate of foot
admission. Our root risk assessment was only 27% (national
average = 37%) our mild hypos were 27% (national average 20%),
our severe hypos were 16.2% (national average 9.2%).
Diabetes (Adult), includes
National Diabetes Inpatient
Audit (NADIA),
diabetes care in pregnancy,
diabetes footcare*
The report has been reviewed by the diabetes team at monthly
meetings and Away Days and appropriate actions implemented and
followed up.
The National diabetes care in pregnancy report was reviewed by
CAC in Nov 2014. We have no access to local data at present so
unable to comment on our position and actions. Regional
recommendations are already embedded in our practice here at
DCH.
National Cardiac Arrest Audit
To communicate the learning points from compliance monitoring
amongst the medical staff.
Use the cardiac arrest statistics to target training and improve
management of deteriorating patients.
27
Dorset County Hospital NHS Foundation Trust Quality Report 2014/15 The reports of 115 local clinical audits were reviewed by the Trust in 2014/15 and we intend to take
the following actions to improve the quality of healthcare we provide. This is a sample of the actions
taken from these audits.
Actions arising from Local Clinical Audits
Name of audit
Actions required
Decontamination
of Invasive Devices
An initial audit of decontamination of probes used in the Urology
rectal biopsy clinic, Gynae outpatients and Gynae ultrasound clinics
in July 2013 showed only 50% compliance with the recommended
cleaning system. Following training and introduction of a formal
policy compliance this increased to 96% April 2014 and 100% in
November 2014.
Consultant Review
of admissions
within
recommended timeframes
Following an initial audit which identified poor documentation of time
of review of admissions by senior medical staff, there has been an
improvement in documentation in the clinical notes.
Audit of DNA rates and waiting
times for patients referred to
Colorectal
Telephone
Assessment Clinic
following the introduction of a telephone assessment clinic for
patients referred to the colorectal team the DNA rate has reduced
from 5.3% in 2007/8 to 3.1% in 2013/14. In addition patients
assessed within three weeks of referral improved from 34% to 91%
during this time period.
Analgesia
prescribing
surgical patients
An initial audit carried out in 2012 showed that only 14% of
foundation trainees prescribed analgesia in accordance with the
WHO analgesic ladder guidelines.
Following introduction of
teaching sessions and a poster this increased to 82% in 2013.
for
Paracetamol
overdose audit
Although our Trust performed favourably in our management of
patients presenting with paracetamol overdose, our local guidelines
were found to be wordy. The ED and Gastroenterology teams have
rewritten the guidelines to guide clinicians in appropriate and timely
care
Management
of Gonorrhoea
Although local management of gonorrhoea compared very
favourably against the rest of Wessex this audit identified that the
most effective screening lab test was not available. Funding was
secured for NAAT’s testing locally. To continue auditing.
28
Actions arising from Local Clinical Audits
Name of audit
Audit of management of
patients with suspected deep
venous thrombosis (DVT)
Actions required
Following an initial audit in 2013 where only 18.6 % of patients with
suspected DVT had Well’s score documented in notes and no
patients with an unprovoked DVT had any investigations for
underlying malignancy, staff education sessions and posters
outlining the flowchart for DVT management were introduced. When
re-audited in 2014 there had been improvement – 38% had Wells
score documented and 83% of unprovoked DVT had investigations
for underlying malignancy.
Perineal suturing swab count
audit
Following an incident where a swab was retained post-natal, a
proforma was introduced to document swab counting.
Documentation of swab count has measurably improved.
Audit
of
haemorrhage
Following education sessions for staff and introduction of a postpartum haemorrhage proforma, management and documentation of
blood loss has measurably improved since the initial audit in 2012
post-partum
Filing reports on ICE
Audit of
pathway
nSTEMI
Accountability for patient results – Following an initial audit in 2013
which showed only 89% of reports on ICE had been marked as
reviewed and 10% were filed, education of the paediatric staff took
place. In a re audit in 2014, 98% of reports were marked as
reviewed and 63% of reports were filed.
hospital
This audit showed only 62% of patients had an angiogram within 60
hours of admission. Delays are often due to patients not being
admitted to a cardiology bed. The chest pain specialist nurse is now
reviewing all patients. In addition she is carrying out a Friday
morning review of all patients waiting for an angiogram
Audit of obstetric outcomes for
young mothers (Aged 13-18)
This audit showed a higher rate of anaemia and smoking during
pregnancy. A slightly higher risk of pre-term babies was also
identified. The results of this audit have allowed midwives to target
pre-natal care.
Last Offices Audit
A paper shroud be used where the patient does not have their own
nightclothes; a member of staff who attended to the patient should
accompany the deceased to the mortuary to fill out the admission
form;
Members of staff refer to the identification card on the body bag
when filling out the admission form, removing the card from the bag
to facilitate this;
Zip body bags should be used in all circumstances;
The patients eyes be closed in all circumstances;
The deceased patient should be clean when brought to the
mortuary, with dignity pads in place and dressings on any wounds.
29
Dorset County Hospital NHS Foundation Trust Quality Report 2014/15 Actions arising from Local Clinical Audits
Name of audit
Actions required
Australian Therapy Outcomes
Measures in Occupational
Therapy
Information on standards to be displayed in department to raise
awareness in daily practice and improve quality Raise compliance
rate in areas already using.
Use in other areas
Insert column in electronic data tabs to record completed AusTOMs
To design and utilise a questionnaire to gain feedback from
patients/carers – to link in with Quality Improvement Project (focus
group)
To design and utilise a questionnaire to review audit possibilities for
future service development.
In line with benchmarking project 2014 – small project groups to
look at defining best practice for clinical areas and trust policies
Feeding Times in Elective
Paediatric Surgery – a ReAudit
Educational of nursing and health care staff of Kingfisher about
appropriate fasting times and consequences of excessive fasting.
Re-wording and updating the present leaflet given to
patients/parents
Implementing an automated texting system to remind patients and
parents of the time of their surgery and the fasting times,
encouraging them to eat and drink up until the deadlines.
Management of Hypertensive
Disorder in Pregnancy
Costly over-investigation and treatment (including delivery) in mild
cases
Incorrect diagnosis
This will be done by putting a laminated copy of the definition and
management table on the DAU wall. 2. Improve induction
information for SHOs re EDS and PN f/u – AR to discuss with new
doctors at induction.
Consider a handbook of information
Educate MW re EDS – Senior midwives to update their teams on
the need for junior doctors to create a discharge summary and
inform the juniors of the patients discharge so that they can e-mail
this to the GP.
Ensure hypertensive patients are flagged for post-natal review on
handover board – Supervising midwives to add these patients to the
handover board.
30
Actions arising from Local Clinical Audits
Name of audit
Re-Audit of Stethoscope
Cleaning Among Doctors in
the Emergency Department
Actions required
We will over the next 3 months: present the findings to the ED
doctors of various grades, send out the results and
recommendations by email to promote awareness and produce
posters to display around the emergency department (possibly
above sinks). We will then re-audit to check for improvement in
proportion of people: cleaning as frequently as recommended, who
see others cleaning their stethoscope regularly, feeling confident in
how to clean stethoscopes properly, using the correct method of
cleaning, acknowledging that stethoscopes are an infection hazard
as well as check for a reduction in the proportion of people using
their own stethoscope to examine patients for infection control
purposes. We will also arrange for there to be a clean stethoscope
to be included on the trolley (containing gloves etc) already placed
outside of the room a patient is being isolated in for infection control
purposes.
Participation in Clinical Research
A total of 761 patients were recruited to 93 different research projects at DCHFT in 2014-15. All
projects are approved by a research ethics committee and we opened, on average, 3 new projects
every month. Over 200 staff are actively supporting research projects at the trust. Highlights in 201415 include: 
DCHFT was the first site in Europe to open, and the first in the UK to recruit a patient to, the
Abbvie M14-217 study. This is a global study investigating a new drug for treating colorectal
cancer. The Trust achieved this goal ahead of a number of major UK teaching hospitals.

We continue to deliver excellent recruitment figures for trials. In particular, we were the best
recruiting site in the UK for the HARP III study; a study of a new drug for treating chronic
kidney disease. We were commended by the trial sponsor, Oxford University, for high
standards of data management. We are also in the top 10 UK sites for recruitment for a
number of other clinical studies.

Our Trust is being offered access to an increasing number of commercial trials on the basis of
our reputation for high standards of trial management. In particular, in 2014-15 we were
invited to take part in research studies sponsored by pharmaceutical companies Novartis and
Abbvie.
31
Quality Report 2014/15 Dorset County Hospital NHS Foundation Trust CQUIN performance
A proportion of the income that the Trust receives each year is conditional on achieving quality
improvement and innovation goals agreed between the Trust and the NHS bodies that commission
services from us. This system is called the Commissioning for Quality and Innovation (CQUIN)
payment framework.
In 2014/15, 2.15% of our clinical income depended on achieving these goals. This equated to £3.1
million of income, and we secured all £3.1 million of this (2013/14: £3.0 million).
Registration with the Care Quality Commission
The Trust’s current CCQ status is registered in full without conditions. Dorset County Hospital
Foundation Trust has not participated in any special reviews or investigations during the reporting
period. The Care Quality Commission has not taken enforcement action against Dorset County
Hospital NHS Foundation Trust during 2014/15. Data Quality
Accurate data is vital to the decision making processes of any organisation. It forms the basis for
meaningful planning and it is crucial that the data we capture about patients is accurate. NHS
managers and clinicians are dependent upon good quality information to ensure effective delivery of
patient care.
The Secondary Uses Service (SUS) provides a single source of comprehensive data to enable a
range of reporting and analysis of healthcare in the UK. The SUS is run by the NHS Information
Centre. The Trust submitted records during 2014/15 to the Secondary Uses service for inclusion in
the Hospital Episode Statistics which are included in the latest published data.
National research has identified that improving the quality of the NHS number data has a direct
impact on improving clinical safety. The percentage of records in the published data which included
the patient’s valid NHS number was:
Trust
2012/13
Trust
2013/14
Trust
2014/15
National
average
Admitted patient care
99.9%
99.9%
99.9%
99.2%
Out-patient care
99.9%
100.0%
99.9%
99.3%
Accident and emergency care
99.1%
99.3%
99.3%
95.2%
DCHFT will be taking the following action to improve data quality: Challenge current practice and
innovate data collection through the adoption of automated processes and mobile technology.
32
A General Medical Practice Code is essential to enable the transfer of clinical information about the
patient from a Trust to the patient’s GP. The percentage of records in the published data which
included the patient’s valid General Medical Practice Code was:
Trust
2012/13
Trust
2013/14
Trust
2014/15
National
average
Admitted patient care
100%
100%
100%
99.9%
Out-patient care
100%
100%
100%
99.9%
Accident and emergency care
100%
100%
100%
99.2%
Information Governance Toolkit
Information governance is the controls and procedures in place to regulate, safeguard and oversee
the use of patient, staff and corporate information, in line with the relevant legislation and common law
duties. The Information Governance Toolkit is an annual self-assessment, supplied by the
Department of Health, to support and assess the effectiveness of the procedures and protocols in
place within the Trust, in relation to the management of confidential data.
The Trust’s Information Governance Toolkit score for 2014/2015 is 89% (2013/2014: 84%). The
target score, as set by the Department of Health is 80% and the Trust has therefore been graded
green.
Clinical Coding Error Rate
Clinical Coding is "the translation of medical terminology as written by the clinician to describe a
patient's complaint, problem, diagnosis, treatment, into a coded format" which is nationally and
internationally recognised.
The Trust was not subject to the Payment by Results clinical coding audit during 2014/15.
33
Quality Report 2014/15 Dorset County Hospital NHS Foundation Trust Part 2.3 – Reporting Against Core Indicators
Mortality Rate
DCHFT considers that this data is as described. DCHFT has taken the following action to improve this
data and so the quality of its services by undertaking regular mortality reviews with the clinical teams.
The Summary Hospital-level Mortality Indicator (SHMI) reports on mortality at trust level across the
NHS in England. This indicator is produced and published quarterly as an official statistic by the
Health and Social Care Information Centre (HSCIC). SHMI is the ratio between the actual number of
patients who die following hospitalisation at the trust and the number that would be expected to die on
the basis of average England figures, given the characteristics of the patients treated there.
It covers all deaths reported of patients who were admitted to non-specialist acute trusts in England
and either die while in hospital or within 30 days of discharge. The expected number of deaths is
calculated from statistical models derived to estimate the risk of mortality based on the characteristics
of the patients (including the condition the patient is in hospital for, other underlying conditions the
patient suffers from, age, gender and method of admission to hospital).
Data is published for a rolling one-year period, six months in arrears. At the time of writing this report,
the latest data available is October 2013 to September 2014 (reported against Q4). A lower score
indicates better performance. In addition to individual scores, Trusts are categorised into one of three
bandings: 1 (SHMI higher than expected); 2 (SHMI as expected); 3 (SHMI lower than expected).
Summary Hospital-level
Mortality Indicator
14/15
Banding
Q1
Dorset County Hospital
2
1.12
2014/15
Q2
Q3
1.11
1.10
Q4
1.12
For the period October 2013 to September 2014
 64.33% of deaths occurred in hospital
 35.67% of deaths occurred outside of hospital
 0.64% of elective admissions resulted in a death *
 4.39% of non-elective admissions *
* Death occurred either in-hospital or within 30 days of being discharged; cause of death may not
necessarily be related to the original admission.
% of patient deaths with palliative care
coded at either diagnosis or speciality level
Dorset County Hospital
2012/13
2013/14
2014/15
8.6%
11.5%
15.6%
Readmission Rates
DCHFT considers that this data is as described. DCHFT intends to take the following action to
improve this percentage and so the quality of its services by working closely with our commissioners
to ascertain the reasons for readmission. The table below shows the percentage of emergency readmissions to the Trust within 28 days of a patient being discharged and is taken from CHKS (the
Trust’s current benchmarking tool).
34
2012/13
2013/14
2014/15
Under 16 – Dorset County Hospital
11.2%
9.0%
10.3%
Under 16 – National Average
9.1%
9.0%
8.9%
16 years or older – Dorset County Hospital
3.2%
3.2%
3.6%
16 years or older – National Average
6.3%
6.3%
6.3%
Patient age
35
Quality Report 2014/15 Dorset County Hospital NHS Foundation Trust Patient Reported Outcome Measures
DCHFT considers that this data is as described. DCHFT has taken the following action to improve this
score and so the quality of its services by actively encouraging all patients to return their
questionnaire. Patient reported outcome measures (PROMs) measure quality from the patient
perspective, and seek to calculate the health gain experienced by patients following a clinical
procedure. Patients are asked to complete a short questionnaire which measures their health status
or health related quality of life both before and after their surgery or treatment. The difference
between the two sets of responses is used to determine the outcome of the procedure as perceived
by the patient and provides an indication of the quality of care delivered. Information is captured for
the following three clinical procedures:

Groin hernia repair;

Hip replacement;

Knee replacement.
A higher number demonstrates that patients have experienced a greater improvement in their health.
DCHFT continues to actively encourage all patients to send in their PROMs questionnaires so that it
can take actions to continue to improve the outcome scores.
Adjusted average health gain
2011/12
2012/13
2013/14
Dorset County Hospital
0.106
0.076
0.076
National average
0.087
0.085
0.085
Dorset County Hospital
0.470
0.461
0.445
National average
0.416
0.438
0.436
Dorset County Hospital
0.306
0.304
0.297
National average
0.302
0.318
0.323
Groin hernia repair
Hip replacement
Knee replacement
Data Source: hscic
Patient Experience
DCHFT considers that this data is as described. The table below shows the Trust’s overall patient
experience score produced by NHS England using results taken from the national inpatient survey
programme. The overall score can range from zero to 100, a higher score indicating better
performance. If all patients were to report all aspects of their care as “very good”, this would equate
to an overall score of approximately 80. A score of around 60 indicates “good” patient experience.
Information for the year 2014/15 is not yet available as the survey results are currently under embargo
36
Responsiveness to the personal needs of patients
2011/12
2012/13
2013/14
Dorset County Hospital
77.9
76.0
77.9
National Average (acute trusts)
75.6
76.5
76.9
Lowest
67.4
68.0
67.1
Highest
87.8
88.2
87.0
In the previous year DCHFT has taken the following actions to improve this score/and so the quality of
its services, by providing friends and family responses at individual clinical area level in order to
promote service developments and identify themes or trends in need of further progress.
Staff Recommendation DCHFT considers that this data is as described. The Trust gauges staff responses in each quarter as to whether they would recommend the Trust to
family or friends as a place to work. In quarters 1, 2 and 4 this information is gathered via the staff
friends and family test (Staff FFT); in quarter 3 this test forms part of the national staff survey. Staff survey feedback - staff who would recommend
the Trust as a place to work to family or friends 2012
Dorset County Hospital 41%
56% National Average (median) 55%
59% 2013 2014 61%
58%
Staff FFT feedback - staff who would
recommend the Trust as a place to work to
family or friends Quarter 1
Quarter 2
Quarter 4 Dorset County Hospital 65% 65% National Average (mean) 62%
61%
Highest 90% 95% Lowest 15% 22% 59% DCHFT has taken a number of actions to improve staff satisfaction and in turn the quality of its
services. Actions taken in 2014 in response to staff feedback include a review of the Trust appraisal
system, extended provision of leadership training and the introduction of health and wellbeing training
for staff. Further work continues this year to continue to improve based on staff feedback, in line with
the Trust’s Staff Engagement Action Plan. 37
Quality Report 2014/15 Dorset County Hospital NHS Foundation Trust Venous Thrombo-embolism
DCHFT considers that this data is as described. Venous thrombo-embolism (VTE), or blood clots, is a
major cause of death in the UK. Some blood clots can be prevented by early assessment.
Rate of admitted patients assessed for VTE
2012/13
2013/14
2014/15
Dorset County Hospital
91.9%
97.5%
95.5%
NHS Target
92.0%
95.0%
95.0%
National Average
94.2%
95.6%
96.1%
Lowest
87.9%
71.3%
83.8%
Highest
100.0%
100.0%
100.0%
Data Source: NHS England
Infection Control
DCHFT considers that this data is as described.
C-difficile rates per 100,000 bed-days
2012/13
2013/14
2014/15
Bed-days
101,156
102,674
98,654
C-difficile cases
22
27
8
Objective Cases
27
18
22
C-difficile rate
21.7
26.3
8.11
National Average (rate)
17.4
14.7
n/a
Lowest (rate)
0
0
n/a
Highest (rate)
31.2
37.1
n/a
Data Source: Public Health England
38
Patient Safety Incidents
DCHFT considers that this data is as described. Patient safety incidents reported
2011/12
2012/13
2013/14
2014/15
3,294
3,262
3,612
4,035
32.8
32.2
35.2
40.9
12
38
28
36
Percentage of incidents resulting in severe
harm or death
0.36%
1.16%
0.78%
0.89%
Number of admissions
93,841
95,502
94,060
98,579
Incident report rate per 100 admissions
3.5
3.4
3.8
4.09
National median per 100 admissions for small
acute organisations (six month period to 31
March)
7.2
7.9
Number of patient safety incidents reported
Incident report rate per 1,000 bed days
Reported incidents resulting in severe harm or
death
DCHFT has taken the following actions to improve the quality of its services, by the following actions.
The Trust reviews every incident resulting in severe harm or death and the key learning points are
shared throughout the organisation – including with the Trust Board. The Trust will continue to
encourage staff to report incidents and it is therefore not appropriate to set a target for a reduction in
the number of incidents. The Trust does aim to dramatically reduce the number of incidents where the
same learning points are identified in similar circumstances.
39
Quality Report 2014/15 Dorset County Hospital NHS Foundation Trust Part 3 – Other Information
National and Local Targets
The Trust’s performance against National Standards and key local quality targets are set out in the
following tables:
Performance against National Standards
Infection Control - C-Diff hospital acquired (post 72
hours)
% of patients seen within 18wks (Admitted)
% of patients seen within 18wks (Non-Admitted)
% of patients under 18wks (Incomplete pathway)
ED - Maximum waiting time of 4 hours from arrival to
admission/transfer/ discharge
Cancer (ALL) - 14 day from urgent gp referral to first
seen
Cancer (Breast Symptoms) -14 day from gp referral to
first seen
Cancer (ALL) - 31 day diagnosis to first treatment
Cancer (ALL) - 31 day DTT for subsequent treatment Surgery
Cancer (ALL) - 31 day DTT for subsequent treatment Anti-cancer drug regimen
Cancer (ALL) - 62 day referral to treatment following an
urgent referral from GP
Cancer (ALL) - 62 day referral to treatment following a
referral from screening service
Performance against key local quality targets
Target/Plan
2014/15
Actual
2014/15
Actual
2013/14
Actual
2012/13
<22
8 27 22 90%
95%
92%
87.3% 96.8% 93.1% 92.8% 98.2% 94.9% 92.9% 97.8% 95.5% 95%
94.9% 94.7% 96.5% 93%
94.2% 98.9% 99.1% 93%
85.4% 98.7% 99.5% 96%
99.6% 99.2% 99.7% 94%
97.7% 97.8% 99.5% 98%
100.0% 99.8% 100.0% 85%
85.5% 88.4% 93.4% 90%
98.3% 96.0% 96.8% Target/Plan
2014/15
Actual
2014/15
Actual
2013/14
Actual
2012/13
0
0 1 1 100%
95%
14
80
99.2% 95.7% 15 60 98.8% 97.5% 14 162 96.1% 91.9% 19 118 90%
94.5% 94.8% 93.6% 95%
98.0% 98.1% 97.0% 80%
93.2% 82.2% 83.6% 90%
92.3% 93.9% 82.4% 0
30%
-
0 36.0% n/a 95.8% 0 25.7% 81 n/a 4 n/a n/a n/a Patient Safety Infection Control - Methicillin Resistant Staphylococcus
Aureus (MRSA) bacteraemia hospital acquired post
48hrs
Who Checklist Compliance
VTE Risk Assessment
Number of falls resulting in moderate or severe harm
Medication errors- Omitted doses
Clinical Effectiveness Infection Control - Ward cleaning audit results
Infection Control - Hand Hygiene audits compliance
levels (all areas)
% Stroke patients with 90% of their stay on the stroke
unit
Fracture Neck Of Femur - % of # NoF patients operated
on <36 hours of admission
Patient Experience Mixed sex accommodation breaches
Friends and Family - Inpatient - Response Rate
Friends and Family - Inpatient - Test Score
Friends and Family - Inpatient - Recommend
40
Friends and Family - Emergency Department - Response
Rate
Friends and Family - Emergency Department - Test
Score
Friends and Family - Emergency Department Recommend
20%
22.3% 14.1% n/a -
n/a 74.1 n/a -
86.3% n/a n/a Target
achieved
The above quality measures provide a range of measures of patient safety, clinical effectiveness and
patient experience. The measures have been chosen in line with the priorities identified in this Quality
Report, as well as covering areas that our patients and stakeholders have told us are important to
them, such as cleaning standards and Infection Prevention and Control measures. Our
commissioners review a number of these measures and our CQUIN contract supports further
specified improvement measures. These are reviewed each year as part of the contract discussions.
They include both national schemes and locally agreed schemes. The schemes are intended to
improve the health services offered to patients and improve the efficiency of running the hospital. The
national schemes include, but not limited to, a reduction in the proportion of avoidable emergency
admissions to hospital and improving the recording of diagnoses and a reduction in mental health reattendances in the Emergency Department. Local schemes include learning disability risk
assessments, admissions avoidance, discharge and transfers of care and cancer records and
pathways of care.
A number of these indicators are included in monthly patient safety and quality reports to the Trust
Board. The data has been sourced from the Trust’s information systems.
41
Target not
met
Dorset County Hospital NHS Foundation Trust Quality Report 2014/15 Statement of Directors’ Responsibilities
in Respect of the Quality Report
The directors are required under the Health Act 2009 and the National Health Service (Quality
Accounts) Regulations to prepare Quality Accounts for each financial year.
Monitor has issued guidance to NHS foundation trust boards on the form and content of annual
quality reports (which incorporate the above legal requirements) and on the arrangements that
foundation trust boards should put in place to support the data quality for the preparation of the quality
report.
In preparing the quality report, directors are required to take steps to satisfy themselves that:
 the content of the quality report meets the requirements set out in the NHS Foundation Trust
Annual Reporting Manual 2014/15;
 the content of the Quality Report is not inconsistent with internal and external sources of
information including:
Board minutes and papers for the period April 2014 to May 2015;
Papers relating to Quality reported to the Board over the period April 2014 to May 2015;
Feedback from Dorset Clinical Commissioning Group (lead commissioner) dated 06/05/15;
Feedback from governors dated 20/05/15;
Feedback from Local Healthwatch organisations dated 07/05/15;
The trust’s complaints report published under regulation 18 of the Local Authority Social
Services and NHS Complaints Regulations 2009, dated 05/05/15;
o The 2013 national patient survey published on 21/05/15;
o The 2014 national staff survey published on 24/02/15;
o The Head of Internal Audit’s annual opinion over the trust’s control environment dated
31/03/15; and
o CQC quality and risk profiles dated 20/06/2014, 18/07/2014, 27/10/2014, 01/12/2014
the Quality Report presents a balanced picture of the NHS foundation trust’s performance over the
period covered;
the performance information reported in the Quality Report is reliable and accurate;
there are proper internal controls over the collection and reporting of the measures of performance
included in the Quality Report, and these controls are subject to review to confirm that they are
working effectively in practice;
the data underpinning the measures of performance reported in the Quality Report is robust and
reliable, conforms to specified data quality standards and prescribed definitions, is subject to
appropriate scrutiny and review; and the Quality Report has been prepared in accordance with
Monitor’s annual reporting guidance (which incorporates the Quality Accounts regulations)
(published at www.monitor-nhsft.gov.uk/annualreportingmanual ) as well as the standards to
support data quality for the preparation of the Quality Report (available at www.monitornhsft.gov.uk/annualreportingmanual ).
o
o
o
o
o
o




The directors confirm to the best of their knowledge and belief they have complied with the above
requirements in preparing the Quality Report.
By order of the Board
Dr Jeffrey Ellwood
Chairman
26 May 2015
Patricia Miller
Chief Executive
26 May 2015
42
Independent Auditor’s Limited Assurance Report to the
Council of Governors of Dorset County Hospital NHS
Foundation Trust on the Quality Report
We have been engaged by the council of governors of Dorset County Hospital NHS Foundation Trust
to perform an independent assurance engagement in respect of Dorset County Hospital NHS
Foundation Trust’s quality report for the year ended 31 March 2015 (the ‘Quality Report’) and certain
performance indicators contained therein.
Scope and subject matter
The indicators for the year ended 31 March 2015 subject to limited assurance consist of the national
priority indicators as mandated by Monitor:


percentage of incomplete pathways within 18 weeks for patient on incomplete pathways at the
end of the reporting period
62 days urgent GP referral to first treatment for all cancers
We refer to these national priority indicators collectively as the ‘indicators’.
Respective responsibilities of the directors and auditors
The directors are responsible for the content and the preparation of the quality report in accordance
with the criteria set out in the ‘NHS foundation trust annual reporting manual’ issued by Monitor.
Our responsibility is to form a conclusion, based on limited assurance procedures, on whether
anything has come to our attention that causes us to believe that:



the quality report is not prepared in all material respects in line with the criteria set out in the ‘NHS
foundation trust annual reporting manual’
the quality report is not consistent in all material respects with the sources specified in Monitor’s
Annual Reporting Manual 2014/15 and detailed guidance for external assurance on quality
reports 2014/15
the indicators in the quality report identified as having been the subject of limited assurance in the
quality report are not reasonably stated in all material respects in accordance with the ‘NHS
foundation trust annual reporting manual’ and the six dimensions of data quality set out in the
‘Detailed guidance for external assurance on quality reports’.
We read the quality report and consider whether it addresses the content requirements of the ‘NHS
foundation trust annual reporting manual’, and consider the implications for our report if we become
aware of any material omissions.
We read the other information contained in the quality report and consider whether it is materially
inconsistent with:











Board minutes and papers for the period April 2014 to May 2015
Papers relating to Quality reported to the Board over the period April 2014 to May 2015
Feedback from Dorset Clinical Commissioning Group (lead commissioner) dated 06/05/15
Feedback from governors dated 20 May 2015
Feedback from Local Healthwatch organisations dated 07/05/15
The trust’s complaints report published under regulation 18 of the Local Authority Social Services
and NHS Complaints Regulations 2009, dated 05/05/15
The 2013 national patient survey published on 21/05/15
The 2014 national staff survey published on 24/02/15
The Head of Internal Audit’s annual opinion over the trust’s control environment dated 31/03/15
Care Quality Commission quality and risk profiles dated 20/06/2014, 18/07/2014, 27/10/2014,
01/12/2014
Annual governance statement.
43
Dorset County Hospital NHS Foundation Trust Quality Report 2014/15 We consider the implications for our report if we become aware of any apparent misstatements or
material inconsistencies with those documents (collectively, the ‘documents’). Our responsibilities do
not extend to any other information.
We are in compliance with the applicable independence and competency requirements of the Institute
of Chartered Accountants in England and Wales (ICAEW) Code of Ethics. Our team comprised
assurance practitioners and relevant subject matter experts.
This report, including the conclusion, has been prepared solely for the Council of Governors of Dorset
County Hospital NHS Foundation Trust as a body, to assist the Council of Governors in reporting
Dorset County Hospital NHS Foundation Trust’s quality agenda, performance and activities. We
permit the disclosure of this report within the Annual Report for the year ended 31 March 2015, to
enable the Council of Governors to demonstrate they have discharged their governance
responsibilities by commissioning an independent assurance report in connection with the indicators.
To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than
the Council of Governors as a body and Dorset County Hospital NHS Foundation Trust for our work
or this report, except where terms are expressly agreed and with our prior consent in writing.
Assurance work performed
We conducted this limited assurance engagement in accordance with International Standard on
Assurance Engagements 3000 (Revised) – ‘Assurance Engagements other than Audits or Reviews of
Historical Financial Information’, issued by the International Auditing and Assurance Standards Board
(‘ISAE 3000’). Our limited assurance procedures included:






evaluating the design and implementation of the key processes and controls for managing and
reporting the indicators
making enquiries of management
testing key management controls
limited testing, on a selective basis, of the data used to calculate the indicator back to supporting
documentation
comparing the content requirements of the ‘NHS foundation trust annual reporting manual’ to the
categories reported in the quality report.
reading the documents.
A limited assurance engagement is smaller in scope than a reasonable assurance engagement. The
nature, timing and extent of procedures for gathering sufficient appropriate evidence are deliberately
limited relative to a reasonable assurance engagement.
Limitations
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 affect comparability. The precision of different measurement techniques may
also vary. Furthermore, the nature and methods used to determine such information, as well as the
measurement criteria and the precision of these criteria, may change over time. It is important to read
the quality report in the context of the criteria set out in the ‘NHS foundation trust annual reporting
manual’.
The scope of our assurance work has not included governance over quality or non-mandated
indicators, which have been determined locally by Dorset County Hospital NHS Foundation Trust.
44
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 report is not prepared in all material respects in line with the criteria set out in the ‘NHS
foundation trust annual reporting manual’
the quality report is not consistent in all material respects with the sources specified in Monitor’s
Annual Reporting Manual 2014/15 and detailed guidance for external assurance on quality
reports 2014/15
the indicators in the quality report subject to limited assurance have not been reasonably stated in
all material respects in accordance with the ‘NHS foundation trust annual reporting manual’.
Greg Rubins (senior statutory auditor)
for and on behalf of BDO LLP, statutory auditor
Southampton, UK
27 May 2015
45
Dorset County Hospital NHS Foundation Trust Statement from Dorset Clinical Commissioning Group
46
Quality Report 2014/15 47
Dorset County Hospital NHS Foundation Trust Statement from Dorset Health Scrutiny Committee
48
Quality Report 2014/15 49
Quallity Repo
ort 2014/15 Dorse
et County Hospital
H
N
NHS
Foundation Tru
ust State
ement frrom Hea
althwattch Dors
set
Healthwatch Dorset
D
co
omment for DCHF
FT Qualitty Accou
unt 7/5/15
In the pa
ast year Hea
althwatch Do
orset has rec
ceived feedba
ack about th
he Trust’s se
ervices from
patientss, relatives, carers
c
and professionals
p
. Positive feedback often relates to staff attitud
des and
the high
h quality of care
c
and com
mpassion patients receive
e.
However, we are stiill receiving concerns abo
out lack of communicati
c
ion especially regarding
dischargge (unsure off times, waitting for pape
not being ke
erwork and medication,
m
ept informed of
what’s happening,
h
la
ack of co-ord
dination between hospittal departme
ents and feellings of being
g
dischargged too earlyy without appropriate support in placce). We are therefore plleased to notte that
the Trusst’s Priority “Improving
“
e
effectivenesss of discharg
ge” and the pilot
p
new iniitiative to re
educe
waiting times for me
edication has provided “significant
“
improvementts in turn-aro
ound times for
f
dischargge meds, rou
utinely one hour”. This in
nitiative is to
o be extende
ed to all adu
ult wards and
d we
look forw
ward to seeiing further im
mprovementts.
We welccome the fac
ct that “Redu
ucing the nu
umber of pattients discharged at night” is a prioriity for
2015/16
6. Vulnerable
e people should never be
e discharged at night if they
t
do not have
h
suitable
e
support in place.
ortunate tha
at the work undertaken
u
o Priority 7 “Improve th
on
he experienc
ce of carers of
o
It is unfo
patientss with demen
ntia” did nott elicit a goo
od response. We urge the
e Trust to ex
xplore more
innovative methods to engage with
w
carers and look forw
ward to seein
ng the resultss.
watch is pleassed to note that
t
prioritie
es for 2015/16 include “Timely and Compassiona
C
ate
Healthw
Response to Compla
aints” and en
nsuring good communicattion between professionals when som
meone
e treatment.. We have re
eceived feedback from patients
p
when
n their GP ha
as not
has had non-elective
been infformed of an
n emergencyy hospital adm
mission or trreatment.
Our 2014
4 report “Evvery One Mattters” highlig
ghted the wiide variation
n in the stand
dard of care
e
received
d at hospitalls in Dorset. We will be monitoring
m
tthe outcome
es from the Trust’s
T
respo
onse to
our repo
ort in 2015/16.
Our Com
mmunity Inve
estment Projjects have ga
athered feed
dback from people
p
and communities
c
whose
views might otherwiise be underr-represented
d when it co
omes to mattters of health
h and social care.
We’ll be
e producing a report of these projectts in 2015 an
nd there will be opportun
nities for the
e Trust
to respo
ond to issues raised.
We ackn
nowledge and
d welcome the
t Trust’s openness
o
in discussing
d
with us our fin
ndings - both
h from
our repo
ort “Every On
ne Matters” and from the feedback patients,
p
vissitors & stafff share with us. We
look forw
ward to conttinuing to wo
ork with the Trust to enssure that peo
ople's feedba
ack on the Trust's
T
services, both good and bad, is welcomed,
w
listened
l
to, learned
l
from
m and drives forward
improve
ements.
Tell: 0300 111 0102
www
w.healthwa
atchdorsett.co.uk
50
Statement from the Lead Governor
of Dorset County Hospital NHS Foundation Trust
As Foundation Trust Lead Governor I have been asked to provide a commentary on the Dorset
County Hospital NHS Foundation Trust Quality Report 2014-2015. The report details progress
against 9 quality priorities which have been set both locally, nationally and also influenced by Trust
Governor’s, staff and local groups such as Dorset Health Scrutiny Committee, Dorset Health Watch
and the Dorset Clinical Commissioning Group.
Priority 1 - Zero Tolerance to Hospital Acquired Pressure Ulcers
The priority set a zero tolerance for patients developing an unavoidable hospital acquired pressure
ulcer due to a lapse in care. This is a useful priority as it is a good indicator of the general standard of
nursing care provided to patients. In the vast majority of cases pressure ulcers are a preventable
complication. The Trust has aimed to reduce the incidence of pressure ulcers through the role of the
tissue viability nurse, education, prevention, treatments and pressure ulcer data. Pressure ulcers
have been a quality priority in previous years. The report shows a graph demonstrating the incidence
of grade 2, 3 and 4 ulcers from April 2013 to March 2015. During that time there have been no grade
4 ulcers but it looks as though the incidents of grade 2 and 3 ulcers is unchanged although no
numerical data has been provided. I note that hospital acquired pressure ulcers will remain a quality
priority for 2015/2016.
Priority 2 – Reducing Harm to Patients who Fall in Hospital
The Trust acknowledges that there are a number of patients that sustain falls whilst in hospital. A lot
of these falls are not preventable but is hoped by identifying those at high risk that the number of
patients experiencing moderate or severe harm could be reduced. A risk assessment process has
been set in place and compliance with this has been greater than 85%. A graph has been produced
which compares the number of falls resulting in moderate and severe harm for 2013 and 2014 but no
numerical data has been provided. The data suggests an increase in instance of falls resulting in
severe harm. This is disappointing but may just represent improved reporting of these incidents. This
remains a priority for the Trust for 2015/16.
Priority 3 – Management of Diabetes as a Co-morbidity to Hospital Admission
20% of in-patients have diabetes as a co-morbidity. This priority was set to examine and ensure that
the diabetic management is of a high standard in this group of patients. In order to improve the
management of these patients the following have been implemented. Firstly improved blood glucose
monitoring and secondly a system to ensure that when a patient’s blood sugars are not in an
acceptable range they are reviewed by the Diabetic Specialist Nurse. There has also been a
widespread education of staff including hypoglycaemia awareness and safe use of insulin. No data
has been presented to compare current with previous quality of diabetic management in this group of
patients. However the report states that there have been no serious incidents relating to the care
management of people admitted to the hospital with diabetes as a secondary condition.
Priority 4 – Improve the Effectiveness of Discharge from Hospital
This priority was set to try and ensure effective discharge planning and ensure that patients are
discharged efficiently and safely. One major issue was the availability of patient's discharge
medicine within 2 hours from the decision to discharge. The priority was included because of
feedback from friends and family tests. Some patients and their families had a poor experience
predominantly waiting for discharge medication. The Trust has implemented ward based Pharmacy
discharge teams and also implemented electronic prescribing. This new service has been piloted on
2 wards which has dramatically reduced the time to availability of discharge medications. Currently
they are available in around an hour whereas before it was sometimes taking over 3 hours. This
system will be implemented to all wards of the hospital over the next 6 months.
51
Dorset County Hospital NHS Foundation Trust Quality Report 2014/15 Priority 5 – All Patients will be Reviewed by a Consultant Within 14 Hours of
Admissions to Hospital
This is a nationally set target to support 7 day services and to ensure that a senior doctor reviews
emergency admissions within 14 hours of their arrival in hospital. The report details the percentage of
patients between medicine, surgery and paediatrics who have had a consultant review within 14
hours of being admitted to hospital. In medicine there has been a dramatic improvement from 64% in
May 2014 to 96% in April 2015. In surgery there has been a modest increase from 59% to 67%,
although from month to month there seems to be a large variation and it is not clear why this is. In
paediatrics the consultant review is 100%. Cases where consultant input did not occur within the 14
hours are being reviewed.
Priority 6 – Zero Tolerance to Preventable Cancelled Operations Due To Equipment
Availability
This priority was set because of feedback from friends and family. It is obviously a very frustrating
experience for patients and their families if their operation is cancelled at late notice due to equipment
issues. The data provided shows that in over 8½ months there were 13 cancelled operations on the
day of surgery due to lack of equipment. There is no historic data to compare with. Looking and
investigating this data has enabled theatre to take a more proactive approach to theatre planning.
Hopefully this will reduce the number of cancelled operations. They do acknowledge however that
the problem cannot be completely eradicated.
Priority 7 – Improve the Experience of Carers of Patients with Dementia
The Trust included this priority because they acknowledged that patients with dementia and their
carers should have a positive experience in hospital. The Trust aimed to evaluate the situation
through a questionnaire to 240 carers. The response rate was very low with only 61 responders
(25%). The conclusion from the data was that in some areas the complex needs and nature of
dementia requires that the staff have more education. The Trust has made dementia awareness
training mandatory for all clinical staff. It would be useful to see if this improves the experience of
dementia patients and their carers.
Priority 8 – Friends and Family Test
The aim of the friends and family test is to get feedback from patients when they leave hospital. The
question asks if they would recommend the service that they have received to friends or family. Data
has been provided for the four quarters in 2014 to 2015. The response rate has been fairly consistent
for in-patients around 40% and for emergency department patients around 20%. Overall the
response rate of around 30% of those who responded there was a 97% likely to recommend for inpatients, around 87% for the emergency department and an average across emergency department
and in-patients of 92%. This is very positive data. It would be good if we could get a higher response
rate.
Priority 9 Improve Access to Clinics
The aim of this priority is to reduce the number of late cancellations of outpatient clinic appointments
as a percentage of all clinic cancellations.
I am not sure why the target is a percentage and not an absolute number. There is no numerical data
in the report to indicate the scale of the problem.
The information presented states a percentage reduction from 44.5% in 2013/2014 to 25.5% in
2014/2015. I am not sure of the significance of this without the numerical data. Dr Duncan Farquhar-Thomson
Lead Governor DCHFT
20 May 2015
52