Quality report
for the year ended 31 March 2015
2
Contents
Section
Page
Introduction
5
How we produced the quality report
5
Part 1 - Chief Executive’s Statement on Quality
7
Part 2 - Priorities for Improvement
8
Looking back: priorities for improvement in 2014/15
8
Patient Safety Priorities 2014/15
9
Clinical Effectiveness Priorities 2014/15
10
Patient Experience Priorities 2014/15
14
Looking forward: priorities for improvement in 2015/16
16
Developing quality improvement capacity and capability
18
Statements of assurance
22
Reporting against core indicators
23
Review of services
35
Participation in Clinical Audits
35
What the regulators said about the Trust
48
Part 3 - Review of quality performance
51
Appendix 1 – Statement from Directors
52
Appendix 2 – Statement from Stakeholders
54
Appendix 3 – Supplementary Performance Information
62
Independent auditors report to the Council of Governors of Basildon and
Thurrock University Hospitals NHS Foundation Trust on the Quality Report
69
3
4
Introduction
How we produced the quality report
Foundation Trusts are required to produce
an annual quality report published within the
Annual Report, providing information about the
quality of services delivered and priorities for
improvement.
As a provider of healthcare, the Trust’s priority
is to ensure our patients receive high quality,
safe care.
The Trust is committed to making ongoing improvements, and each year we set
challenging quality improvement goals with the
aim of becoming one of the safest organisations
in the NHS.
The quality report provides a good opportunity
to show how well we have performed and
where we could make improvements. It shows
the data we use to monitor improvement in
patient safety, clinical effectiveness and patient
experience.
In developing this year’s quality report, the Trust
has ensured that governors, local HealthWatch,
staff and other stakeholders including the local
Clinical Commissioning Groups (CCGs), have
had an opportunity to comment on the quality
priorities for the Trust.
This is the sixth quality report produced by the
Trust.
The quality report is set out in three sections:
A variety of methods were used to collect
feedback and views, including face-toface meetings, presentations and written
correspondence. A dedicated email account
was also set up to help a wider audience
participate in decisions about the Trust’s quality
goals for the coming year.
Part 1: A statement on quality from the Chief
Executive, Clare Panniker
Part 2: Priorities for improvement
In this section the Trust sets out key
commitments for improving the quality
of services provided. We look back at
our quality aims for last year and look
forward as we set out priorities for the
year ahead.
We asked our stakeholders to comment on
key quality goals that will support care that is
safer, offers better clinical outcomes, improves
reliability and delivers better patient experience
under the following headings:
Included in this section are statements
about the organisation which are
intended to help people compare
different health organisations.
Care that is safer:
z Reducing harm from hospital acquired
pressure ulcers.
Part 3: Review of quality performance
This demonstrates how the organisation
has performed to date.
z Reducing harm from injurious falls.
5
z Patient experience
Care that is reliable:
Quality of care includes quality of caring.
This means how personal care is delivered
and the compassion, dignity and respect
with which patients are treated. It can only
be improved by analysing and understanding
patient satisfaction with their experience of
NHS services.
z Further reduce hospital mortality (measured
through Hospital Standardised Mortality
Ratio, (HSMR) and Summary Hospitallevel Mortality Indicator (SHMI) and crude
mortality).
z Reducing harm from deterioration by
reducing our cardiac arrest rate.
z Clinical effectiveness
Care that is personal:
This means understanding success rates
from different treatments for different
conditions. Assessing this will include clinical
measures such as mortality or survival rates,
complication rates and measures of clinical
improvement. Clinical effectiveness may also
extend to people’s wellbeing and ability to
live independent lives.
z Improve both the response rate and
recommender score for the Friends and
Family Test.
We also looked at our internal clinical quality
performance information and national indicators
to reach our decision on what the quality
priorities for the Trust should be in 2015/16.
The goals will be monitored through the
Trust’s quality governance processes. These
include performance reports at monthly Board
meetings, corporate quality governance
meetings for safety, patient experience and risk
and compliance, Divisional governance groups,
clinical support unit performance meetings and,
where relevant, for public display on wards and
in departments.
What is quality in healthcare?
High quality healthcare is safe and effective
care that is delivered in a compassionate
way, treating patients with respect. Quality in
healthcare can be described through three
domains:
z Patient safety
The first domain of quality must be that we
do no harm to patients. This means ensuring
the environment is safe and clean, reducing
avoidable harm such as drug errors or rates
of healthcare associated infections.
6
The year has not been without its challenges.
Increasing patient expectations, national
financial constraints and patients who are living
longer with more complicated health needs
mean the NHS has been under unprecedented
pressure and needs to find ways to change in
order to meet the new demands. We spent the
year looking at different ways of working to see
how we can improve our services at the same
time as becoming more efficient.
Part 1 - Chief Executive’s Statement
on Quality
This is the third quality report I have overseen
for the Trust. The quality of our services has
improved significantly during 2014/15 and I
know from the messages I receive, patients are
more satisfied than they ever have been.
The Care Quality Commission (CQC) published
its report in June 2014 into our services
following their inspection of the Trust in March
2014. We achieved an overall rating of ‘good’
and on the advice of Professor Sir Mike
Richards, chief inspector of hospitals, the Trust
was removed from special measures. I am
particularly proud of our maternity services that
were rated as ‘outstanding’ with an open culture
and strong focus on patient experience, safety
and risk management.
In particular this year, in common with many
acute Trusts, we have experienced an
unprecedented high demand for emergency
inpatient services, which has meant bed
capacity has been stretched. This has required
an intense focus on how we manage the flow
of patients through our hospitals; it has placed
additional pressure on our staff and created
challenges to maintaining the quality of care
and positive experience of patients.
To quote the CQC ‘“Excellent leadership” has
changed the culture and behaviour of staff at
Basildon and Thurrock University Hospitals
NHS Foundation Trust – and the CQC reported
“outstanding care and treatment” as well as
“innovation and good practice”.
I cannot pretend this has not been difficult, but
I do think the staff in our hospitals and those
working for other organisations that support our
hospitals have been incredible at keeping the
health system in south west Essex going during
such difficult times.
My response has been a simple one; we
couldn’t have done any of this without the
extraordinary hard work, dedication and
commitment of staff.
I am very proud of what has been achieved and
look forward to another year of putting care and
compassion at the heart of everything we do.
We have developed a positive culture, putting
patients first. We will continue to be open and
transparent, we will learn from our mistakes
and we will listen to our patients and respond
to their concerns. We have made it a priority to
encourage people to speak out if they think any
activity is jeopardising patient safety.
I can confirm to the best of my knowledge the
information contained within this document is
accurate and has received the full approval of
the Trust Board.
We recognise that this is not the end of our
journey. The CQC report did identify areas
where we need to improve and we have been
developing plans to address their concerns.
Clare Panniker
Chief Executive
7
Date: 27 May 2015
Part 2 - Priorities for Improvement
In this section of the quality report we look back at our quality goals for last year and look forward
as we set out the goals for the year ahead.
This section also includes statements about the organisation, which are intended to help people
compare different health organisations.
Looking back: priorities for improvement
in 2014/15
routine measures for the Trust on how well the
organisation is performing.
All of the goals identified in last year’s
quality account were important to the safe
and effective delivery of patient care. While
some continue to be priorities for this year
with additional resources allocated to make
further improvements, others have become
Fig.1 is a summary of the Trust’s performance
against the quality goals for 2014/15.
Fig.1: Performance against quality goals 2014/15
Patient Safety
Clinical
Effectiveness
Patient
Experience
Priority
Key objective
Measure
Rating
Improving patient safety:
Providing harm free care
to our patients both in and
out of hospital
Improving quality
and reliability of care:
Delivering excellent
outcomes for our patients
by implementing best
practice
Improving patient
and staff experience:
Providing our patients
and their carers with the
best possible experience
while they are using our
services and those of our
partners
To reduce patient
harm events
Process and
Outcome
Mostly
Achieved
To reduce harm
from deterioration
Outcome
Achieved
To improve score
for the Friends and
Family Test
Process and
Outcome
Mostly
Achieved
Red Quality priority not achieved
Amber Quality priority partially/mostly achieved
Green Quality priority achieved
8
Patient Safety Priorities 2014/15
Care that is safer:
The activities undertaken to achieve the quality goals in 2014/15 are described in further detail
below.
Fig 2: Improving patient safety
Quality
improvement goal
Aim
Achieved/
Not achieved
2013/14
2014/15 National
average
Source
Improving patient safety: Providing harm-free care to our patients both in and out of hospital.
Goal to reduce patient harm events.
Percentage of
patients with harm
free care
On or above
national average by
end of Q4
Improvement made
target not achieved
92.6%
93.8%
94.8%
HSCIC
Harm from injurious 20% reduction by
falls
end of Q4
Improvement made
target not achieved
8
1
N/A
Internal
Pressure ulcer
incidence
0.25 per 1,000 bed
days by end of Q4
Achieved
0.261
0.176
N/A
Internal
Reduction in Never
Events *
Zero
Not achieved
3
2
N/A
Internal
Reduction in
avoidable VTE
events **
20% based on Q1 & Achieved
2 outturn
14
8
N/A
Internal
* Cumulative for the year
** 14 events for the period March 2014 to September 2014 and 8 events for the period
October 2014 to March 2015
Percentage of patients with harm free care
Staff in the hospital carry out a survey once
a month on the wards looking at harm events
including:
The Trust measures harm free care through the
national benchmarking tool the Patient Safety
Thermometer. Developed by the NHS the
Safety Thermometer provides a ‘temperature
check’ on harm.
z Pressure ulcers
z Falls
z Catheter associated urine infections (UTI)
The results below reflect the work that has
been on-going throughout the year to improve
awareness of patient harm events and the
work to learn from when things go wrong and
change practices to reduce the risk of harm in
the future.
z Venous thromboembolism (VTE) events
There has been an improvement in the rate
of harm free care in 2014/15 when compared
to 2013/14, although performance is not yet
consistently on or above the national average
which was the goal set by the Trust last year.
9
dedicated time to work with staff to embed
knowledge and skills in reducing the number of
falls that result in serious injury.
The improvement made was supported by
the establishment of a Patient Harm Scrutiny
Group to ensure peer review of patient harm
events and to promote rapid sharing of any
learning from a harm event. The group’s main
achievements have been through:
Reducing harm from avoidable pressure
ulcers
z Engagement from matrons, senior sisters and
charge nurses, developing the ‘not on my
ward’ zero tolerance attitude to patient harm.
The incidence of pressure ulcers is a good
measure of the quality of care a patient
receives. If the fundamental elements of care
are in place, such as feeding and hydration,
and if patients are assessed correctly and
appropriate pressure relieving techniques are
used, then pressure ulcers should be a rare
occurrence. The Trust had a quality goal in
2014/15 to sustain a level of avoidable pressure
ulcers below 0.25 per 1,000 bed days and an
ambition to get to zero avoidable pressure
ulcers.
z Improved holding to account.
z Commissioner attendance and participation
ensuring transparency and openness to
tackling harm.
Reducing harm from falls
Accidental falls are the most commonly
reported patient safety incidents in NHS
hospitals. More than 200,000 hospital falls are
reported in English trusts each year, though
the actual figure is thought to be much higher.
Falls can lead to injury including fractures and
head injuries, impaired confidence, anxiety and
poor rehabilitation, and are a frequent factor
in patients needing long-term care. However,
there is evidence that the risk of falling in
hospital can be reduced and that these often
simple interventions can be missed.
Successes include:
z Reduce from 0.5 to 0.25 per 1,000 bed days
avoidable pressure ulcers 13/14.
z Reduce from 0.25 to 1.9 per 1,000 bed days
avoidable pressure ulcers 14/15.
The main work this year centred on targeted
support to clinical areas experiencing the
highest number of pressure ulcers. A business
case for additional Tissue Viability Nurses
was successfully submitted in 2014/15,
and the additional staff will support further
improvements in 2015/16.
This year the Trust has been involved in the
FallSafe project, which is a key initiative to
reduce harm from falls. The FallSafe project
facilitates improved knowledge and skills
among key ward staff and implements the use
of care bundles - important tasks that reduce
the risk of fall - and key visual prompts for staff
to help ensure that are aware of the risks to
their patients.
Never events
Never events are serious and largely
preventable. An updated list of never events is
published by the Department of Health each
year. This list includes a number of safetyrelated incidents that should not occur if best
practice guidance is followed.
A major initiative this year was the appointment
of the Quality Improvement Fellow with
10
Reducing harm from VTE
When a never event occurs it is essential to
ensure that learning takes place to mitigate any
risk of a similar event occurring again. This
action goes hand in hand with fully working in
partnership with the Clinical Commissioning
Group and ensuring that the patient and/
or family affected is kept fully informed and
supported through the process, in line with Duty
of Candour.
One of the Trust quality goals in 2014/15 was
to reduce the number of avoidable venous
thromboembolism (VTE) events that affect our
patients. These are blood clots that can occur
as a result of an episode of hospital care when
patients are less mobile or following surgery.
The improvement milestones we chose were:
z Quarter 1 and 2 set the baseline, we had four
events reported.
The Trust declared two never events during
2014/15. In response to these particular
incidents extensive improvement work has
been undertaken involving:
z Our improvement trajectory was to reduce by
20% and measure again in Quarter 3 and 4.
z Number of events in Quarter 3 and 4 was
three, the source of the data was from the
incident reporting system.
z Review of the compliance with the World
Health Organisation surgical checklist.
z Ensuring that local standard operating
procedures are reviewed to address the root
causes and contributory factors for these
events occurring.
z The number of reported hospital associated
VTE events may be below the number of
actual events that occur. The Trust will be
working towards ensuring all VTE events are
incident reported and investigated in 2015/16.
z Providing additional training and education to
specific staff groups involved.
z Initiatives that took place in 2014/15 included
an awareness campaign on the correct
prescription of thromboprophylaxis to reduce
the risk of blood clots occurring while patients
are in hospital.
The Trust declared three never events during
2013/14.
11
Clinical Effectiveness Priorities 2014/15
Care that is effective:
The activities undertaken to achieve the quality goals in 2014/15 are described in further detail
below.
Fig 3: Improving quality and reliability of care
Quality
improvement goal
Aim
Achieved/
Not achieved
2013/14
2014/15 National
average
Source
Improving quality and reliability of care: Delivering excellent outcomes for our patients by
implementing best practice
Goal: to reduce harm from deterioration
Reduction in
cardiac arrests
Median per 1,000
admissions
Improvement made
target not achieved
4.2
N/A
N/A
Internal
Crude mortality
On or below 1.9%
Achieved
1.8
1.8
N/A
Internal
HSMR
Below 95
Achieved
88.48
88.57
100
HSCIC
SHMI*
< 1.05
Achieved
1.04
1.03
1
HSCIC
* SHMI – Summary Hospital-level Mortality Indicator
The SHMI is the ratio between the actual number of patients who die following treatment 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.
Reducing cardiac arrests
Nationally it has been shown that two thirds
of all cardiac arrests are predictable while
one third are avoidable. A recent review into
deaths across England showed there was
often a failure to recognise deterioration and
so the Trust chose reducing cardiac arrests as
a priority in 2014/15. Unfortunately, despite
improvements, we were unable to reduce the
rate to the national median of 1.56 per 1,000
admissions. We believe we can still improve
the recognition and response to these patients
and dramatically reduce cardiac arrests. Since
April 2013 a set of quality improvements
have been implemented and have reduced
the number of cardiac arrests by a third. We
will continue to make changes to our care of
the patients at risk of deterioration and have
included this within a work stream of the ‘Sign
up to Safety’ initiative.
Crude mortality
The Trust’s rolling 12 month average for crude
mortality was 1.83%, below the 1.9% trajectory
with significant seasonal variation. This was in
line with nationally published data. Enhanced
surveillance of deaths in the winter period did
not show any clinical care concerns. Crude
mortality was chosen as a quality goal in
2014/15 and work will continue through the
deteriorating patient workstream in ‘Sign up
to Safety’ in 2015/16 to improve performance
further.
12
Hospital standardised mortality ratio (HSMR)
hospital. Rates of death take account their age,
the illness and issues such as whether they live
in a deprived area.
The hospital standardised mortality ratio
(HSMR) measures whether the number of
people who die in hospital is higher or lower
than would be expected.
This chart shows how the hospital mortality ratio
varies in relation to the national average of 100.
The information gives hospitals an indicator of
whether their mortality rates are above average
and need further investigation.
Groups of patients with conditions that
commonly result in death, such as heart attacks
or strokes, are assessed to see how many,
on average in England, survive their stay in
Fig.4: HMSR quarterly figures (Dr Foster)
Source of data: Health and Social Care Information Centre
13
Patient Experience Priorities 2014/15
Care that is personal:
The activities undertaken to achieve the quality goals in 2014/15 are described in further detail
below.
Fig.5: Activities undertaken to achieve quality goals 2014/15
Quality
improvement goal
Aim
Achieved/
Not achieved
2013/14
2014/15 National
average
Source
Improving patient and staff experience: Providing our patients and their carers with the best possible
experience while they are using our services and those of our partners
Goal: to go above and beyond the friends and family test
Patient Friends and On median
Achieved
Family test *
Response rate
Achieved
inpatient: 40% Q4 in
inpatient areas
N/A
Staff Friends and
Family Test **
N/A
Establish baseline
in Q4 for proportion
of staff uptake and
staff recommender
score
Improvement made
target not achieved
Patient Reported
Median or better
Outcome Measures
***
Data not available
Cancer survey
Not achieved
Median or better
91%
56.2%
95%
HSCIC
44.9%
HSCIC
Suppressed due to
small numbers
86%
86%
89%
HSCIC
Quality
Health
* See Part 2, vi
** See Part 2, v
*** See Part 2, ii
Cancer survey
z Any other comments?
The 2014 National Cancer Patient Experience
Survey Programme questionnaire included
three sections where patients could make
comments in their own words about the cancer
care they had received. The comments were
under the following headings:
The Cancer Patient Experience Survey 2014
follows on from previous years, designed to
monitor national progress on cancer care. The
survey includes 70 questions and is collected
against different tumour sites.
The Trust did not reach the goal of being at the
median or better for every relevant question.
The survey would be difficult to summarise
succinctly within the body of this report.
However one question offers an overview
of what patients think about their care; Q70
-Patient`s rating of care `excellent`/ `very good`.
z Was there anything particularly good about
your NHS cancer care?
z Was there anything that could have been
improved?
14
National patient survey
The 2014 score for the trust was 86%
compared to the national average of 89%.
The Care Quality Commission uses national
surveys to find out about the experience of
patients when receiving care and treatment
from healthcare organisations.
There were other areas of good performance
in the 2014 survey and areas that require
improvement. A detailed improvement plan is
being implemented.
Accident and Emergency survey
Full details of the survey method are in
the National Report of the Cancer Patient
Experience Survey 2014, are available at
www.quality-health.co.uk
During the summer 2014, a questionnaire was
sent to all patient aged 16 years or over who
attended A&E in February 2014. Responses
were received from 244 (30%) patients.
National staff survey
Fig.6 provides a summary of the survey and
how the scores compare to other trusts (the full
survey is available at www.cqc.org.uk)
For the third year running, the national NHS
staff survey shows an increase in the number
of staff who would be happy with the standard
of care at the Trust if a relative or friend needed
treatment here.
In 2014, 64% of our staff would be happy
with the standard of care provided by this
organisation compared to the national average
of 65%.
In addition nearly three quarters of staff said
that patient care is the Trust’s top priority; in
the latest survey, 74% said they agreed with
this statement. The annual survey asks NHS
staff to give their views anonymously about
their experiences at work, including reporting
incidents, training and stress.
The 2014 survey also showed that nine out of
ten staff agree their role makes a difference to
patients and 80 per cent are satisfied with the
quality of work and patient care they are able to
deliver (both above the national average).
However there was a slight decrease in the
number of respondents who would recommend
the Trust as a place to work, from 56% in 2013
to 54% in 2014.
Improvements needed include job relevant
training for staff and supporting staff to raise
concerns. Action plans for improvements are
being prepared by the relevant divisions.
15
Fig 6: Summary of Accident and Emergency Survey 2014
Section
How this score
compares with other
Trusts
Score
Arrival at A&E
8.1/10
Worse
About
the
same
Better
Waiting times
6.1/10
Worse
About
the
same
Better
Doctors and nurses
8.4/10
Worse
About
the
same
Better
Care and treatment
7.8/10
Worse
About
the
same
Better
Tests
8.3/10
Worse
About
the
same
Better
Hospital environment and facilities
8.4/10
Worse
About
the
same
Better
Leaving A&E
6.1/10
Worse
About
the
same
Better
Experience overall
8.4/10
Worse
About
the
same
Better
The survey shows that the Trust ranks similar to other Trusts
Looking forward: priorities for improvement in 2015/16
to develop a culture of safety, which anticipates
safety risks and shows preparedness to
respond.
Setting the quality agenda
The Trust aims to provide a safe environment
for patients. We understand that treatments
have inherent risks associated with them but
we want to ensure that we are continuously
working towards reducing harm and learning
when things do go wrong. We promote and
encourage an open and transparent culture,
and Trust staff are actively supported and
encouraged to report and speak up when they
identify a risk or something has gone wrong.
The Trust has made a huge improvement in
this area and we are now in the top 10% in
England for reporting such incidents. Our aim is
Following consultation with stakeholders,
the areas listed below will form the core of
our quality improvement work for 2015/16,
supporting the clinical strategy strategic
objective ‘deliver high quality care wherever
needed’.
Care that is safer:
z Reducing harm from hospital acquired
pressure ulcers
z Reducing harm from injurious falls
16
Organisations and individuals who sign up to
the campaign commit to setting out actions they
will undertake in response to the following five
pledges:
Care that is reliable:
z Further reduce hospital mortality (measured
through Hospital Standardised Mortality
Ratio, (HSMR) and Summary Hospitallevel Mortality Indicator (SHMI) and crude
mortality)
z Put safety first
Commit to reduce avoidable harm in the NHS
by half and make public the goals and plans
developed locally.
z Reducing harm from deterioration by
reducing our cardiac arrest rate
z Continually learn
Make their organisations more resilient to
risks, by acting on the feedback from patients
and by constantly measuring and monitoring
how safe their services are.
Care that is personal:
z Improve both the response rate and
recommender score for the Friends and
Family Test
We aim to do this within the framework
provided through the national ‘Sign up to Safety’
campaign.
z Honesty
Be transparent with people about their
progress to tackle patient safety issues and
support staff to be candid with patients and
their families if something goes wrong.
The ‘Sign up to Safety’ campaign is designed
to help realise the ambition of making the
NHS the safest healthcare system in the world
by creating a system devoted to continuous
learning and improvement. This ambition is
bigger than any individual or organisation and
achieving it requires us all to unite behind this
common purpose. We need to give patients
confidence that we are doing all we can to
ensure that the care they receive will be safe
and effective at all times.
z Collaborate
Take a leading role in supporting local
collaborative learning, so that improvements
are made across all of the local services that
patients use.
z Support
Help people understand why things go wrong
and how to put them right. Give staff the time
and support to improve and celebrate the
progress.
‘Sign up to Safety’ aims to deliver harm-free
care for every patient, every time, everywhere.
It champions openness and honesty and
supports everyone to improve patient safety.
The Trust has completed a Safety Improvement
Plan, which sets out the organisation’s plans
for the next 3-5 years in relation to quality and
safety.
17
Professor Bohmer Programme
Developing quality improvement
capacity and capability
We have been working with Professor Bohmer
(Harvard Business School) to transform the
Trust into a truly clinically-led organisation. The
programme commenced in April 2014, when
65 senior clinical leaders attended monthly
sessions to learn more about how to approach
whole system re-design.
The quality goals identified above were not the
only improvements we made to our services.
The following are a few examples of good
practice that we are proud to report in our
quality report.
A key aim has been to increase the capacity
of our workforce to deliver care that is
compassionate as well as safe and effective.
Staff worked in teams while being mentored by
Professor Bohmer on a range of projects, with
the aim of improving the services we provide.
Schwartz Rounds
The aims of the programme are:
Working in healthcare can be stressful to a
degree rarely seen in other professions. Our
staff make decisions that have life and death
implications and so need to develop strategies
to deal with this. In a culture envisaged as
‘don’t moan’ and ‘don’t hesitate to cope’, NHS
workers are generally not good at talking to
each other about how they are feeling.
z To define the Trust’s approach to improving
quality across the whole system for defined
populations
Schwartz Rounds were developed in the United
States about 20 years ago by the Schwartz
Centre for Compassionate Healthcare. The
founder, Ken Schwartz, was a healthcare
attorney who at the age of 40 developed
terminal lung cancer. During the 10 months
up to his death he wrote movingly about his
experience.
z To develop a core group of clinicians who
lead improvement programmes each year
z To develop the capabilities of senior leaders
within the organisation
z To demonstrate clear improvements in care
for defined populations
In putting this into practice, clinical teams work
with patients to understand and define what
they value most about their care. They are then
expected to take a critical look at the current
operating system and propose a new model of
care, including how patient experience will be
measured. This encourages clinicians to be
outward-looking, to identify who is delivering
new models of care as well as encouraging
internal and local innovation.
Schwartz Rounds are structured meetings
for all members of clinical and non-clinical
staff. They consist of brief presentations from
three or four staff members about a particular
experience followed by a facilitated discussion
on the emotional aspects of caring in that
situation. Everything that is said during the
meeting is regarded as confidential.
In 2015/16 a second cohort will go through
the programme to ensure sustainability and to
develop further capacity and capabilities.
We have held six rounds at the Trust, all of
which have been well attended and evaluated
by our staff.
18
Improvement advisor role
Sepsis six care bundle
The Trust has an ambition to become one
of the safest organisations in the NHS. We
knew that we could improve but we needed
to build capacity within our clinical teams to
make the changes necessary to ensure reliable
compliance with best practice. One of the ways
we achieved this was to introduce the role of
improvement advisor, to:
A number of serious incident investigations
highlighted a delay in recognising and treating
sepsis. Research evidence shows that the
sepsis six care bundle (a series of tasks and
interventions that should take place if sepsis
is suspected) is proven to reduce deaths and
complications related to sepsis. The sepsis
care bundle had already been implemented
across the Trust but there was wide variation
in its use and few measures to demonstrate
its effectiveness, so it was time for a new
approach.
z Develop the ‘introduction to Quality
Improvement’ (QI) course and train members
of staff to deliver the course independently
z Support the existing clinical effectiveness
team to adopt a QI approach to bring about
change in practice
Our aim was to halve the number of deaths
from sepsis within one year, ensure reliable
recognition and use of the sepsis care bundle
and delivery of the highest quality care for the
patient, every time.
z Support the clinical effectiveness team in
their advisory role with individual projects
z Coach individual staff on quality based
projects
An improvement advisor from UCLPartners
worked with us to facilitate the quality
improvement approach in our accident and
emergency department. They identified a
sepsis champion within the department and
trained them to develop staff capabilities and
deliver sustainable results. Several small
changes were introduced alongside a cultural
shift to collect and act upon real-time data,
which is fed back to frontline staff.
z Lead the adoption of the QI approach within
existing Trust improvement teams, planning
and testing change related to patients at risk
of deterioration
z Raise patient safety issues when highlighted
through QI work
As well as improving our capacity to make care
safer and more effective, they did targeted work
to:
Our results show a 58% sustained reduction
in sepsis related mortality, and improvements
in the consistency of care delivered. It
demonstrates that through relentless regular
measurement and using data for improvement,
patient care can improve in quality, safety,
experience and productivity with a reduced
length of stay.
z Reduce harm from falls
z Improve compliance with the sepsis care
bundles (a tool that helps staff to treat
infections earlier and more effectively)
z Ensure fewer errors in blood sampling
z Reduce cardiac arrests
19
Commissioners have invested an additional
£1million for stroke services at Basildon
Hospital to bring them up to the highest
standards. A long term decision on the
organisation of stroke services in south Essex
has yet to be made, but the extra funding will
ensure patients receive high quality stroke care.
Improving stroke care
The care and treatment of stroke patients at
Basildon University Hospital has improved
significantly over the last three years, according
to the latest figures from the National Stroke
Strategy.
During the first half of 2014, the care of stroke
patients exceeded the required level for four out
of five key standards:
So far, the Trust has used some of the extra
funding to extend consultant cover to seven
days a week and for additional staff including
a consultant, eight nurses to care for stroke
patients, six occupational therapists, six
physiotherapists, a speech therapists and a
psychological support worker.
z Patients with suspected stroke who are
scanned within an hour of arriving at hospital
– 75%, compared to 31% in 2011.
z Patients receiving clot-busting medication, if
appropriate, within three hours of arrival at
hospital -15%, compared to 4% in 2011.
Extending radiology hours for CT and MRI
scans
z Patients with transient ischaemic attack (mini
stroke) not admitted but treated within
24 hours – 66%, compared to 55% in 2011.
Patients and staff are feeling the benefit of
reduced waiting times following the extension
of the radiology hours for routine CT and MRI
scans.
z Proportion of stroke patients admitted to
hospital who spend 90% of their stay on a
specialist stroke ward – 89%, compared to
76% in 2011.
In the past only clinically urgent scans would be
carried out between 5pm and 9am. This meant
that routine inpatient scans might need to wait
until the next day if there weren’t enough slots
to meet demand, and that any patient admitted
or seen after 5pm would have to wait until the
next day.
The standard that the Trust did not meet relates
to the time taken to settle the patient on the
stroke unit once a decision has been made to
admit them. The national standard requires
that 90% of patients should go to the stroke
unit within four hours. The Trust achieved this
for 80% of patients, which is short of the target
but a significant improvement since 2011, when
just 41% of patients were placed on the stroke
unit within the time limit. Action has been taken
to address the shortfall, including an improved
triage and assessment system to help nurses
identify patients arriving at A&E who are not
showing obvious signs of stroke.
Since January 2015, there has been a
radiologist on site seven days a week. Routine
inpatient scans are carried out 9am to 8pm
Monday-Friday, and 9am to 4pm at weekends,
(with a radiologist available 4pm to 8pm from
home). Outside these hours there is an on-call
radiologist to report on urgent scans, which is
provided on an outsourced basis.
20
The dementia project was officially launched
with the opening of a new reminiscence room at
Basildon University Hospital. The 50’s-themed
room includes a kitchen and living room area,
old-fashioned furnishings and a TV, giving a
familiar background to activities for patients with
dementia, for who the hospital environment can
seem extremely daunting.
The number of patients now waiting for scans
at the beginning of each day has reduced
from 20 to less than five. With careful planning
outpatients can also be scanned in the evening,
which has a direct impact on both the
two-week cancer pathway and 18-week referral
to treatment pathway. Extending the scanning
day also makes more effective and productive
use of the scanners.
Award-winning cancer services
Dementia project
The team at Basildon University Hospital who
care for people with cancer won the Cancer
Team of the Year award in the national Quality
in Care Programme which recognises and
rewards good practice in the NHS. The staff
were commended for their work to integrate
cancer care in hospital and for improving care
for patients by co-ordinating their services
effectively.
It is estimated that there are 850,000 people
with dementia in the UK, and that 1 in 14 people
over the age of 65 has dementia.
Each year in our hospitals we care for hundreds
of patients with dementia. They will be in
hospital for many reasons, but we also need to
ensure that we meet any additional needs they
have due to their dementia.
The cancer service at Basildon University
Hospital is exceptional in that it co-ordinates
three teams – Acute Oncology, Cancer of
Unknown Primary and Specialist Palliative
Care.
To provide a focus to improving care for patients
with dementia, the Trust has established the
Dementia Project.
Areas the dementia project is concentrating on
include:
The acute oncology service offers prompt
assessment and advice, seven days a week,
for people with cancer that suffer side effects
or complications, as a result of their condition,
or because of the cancer treatment they are
receiving. These side effects are most likely
to occur within six weeks of cancer treatment,
and may include nausea and vomiting, or more
serious conditions such as neutropenic sepsis,
an infection which requires rapid treatment
with antibiotics. When cancer patients come
to the accident and emergency department
for treatment, or are admitted to other wards
in hospital, they are assessed by a specialist
acute oncology nurse, to ensure that they
receive timely and quality care.
z Creating dementia friends, linking with the
Alzheimer’s Society. Dementia friends learn
about what it’s like to live with dementia and
then turn that understanding into action.
z Identifying dementia champions on each
ward.
z Developing a dementia ‘care bundle’, which
is a set of documents that describe the care
to be provided.
z Setting up a carers forum.
z Ensuring there is high quality staff education,
training and support.
21
The Cancer of Unknown Primary service (CUP)
is the only one of its kind in south Essex, and
was established last year. It provides care for
patients who have advanced cancer but the
exact type cannot be identified. In England and
Wales, more than 10,000 cases of CUP occur
annually and it is the fourth most common
cause of cancer death.
Statements of assurance
In this section of the quality report the Trust
must include certain statements, in common
with other Trusts, to enable comparisons to be
made between organisations.
Statements from Directors
The Statements from Directors confirm that the
information in the quality report is an accurate
reflection of quality in the organisation.
The Macmillan Specialist Palliative Care
Service also provides a seven day a week
service at Basildon University Hospital, from
9am to 5pm. Telephone advice and face-to-face
assessments are available for patients with
specialist palliative care needs.
Please see appendix 1.
Parents praise care for youngest patients
The care provided to babies at Basildon
University Hospital received praise in a recent
survey carried out among parents in the
neonatal intensive care unit, which shows an
extremely high level of satisfaction with the
service for premature and seriously ill babies.
Parents were asked 24 questions about the
care and communication they received on the
unit. The response was 100 per cent positive to
11 questions, and over 90 per cent positive to a
further 10 questions.
Parents commented on how friendly and
helpful they found the staff, and said that they
were given useful advice about feeding and
equipment.
22
Reporting against core indicators
The following indicators are mandated in all
quality reports and so help stakeholders and
the public compare the Trust’s performance with
other organisations providing health care.
occur if they were conforming to the national
average. The measure takes into account
factors such as differences in age, sex,
diagnosis, type of admission and other
diseases (co-morbidity). This figure is
compared with the number of deaths that
did occur in the hospital and the SHMI is the
ratio between the two. If the same number
of deaths occurred as expected the ratio will
be one. A SHMI of greater than one implies
more deaths occurred than predicted by the
measure.
i) Summary Hospital-Level Mortality
Indicator
NHS England has created a method for
measuring hospital death rates. This
measure is known as SHMI - summary
hospital-level mortality indicator.
The SHMI measure is based on national
data, which calculates for each hospital
how many deaths would be expected to
Figs. 7a, 7b and 8 show the values for SHMI
for the Trust for the reporting period.
Fig.7a: Our latest SHMI result for the period to September 2014 is 1.03.
The banding is 2 (banding is a rating score from 1 to 3 with 1 being the best)
Publication
Reporting period
Date
Jan 2015 Jul 2013 - Jun 2014
Apr 2015
Oct 2013 - Sep 2014
1.040
National
Average
1.0
National
Lowest
0.893
National
Highest
1.119
1.030
1.0
0.597
1.107
BTUH value
Fig.7b: SHMI for period July 2012 to September 2014
Fig.8: The percentage of patient deaths with palliative care coded at either diagnosis or
speciality level for the Trust is 27.7%
Publication
Reporting period
Date
Jan 2015 Jul 2013 - Jun 2014
Apr 2015
Oct 2013 - Sep 2014
28.1%
National
Average
24.6%
National
Lowest
7.4%
National
Highest
49.0%
27.8%
25.4%
7.5%
49.4%
BTUH value
Source of data: Health and Social Care Information Centre
23
The Trust considers that this data is as
described for the following reasons: the
data is reported and monitored externally to
the Trust, and is based on data published
by the Health and Social Care Information
Centre, the Trust also uses a proxy measure
to calculate hospital mortality which helps
assess the validity of all mortality data.
effectively and ensuring a senior clinical
review within 12 hours of admission and then
daily.
ii) Patient Reported Outcome Measures
(PROMs)
PROMs calculate the health benefits for
patients after surgical treatment using preand post-operative surveys. Figs. 9 to 12 set
out key statistics on patients’ self-reported
health before undergoing four common
elective surgical procedures. It includes
analysis of questionnaires that all NHS
hospitals asked to collect from all willing
patients. A higher number indicates a more
positive response.
Reducing SHMI continues to be a quality
priority for the Trust in 2015/16. The Trust
intends to take the following actions to
improve the SHMI, and so the quality of its
services, by continuing the work streams
to reduce patient harm from deterioration,
avoidable cardiac arrests, avoiding harm
from sepsis; treating acute kidney injury
Fig.9: Groin hernia surgery
Publication
Reporting period
Date
February April 2013 to
EQ-5D Index
2015
March 2014
EQ VAS
February
2015
EQ-5D Index
April 2014 to
September 2014
EQ VAS
(provisional)
BTUH value
0.067
-0.918
Suppressed
due to small
numbers of
questionnaires
returned
National
Average
0.085
-1.053
0.081
National
Lowest
0.008
-5.791
0.009
National
Highest
0.139
2.864
0.125
-0.397
-4.070
3.237
National
Average
0.436
11.487
21.340
National
Lowest
0.342
7.005
17.634
National
Highest
0.545
17.189
24.444
0.442
0.350
0.501
12.162
5.380
16.537
21.922
18.357
25.418
Fig.10: Hip replacement surgery
Publication
Reporting period
Date
February April 2013 to
EQ-5D Index
2015
March 2014
EQ VAS
February
2015
Oxford Hip
Score
EQ-5D Index
April 2014 to
September 2014
EQ VAS
(provisional)
Oxford Hip
Score
BTUH value
0.447
10.711
21.661
Suppressed
due to small
numbers of
questionnaires
returned
24
Fig.11: Knee replacement surgery
Publication
Reporting period
Date
February April 2013 to
EQ-5D Index
2015
March 2014
EQ VAS
Oxford Knee
Score
EQ-5D Index
February April 2014 to
2015
September 2014
EQ VAS
(provisional)
Oxford Knee
Score
BTUH value
0.275
3.788
15.893
Suppressed
due to small
numbers of
questionnaires
returned
National
Average
0.323
5.640
16.248
National
Lowest
0.215
-1.547
12.049
National
Highest
0.416
15.401
19.762
0.328
0.249
0.394
6.369
-0.665
12.508
16.702
14.416
20.440
National
Average
0.093
-0.553
-8.698
National
Lowest
0.023
-7.677
-16.849
National
Highest
0.150
4.093
11.292
0.100
0.054
0.142
-0.465
-2.799
3.955
-9.479
-16.762
-4.567
Fig.12: Varicose vein surgery
Publication
Reporting period
Date
February April 2013 to
EQ-5D Index
2015
March 2014
EQ VAS
February
2015
Aberdeen
Questionnaire
EQ-5D Index
April 2014 to
September 2014
EQ VAS
(provisional)
BTUH value
Suppressed
due to small
numbers of
questionnaires
returned
Aberdeen
Questionnaire
Data source: Health and Social Care Information Centre
quality of its services, by changing elective
service provision in the following ways:
The Trust considers that this data is as
described for the following reasons: The data
is collected independently of the Trust by an
approved provider and analysed and published
by the Health and Social Care Information
Centre. Unfortunately some of the sample sizes
were too small to analyse.
z Musculoskeletal hub referring into hip and
knee subspecialty clinics
The Trust intends to take the following actions
to improve the PROMs scores, and so the
z New procedure to create a ‘ring-fenced’
orthopaedic only ward – Horndon Ward
z Ensuring a specified number of consultants
performing the procedures
z All post-op patients receiving physiotherapy
from Trust services.
25
(This data has not been published nationally
since 2011, however it is a requirement within
the Quality Account reporting guidelines)
iii) Emergency readmissions to hospital
within 28 days
Emergency readmission indicators help
the NHS monitor success in avoiding
(or reducing to a minimum) readmission
following discharge from hospital.
The Trust considers that the data published
in 2013 is as described for the following
reasons the data is collated nationally and
is published by the Health and Social Care
information centre.
Not all emergency readmissions are likely to
be part of the originally planned treatment
and some may be avoidable. To prevent
avoidable readmissions it may help to
compare figures with and learn lessons from
organisations with low readmission rates.
The national highest and lowest figures
are for comparable medium acute trusts
as defined in the report, while the national
average is across all trusts.
The Trust intends to take the following
actions to improve the emergency
readmission rates within 28 days, and so
the quality of its services: undertaking audits
of the reason for readmission to ensure
that any relevant learning can be shared
within the Trust to where possible prevent
unnecessary readmissions.
Comparison of emergency readmissions to hospital within 28 days of discharge: indirectly
standardised percentage (2003/04 to 2011/12) .
Fig.13: All emergency readmissions (16+ yrs)
Publication
Date
December
2013
December
2013
9.18%
National
Average
11.43%
National
Lowest
4.88%
National
Highest
17.15%
9.05%
11.45%
6.67%
17.10%
National
Lowest
3.75%
National
Highest
14.94%
4.04%
16.05%
Reporting period
BTUH value
March 2010 to April
2011
March 2011 to April
2012
Fig.14: All emergency readmissions (0-15 yrs)
Publication
Date
December
2013
December
2013
Reporting period
BTUH value
March 2011 to April
2012
March 2010 to April
2011
7.25
National
Average
10.01%
8.61
10.01%
Data source: Health and Social Care Information Centre
26
iv) Trust responsiveness to patient needs
The Trust considers that this data is as
described for the following reasons: it is
collected independently from the Trust and
published by the Care Quality Commission.
Patient experience is a key measure of the
quality of care. The NHS should continually
strive to be more responsive to the needs of
those using its services, including the need
for privacy, information and involvement in
decisions.
The Trust intends to take the following
actions to improve the staff responsiveness
to patients needs and so the quality of its
services, by implementing the following
patient experience improvement programme:
Improving hospitals’ responsiveness to
personal needs is a key indication of the
quality of patient experience. This score is
based on the average of answers to five
questions from the National Inpatient Survey
(figs. 15 to 19):
z See vi) Friends and Family Test
Fig.15: Q32: Were you involved as much as you wanted to be in decisions about your care
and treatment?
Publication
Reporting period
Date
May 2014 September 2013 to
January 2014
May 2015 September 2014 to
January 2015
6.9
National
Average
n/a
National
Lowest
5.9
National
Highest
8.6
7.2
n/a
6.1
9.2
BTUH value
Fig.16: Q34: Did you find someone on the hospital staff to talk to about your worries and
fears?
Publication
Reporting period
Date
May 2014 September 2013 to
January 2014
May 2015 September 2014 to
January 2015
5.6
National
Average
n/a
National
Lowest
3.9
National
Highest
8.1
8.0
n/a
7.0
9.5
BTUH value
27
Fig.17: Q36: Were you given enough privacy when discussing your condition or treatment?
Publication
Reporting period
Date
May 2014 September 2013 to
January 2014
May 2015 September 2014 to
January 2015
8.5
National
Average
n/a
National
Lowest
7.6
National
Highest
9.2
7.3
n/a
5.7
9.0
BTUH value
Fig.18: Q56: Did a member of staff tell you about medication side effects to watch for when
you went home?
Publication
Reporting period
Date
May 2014 September 2013 to
January 2014
May 2015 September 2014 to
January 2015
4.0
National
Average
n/a
National
Lowest
3.6
National
Highest
7.4
8.1
n/a
7.3
9.7
BTUH value
Fig.19: Q63: Did hospital staff tell you who to contact if you were worried about your
condition or treatment after you left hospital?
Publication
Reporting period
Date
May 2014 September 2013 to
January 2014
May 2015 September 2014 to
January 2015
7.4
National
Average
n/a
National
Lowest
6.2
National
Highest
9.7
7.7
n/a
6.4
9.7
BTUH value
Data source: Care Quality Commission
28
The Trust considers that this data is as
described for the following reason; it is
collected and analysed independently of the
Trust.
v) Staff recommender score
The staff recommender score below is taken
from the national Staff Survey. In April 2014,
NHS England introduced the Staff Friends
and Family Test (FFT) in all NHS trusts
providing acute, community, ambulance and
mental health services in England.
The Trust intends to take the following
actions to improve the staff recommender
score and so the quality of its services,
by: continuing to engage with and listen
to staff views about working for the Trust;
maintaining the quarterly mini staff survey to
help facilitate rapid intervention when staff
identify problems and issues affecting care;
to continue to hold open forum sessions with
staff to listen to their views and through the
‘Stepping Up’ meetings help each morning
to listen to staff feedback on the issues that
may impact on their ability to deliver care that
is safe and effective.
NHS England’s vision is that all staff should
have the opportunity to feedback their views
on their organisation at least once per year.
It is hoped that Staff FFT will help to promote
a big cultural shift in the NHS, where staff
have further opportunity and confidence to
speak up, and where the views of staff are
increasingly heard and are acted upon.
The data in Fig.20 is taken from the national
Staff Survey carried out in 2014. It shows that
the recommender score has improved since
last year and is now close to the national
average for acute trusts.
Fig.20: Staff recommender score improvement
Publication
Reporting period
Date
February September 2013
2014
February September 2014
2015
3.63
National
Average
3.66
National
Lowest
2.78
National
Highest
4.25
3.65
3.67
3.00
4.20
BTUH value
Data source: National NHS Staff Survey 2014 – acute trusts Health and Social Care Information Centre
29
vi) Friends and Family Test – Patient
recommender score
The NHS Friends and Family Test (FFT)
provides feedback on the services provided
by the Trust and includes inpatient areas and
the Accident and Emergency Department.
Feedback is used to help The Trust to
improve services for everyone.
Please note there is not a comparable score
for response rates for 2013/14 as the scoring
system changed during 2014.
Fig.21: Inpatients - % recommended
Publication
Reporting period
Date
April 2015 February 2015
May 2015 March 2015
94%
National
Average
95%
National
Lowest
82%
National
Highest
100%
91%
95%
78%
100%
BTUH value
Response rates for March 2015 were 56.2% with a national average of 44.9%.
z Develop an experience-sharing learning
method ‘see it my way’ where members of
staff and patients get together to share their
experiences and discuss together ways to
improve services
The Trust considers that this data is as
described for the following reason: it is analysed
independently of the Trust.
The Trust intends to take the following actions
to improve the staff recommender score and so
the quality of its services:
z Develop a Trust patient experience video to
train staff.
z Involve people who have made a complaint in
service redesign and improvement
z Introduce an inpatient information booklet,
and amenity packs for emergency admissions
30
vii) VTE assessment
VTE assessment is a national patient safety
initiative to reduce avoidable deaths from blood
clots that may develop as a result of admission
to hospital. When patients are assessed and
treated appropriately, it can significantly reduce
rates of mortality associated with this condition.
The Trust met the target for 2014/15 to ensure
that risk assessments are recorded for 95% or
above of all patients admitted to the Trust.
Fig.22: VTE assessment
Publication
Reporting period
Date
March 2015 February 2015
April 2015
100%
National
Average
95%
National
Lowest
N/A
National
Highest
N/A
100%
95%
N/A
N/A
BTUH value
March 2015
Data source: VTE assessment daily recording on electronic patient record system (EPR)
The Trust considers that this data is as
described for the following reasons:
The Trust intends to take the following
actions to improve the VTE risk assessment
scores, and so the quality of its services, by:
introducing a new thrombosis improvement
plan in 2015/16 with the aim of continuing
improvements in compliance with assessment
and effective prophylaxis and by undertaking
root cause analysis on all hospital associated
VTE events.
z We measure VTE assessment electronically
daily to make sure that we can sustain our
performance. We also carry out a monthly
audit of a sample of patient notes to see if
when a risk is identified, the correct treatment
plan is put in place.
31
a higher number of cases, to identify
any additional areas for concern and
make recommendations for change or
improvement that may not have previously
been considered. Further work with PHE’s
regional epidemiology unit and the wider
local health economy continues to be
undertaken during 2015/16 to identify areas
which may impact on reduction of cases.
The threshold for 2015/16 has been set at
31 cases.
vii) Rate per 100,000 bed days Clostridium
difficile
Upon notification, all cases of Clostridium
difficile (C.difficile) are reported to a national
Public Health England data capture system.
A root cause analysis (RCA) is instigated
by the Trust for all cases identified 72 hours
after admission.
The total number of cases of C. difficile
attributed to the Trust since April 2014 is
37 against a trajectory of 18. The number
of cases per month has reduced since an
increase in June – August 2014. Much work
has been undertaken by all staff to reduce
the number of cases including managing
patients identified as carriers in the same
way as those with C. difficile infection.
The Trust considers that this data is as
described for the following reasons: The
data is reported nationally and although
higher than last year is within expected
limits.
The Trust intends to take the following
actions to improve the rate of Clostridium
difficile and so the quality of its services, by
continuing to apply and embed practice in
accordance with Trust infection prevention
and control policies.
Due to the number of cases of C. difficile,
Public Health England (PHE) were
invited to undertake a peer review, this
included scrutiny of the RCAs undertaken
and ward visits where there had been
Fig.23: Clostridium difficile - bed days (rate per 100,000)
Publication
Reporting period
Date
July 2014
April 2012 to March
2013
July 2014
April 2013 to March
2014
13.3
National
Average
17.4
National
Lowest
0.0
National
Highest
31.2
8.8
14.7
0.0
37.1
BTUH value
Data source: Public Health England Report
32
Clinical Governance and Risk Department,
and subsequently presented to the
Executive Directors for final ratification.
All serious incidents are shared with
the Clinical Commissioning Group, who
externally review all serious incident
investigations to provide an external
independent assurance function.
viii) Rate of patient safety incidents
Trust staff are actively supported and
encouraged to report incidents and near
misses as part of a culture that puts a high
priority on patient safety. Some incidents
that occur in the NHS are defined as
serious incidents (SIs). Serious incidents in
healthcare are uncommon but when they
occur NHS trusts have a responsibility to
ensure these are thoroughly investigated
so that action can be taken, and lessons
learned to mitigate the risk of similar
incidents occurring in the future.
The Trust promotes a ‘fair and just’ culture,
which encourages staff confidence to report
any concerns. The purpose of investigation
is to encourage openness, learning is
shared widely and quality improvement is
positively endorsed, so that care provided
to patients is continually improved. In
addition, continuous analysis of incidents
and serious incidents is undertaken and
shared widely across the organisation.
Where any areas of concern are identified,
then specific actions are taken to undertake
a deeper level of investigation, so that
potential risks are mitigated.
When a serious incident occurs, the Trust
appoints a trained investigating officer to
ensure that the circumstances surrounding
the incident are investigated in accordance
with Root Cause Analysis best practice.
They are also responsible for making
recommendations that are implemented
by the relevant department. Evidence
to support that these actions have been
completed is reviewed by the corporate
Fig.24: Rate of patient safety incidents
Publication Reporting
Date
period
April 2015
April 2015
October 2013 to
March 2014
April 2014 to
September 2014
Number of patient
safety incidents
% resulting in severe
harm or death
Number of patient
safety incidents
% resulting in severe
harm or death
Data source: National Reporting and Learning Service
33
BTUH
value
4,517
National
Average
3,083
National
Lowest
1,048
National
Highest
5,495
1.1%
0.7%
0%
2.3%
5,662
4,196
35
12,020
0.2%
0.5%
0%
82.9%
During 2014/15 further development work
has been focussed on the improvements
already seen in 2013/14, which have
included:
z Data is reported from ward to board on a
monthly basis, outlining trend analysis and
evidence of compliance against internal and
external Key Performance Indicators
z Falls prevention
z This data are supported through externally
verified sources, including NHS England and
the National Reporting and Learning Service
(NRLS). The Clinical Governance and Risk
team have a robust process for the daily
upload of data to the NRLS which includes
a weekly reconciliation between internal
submitted incident reports and externally
uploaded reports to NRLS. If a discrepancy
rate is identified the team undertake analysis
and review to identify any potential errors.
z Pressure ulcer prevention
z Identification and management of the
deteriorating patient
The Trust has ensured that incident
reporting and risk assessment has become
mandatory training for all staff (clinical and
non-clinical). Further bespoke training
sessions are provided for those staff who
have the responsibility of investigating
incidents, and managing risk in their areas
of responsibility.
z NRLS summary reports are reported
internally to the Trust Board and analysis
includes a review of the Trust’s national
benchmark position.
The evidence of improvement related to
incident reporting can be evidenced as the
number of incidents reported during April
2014 to September 2014 was 5,662. This is
a 25% increase on October 2013 to March
2014. Out of the 5,662 incidents reported
in April 2014 to September 2014, 0.2%
resulted in severe harm or death. This is a
significant improvement on 1.1% reported
for the previous period.
The Trust intends to take the following actions
to improve the incidents resulting in severe
harm or death and so the quality of its services,
by:
z Continuing to undertake robust serious
incident investigations into all incidents that
evidence moderate harm or greater, and also
for those incidents that pose a significant risk
to patient safety.
This is a strong indicator that the increase
in reporting, supported by the marked
reduction in the percentage of harm
resulting in severe harm or death, shows
that patient safety remains the highest
priority for all staff working at the Trust.
z Continuing to undertake chief executive
chaired scrutiny panels whenever a trend is
identified that poses a risk to patient safety.
z Utilising incident data as a means by which
‘near miss’ incidents are reviewed to predict
any future risk to patient experience, patient
safety, by closely working with any location/
profession/specialty based ‘hot spot’.
The Trust considers that this data is as
described for the following reasons:
z The Clinical Governance and Risk team
review every individual reported patient
safety incident as part of an internal daily
safety briefing process.
34
z Continuing to improve the levels of support
and information sharing with patients and
families affected by serious incidents through
the Duty of Candour. Openly investigating
all severe harm or death incidents using
a comprehensive root cause analysis
investigation as part of the serious incident
process.
Participation in Clinical Audits
National Clinical Audits
The national clinical audits and national
confidential enquires that Basildon and
Thurrock University Hospitals NHS Foundation
Trust participated in, and for which data
collection was completed during 2014/15, are
listed in Fig.25 overpage alongside the number
of cases submitted to each audit or enquiry as
a percentage of the number of registered cases
required by the terms of that audit or enquiry
(Fig.26).
z Continuous development of systems and
processes to support cross-divisional learning
from all reported incidents.
z Robust processes to assure key
recommendations and actions from serious
incident investigations lead to genuine
improvement in care pathways for patients
During that period the Trust participated in
100% (41/41) national clinical audits and
100% (4) national confidential enquiries of the
national clinical audits and national confidential
enquiries which it was eligible to participate in.
Review of services
During the reporting period 2014/15 Basildon
and Thurrock University Hospitals NHS
Foundation Trust provided and/or subcontracted
36 relevant health services.
Basildon and Thurrock University Hospitals
NHS Foundation Trust has reviewed all the data
available to them on the quality of care in 36 of
these relevant health services.
The income generated by the relevant health
services reviewed in reporting period 2014/15
represents 90.3% per cent of the total income
generated from the provision of relevant
services by Basildon and Thurrock University
Hospitals NHS Foundation Trust for reporting
period 2014/15.
35
Fig.25: Data collection/participation for National Clinical Audit 2014/15
Target
sample size
Cases
submitted
(%)
Adult Cardiac Surgery (SCTS)
All cases
100%
Adult community acquired pneumonia
All cases
In progress
BCIS Cardiovascular Intervention (Coronary Angioplasty) 2014
All cases
100%
BTS Pleural procedures Audit
All cases
100%
Case Mix Programme (ICNARC)
All cases
100%
CEM Fitting child (care in emergency departments)
Max of 50
100%
CEM Mental health (care in emergency departments)
Max of 50
100%
CEM Older people (care in emergency departments)
Max of 100
100%
Congenital Heart Disease (Paediatric cardiac surgery)
All cases
100%
DAHNO National Head & Neck Cancer Audit
All cases
100%
Epilepsy 12 (Childhood epilepsy)
All cases
100%
Falls & Fragility Fractures Audit Programme (FFFAP) (National Hip
Fracture Database & Audit of falls & bone health NAFBH)
All cases
100%
IBD Inflammatory bowel disease Audit
All cases
In progress
IBD Inflammatory bowel disease Biologics
All cases
100%
Maternal, Newborn & Infant Clinical Outcome Review Programme
(MBRRACE-UK)
All cases
100%
MINAP Myocardial Infarction National Audit
All cases
100%
National Audit of Dementia (care in general hospitals) Pilot
All cases
In progress
National Bowel Cancer Audit 2014
All cases
In progress
National Cardiac Arrest Audit (NCAA)
All cases
100%
National Cardiac Rhythm Audit (Cardiac arrhythmia)
All cases
In progress
National Comparative Audits of Blood Transfusion Programme
All cases
100%
National Diabetes Core Audit (NDA)
All cases
100%
National Diabetes Foot Care Audit NDFA
All cases
In progress
National Diabetes Inpatient Audit (NADIA) 2014
All cases
100%
National Emergency Laparotomy Audit (NELA)
All cases
In progress
National Clinical Audit
36
Target
sample size
Cases
submitted
(%)
National Heart Failure Audit
All cases
100%
National Joint Registry 2014
All cases
100%
National Lung Cancer Audit 2013
All cases
In progress
National Neonatal intensive & Special care (NNAP) Audit
All cases
100%
National Oesophago-gastric Audit (NAOGC)
All cases
100%
National Paediatric Diabetes Audit (NPDA)
All cases
100%
National Pregnancy in Diabetes Audit
All cases
100%
National Rheumatoid & Early Inflammatory Arthritis Audit
All cases
In progress
National Vascular Registry – Carotid Endarterectomy
Interventions Audit
All cases
100%
National Vascular Registry – Peripheral Arterial Disease
All cases
In progress
National Vascular Registry – Abdominal Aortic Aneurysms
All cases
100%
Patient Reported Outcome Measures for Elective Surgery 2014
All cases
100%
Prostate Cancer Audit
All cases
In progress
Renal replacement therapy (Renal Registry)
All cases
100%
Sentinel Stroke National Audit Programme (SSNAP)
All cases
100%
Severe Trauma Audit & Research Network (TARN)
All cases
100%
National Clinical Audit
Fig.26: National confidential enquiries 2014/15
Cases
included
Clinical
questionnaire
returned
Case notes
returned
Organisational
questionnaire
returned
NCEPOD – Sepsis
5
2
4
1
NCEPOD – Gastrointestinal Haemorrhage
3
0
0
1
NCEPOD – Lower Limb Amputation
6
5
5
1
NCEPOD – Tracheostomy Care
19
19
4
1
National Confidential Enquiries (3)
37
In 2014/15 the Trust also submitted data to 10 other national clinical audit projects.
Fig.27: Other national projects
Target
sample size
Cases
submitted
(%)
Urological surgery BAUS Cancer registry nephrectomy
All cases
100%
NHFD Anaesthetic Sprint Audit Project
All cases
100%
All cases
100%
All cases
100%
All cases
In progress
Surgical Site Infection Surveillance (Large Bowel Surgery)
All cases
In progress
ESCP pan-European right hemicolectomy / ileocaecal resection
audit
All cases
In progress
National Surgical Site Surveillance (Orthopaedics)
All cases
100%
10
100%
All cases
In progress
Other National Projects (10)
Breast Cancer Clinical Outcome Measures Project (BCCOM)
2014
Determining Universal Processes related to best outcome in
Emergency Abdominal Surgery
Orchestra audit- Orchidopexy - Does earlier surgery affect
testicular atrophy
BAD Non Melanoma Skin Cancer Audit 2014 (1st round)
SCTC Thoracic Surgery Dataset 2014/15
38
Published National Clinical Audit and
Confidential Enquiry Reports during 2014/15
General Medicine
z UK Renal Registry
The report was presented to the Renal
Services User Group and three areas for
improvement were identified; referral rates
for renal transplant, reducing infection rates
with methicillin sensitive staphylococcus
aureus and improving achievement of target
haemoglobin levels.
The reports of 28 national clinical audits and
four confidential enquiries were reviewed by the
provider in 2014/15 and Basildon and Thurrock
University Hospitals NHS Foundation Trust
intends to take the following actions to improve
the quality of healthcare provided.
Trust-wide
z Sentinel Stroke National Audit Programme
(SSNAP) Quarterly Reports
The reports are presented and reviewed at
the monthly Stroke Service Group and the
ongoing stroke action plan is updated. Key
areas for improvement are the provision of
ring fenced stroke beds, resources for speech
and language therapy and improvements in
documentation by the multidisciplinary team.
z National Cardiac Arrest Audit 2013/14
The report was reviewed by the Resuscitation
Group. The Trust is reported as having
a higher than national average cardiac
arrest rate per 1000 admissions. The Trust
Deteriorating Patient Board is overseeing a
programme of improvement work to reduce
avoidable cardiac arrests rate by 50% with a
stretch target of 75% which is a rate of less
than 1.0/1000 admissions.
z British Thoracic Society (BTS) Adult
Emergency Oxygen Audit 2013
The report was presented to the Respiratory
MDT meeting. A local audit is being carried
out to ensure that the nursing teaching
programme carried out in 2013 has had an
effect on improved practice in titrating oxygen
to meet target saturation ranges.
z National Cancer Patient Experience
Survey 2013/14
The report was presented and reviewed
at the Medicine Audit Meeting and there is
an ongoing, routinely updated action plan.
There are ongoing meetings to provide clear
improvement strategies incorporated within
each tumour sites’ work plan. Key areas for
improvement are around communication,
provision of information and pain control.
The Macmillan Value Based Standards
pilot project continues to be rolled out and
there is a continuing robust Palliative Care
Educational Programme run by the team,
which is accessible to all disciplines.
z British Thoracic Society (BTS) National
Pleural Procedures Audit 2014
The report was presented and reviewed
at the Medicine Audit Meeting. In keeping
with national guidance all chest drains were
inserted by trained staff or under adequate
supervision. The service plans to: introduce
a pre-procedure checklist which will ensure
written consent is taken; train all Respiratory
Specialist Registrars to Level 1 competency
for inserting chest drains under ultrasound
guidance; and purchase drain fix dressings to
prevent drain migration, kinking and fall out.
39
z Royal College of Physicians (RCP) and
British Thoracic Society (BTS) Chronic
Obstructive Pulmonary Disease (COPD)
2013/14
The report was presented and reviewed at
the Respiratory MDT Team meeting. Work
is currently ongoing to reduce length of stay
and improve acute non-invasive ventilation
capacity with a business case being
submitted for weekend working specialist
nurses.
z Inflammatory Bowel Disease (IBD)
Biologics Audit & Organisational Audit
2013
The report was presented and reviewed at
the IBD Multi-disciplinary Group. A review will
be undertaken of concomitant medication for
patients with Crohn’s disease on biologics,
improved collection of quality of life scores
and ensuring patients with IBD have a named
dietitian.
z National Lung Cancer Audit 2013
The report was presented and reviewed at
both the weekly cancer MDT meetings and
the Essex Lung Cancer Network Meeting.
Since the 2013 report, we now have more
lung cancer clinical nurse specialists (CNS) in
post and more patients with a new diagnosis
of lung cancer will be seen by the CNSs.
Surgical Services
z National Emergency Laparotomy Audit
(NELA) Organisational Report
The organisational report was presented
and reviewed at the Surgical Divisional Audit
Meeting. Critical care and outreach services
need to be staffed at adequate levels to
ensure 24-hour specialist input and work is
currently in progress to address this.
z Inflammatory Bowel Disease (IBD)
Inpatient Care & Experience Reports
2013/14
The report was presented and reviewed
at the Gastroenterology Service meeting.
We comply with all areas but there are
further improvements required. More
robust documentation in healthcare records
and outpatient clinic letters is required,
prescription of calcium and vitamin D
supplements for patients on steroids for
bone protection needs to be reinforced and
a new pathway for anaemia is already being
implemented.
z Anaesthetic Sprint Audit of Practice
(ASAP)
The report was presented at the Anaesthetic
Clinical Audit Meeting. Further education and
training of anaesthetists is being provided
to ensure peri-operative nerve blocks are
offered to all patients with hip fracture,
to reduce the incidence of hypotension
with spinal anaesthesia and reduce bone
cement implantation syndrome. A quality
improvement project is also in progress to
extend the use of nerve blocks and spinal
anaesthesia.
40
z Intensive Care National Audit and
Research Centre (ICNARC)
The report was presented and reviewed at
the critical care departmental meeting and
shows notable practice compared with similar
units. Work is being undertaken to address
documentation issues affecting mortality
figures and these include improved data
quality to ensure relevant risk factors and
co-morbidities are captured. Consultant job
plans have been re-configured to improve
admission and discharge processes.
z National Vascular Registry (NVR) Carotid
Endarterectomy Interventions Round 6
The report was presented and reviewed at
the Surgical Division Governance meeting.
All three vascular surgeons perform carotid
surgery within accepted safety margins.
Actions are being taken to ensure earlier
completion of pre-operative investigations.
Women and Children Services
z British Thoracic Society (BTS) Paediatric
Asthma Report 2013
The report was presented and reviewed by
the Paediatric Governance Meeting. Use
of a written asthma plan and discharge
information leaflet before discharge will be
implemented.
z National Bowel Cancer Audit Annual
Report 2014
The report was presented and reviewed at
the colorectal multi-disciplinary meeting.
The method of data capture and upload will
be reviewed due to inconsistencies. More
recently data has been uploaded using the
Somerset system, so it is expected that the
majority of the issues will be resolved.
z National Neonatal Audit Programme
(NNAP) 2013
The report was presented and reviewed
at the Neonatal Audit meeting. Action will
be taken to inform the obstetric team of
the results for babies receiving antenatal
steroids. The service is carrying out a quality
improvement project to improve the number
of babies receiving first retinopathy screening
and further training will be provided to staff to
increase the proportion of babies receiving
any of their mother’s milk when discharged
from the unit.
z Falls & Fragility Fractures Audit 2013/14
(National Hip Fracture Database)
The report was presented and reviewed
at the monthly Hip Fracture Programme
meeting. We offer an excellent orthogeriatric
programme, with a consistently low mortality
rate. However, actions will be taken to
initiate a programme of audit centred on the
NICE quality standard including reviewing
drivers to improve time to theatre, access to
orthogeriatric care, examine the provision
of fracture liaison nurses and on-site DEXA
scan facilities.
z Epilepsy 12 Round 2 2013
The report was presented and reviewed at
the Paediatric Governance Meeting. A model
has been agreed to implement a transition
clinic once numbers of patients have been
identified, an epilepsy database is being
implemented and work is underway to secure
a further contract for the Epilepsy Nurse
Specialist.
41
z National Paediatric Diabetes Audit (NPDA)
2012/13
The report was presented and reviewed
at both the Paediatric Diabetes MDT
meeting and East of England Paediatric
Diabetes Network. There are no specific
recommendations following the audit,
although there is an ongoing work plan in
place to improve care outcomes.
The reports of the following National Clinical
Audit were reviewed by the Trust and no
improvements were required
z National Head and Neck Cancer Audit
(DAHNO) 9th Report
This is a network based audit and the
network came first in multiple parameters.
The report was presented and reviewed in
the Head and Neck Clinical Governance
meeting.
z National Diabetes in Pregnancy (NPID)
Audit 2013
The report was presented and reviewed
by both the Maternity Clinical Governance
Group and Divisional Governance Group.
Actions in response to the report, currently
being undertaken are: meeting with
commissioners and primary care teams to
develop and implement a strategic plan and
to increase consultant cover to cope with
increased demand in capacity for pregnant
diabetic women.
z National Vascular Registry (NVR)
Abdominal Aortic Aneurysm Round 3
The report was presented and reviewed at
the Surgical Division Governance meeting.
AAA outcomes are within nationally accepted
limits and therefore no specific local actions
in response to the report are currently
identified.
z Prostate Cancer Organisational Audit
The report was presented and reviewed by
the Trust’s Cancer Board. After reviewing
report recommendations no specific local
actions in response to the report are currently
identified.
z National Comparative Audits of Blood
Transfusion 2013 – Anti D Blood
The report was presented and reviewed at
both the Trust’s Transfusion Committee and
Maternity Audit meeting. The audit identified
four women who did not have a discussion
and were never offered anti-D. Since the
audit a failsafe officer has been appointed
working in conjunction with the antenatal
screening midwife. We can confirm that since
the failsafe officer was appointed there have
no further reported cases. A local re-audit is
currently in progress to provide continued
assurance. The midwifery management
team will be incorporating anti-D prophylaxis
into the mandatory training programme for
relevant staff.
z National Institute for Cardiovascular
Outcomes Research (NICOR) National
Cardiac Rhythm Audit 2012
The report was presented and reviewed at
the monthly CTC Electrophysiology meetings.
After reviewing the report recommendations
no specific local actions in response to the
report are currently identified.
42
z Royal College of Physicians National
Review of Asthma Deaths 2014
The report was reviewed by the Respiratory
Team and the need for improved
psychological support for patients with
asthma was identified and this will be
explored.
z British Cardiovascular Interventional
Society (BCIS) Coronary Angioplasty
National Audit 2013
The report was presented and reviewed at
the MINAP and PPCI meeting. The data is
consistent with previous years. No anomalies
were noted last year and no further action is
required beyond our current processes as
we are performing better than our predicted
complication rate.
z National Confidential Enquiries into
Patient Outcome and Death (NCEPOD) –
Tracheostomy Care 2014
The report was reviewed by the anaesthetic
services. Actions for improvement include
staff training and competencies, improved
documentation, review of equipment and
availability and agreement of formal policies.
z Myocardial Infarction National Audit
Project (MINAP)
The report was presented and reviewed at the
monthly cardiology meeting. Standards have
generally improved and no specific local actions
in response to the report are currently identified.
Local Clinical Audits
The Corporate Clinical Audit Programme links
with the Trust Quality Strategy and Quality
Goals and provides evidence and measures for
a number of projects.
The reports of the following National
Confidential Enquiries were reviewed by the
Trust.
z Maternal, Newborn & Infant Clinical
Outcome Review Programme: MBRRACE
Mortality report
The report was presented and reviewed at
the Maternity Clinical Governance & Risk
Management Committee. In response to
report recommendations, local actions
include:
The reports of 14 local clinical audits were
reviewed in 2014/15 and Basildon and Thurrock
University Hospitals NHS Foundation Trust
intends to take the following actions to improve
the quality of healthcare provided:
Goal 1: Improving Patient Safety
„ Writing a guideline for sepsis in maternity.
Fewer avoidable pressure ulcers, fewer patients
harmed from falls and no never events.
„ Sepsis and a guideline for Maternity Early
Warning Score has been included in
mandatory multidisciplinary skills and drills
training.
z Pressure Ulcer Documentation (SSKIN
bundle)
Compliance with the pressure ulcer risk
assessment (Waterlow assessment) is
audited monthly and every quarter a more
detailed clinical audit is carried out. The
results are disseminated to senior sisters
and head of nursing for any remedial action
required on specified wards.
„ Sepsis six campaign was launched in
maternity in November 2014, raising the
profile of sepsis recognition.
„ The epilepsy guideline has been approved
by the Maternity Policy Steering Group.
„ There have been discussions for a Trust
care pathway for women with headaches.
43
z Falls Prevention Pathway (Fallsafe)
Compliance with the falls risk assessment
document is audited monthly and compliance
has been maintained above 95%. The
Fallsafe project collects more detailed
measures for elements of falls prevention
and the results are examined by the Fallsafe
group and improvement actions developed.
z Quality of Discharge Summaries
The aim of this audit was to provide baseline
data on compliance with the standards
for completing a discharge summary
and focused on the quality of information
provided. Following the audit a quality
improvement project group has been
established that will take forward ideas for
improvement using quality improvement
methodologies such as frequent data
collection and testing changes using plan, do,
study, act (PDSA) cycles.
z Hydration audit
Compliance with fluid balance chart
completion is monitored monthly. Following
lower than expected audit results the
organisation updated and re-issued the
essential standards of care for hydration to
all nursing staff and delivered training to all
ward-based nursing staff.
Goal 2: Improving the Quality and Reliability
of Care
Fewer cardiac arrests, patients treated earlier
for signs of deterioration and better use of the
sepsis care bundle.
z VTE Prevention - appropriate prophylaxis
The administration of VTE prophylaxis is
audited monthly. During the year the results
fell outside expected limits and a number of
actions were taken to improve awareness
and compliance with good practice in
reducing the risk of VTE. These included a
staff presentation, messages in the Trust ‘Hot
Spots’ bulletin and posters were displayed
in clinical areas. Following these actions the
results increased to within normal limits.
z Management of Sepsis
Data from this quality improvement project
is reviewed monthly by the Sepsis Board to
determine areas for further improvement. Key
actions for 2015/16 are to improve reliable
delivery of the care bundle and to implement
the sepsis care bundle within the Acute
Medical Assessment Unit and in maternity.
z Urinary Tract Infection (UTI) Pathway
The outcome of the audit was presented to
the Right Place Right Time Board in May
2014. Improvement actions agreed were to
incorporate information relating to UTI into
the sepsis care bundle and junior doctor
induction training and to update the empirical
antibiotic policy.
z WHO Surgical Checklist (including Main
Theatres, Dermatology, Colposcopy,
Endoscopy, Radiology, Interventional
Cardiology and Cardiac Surgery)
The quarterly World Health Organisation
(WHO) surgical checklist audit carried out
in main theatres demonstrated sustained
improvement. The audit was extended during
the year to cover a number of other areas.
Improvements were made to the availability
of and use of surgical checklists in these
areas and quarterly audits are continuing to
improve compliance with the process.
44
z Treatment Escalation Plans
Compliance with the completion of treatment
escalation plans (TEP) is reviewed monthly
by the Divisions. Compliance within the
medical wards has improved over the
year. The TEP group plans to discuss the
requirement for the use of TEP forms for
surgical patients and for medical patients
admitted to surgical wards.
z Acute Kidney Injury
A Quality Improvement project to reduce
mortality and complications from acute kidney
injury (AKI) is in progress. A new AKI care
bundle is being developed and tested to
ensure that essential components of care for
patients with AKI are carried out and ongoing
monitoring and improvement cycles will
continue.
z Audit of clinical observations
A monthly audit is conducted which includes
ensuring there is a plan for the frequency of
observations, observations are completed
and patients escalated appropriately.
Results are discussed within the divisional
performance meetings and improvements
were made during the year to ensure
staff are fully aware of the standards and
expectations.
Goal 3: Improving patient and staff
experience
Providing our patients and their carers with the
best possible experience:
z Dementia (assessment and onward
referral) and carers survey - CQUIN
related
Results from the dementia audit and carer’s
survey are reviewed monthly by the Dementia
Strategy Group. Improvements were made
during the year to the process for ensuring
that a dementia assessment is completed on
admission for relevant patients and this has
resulted in sustained improvement exceeding
90%.
z Do not attempt cardiopulmonary
resuscitation (DNACPR)
The DNACPR audit is conducted to ensure
that records are completed and discussion
with patients, family / carers is documented.
The outcome of the audits are reviewed
by the Resuscitation Group and divisions
and any remedial actions are developed to
address any gaps highlighted.
z Participation in clinical research
Clinical research is a central part of the NHS,
as it is through research that the NHS is able
to offer new treatments and improve people’s
health. Organisations that take part in clinical
research are actively working to improve the
drugs and treatments offered to patients.
z Pneumonia Care Bundle
A Quality Improvement project to reduce
mortality from pneumonia is in progress. A
new community-acquired pneumonia care
bundle has been developed and tested to
ensure that essential components of care
for patients with pneumonia are carried
out. The care bundle is being implemented
within the emergency department and acute
assessment units and ongoing monitoring
and improvement cycles will continue.
The statement below shows the number
of patients who were recruited to take part
in clinical research and being treated by
the Trust. Participation in clinical research
gives patients access to the latest drugs and
treatments in development.
45
Basildon and Thurrock University Hospitals
NHS Foundation Trust is a partner in the
National Institute for Health Research (NIHR)
Clinical Research Network: North Thames
and works closely with the core team to
maximise funding to support the delivery of
high quality research.
Participation in clinical research demonstrates
our commitment to improving the quality of
care we offer and to making our contribution
to wider health improvement. Our clinical
staff stay abreast of the latest treatment
possibilities and active participation in
research leads to successful patient
outcomes.
The number of patients receiving relevant
health services provided or sub-contracted
by the Trust in 2014/15 that were recruited to
participate in research approved by a NHS
research ethics committee was 1,927. 1,578
recruits were to NIHR portfolio studies with
the remaining 349 to studies that have not
been adopted
We believe that patients should have access
to good quality, ethically-approved research
and that whether or not someone participants
in a research study they should receive
nothing less than the NHS gold standard.
z Use of the Commissioning for Quality and
Innovation (CQUIN) Payment Framework
The CQUIN payment framework was
introduced with the aim of making care
quality the core value of NHS providers. The
framework makes a proportion of provider
income conditional on locally agreed quality
and innovation goals.
Of the newly recruited patients, 404 (21%)
were enrolled to interventional clinical trials;
these are complex and time-consuming
studies. The remaining 1,506 participants
(79%) were enrolled in observational studies.
We were involved in 177 active clinical
research studies, of which 100 remain actively
recruiting patients, 44 following-up patients
and 33 that have closed within the year.
These studies took place across 22 clinical
specialties. Cardiology, diabetes and cancer
are the top recruiting specialties.
A proportion of the Trust’s income in
2014/15 was conditional on achieving quality
improvement and innovation goals agreed
between the Trust and any person or body
they entered into a contract, agreement or
arrangement with for the provision of relevant
health services, through the Commissioning
for Quality and Innovation payment
framework.
During the reporting period seven Adverse
Events, eight Serious Adverse Events and
0 Suspected Unexpected Serious Adverse
Reactions were reported. A total of two
research participants died and the incidence
of death was unrelated to the research in all
cases.
The monetary total for income in 2013/14,
conditional upon achieving quality
improvement and innovation goals was:
£288.4million (this represents the total income
for the Trust and not just the CQUIN portion of
payment).
The Trust continues to support educational
research and provide training and advice
to staff requiring support for academic
qualifications and to external students.
46
The CQUIN Schemes agreed with the Trust’s main commissioner for 2014/15 are:
Fig.28: Agreed CQUIN schemes
CQUIN scheme
Friends and Family Test – Implementation of staff FFT - NHS Trusts Only
Friends and Family Test - Early Implementation in outpatient and daycase
Friends and Family Test - Increased or maintained response rate
Friends and Family Test - Increased response rate in acute inpatient services
NHS Safety Thermometer - Improvement Goal Specification
Dementia - Find, Assess, Investigate and Refer
Dementia - Clinical Leadership
Dementia - Supporting Carers of People with Dementia
Co-ordinated End of Life
Implementation of SystmOne
Sepsis
Improved Management of Frail Individuals
Ambulatory Emergency Care
Improved Discharge
Hearing Loss / Dementia
Introduction of a Blueteq system
Expected Value
CQUINs 2014/15 = 2.5%
(Currently payment for CQUINS is part of an arbitration process to agree a final settlement of
Trust income from commissioners)
Further information about locally agreed CQUIN goals is available from the Trust on request
(01268 524900 ext. 3943).
47
The maternity unit received an outstanding
rating. Some of the things the CQC highlighted
included exceptional care and treatment, open
culture with strong focus on patient safety and
risk management. The service continuously
reviews and acts on feedback from patients
and relatives, and patients said they felt safe
in the hands of staff. Leadership encourages
cooperative, supportive relationships among
staff and compassion towards patients.
What the regulators said about the Trust
The Care Quality Commission
The Care Quality Commission (CQC) is the
independent regulator of health and adult
social care in England. The CQC make sure
that the care provided by hospitals, dentists,
ambulances, care homes and home-care
agencies meets government standards of
quality and safety. They also protect the
interests of vulnerable people, including those
whose rights are restricted under the Mental
Health Act.
The ratings for services provided by the Trust
are:
The Trust is required to register with the CQC
and has no conditions on registration.
The Trust is currently registered to carry out the
following legally regulated services:
At Basildon University Hospital: Maternity and
midwifery services, termination of pregnancies,
treatment of disease, disorder or injury,
surgical procedures, diagnostic and screening
procedures, management of supply of blood
and blood derived products, assessment or
medical treatment for persons detained under
the Mental Health Act 1983 and family planning.
The Trust has not participated in any special
reviews or investigations by the CQC during the
reporting period.
CQC report Celebrating Good Care
The Trust is particularly pleased to be
referenced in the CQC Celebrating Good
Care Report in March 2015. This reflects the
transformational improvement journey the Trust
has gone through over the last few years.
At Orsett Hospital: Termination of pregnancies,
treatment of disease, disorder or injury;
surgical procedures, diagnostic and screening
procedures and family planning.
For further information about the CQC’s
new acute regulatory model and inspection
framework please visit: www.cqc.org.uk
The report references the work undertaken
to improve good governance processes in
particular to support responsiveness to patients
and the public. A copy of the report is available
at the following web address:
Basildon University Hospital was inspected
by the CQC utilising a ‘Wave 2’ inspection
approach, the review took place over two days
– 19 to 20 March 2014.
www.cqc.org.uk/content/celebrating-good-carechampioning-outstanding-care-1
Basildon University Hospital was awarded an
overall rating of ‘good’ with very few areas
requiring improvement.
48
Data Quality
Clinicians and managers are dependent on
good quality data from clinical systems to
ensure that they are delivering appropriate
services to patients. This data must be accurate
and accessible when needed to ensure it
effectively supports the delivery of patient
services.
Secondary Uses Service (SUS) Submissions
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. The percentage
of records in the published data is shown in
Fig.29:
Fig.29: Percentage of records published in Hospital Episode Statistics
2013/14
2014/15
% for admitted patient care
99.6%
99.7%
% for outpatient care:
99.7%
99.8%
% for accident and emergency care:
98.5%
98.7%
Which included the patient’s valid NHS number was:
Which included the patient’s valid General Medical Practice Code was:
% for admitted patient care:
100%
100%
% for outpatient care:
100%
100%
% for accident and emergency care
100%
99.9%
49
Information Governance toolkit attainment
rates
The Trust Information Governance Assessment
Report for the period 2014/15 was 71% and
was graded as green, satisfactory.
By comparison the Trust Information
Governance Assessment Report for the period
2013/14 was 71% and was graded as green,
satisfactory.
Clinical coding error rate
The Trust was not subject to the Payment by
Results clinical coding audit during 2014/15 or
2013/14 by the Audit Commission.
The Trust has taken the following actions to
improve data quality:
z An independent audit of information
governance arrangements
50
Part 3 - Review of quality performance
The Trust uses a wide range of information to monitor performance and the quality of services. The
Trust board have reviewed the indicators required for the quality strategy and as a result a number
of indicators are no longer referenced in the quality report. Each of the three indicators for patient
safety, clinical effectveness and patient experience monitired in 2014/15 has been discussed in
detail with historical and benchmarked data in Section 2.
Fig.30 below shows summary of indicators, with a comparison of performance over the past four
quarters and the arithmetic average as part of the Monitor risk assessment framework (RAF).
Further information is included in Appendix 3 that including locally defined measures and targets.
Fig.30: Summary of indicators
Target
YTD
Q1
Q2
Q3
Q4
2014/15
average
90%
77.3%
76.9%
82.4%
83.7%
82.8%
95%
93.1%
88.4%
89.0%
88.2%
91.3%
92%
82.7%
85.4%
90.5%
87.8%
88.9%
95%
95.9%
95.0%
94.7%
88.8%
94.4%
85%
81.5%
77.8%
82.2%
76.0%
79.5%
90%
91.7%
100.0%
60.0%
92.3%
91.2%
94%
100.0%
100.0%
100.0%
100.0%
100.0%
98%
100.0%
100.0%
100.0%
100.0%
100.0%
96%
100.0%
99.2%
100.0%
100.0%
99.6%
Cancer 2 week (all cancers)
93%
95.1%
94.9%
95.6%
96.4%
95.3%
Cancer 2 week (breast symptoms)
93%
95.4%
96.2%
100.0%
93.7%
95.3%
18
10
23
30
37
37
CQUIN scheme
*Referral to treatment time, 18 weeks
in aggregate, admitted patients
*Referral to treatment time, 18 weeks
in aggregate, non-admitted patients
*Referral to treatment time, 18 weeks
in aggregate, incomplete pathways
A&E Clinical Quality- Total Time in
A&E under 4 hours
Cancer 62 Day Waits for first
treatment (from urgent GP referral)
Cancer 62 Day Waits for first
treatment (from NHS Cancer
Screening Service referral)
Cancer 31 day wait for second or
subsequent treatment - surgery
Cancer 31 day wait for second
or subsequent treatment - drug
treatments
Cancer 31 day wait from diagnosis to
first treatment
Cumulative total C.diff (including:
cases deemed not to be due to lapse
in care and cases under review)
* RTT for the quarter is reported as the performance for the worst month of the quarter
51
„ The Trust’s complaints report published
under regulation 18 of the Local Authority
Social Services and NHS Complaints
Regulations 2009 dated 12 November
2014, 11 February 2015, 27 May 2015
Appendix 1 – Statement from Directors
The following is a statement of directors’
responsibilities in respect of the quality report
and is required by the Foundation Trust
regulator Monitor.
„ The national patient survey dated March
2015
The Directors are required under the Health Act
2009 and the National Health Service Quality
Accounts Regulations 2010 to prepare Quality
Accounts for each financial year. Monitor has
issued guidance to NHS foundation trust boards
on the form and content of annual quality
reports (which incorporate the above legal
requirements) and on the arrangements that
NHS foundation trust boards should put in place
to support the data quality for the preparation of
the quality report.
„ The national staff survey May 2015
„ The Head of Internal Audits annual
opinion over the Trust’s control
environment dated 22 May 2015
„ CQC Intelligent Monitoring Report dated
December 2014
z the Quality Report presents a balanced
picture of the NHS foundation trust’s
performance over the period covered;
In preparing the quality report, directors are
required to take steps to satisfy themselves
that:
z the performance information reported in the
Quality Report is reliable and accurate;
z the content of the quality report meets the
requirements set out in the NHS Foundation
Trust Annual Reporting Manual 2014/15
z 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;
z the content of the Quality Report is not
inconsistent with internal and external
sources of information including:
z 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) as well as
the standards to support data quality for the
preparations of the quality report.
„ Board minutes and papers for the period
April 2014 to April 2015
„ Papers relating to Quality reported to the
Board over the period April 2014 to April
2015
„ Feedback from the commissioners dated
8 May 2015
„ Feedback from the governors
„ Feedback from local Healthwatch
organisations dated 8 May 2015
52
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
Bob Holmes
Acting Trust Chairman
27 May 2015
Clare Panniker
Chief Executive
27 May 2015
53
This is of course at a time when the
future sustainability of the NHS has to be
addressed; it is of note that BTUH is keen
to be at the forefront of system re-design
alongside the CCG and other health care
providers.
Appendix 2 – Statement from
Stakeholders
Commissioners
z Basildon and Brentwood Clinical
Commissioning Group
Basildon and Brentwood Clinical
Commissioning Group welcomes the
opportunity to comment on the Quality Annual
Account prepared by Basildon and Thurrock
University Hospitals NHS Foundation Trust
(BTUH).
The CCG agree with and support the key
quality goals that the Trust has described
and we have the sight of a number of other
metrics to ensure further breadth and depth
of assurances of additional initiatives and
plans to continually improve patient safety
and quality of care.
As a primary commissioner of services,
Basildon and Brentwood has the following
statement to make for inclusion in the BTUH
Quality Account. This commentary is also
made on behalf of Thurrock CCG.
There have been a number of further
improvements to help embed the divisional
governance structure to improve patient
safety and quality:
To the best of the CCGs knowledge, the
information contained in the account is
accurate and reflects a true and balanced
description of the quality of the provision of
services
„ The Trust has signed up for the ‘Sign Up
To Safety’ campaign.
„ Staff are supported in a number of different
and innovative ways – such as the
‘Schwartz Rounds’ which acknowledge the
stressful environment staff work within and
offers a method of support to all staff at all
levels who wish to participate.
This year has seen vast improvements for
patient safety and quality of care at BTUH
throughout 2014/15, with the ‘good’ rating
by the CQC and the removal of special
measures by Monitor.
„ The ‘Bohmer’ programme has developed
a progressive move towards improved
clinical leadership with the aim of
improving quality and enabling clinicians to
better understand their role in leading the
organisation.
These achievements are a reflection of the
dedication and hard work of all staff at the
Trust, from the impressive leaders to those
who deliver hands on care and the functions
behind the scenes. The Trust should be
proud of its achievements.
„ The introduction of a Quality Improvement
advisor role.
Continued drive and improvement is still
required; but this is achievable due to the
positive, open and transparent culture, and
an organisation who have demonstrated that
they have become a learning organisation.
54
focus our attention to gain the required
assurance about standards of care. This
team provides valuable independent
assurance to the Trust Board about
standards of care.
Assurance
The CCG formally monitors and gains
assurances about the standards of practice
within the Trust through the Clinical Quality
Review Group. This group meets monthly
and consists of executives from the provider
and the CCG, plus other senior members
of each team. The overarching purpose
of the group is to provide assurance to
the CCG regarding the delivery of clinical
quality at BTUH, by having an overarching
view of quality standards within the Trust. It
examines and reviews all quality indicators,
including the Trust’s Clinical Quality
Performance Report, which details level of
compliance, and reason for any failure to
meet the quality indicators and information
requirements contained within the contract.
„ Mortality Rates (including care of the
deteriorating patient)
The Standard Hospital Mortality Indices
(SHMI) value for Basildon Hospital has
been improving for consecutive quarters
since June 2012. The latest SHMI data
shows the value to be within the expected
limits, meaning the number of people who
die following treatment is within the range
that would be expected to die.
„ Care of the Deteriorating Patient Methodologies to improve the escalation
and care of the deteriorating patient have
been another key focus this year. The key
improvements have included:
In 2014/15 the Trust identified and committed
to 13 sub-sets of three over-arching goals for
quality. Of those 13:
„ six were achieved
- Implementation of a new National Early
Warning System (NEWS)
„ four although target was not achieved,
improvements were made
- The development of the Critical Care
Outreach Team
„ three were not achieved (reduction in
Never Events, improved PROMs, improved
cancer care survey)
- Introduction of key care bundles
Areas of note within the Trust
- Extension of senior medical working
hours
- Improvements to the Hospital at Night
Service
„ The Trust has its own internal
Compliance Team who regularly
undertake unannounced compliance
visits within the Trust, co-opting specialist
support in to the team when required
to assess compliance against expected
standards. The CCG works closely
with team, feeding them each other’s
intelligence as to where we should both
- Extension of diagnostic working hours
All of these ensure improved monitoring,
communication and escalation when
patients begin to deteriorate.
55
„ Workforce – numbers and satisfaction
Nurses - The Trust continues to close the
nursing vacancy gap with substantively
recruited staff, however, this remains a
challenge. In response to that challenge,
the Trust has developed a number of
recruitment initiatives which includes:
„ Learning culture
Incidents - Incident reporting by the
Trust remains at a consistent level,
having previously risen from being in the
lowest quartile of reporters nationally
to the highest quartile of reporters, with
evidence of good management at local
levels. Incident trends are analysed and
information triangulated with complaints,
staffing levels etc to ensure learning is
identified and embedded in practice.
- work based learning enabling HCAs to
enrol with Essex University on a work
based nursing degree programme
- Partnership work with Anglia Ruskin
University to facilitate the ‘Return to
practice’ course which will develop a
small but consistent supply of nurses
who wish to re-join the workforce
The CCG is pleased to see the continued
high reporting of all incidents, including
serious incidents, as this demonstrates
that the organisation is open and honest.
In addition, there is good evidence that the
Trust is a learning organisation.
- Overseas recruitment from Spain,
Portugal and the Philippines
„ Specific elements of care – falls,
pressure ulcers VTE, IPC, EMSA.
- In-house recruitment event for student
nurses
Falls - BTUH have adopted a number of
schemes to reduce the number of falls:
The Trust continues to take measures to
ensure that all newly recruited staff have
their competencies checked and signed off
as part of the Trust’s induction programme
and their commitment to ensuring staff are
competent and safe to practice.
- The ‘FallsSafe’ project, a proven
methodology to reduce falls. The
project involves formal education and
training and recruitment of ‘champions’
who can scrutinise audit data, cascade
learning and skills to empower their ward
colleagues and the multi-disciplinary
teams to implement high quality falls
related care. Since adoption of the
methodology, BTUH have seen an 8%
reduction in falls, improvement in risk
assessing and general falls management.
Medical - Recruitment to specialist areas
such as A&E and CCU continue to be a
challenge, as does the need to recruit to
meet the 7 day requirements.
Staff Satisfaction - The 2014 National
Staff Survey highlighted that for the third
consecutive year, BTUH has seen an
improvement in the number of staff who
would be happy with the standard of care
at the Trust, if a relative or friend needed
treatment at the Trust.
- The monthly Trust Falls Prevention
Group which is attended by the CCG and
looks at themes and trends as well as
the weekly Harm Free Care Group where
individual cases are peer reviewed to
assess avoidability and learning.
56
„ Infection Prevention and Control
The challenge to reduce Hospital Acquired
Infections (HCAIs) continues.
- All falls with harm are reported as serious
incidents, the Root Cause Analysis
investigations carried out by BTUH are
scrutinised and signed off by the CCG.
-
Re organisation of the falls team.
-
Application to become part of ‘Sign
up to Safety’, a national campaign to
reduce avoidable harm.
- MRSA bacteraemia - whilst a zero
tolerance for MRSA bacteraemia
continues; there have been two
contaminates and five actual cases
in 2014/15. These cases have
been for patients with multiple,
serious co-morbidities, with minimal
recommendations from the Post Infection
Review for improvements in infection
prevention and control practices. The
challenge for MRSA in 2015-16 remains
at zero.
„ Pressure Ulcers
For 2014/15, the Trust had the reduction of
avoidable pressure ulcers, grades 2, 3 and
4 to below 0.25 per 1000 bed days as a
quality goal; this has been achieved in 9 of
the 11 months from April 2014.
In order to work towards their ambition of
zero pressure ulcer days, the Trust has
undertaken the following:
- Clostridium difficile - robust systems
are in place to review all HCAI’s and
the CCG infection Prevention & Control
Team attend multidisciplinary meetings
to ensure there are no lapses in patient
care.
- Establishment of the Harm Free Care
weekly peer review meetings which the
CCG attends.
Fig.31 below shows the number of cases
across the CCG.
- Re-launch of SSKIN care bundles.
- Heels up campaign which included
providing staff with a mirror and supported
leaflets.
Fig.31: Clostridium difficile cases
across CCG
- Increased capacity with the tissue
viability team.
C.diff figures
- ‘Sign up to Safety’ campaign
BTUH
„ Venous Thromboembolism (VTE)
Following last year’s fall in performance
around VTE; BTUH took actions to
improve awareness and compliance with
good prescribing and administration of
prophylaxis. As a result, their internal
monthly audits have shown an improving
picture over the last six months.
57
Actuals
Trajectory
37
18
„ Eliminating Mixed Sex Accommodation
(EMSA)
BTUH have had a number of breaches with
regards to EMSA. Apart from two, these
were all in relation to CCU patients. The
CCG has worked with the Trust to revise
their policy to ensure they are not unfairly
judging their compliance to this standard
for this particular group of patients, who
arguably would have a clinical reason for
not moving promptly from CCU.
From April 2014, the Staff FFT was
introduced, staff were asked to respond
to two questions:
z how likely they are to recommend the
NHS services they work in to friends
and family as a place for care?
z how likely they would be to recommend
the NHS service they work in to friends
and family as a place to work?
The Staff FFT is conducted on a quarterly
basis, for Quarter 1, 56% recommended
BTUH as a place to work and 66% as a
place for care. Quarter 2 saw improved
results with 57% of staff stating that they
would recommend BTUH as a place to
work, and 73% as a place for care.
„ Patient experience
- Friends and Family Test (FFT)
BTUH have steadily improved their
FFT response rates in both A&E and
inpatients.
For A&E April to February 2015, a
mean average of 74% of respondents
recommended the service.
„ Patient Advisory Liaison Service (PALS)
This service was previously criticised
by CQC and during the Keogh review –
following that feedback a senior clinical
post was created and the office has now
moved to the front of the hospital. The
development of the Patient Advice and
Liaison Service has assisted in directing
patients and relatives to have the ability to
find an early remedy to many issues that
with good communication can often be
rectified at ward level, without the need to
escalate further.
For inpatients April to February 2015, a
mean average of 95% of respondents
recommended the service.
For CTC, 98% April to February 2015,
a mean average of respondents
recommended the service.
For Maternity birth and antenatal, April to
February 2015, a mean average of 100%
and 98% respectively.
In October 2014 FFT was implemented in
main outpatient departments at Basildon
and Orsett, CTC and fracture clinic. Of
those who responded, 93% of the said
they would recommend the Trust.
„ Patient Engagement
The Trust has joined the Patient Leaders
programme with the CCG. They hold
listening surgeries, have good links with
Healthwatch and now have patient stories
at Board.
At the end of the Friends and Family test
survey BTUH pose two questions asking
patients to state what they thought BTUH
did well and what we could do better. Key
issues raised in 2014/15 were around
waiting times in A&E, care staff and food
for inpatients.
58
„ Children’s safeguarding
Previous concerns around child
safeguarding have been vastly reduced.
The structure for safeguarding has been
improved as has the relationship with
the two Child Safeguarding Boards for
Thurrock and Essex.
In order to improve the ease of understanding
of the issues faced by the Trust a high level
assurance document has been developed to
assist the Trust and others to track on-going
improvements. This document will scrutinise the
following areas:
„ CIP review
The National Quality Board: HOW TO:
Quality Impact Assess Provider Cost
Improvement Plans guidance recommends
a multi-disciplinary approach to the
assessment and sign off of provider
CIPs through the development of a ‘Star
Chamber’. Although the CCG have not
adopted the ‘Star Chamber’ approach in its
entirety, the guiding principles, promoting
systematic exploration of quantitative and
qualitative intelligence and encourages
the orderly triangulation of information to
help assess the quality impact of our main
provider’s CIPs.
„ Legionella
This past year has seen a year of
sustained improvements. The joint
Steering Group have passed ongoing
monitoring to the CCG.
Monthly review meeting continue, when
detailed discussions around the Key
Performance Indicators are discussed and
reviewed.
There have been a number of challenges
around maintaining water temperatures
and achieving the required levels of
silver and copper in the water system,
despite this there has been a consistent
achievement of nil/minimal positive
Legionella results on the Basildon Hospital
site.
The CCG have continued to have quarterly
meetings with BTUH to gain assurance on
the quality impact of the CIPS.
Major work is needed in the coming year
on the old block to improve hot water
return temperature.
59
z Thurrock Clinical Commissioning Group
Thurrock CCG welcomes the opportunity to
comment on the annual Quality Account of
Basildon and Thurrock University Hospitals
NHS Foundation Trust for 2014/15.
The infection control incidences relating to
CDiff, MRSA and IGAS have been monitored
consistently by the Trust and CCG’s Infection
Control Teams. The CCG consider that this
significant work to reduce harm from these
incidents will need to continue for 2015/16.
The CCG notes the summary of the Trust’s
Performance for 2014/15. Whilst some
quality goals have been achieved it is
recognised that there is still some work to
do to improve harm free care although the
Trust has enhanced its incident reporting
processes. From a national perspective this
is demonstrated by the improvement in the
Trust performance which is now in the top
10% of hospitals for reporting harm.
The CCG welcomes the development of
key priorities for quality improvement during
2015/16 and will continue to provide support
and guidance. It is recognised that the
Trust is experiencing significant financial
challenges and assurances will be sought to
ensure that the quality and safety of patients
is not compromised. The rigour of quality
assurance monitoring will continue.
The CCG is pleased to note the work to
improve quality through the Schwartz
Round processes and the work with Harvard
Business School implementing the Bohmer
Programme to ensure sustainability.
The CCG is also pleased that the Trust is
referenced in the Care Quality Commission
Celebrating Good Care Report published in
March 2015, reflecting its transformational
improvement and removal from special
measures.
The further measures to improve quality
through the recognition and treatment of
sepsis are also noted, together with the work
with UCL Partners. It is anticipated that this
will reduce mortality through sepsis during
2015/16.
The CCG note that some cancer and other
quality targets have been challenging and not
achieved during 2014/15. The CCG would
welcome information on actions being taken
to optimise performance.
60
z Healthwatch Essex
Healthwatch Essex is an independent
organisation with a vision to be a voice
for the people of Essex, helping to shape
and improve local health and social care
services. We believe that people who use
health and social care services and their lived
experience should be at the heart of the NHS
and social care services.
It is commendable that the Trust has
focused on patient experience as one of
their priorities over the past year, and it
has achieved the goal of increasing the
response rate and recommender score in
their Friends and Family tests (although data
is not entirely clear cut). In the priorities for
2015/16, BTUH is keeping a focus on these.
Healthwatch Essex supports the Trust in
these endeavours, but would encourage
the Trust to think about how other methods
can be used to capture qualitative insights
of people’s lived experiences of care, and to
use this to continue to drive improvement.
We recognise that Quality Account reports
are an important way for local NHS services
to report on what services are working well,
as well as where there may be scope for
improvements. The quality of the services
is measured by looking at patient safety,
the effectiveness of treatments that patients
receive and patient feedback about the
care provided. We welcome the opportunity
to provide a critical, but constructive,
perspective on the Quality Accounts for
BTUH, and we will comment where we
believe we have evidence – grounded in
people’s voice and lived experience – that is
relevant to the quality of services delivered
by BTUH.
The Trust has also improved its performance
on complaints and compliments, which is
encouraging. In 2014/15, BTUH had a 16%
reduction in complaints received, and a 66%
increase in the number of positive comments,
with a total of 478 in 2014/15 compared to
288 in the previous year.
In this account, BTUH outline the actions
being taken to help further improve the
experience of patients. These actions include
involving people who have made a complaint
in service redesign and improvement,
introducing an inpatient information booklet,
amenity packs for emergency admissions, an
experience sharing learning method ‘see it
my way’ where members of staff and patients
share their experiences and discuss ways to
improve services, and the development of
Trust patient experience video to train staff.
Over the past year, the Trust has seen
improvements, after receiving a rating of
‘good’ by the CQC and being removed from
special measures. However, the Trust has
also begun to experience financial difficulties
in 2014/15 – a fact that the Trust recognises
it has in common with many other acute
Trusts. This coincides with other common
factors that are placing an additional burden
on the Trust’s resources, such as bed
capacity and high demand for services. It is
important to remain vigilant to the impact this
could have on patient and carer experience
at BTUH.
Healthwatch Essex believes that lived
experience should be at the heart of services,
and believes that listening to the voice and
lived experience of patients, service users,
carers, and the wider population, is a vital
component of providing good quality care.
We will continue to support the work of BTUH
in this regard.
61
Group (CCG), is instigated. This review
identifies contributory factors, non-optimal
practice and lessons learned from the case
to improve future practice. It also identifies
the organisation best placed to ensure these
lessons are acted upon and the organisation
to which the case is assigned.
Appendix 3 – Supplementary
Performance Information
In addition to the information provided in the
main part of the report with regard to quality
improvement and performance delivery, this
section describes other quality measures that
the Trust seeks to achieve.
There have been six cases of MRSA
bacteraemia during 2014/15; four cases
were assigned to the Trust. Two cases were
agreed contaminants.
z Infection prevention and control
The Trust Infection Prevention and Control
team work closely with staff across the Trust
to embed robust infection prevention and
control processes, to ensure high quality,
safe, patient care.
The MRSA threshold will remain as zero for
2015/16.
z Delayed transfer of care
The ambition is to maintain the lowest
possible rate of delayed transfers of care.
Good performance is demonstrated by a
consistently low rate over time, and/or by a
decreasing rate.
z MRSA bacteraemia
The national guidance on the reporting and
monitoring and post infection review (PIR)
process for MRSA bloodstream infections
(BSI) was implemented in April 2013 as part
of a strategy for achieving a zero tolerance to
Healthcare Associated Infection (HCAI).
Performance throughout the year, as shown
on the chart below, has been variable and is
affected by the complexity of patient needs.
Our aim is to ensure that discharges are safe
and meet the needs of patients while still
being undertaken in a timely way.
Following laboratory identification, each case
of MRSA BSI is reported immediately to a
national Public Health England data capture
system, and a multi-disciplinary post infection
review, which includes a representative
from the local Clinical Commissioning
Fig.32: Delayed transfer of care April 2013 to March 2015
Source of data: Trust internal report
62
z Complaints
The Trust received a 16% reduction in
complaints in 2014/15. We use information
from complaints and from PALS to take
immediate action when people using our
services identify a problem that needs to be
resolved.
Fig.33: Complaints received 2014/15
Total complaints
2011/12
2012/13
2013/14
2014/15
484
633
833
700
Source of data: Internal complaints report
The key themes and trends are reported
monthly to the Board of Directors within the
performance report and within each division
to ensure a local response to any problems
identified.
Fig.34: Top three complaints themes 2011-2015
2011/12
1
2
3
2012/13
2013/14
Medical judgement/
diagnosis (120)
Medical care/
treatment (159)
Medical care/
treatment (103)
Nursing care/
treatment (64)
Medical judgement/
diagnosis (95)
Nursing care/
treatment (85)
Source of data: Trust risk management database, Ulysses
63
Medical care/
treatment
(186)
Medical judgement/
diagnosis (115)
Nursing care/
treatment (114)
2014/15
Medical care/
treatment (170)
Communication
(103)
Medial judgment
diagnosis (84)
z Responding to our public
The Trust uses a variety of sources of
information to assess how we could do things
differently to improve patient experience.
Comment cards have always been a rich
source of capturing feedback.
z Dementia friendly hospitals
Hospitals play an important role in people’s
journey through dementia. Up to 25%
of patients in hospital can be living with
dementia and they are at greater risk of
dehydration, malnutrition and harm from falls.
It is important that the Trust has staff with the
right skills and knowledge to care for people
with dementia and that we help identify those
with people with signs of dementia as early
as possible.
From March 2014, the ‘Get It Right’ cards
and leaflets were replaced with a refreshed
version ‘We’re Listening’, to coincide with the
relocation of the PALS office.
Fig.35: Comment Cards 2011-2014
Year
Qtr 1
Qtr 2
Qtr 3
Atr 4
2011/12
89
107
113
57
2012/13
61
63
64
63
2013/14
75
94
170
132
2014/15
39
64
78
35
Early diagnosis
(Abbreviated Mental Test Score)
The Trust undertakes an assessment of
all patients over the age of 75 to test their
cognitive performance. The aim is to help
identify any potential problems and then
refer the patient on for a more detailed
assessment. Following implementation of
a new method for collecting the data our
performance has been good.
The Trust also captures feedback from the
NHS Choices website, which is scrutinised by
our external regulators for comments relating
to the Trust. In 2014/15, a feedback email
address was set up to capture comments to
help shape and develop services provided
by the Trust. Comments are acknowledged
where possible, and if further investigation is
required or a concern raised about a current
inpatient, advice is given to contact the PALS
team or speak with the senior ward staff.
The Trust has experienced a significant
increase (66%) in the number of positive
comments in the form of formal plaudits, with
a total of 478 logged in 2014/15 compared to
288 in 2013/14. These are in addition to the
expressions of thanks received and displayed
in wards/departments.
64
Fig.36: Dementia screening April 2013 to March 2015
Source of data: Internal Trust documentation audit
Fig.37: Nursing documentation audit April 2013 to March 2015
Source of data: Internal Trust documentation audit
65
Improving staff awareness of dementia
All Trust staff are required to undertake an
awareness session in dementia. We believe
this benefits our patients and will help
support our local community by reducing
stigma associated with this condition and
encouraging people to get involved and be
more supportive to people with dementia.
This is a new quality measure at which our
performance has been good.
Fig.38: Improving staff awareness
(tier 1 training)
Source of data: Internal training data
66
z Eliminating mixed-sex accommodation
There is a commitment across the NHS to
reduce and, where possible, eliminate mixedsex accommodation. The Trust is committed
to eliminating mixed-sex accommodation
and to maximise privacy and dignity for our
patients.
The graph below shows that some incidents
of mixed-sex accommodation still occur.
These are all related to two areas in the Trust,
the critical care unit (CCU) and endoscopy
department. In CCU the incidents occurred
when patients were deemed fit for transfer
out of the unit but a bed was not available
on a ward within 12 hours. In endoscopy,
the Trust normally runs lists of same gender
patients, however on a few occasions it was
necessary to add someone of the opposite
gender to a list because an investigation was
urgent. While this was in the best interests
of the patient, it was not necessarily in the
best interest of other patients in the unit and
so was regarded as a breach of the rules
governing mixed-sex accommodation.
Fig.39: Eliminating mixed-sex accommdation April 2013 to March 2015
Source of data: Trust internal report
67
New foot clinic means better experience for diabetes
patients
Nicola Lewis, lead diabetes nurse, said:
“The purpose of the early access foot clinic
is to make sure the wounds are treated and
prevent amputations, which is a possibility in
the most extreme of cases.”
Diabetic patients are benefitting from a better
experience thanks to the opening of the new
foot clinic. Foot care is important for patients
with type 1 or 2 diabetes, because glucose
levels affect the circulatory system, causing
problems to blood flow. Any ulcers that form
have great difficulty in healing due to the
reduced blood supply.
“Around 50 patients a week attend the foot
clinic,” explains Nicola. “Previously we were
in a side room on a ward, where space
was much more limited. The new clinic
room is more spacious and has the latest
air-exchange system which is important
for infection control. As it is located in the
outpatient department, closer to the car park,
it is easier for patients to access.”
The newly refurbished clinic room in the
outpatient department is purpose-built to allow
for the debridement of diabetic foot wounds.
Debridement speeds up the healing process
for ulcers, by removing the affected tissue
from the wound.
Diabetes team
68
Independent auditors report to the Council of Governors
of Basildon and Thurrock University Hospitals NHS
Foundation Trust on the Quality Report
We have been engaged by the Council of
Governors of Basildon and Thurrock University
Hospitals NHS Foundation Trust to perform an
independent assurance engagement in respect
of Basildon and Thurrock University Hospitals
NHS Foundation Trust’s Quality Report for
the year ended 31 March 2015 (the ‘Quality
Report’) and certain performance indicators
contained therein.
out in the NHS Foundation Trust Annual
Reporting Manual;
z the Quality Report is not consistent in all
material respects with the sources specified
below; and
z 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.
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:
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.
z Percentage of incomplete pathways within
18 weeks for patients on incomplete
pathways
z Maximum waiting time of 62 days from urgent
GP referral to first treatment for all cancers
We refer to these national priority indicators
collectively as ‘the indicators’.
We read the other information contained in
the Quality Report and consider whether it is
materially inconsistent with:
Respective responsibilities of the
directors and auditors
z board minutes for the period April 2014 to
March 2015;
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.
z papers relating to quality reported to the
Board over the period April 2014 to April
2015;
z feedback from the commissioners, dated May
2015;
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:
z feedback from Healthwatch Organisations,
dated May 2015;
z the latest national patient survey, dated 2014;
z the Quality Report is not prepared in all
material respects in line with the criteria set
z the latest national staff survey, dated 2014;
69
z Care Quality Commission intelligent
monitoring report dated December 2014; and
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:
z the Head of Internal Audit’s annual opinion
over the Trust’s control environment for
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.
z evaluating the design and implementation of
the key processes and controls for managing
and reporting the indicators
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.
z making enquiries of management
z testing key management controls
z limited testing, on a selective basis, of the
data used to calculate the indicator back to
supporting documentation
This report, including the conclusion, has been
prepared solely for the Council of Governors
of Basildon and Thurrock University Hospitals
NHS Foundation Trust as a body, to assist the
Council of Governors in reporting Basildon and
Thurrock University Hospitals NHS Foundation
Trust’s quality agenda, performance and
activities. We permit the disclosure of this report
within the Annual Report for the year ended 31
March 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 Basildon and
Thurrock University Hospitals NHS Foundation
Trust for our work or this report, except where
terms are expressly agreed and with our prior
consent in writing.
z comparing the content requirements of the
NHS Foundation Trust Annual Reporting
Manual to the categories reported in the
Quality Report
z 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.
70
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.
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:
z 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;
z the Quality Report is not consistent in all
material respects with the sources specified
above;
z with the exception of the 62 days from urgent
GP referral to first treatment for all cancers
indicator referred to in the paragraph above,
the indicators in the quality report subject
to limited assurance have been reasonably
stated in all material respects in accordance
with the ‘NHS foundation trust annual
reporting manual’.
The scope of our assurance work has not
included governance over quality or nonmandated indicators, which have been
determined locally by Basildon and Thurrock
University Hospitals NHS Foundation Trust.
Basis of conclusion in respect of
indicators – 62 days from urgent
GP referral to first treatment for all
cancers
From our testing we found two cases where the
data recorded on the Somerset system was not
consistent with the information recorded on the
GP referral form. One of these had an impact
on the Trust’s reported performance.
David Eagles
For and on behalf of BDO LLP
Ipswich, UK
We tested a further sample and found one
further case where the referral form had not
been scanned on the system and could not be
located in paper form. On further investigation,
it was established that the form had been
destroyed as it was thought to be already
scanned on the system. As a result we were
unable to verify whether this case had been
accurately recorded on the system.
28 May 2015
71
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Basildon and Thurrock University Hospitals NHS Foundation Trust
Nethermayne
Basildon
Essex SS16 5NL
01268 524900
Minicom
01268 593190
Patient Advice and Liaison Service (PALS)
01268 394440
pals@btuh.nhs.uk
www.basildonandthurrock.nhs.uk