Quality Account
1 April 2014 – 31 March 2015
Table of contents
Introduction4
NHS outcomes framework
Foreword from the Director of Nursing
& Patient Experience and the Medical Director
Review of performance against
mandated indicators
36
Further narrative on outcome
framework indicators
39
5
Part 1
6
Statement from the Chief Executive
7
Quality highlights for 2014-15
8
Part 2
9
Quality narrative
10
■■ Domain 1: Preventing people from dying prematurely
■■ Domain 2: Enhancing quality of life for people with
long term conditions
■■ Domain 3: Helping people recover from episodes
of ill health or following injury
■■ Domain 4: Ensuring that people have a positive
experience of care
■■ Summary of performance status for quality priorities set in 2014/15
35
10
■■ Domain 5: Treating and caring for people in a safe
environment and protecting them from avoidable
harm
Our quality priorities for 2015/16
12
Deciding on our quality priorities for the
coming year
13
Our quality priorities in the last 4 years
20
Review of services
21
Participation in Clinical Audit
22
Participation in Clinical Research
29
CQUIN Framework
31
CQC Registration
31
Data Quality
32
Records submitted for Secondary Uses
Services for Hospital Episode Statistics
32
Information governance assessment report
33
Clinical coding error rate
33
Part 3
Review of quality performance
45
■■ Progress made for quality priorities 2014/15
45
Review of other quality measures
55
■■ Compliance with NICE and other National Guidance
■■ Collaboration with Kent, Surrey, and Sussex
Academic Health Science Network (KSS AHSN)
■■ Compliance with Patient Safety Alerts
■■ Achieving Excellence Programme
■■ Harm Free Care
Trust’s performance against some nationally
set targets and regulatory requirements
62
Appendices63
Summary of Stakeholder Involvement
2
44
64
Introduction
3
Introduction
The safety and quality of the care that we deliver at
Royal Surrey County Hospital NHS Foundation Trust
is our utmost priority. This is reflected in our Trust
Strategy to deliver Best Care, Anywhere. Therefore
we value the opportunity to review the quality of
our services each year and outline the progress we
have made against our set quality priorities well as
acknowledging the challenges that we have faced in
some areas in delivering care to the standard that we
aspire.
Each NHS Trust is required to produce an annual report
on quality as outlined in National Health Service (Quality
Account) Regulations 2010. The quality account is the
vehicle by which we, as providers, inform the public
about the quality of the services we provide. The quality
account enables us to explain our progress to the public
and allows leaders, clinicians, governors and staff to
demonstrate their commitment to continuous, evidence
based quality improvement. Through increased patient
choice and scrutiny of healthcare service, patients have
rightfully come to expect a higher standard of care and
accountability from the providers of NHS services.
Therefore a key part of the scrutiny process is the
involvement of relevant stakeholders. To that end,
one of the requirements for inclusion with the quality
account is a statement of assurance from these key
stakeholders and evidence of how the stakeholders
have been engaged. In addition, NHS Foundation
Trusts are required to follow the guidance set out by
Monitor with regard to the quality account and there
are a number of national targets set each year by the
Department of Health against which we monitor the
quality of the services we provide. Through this quality
account, we aim to show how we have performed
against these national targets. We will also report on
a number of locally set targets and describe how we
intend to improve the quality and safety of our services.
We continue to look at quality based on the interwoven
concepts of patient safety, patient experience and
clinical effectiveness as shown below:
patient safety
patient experience
4
clinical effectiveness
Foreword from the Director of
Nursing & Patient Experience
and the Medical Director
This last year has seen further improvements in
quality with the introduction of the new CQC hospital
inspection methodology being rolled across trusts
in England and further revisions to the fundamental
standards of care. We have both been fortunate
enough to have not only been inspected under the
new methodology, but also to have had the opportunity
to chair an inspection at other Trusts. This has been
a most valuable and worthy exercise and we have
used this opportunity to take a closer look at our own
services and make recommendations on how we can
further strengthen the quality of the services we offer.
This opportunity for isomorphic learning, i.e. learning
from others within the health economy is, we believe,
the true strength of the NHS if properly harnessed.
With each new piece of information, we have looked
at how our services compare with a view of continually
striving for excellence.
This has marked the beginning of an exciting journey for
us as leaders for quality and we hope over the coming
year we will continue to build on this experience taking
forward the best of what the NHS has to offer in terms
of innovation and best practice.
Louise Stead
Director of Nursing and Patient Experience
We welcome the drive for transparency, through the new
statutory Duty of Candour within healthcare because
we believe that this will lead to safer care through peer
discussion and challenge. We have already seen the
publication of more outcomes data at consultant level
for a number of specialties and we think that the new
duty of candour regulations will help us build on the
work that we have already started on strengthening our
incident reporting culture and embedding a safety and
just culture within our hospital.
At the time of writing this report, we are also considering
the revalidation requirements for nurses and doctors
and how we can support our staff in understanding
what the changes will mean them and how best we
ensure that staff are appropriately appraised and
revalidated in line with the new national requirements.
This is important that we get this right as it impacts on
our ability to continue to provide a quality service for
our local community.
Dr Christopher Tibbs
Medical Director
5
Part 1
6
Statement from the
Chief Executive
It is always a pleasure to present the quality report as
it is the time that we take stock of the progress and
improvement work that we have undertaken and reflect
on both the successes and challenges of the previous
year. This process of reflection helps to inform our
improvement priorities for the coming year
2014/15 has been a very busy year marked with lots of
activity aimed at reviewing the quality of our services
in preparation for our proposed merger with our
neighbouring Trust, ASPH. You will recall that in our
previous Quality Account, we headlined our intention to
merge and therefore had been working in partnership
for some time. This process has been invaluable and
has provided a useful insight into the areas of service
improvements were we could better focus our efforts.
Our quality account shows our quality improvement
journey and in this sixth edition, we showcase our big
wins, our ambitions for the future and reflect on the
areas that we did not quite achieve our targets. We
certainly have had some challenges and these are
discussed in more detail later in this report including
the remedial action we took to address these short falls.
We have tried to engage with our patients and other
external stakeholders more meaningfully and have
facilitated workshops with our stakeholders to share
our successes and also to learn from them through
their experience of the wider health economy. As we
move in to a new year, I look forward to even greater
collaboration with our stakeholders.
During 2014/15 I have been particularly encouraged
by the work that we have done in relation to managing
sepsis. We assembled an ambitious team who have led
this work and we are now collaborating with the AHSN
on the sepsis patient safety collaborative.
I confirm that to the best of my knowledge and belief,
and in accordance with the regulations governing
Quality Accounts, the information contained in this
quality account is accurate and provides a true
reflection of our organisation.
Finally, I would like to thank you for taking time to read
our quality account. If you have any comments, or
would like this report to be made available in a different
format/language, you may contact us through the
following:
To write to us:
PALS service, RSCH, Egerton Road, GU2 7XX
Follow us on twitter: www.twitter.com/RSCH
Join us on Facebook: www.facebook.com/rsch
Nick Moberly
Chief Executive
7
Quality highlights for 2014-15
Low Mortality Rate
Over the last year we have seen a decrease in our
summary level hospital mortality indicator (SHMI)
value which is testament to the work we started
two years ago when we prioritised setting up a
mortality review process. Consequently we have
seen a steady improvement in our SHMI value
which is now at band 1 – lower than expected.
Emergency Laparotomy Quality
Improvement Pathway
We are proud to announce that we were awarded
a £500,000 grant by the Health Foundation to roll
out the work we did on improving the emergency
laparotomy pathway across the South region.
Palliative Care Award
Our Palliative Care team have been shortlisted
under the Palliative Care Category for the BMJ
Awards 2015. This is in recognition of their work
to improve and standardise the end-of-life care of
patients within the Trust. The BMJ Awards is the
UK's premier medical awards programme.
Accident and Emergency
Department Performance
CHKS Quality of Care
Award Nomination
At the time of producing this report, we have
received notification that we have been shortlisted
for the Quality of Care Award. Making the shortlist
for this important award demonstrates the effort
we have made in continually improving the quality
of care we give to our patients and responding to
patient and carer feedback to improve the patient
experience.
Harm Free Care
We have greatly reduced the number of patients
suffering avoidable harm in hospital across the 4
main key harms as measured by the national safety
thermometer. The hospital’s median for patients
receiving care free from new harms is 97% against
a national median of 955%.
Alcohol Screening Service
A new alcohol support service was set up in 2014,
which established an alcohol pathway for frequent
attendees, therefore reducing length of stay and
enabling prompt assessment and referral to
specialist services as necessary.
We are pleased to report that we were one of
few Trusts achieving the national target of 95%
of patient seen in A&E within 4hours throughout
the year. This is a big achievement for the Trust
and the emergency department (ED) team due to
the very challenging winter pressures that were
experienced and widely reported nationally. Our
ED was also highlighted within the CQC annual
A&E survey as among the top performing for a
number of the survey questions including nutrition
and hydration; pain relief; compassionate care; and
emotional support.
8
Part 2
9
Quality narrative
Summary of performance status for quality priorities set in 2014/15
In our quality account for 2014/15 we set six priorities
reflecting the national health landscape. Some
of the priorities were new priorities reflecting our
responsiveness to local and or national issues and
others were existing priorities from the previous year
that we wanted to carry through to the following
year. The Trust had selected 6 quality priorities for
the 2014/15 reporting year prior to the guidance
requiring 9 priorities was issued. Due to this change in
requirement we are unable to provide data analysis on
the outstanding 3 priorities but the Trust has selected
9 priorities to take forward into 2015-16 to ensure that
this requirement is met for 2015/15.
Our quality priorities were therefore set as follows:
Patient Safety:-
■■ Priority 1 (New): Responding to the deteriorating
patient through management of sepsis
■■ Priority 2 (Refinement of previous priority): To
increase the percentage of all clinical staff working
in clinical areas receiving annual infection control
update to 80%
Clinical Effectiveness:-
■■ Priority 3 (New): To develop consultant level safety
and quality dashboards
■■ Priority 4 (Carried forward from 2013/14): To
implement new emergency processes that will
improve clinical care pathways for patients seen
in A&E
Patient Experience:-
■■ Priority 5 (New): Communicating with patients
and relatives
■■ Priority 6 (Carried forward from 2013/14): To
improve the experience of outpatients
For each of these priorities, a metric for measuring
performance was agreed and it is against this that
progress has been evaluated1. Progress on these
priorities has been monitored throughout the year and
workshops facilitated with external stakeholders to
engage and collaborate with them in the review and
monitoring of these quality priorities. The workshops
are attended by CCG quality leads, Healthwatch
representative, Health Scrutiny Committee members,
Council of Governors representatives, and members
of Surrey County Council. These external stakeholders
provide support and appropriate challenge throughout
the year in monitoring the quality priorities. Their input
to this process is invaluable. Some quality priorities
have proved more challenging to implement than others
and this will be discussed in more detail in Part 3 of
this report.
The work we have done on managing sepsis has been
an interesting challenge and we have collaborated with
national leaders and others in the health economy to
raise awareness of the issues as well as in determining
how best to measure the impact of the work that has
been done. Similarly, the development of a safety
and quality consultant level dashboard has also been
an exciting project to embark on and has led to very
interesting debates about data, its meaning and the
utility of its availability in this format proposed.
We are beginning to see the benefits of having retained
the quality priority for improving outpatients and
have maintained focus on this area of service and
encouraged concerted efforts from all levels across the
Trust to ensure that improvements are carried out in the
areas where they had been highlighted. It has been a
challenging time for most A&E departments across the
country as reported nationally and we have not been
unaffected by these challenges. However we have seen
through the work that we committed to doing at the
beginning of the year and we will discuss our progress
in more detail later in this report. We have also worked
closely with our local CCG, Guildford and Waverly
to improve patient flow in A&E and other aspects of
performance within the Emergency department.
The pace of progress for some of our priorities has
been a little slower than we would have expected
and therefore meant that the full benefits of the
improvement goal have not been realised. For these
priorities, we will carry on the work into the coming year.
However by way of summary, below is a RAG rating
for each priority based on the performance measures
agreed last year.
1 Some metrics are nationally determined and some are derived from locally determined priorities
10
Quality priority
Performance measure
Managing Sepsis
Developing a screening tool and standardised pathway for
managing sepsis patients
Increase uptake of annual
infection control update
Up to 80% of clinical staff to receive infection control annual
update
Develop consultant
level safety and quality
dashboard
Make available a dashboard showing a selection of quality
metrics at consultant level
RAG rating
Implement new emergency Undertake hospital reset project
processes
Clear process for management of pain
Clear timeline for senior clinician review with 60 minutes of
attendance to the department
Communicating with
patients and relatives
Develop a systematic process for communicating with patients
by establishing clear standards for main frame wards
Improve the experience of
outpatients
Review of staffing in outpatients
Clinic template re design
Improving physical environment in ophthalmology and pharmacy
In Part 3 we reflect in more detail on the progress that has been made during the last year against each of these
improvement goals.
11
Our quality
priorities for
2015/16
12
Deciding on our quality priorities
for the coming year
This part of the report describes the areas for
improvement that the Trust has identified for the
forthcoming year 2015/16. The quality priorities have
been derived from a range of information sources
consulting with key staff, including our council of
governors. We have also taken on board feedback from
our local CCG on quality issues to inform our selected
priorities as well as being guided by our performance
in the previous year and the areas of performance
that did not meet the quality standard to which we
aspire. Finally we have been mindful of quality priorities
emerging at national level as evidenced in the revised
CQC fundamental standards; the work of the Academic
Health Science Network patient safety collaboratives
and the ‘Sign up for Safety’ campaign. Through this
process, we have identified the following priorities:
Patient Safety: ■■ Priority 1 (New): Increasing safety within theatres
through participation in the NHS Quest theatre
safety clinical community collaborative improvement
programme
■■ Priority 2 (Carried over from 2014/15): Responding
to deterioration through management of sepsis
■■ Priority 3 (New): Reducing avoidable harm as
Patient Experience:■■ Priority 7 (New): implementation of the duty of
candour principles
■■ Priority 8 (New): Development of a patient
involvement and participation forum
■■ Priority 9 (New): Improved patient involvement in
serious incident investigation process by enabling
patients and/carers to contribute to development
of terms of reference
In choosing our priorities, we also considered the
quality issues raised about the Trust through the
various feedback mechanisms available to our staff
and patients and our Commissioners. We have also
taken account of the national landscape and shaped
our priorities to align with emerging national quality
priorities.
Each of the quality priorities outlined above will be
monitored with progress tracked throughout the
year via existing governance structures which will be
described in more detail below. In addition we will
facilitate stakeholder engagement workshops where
we will chart our progress and discuss any challenges
to implementing the quality improvement priorities as
agreed.
measured by the national safety thermometer
Clinical Effectiveness:■■ Priority 4 (New): Implementation of standardised
clinical pathways.
■■ Priority 5 (Refined and carried over from
2014/15): To increase the percentage of all clinical
staff working in clinical areas receiving annual
infection control update to 90%
■■ Priorit y 6 (New): Strengthening of quality
governance arrangements within the organisation
by establishing standard governance agendas at
portfolio / SBU level.
13
Patient safety
Priority 1:
Increasing safety within theatres by
participating in a collaborative theatre
clinical community improvement
programme
Description of quality issue and
rationale for prioritising
This year we have chosen to focus on theatre safety
as one of our quality priorities. Reviewing our incident
profile in the last year as well as on- going conversations
with external stakeholders such as our commissioners
has led to the impetus for focusing on this via the quality
account. Whilst we do not have major concerns about
theatre safety or indeed high incidence of never events,
we acknowledge that there is scope for improving
some of our theatre practises and will be collaborating
with others across the NHS QUEST network to further
enhance safety in our theatres.
Current picture – Reported incidents relating to
surgery and theatre practice suggest that some
systems would benefit from review and further
improvement
Identified areas for improvement
How will we improve?
■■ Increase frequency of auditing of compliance of
WHO
■■ Baseline safet y culture assessment using
recognised framework, i.e. Manchester Patient
Safety Framework
■■ Systematic reporting of surgical complications in
real time to MD/ clinical governance team
■■ Empowering all theatre staff to be able to ‘stop the
line’ if concerned about safety during operative
procedures
Metrics for measurement
■■ WHO safety checklist
■■ Safety culture score
■■ Reporting of surgical complications
Board sponsor: Christopher Tibbs, Medical Director
Implementation Lead: Matt Dickenson, Clinical
Director for Theatres & Pradeep Prabhu, Theatre risk
lead
Monitoring and Reporting Forum: Clinical Quality
Risk Management Group/ QA workshop
■■ Further measures to be added subject to NHS
Quest clinical community
■■ Increased compliance with completion of WHO
surgical safety checklist
■■ Strengthening communication among theatre staff
2 NHS QUEST is a network of 16 likeminded foundation trusts aiming to work together to make the greatest impact on care quality and patient outcomes
through large scale quality improvement initiatives. The network expects high level of commitment from member organisations and dedication to a body of
work that will both improve patient care and demonstrate the benefits of a collaborative quality improvement approach.
14
Priority 2:
Priority 3:
Responding to the deteriorating patient:
Managing Sepsis
Reducing avoidable harm as measured
by the national safety thermometer
Description of quality issue and
rationale for prioritising
Description of quality issue and
rationale for prioritising
This priority has been chosen for inclusion in the quality
account following a series of discussions within the
NHS QUEST2 network on the quality improvement
work for the coming year. The ‘deteriorating patient’
initiative aims to use a collaborative model across the
network to improve the detection and management
of the deteriorating patient. In particular the quality
improvement works is centred at achieving a reduction
in cardiac arrest and improved management of sepsis,
through standardising the response to early warning
scores. To fully embed this process will likely take two
years.
The Trust has participated in the national safety
thermometer for the last three years and in that time,
has developed a good understanding of the issues that
require further improvement to ensure that the majority
of patients are free from the 4 key harms. Within the
safety thermometer, harm is measured in terms of falls,
catheter associated urinary tract infections (CAUTI),
pressure ulcers and venous thromboembolisms (VTE).
Significant improvements have been made in regard to
falls in comparison to the other areas of harm and so
we wish to focus more closely on the other harm areas
in order to make the greatest impact on patient safety.
Current picture – There is variance in practice to
responding to deteriorating patients
Current picture – Inconsistent performance across
all 4 harms
Identified areas for improvement
Identified areas for improvement
■■ Sepsis management
■■ Safety thermometer performance for new VTE and
new pressure ulcers
How will we improve?
■■ Collecting data at ward level that will highlight the
need for improvement
How will we improve?
■■ Continue to complete the point prevalence monthly
audits
■■ Revision of consultant ward rounds to prioritise
identified deteriorating patients
■■ Development of action plans from audit results
with greater accountability for completing identified
actions
■■ Empowering ward teams to take responsibility of
the deteriorating patients
■■ Agreeing the measures to be used, i.e. sepsis 6 and
how this will be done
■■ Harm free report shared with all matrons
■■ Engagement with the patient safety collaborative
programme run by Kent, Surrey and Sussex
Academic Health Science Network to share best
practice
Metrics for measurement
■■ Snapshot audit of blood cultures to determine how
many were positive and based on this, undertake a
look back exercise
■■ Time to giving antibiotics
■■ Admission to ICU for sepsis
■■ Response to raised EWS (Early warning score)
■■ Compliance to national CQUIN requirements
Board Sponsor: Christopher Tibbs, Medical Director
Implementation Lead: Nial Quiney, Consultant
Anaesthetist
Monitoring and Reporting Forum: Clinical Quality
Governance Committee
Metrics for measurement
■■
■■
■■
■■
Falls,
Pressure ulcers,
VTE
CAUTI
Board Sponsor: Louise Stead, Director of Nursing and
Patient Experience
Implementation Lead: Jenny Faulkner, Deputy
Director of Nursing and Patient Experience
Monitoring and Reporting Forum: Monthly Harm
Free Care meeting
15
Clinical effectiveness
Priority 4:
Priority 5:
Implementation of Standardised clinical
pathways
To increase the percentage of all
clinical staff receiving annual update on
infection control to 90%
Description of quality issue and
rationale for prioritising
T he re is compelling evidence showing that
standardisation of clinical pathways is a linked to
better patient outcomes. Through standardisation, it
is possible to design clinical pathways that reflect the
latest best practise evidence and to be able to measure
this consistently for all patients within that pathway.
Current picture – Lack of standardisation across
clinical pathways representing latent risk to patients
Identified areas for improvement
■■ Standardisation of clinical pathways
How will we improve?
■■ Identification of top 5 pathways for standardisation
for each SBU
Description of quality issue and
rationale for prioritising
This priority was put forward by our council of governors
and has full endorsement of the Trust board. We are
committed to reducing infection rates in the hospital
and this has been a key theme across our last three
quality accounts. The goal of this priority is to focus
on ensuring that staff are receiving the appropriate
training in infection prevention and control. Last year
we made good progress in achieving the target set but
just narrowly missed this by 4%. Therefore we intend
to build on the improvement we made last year by
retaining this priority for a second year.
Current picture – Infection control training targets
not met last year
Identified areas for improvement
■■ Compliance with mandatory training
■■ Templates and archiving approach agreed
■■ Hand hygiene compliance (WHO 5 moments)
■■ Pilot of 2 -3 pathways
■■ Compliance with ‘bare below the elbows’
Metrics for measurement
How will we improve?
■■ Timeline set for reviewing and approving pathways
■■ Improved compliance with infection control as
for each quarter
Board Sponsor: Nick Moberly
Implementation Lead: Graham Layer, Director of
Professional Standards
Monitoring and reporting forum: Clinical Quality
Governance Committee & ELT
evidenced against the monthly IC audits
■■ Reduction in infection rates
Metrics for measurement
■■ >= 90% for clinical staff (including medical staff)
undertaking annual refresher in infection control
■■ Consistent performance on IC monthly audits
Board Sponsor: Christopher Tibbs, Medical Director
and DIPC
Implementation lead: Gill Hickman, Infection Control
Nurse Specialist
Monitoring and reporting forum: Hospital Infection
Control Committee (HICC)
16
Priority 6:
Strengthening of quality governance
arrangements within the organisation
by establishing standard governance
agendas at portfolio / SBU level
Description of quality issue and
rationale for prioritising
It is important to ensure that at specialty level, there
are appropriately robust governance arrangements
that support the monitoring of relevant quality metrics.
Whist the quality governance structure is clearly defined
at corporate level, the arrangements at specialty level
are less well defined and there is no standard agenda
in use to support individual specialties to monitor
the relevant quality metrics that feed into the Trust’s
national quality profile.
Current picture – There is no standard quality
governance agenda in use at specialty level and not all
specialties have a regular quality governance meeting
established.
Identified areas for improvement:
■■ Standardisation of quality governance arrangements
at specialty level
How will we improve?
■■ Agenda with standard quality items to be developed
■■ Quality governance meetings to be established in
each specialty
■■ Reporting process at specialty and portfolio level
to be clarified
Metrics for measurement
■■ Use of standard agendas
■■ Escalation of quality issues from specialty to
portfolio level reflected in portfolio governance
meeting minutes
Board Sponsor: Christopher Tibbs, Medical Director
and Louise Stead, Director of Nursing and Patient
Experience
Implementation Lead: DMDs and Head of Patient
Safety and Quality
Monitoring and Reporting Forum: Clinical Quality
Risk Management Group
17
Patient experience
Priority 7:
Priority 8:
Development of patient involvement and
participation forum
Implementation of duty of candour
principles
Description of quality issue and
rationale for prioritising
Description of quality issue and
rationale for prioritising
Meaningful patient involvement has been linked to
better patient experience and improved quality of
services. With that in mind, we have chosen to focus
on developing a patient involvement and participation
forum. We recognise that we haven’t always engaged
patients well and so we believe that developing a forum
where patients can contribute first hand will enable us
to further capture patient feedback and enable us to
explore solutions to problems directly with patients in
a discursive way that is not within the constraints of
other formal processes, i.e. complaints, FFT survey.
Following the revision of CQC regulations, the duty
of candour will become a legal issue as from 1 April,
2015. With that in mind, we have decided to make this
a quality priority for the coming year. Historically, we
have always encouraged staff to be open about harm to
patients and the requirements for duty of candour will
strengthen our processes in this regard. We are keen
to build a culture of transparency to promote safety
across the hospital.
Current picture – Such a forum currently does not
exist
Identified areas for improvement:
■■ Establish a forum to capture feedback directly from
patients
Current picture – There is currently no legal
requirement for candour and so practice in this
regard is variable across the hospital and there is no
systematic process for documenting and evidencing
when this occurs
Identified areas for improvement:
■■ Standardising practice across the hospital
How will we improve?
How will we improve?
■■ Implementation of patient forum
■■ Clarity of documentation to support duty of candour
conversations
Metrics for measurement
■■ Staff briefing sessions on duty of candour
requirements
■■ Attendance at patient forum
■■ Analysis of feedback from involvement forum once
established
Board Sponsor: Louise Stead, Director of Nursing and
Patient Experience
Implementation Lead: Jenny Faulkner, Deputy
Director of Nursing and Patient Experience
Monitoring and reporting forum: Patient Experience
Committee and Trust Board
Metrics for measurement
■■ Timeliness of communication with patients and or
relatives following harm being detected
■■ Evidence of patient/carer discussions taking place
following harm incidents
■■ Where harm results in SI investigation, carers/
patients to be offered the opportunity to contribute
to the development of terms of reference
Board Sponsor: Christopher Tibbs, Medical Director
Implementation lead: DMDs and Head of Patient
Safety and Quality
Monitoring and reporting forum: Clinical Quality
Governance Committee and Trust Board
18
Priority 9:
Improved patient involvement in serious
incident (SI) investigation process
by enabling patients and/carers to
contribute to development of SI terms of
reference
Description of quality issue and
rationale for prioritising
Metrics for measurement
■■ SI investigation report
■■ Family communication log
Board Sponsors: Louise Stead, Director of Nursing
and Christopher Tibbs, Medical Director
Implementation Lead: Taffy Gatawa, Head of Patient
Safety and Quality
Monitoring and Reporting Forum: Clinical Quality
Governance/ CCG CQRM
Whilst the Trust has a robust process for investigating
serious incidents, it is recognised that the process
could be further enhanced by actively involving
patients and carers, (if they so wish), in this process.
The current process engages patients and carers at
the end of an investigation when patients have the
opportunity to meet with the investigation panel chair
and or relevant clinicians to discuss the investigation
findings. We feel that by involving patients at the outset
of the investigation, we can better improve the patient
experience at what is often a very difficult time. This
will also support the duty of candour requirements.
Current picture – Patients and carers do not currently
contribute to the development of terms of reference
following a serious incident
Identified areas for improvement:
■■ Greater transparency by involving patients in the
development of terms of reference
■■ Greater patient voice in SI process
How will we improve?
■■ Standard letter will go out to patients following
each SI
■■ Following each SI, patients will be offered the
opportunity to contribute to the terms of reference
of the investigation
■■ The SI report section relating to patient involvement
will be used to reflect the issues raised by the
patient/ and or carers and how these have been
addressed as part of the investigation
■■ A log of all contact with the patient/ carer throughout
the SI investigation process will be maintained
19
Our quality priorities in the
last 4 years
Quality 2011 – 2012
Domain
Safety Express, Safer
and smarter care
Patient Safety
Infection prevention
and control
Falls Reduction
Increased incident
reporting &
investigation
Prevention of VTE
2012 -2013
2013 -2014
2014 – 2015
To build a safe culture
Maintain minimal
infection rates
Managing sepsis:
Responding to
deteriorating patients
To lead and support
staff
To integrate risk
management
Reduce Inpatient Falls
Promote and Increase
Harm Free Care
To promote incident
reporting
To involve and
communicate with
patients and the public
To increase the
percentage of all
clinical staff working in
clinical areas receiving
annual infection control
update to 80%
To learn and share
safety lessons
Patient Experience
To implement solutions
to prevent harm
Participation in national To distribute clinically
clinical audits
effective
Increase clinical trials
activity
Communicating with
patients and relatives
Mortality Review
To implement clinically
effective healthcare
Compliance to national
evidence
guidance
To provide assurance
that patients are
receiving clinically
effective healthcare
Improve mortality
review process
To improve the
experience of
outpatients
Enhancing quality
programme
Implement Friends and
Family Test
Clinical Effectiveness
PROMS
Board to ward
leadership
To provide effective
‘board to ward’
leadership
Develop the supportive
and palliative care
services
Implement New
To deliver high quality
emergency processes
patient communication
Improve outpatients
and to optimise first
experience
impressions
To optimise dignity in
care
To develop consultant
level quality and safety
dashboards
To implement new
emergency processes
that will improve
clinical care for
patients seen in A&E
To optimise ethical
spiritual care
To ensure effective
care of vulnerable
people
In this following section we report on matters relating to the quality of NHS services
provided as stipulated in regulations. The content is common to all providers so that
the quality accounts can be comparable between organisations.
20
Review of services
During 2014/15, Royal Surrey County Hospital
NHS Foundation Trust provided and or sub–
contracted 40 NHS services. The Royal Surrey
County Hospital NHS Foundation Trust has
reviewed all the data available to them on the
quality of the care in 40 of these services.
The income generated by the NHS services
reviewed in 2014/15 represents 100% of the
total income generated from the provision of
NHS services by Royal Surrey County
Hospital NHS Foundation Trust.
21
Participation in clinical audit
Clinical audit is a way of finding out if health and social
care is being provided in line with agreed standards.
Clinical audit lets providers know where their service
is doing well and where there could be improvements.
Where services do not meet the agreed standard, the
audit provides a framework where suggestions for
improvements can be made. A third party conducts
national audits. Participating in these audits gives
providers the opportunity to compare their results with
other providers. Local audits are conducted by the
provider itself. Here they evaluate aspects of care that
the healthcare professionals themselves have selected
as being important to their team.The aim is to allow
improvements to take place where they would be most
helpful and will improve patient outcomes. In cases
where clinical audit looks at care provided all over
the country, this is called national clinical audit. Local
audit is so called because it looks at the performance
of a local service instead of looking national or country
wide.
As clinical audit is about quality and finding out if
best practice is being practiced, when conducted
correctly, clinical audit helps to identify and minimize
risk, waste and inefficiencies and improves the quality
of care and patient outcomes. Clinical audit also helps
the Trust in maintaining regulatory compliance with
the Care Quality Commission (CQC) by ensuring that
the standards of safety and quality are met. Other
regulators also interested in clinical audit activity and
outcomes include Monitor, NHSLA and NHS England.
As we all participating in the national audits that are
stipulated in the quality accounts list, it is important
to note that the Royal Surrey County Hospital also
participates in many more audits than those described
within the table and therefore the table represents
a small sub set of the proportion of the audit work
undertaken at the Trust.
The national clinical audits are derived from the annual
Quality Accounts National Clinical Audits list and
the National Clinical Audits and Patients Outcome
Programme (NCAPOP) list. The National Clinical Audit
and Patient Outcomes Programme (NCAPOP) is a
set of centrally-funded national projects that provide
local trusts with a common format by which to collect
audit data. The projects analyse the data centrally and
feedback comparative findings to help participants
identify necessary improvements for patients. From
April 2011 it became mandatory to participate fully
in all NCAPOP approved national audits which are
relevant to the services provided. This duty is reflected
within the NHS standard contract quality particulars.
Participation is externally monitored, and the annual
Quality Accounts include mandatory statements
relating to Trust participation in these audits
Participation in clinical audit is a key quality marker
and the Trust has a good track record of participating
in national clinical audits. The chart below shows the
Trust’s participation over the last four years:
During 2014/15, 37 national clinical audits and 3
confidential enquiries covered NHS services that
Royal Surrey County Hospital NHS Foundation Trust
provides. During that period, Royal Surrey County
Hospital participated in 98% of national clinical audits
and 100% of national confidential enquiries which it
was eligible to participate in. The national clinical audits
and national confidential enquiries that Royal Surrey
County Hospital NHS Foundation Trust was eligible
to participate in during 2014/15 are shown in the table
below including the number and percentage of cases
submitted to each audit or enquiry.
A comaprison of the National Audit participation rate over time
100%
98%
Participation Rate
98%
98%
95%
96%
94%
92%
90%
88%
86%
86%
84%
82%
80%
2011/2012
2012/2013
2013/2014
2014/2015
Year
22
Quality Account National Audits 2014/2015
Blood and Transplant
Acute Care
Audit
Audit
Category
Eligible Data Collection required
(yes/no) 2014/15
% of cases submitted to
each audit
Adult critical care (Case
Mix Programme –
ICNARC CMP)
Yes
yes
Ongoing data input
Data is 100% complete to
date (3 months delay due to
validation between RSCH
and ICNARC)
National Emergency
laparotomy audit (NELA)
Yes
yes
Audit started in January
2014, 3 year funded audit
Organisational audit
completed,
clinical data submitted for
year 1 (100% of expected
case ascertainment)
Adult community acquired
pneumonia (British
Thoracic Society)
yes
yes
Audit period: 1st Dec 14 to
31st Jan 15
In progress, Respiratory
Registrar currently auditing.
Audit data collection
started March 15, data
submission deadline is
31st May 15
National Joint Registry
(NJR)
Yes
yes
ongoing data input
% of case ascertainment
currently unavailable
Severe trauma (Trauma
Audit & Research
Network)
Yes
yes
ongoing data input
Up to Q3 167/243 expected
cases have been submitted,
68.7% case ascertainment.
The accreditation score
indicating data quality for
this period is 92.8%.
National Comparative
audit of Blood
Transfusion: audit of
Patient information &
consent
yes
yes
Data submitted 9th May
2014
Complete
11/24, satisfactory
submission for inclusion in
National report
Red Cell Issue Trace
Survey
yes
yes
2nd phase of audit period:
12th to 18th May 2014,
deadline 13th June 14
Complete 100% case
ascertainment
Audit of transfusion in
children and adults with
Sickle Cell Disease
yes
yes
Part 1 - case capture
phase, all patients
with sickle cell disease
transfused 1st Jan to 30th
June 2014 (data collected
1st Sept 14 deadline 1st
Jan 2015)
Part 2 - sample of case
capture audited (data
entered 6th Feb 15 to 31st
March 2015)
Organisation audit - data
entered 1st September to
31st March 2015
Part 1 and 2 completed 1/1
eligible cases submitted,
and Organisational audit
submitted, 100% case
ascertainment
23
Audit
Audit
Category
Eligible Data Collection required
(yes/no) 2014/15
National Lung Cancer
Audit (NLCA)
yes
yes
audit includes patients
diagnosed 1st January
2013 to 31st December
2013
Bowel Cancer (NBOCAP)
Yes
yes
Waiting for data submission
audit includes patients
details
diagnosed 1st April 2013 to
31st March 2014
deadline 27th March 2015
Head and neck oncology
(DAHNO)
Yes
yes
audit includes patients
diagnosed 1st November
2013 to 31st October 2014
Only 2 cases submitted for
RSCH
Cancer
Heart
24
% of cases submitted to
each audit
97/109 expected cases
submitted, 89% case
ascertainment
The Cancer Service
Manager reported a
resource issue, this was
escalated to the Deputy
Medical Director for the
portfolio and the Trust
Medical Director, and
reported formally to
the appropriate Trust
governance forum, CQRMG.
DAHNO have confirmed that
RSCH submitted low counts
for RSCH and other Trusts
that RSCH submits data on
behalf of for inclusion in the
10th Annual Report (Nov13
to Oct 14 data).
Oesophago-gastric
cancer (NAOGC)
Yes
yes
Data period: 1st April 2013
to 31st March 2014
deadline 27th March 2015
Waiting for submission
details
Prostate Cancer
yes
yes
Audit started April 2013
and is funded for minimum
of 5 years.
Organisational audit
Inpatient audit
Organisational audit
completed
Inpatient audit for year 1
completed, submission
details not yet known
National Cardiac Arrest
Report (NCAA)
Yes
yes
ongoing data input
Waiting for submission
details
Coronary angioplasty
no
not applicable
not applicable
National Vascular
Registry (elements will
include CIA, National
Vascular Database,
AAA, peripheral vascular
surgery/VSGBI Vascular
Surgery Database)
no
not applicable
not applicable
Adult cardiac surgery
audit (ACS)
no
not applicable
not applicable
Acute coronary syndrome
or Acute myocardial
infarction (MINAP)
Yes
yes
ongoing data input
in progress
Mental Health
Long term condition
Heart
Audit
Audit
Category
Eligible Data Collection required
(yes/no) 2014/15
% of cases submitted to
each audit
Heart failure (HF)
Yes
yes
ongoing data input
in progress
Pulmonary Hypertension
no
not applicable
not applicable
Cardiac arrhythmia (HRM)
Yes
yes
ongoing data input
240 cases submitted out
of an expected 207 cases,
100% case ascertainment
Congenital heart disease
(Paediatric cardiac
surgery) (CHD)
no
not applicable
not applicable
National Diabetes Audit
(NDA)
Yes
yes
audit data for 1st Jan 13
to 1st Mar 14 - collected
5th Jan to 20th March 15,
deadline extended to late
April 15
Data extraction is in
progress, data will be
submitted by the deadline
National Pregnancy in
diabetes (NPID) audit
yes
yes
ongoing audit
data entry year 2 14/15
closed Jan 15
5 eligible cases submitted,
100% case ascertainment
National Diabetes Foot
Care Audit (NDFA)
yes
yes
data entry 14th July 2014
to 31st July 2015
Audit in progress, 5 cases
submitted to date for
2014/15
Diabetes (Paediatric)
(NPDA)
Yes
yes
audit period 1st April
2013 to 31st March
2014, deadline for data
submission 14th July 2014
102 cases audited (only
HBA1c data entered), 100%
case ascertainment
Inflammatory bowel
disease (IBD)
Yes
yes
Biologics audit, ongoing
37 cases submitted for
2014/15, 100% case
ascertainment
Chronic Obstructive
Pulmonary disease
(COPD)
yes
yes
audit of patients diagnosed
1st Feb 14 to 31st May 14
Organisational audit
Organisational audit
completed 100%
Clinical audit Completed 97% case ascertainment
Pulmonary Rehabilitation
audit (workstream of the
COPD audit programme)
yes
yes
Data collection Jan 15 to
July 15
11 eligible cases submitted,
100% case ascertainment to
date, audit closes 30th July
2015
Renal replacement
therapy (Renal Registry)
no
not applicable
not applicable
Chronic kidney disease in
primary care
no
not applicable
not applicable
Prescribing in mental
health services (POMH)
no
not applicable
not applicable
Suicide and Homicide in
Mental Health Settings
(NCISH)
no
not applicable
not applicable
Mental Health (CEM)
yes
yes
1st Jan 14 to 31st Dec 14
Data collected
retrospectively up to 50
cases, data entered 1st
August 14 to 31st Jan 15
29 eligible cases submitted,
100% case ascertainment
(maximum of 50 cases
required)
25
Audit
Audit
Category
Gastrointestinal
Haemorrhage Study
Eligible Data Collection required
(yes/no) 2014/15
yes
yes
Patient identifier deadline
31st Jan 2014
Organisational audit
deadline 30th May 2014
Clinical Questionnaires
deadline 12th June 2014,
extended to 30th June 14
% of cases submitted to
each audit
Patient identifier
spreadsheet completed
Organisational questionnaire
completed
Clinician questionnaire
completed 100% (4/4), 1
case note was excluded
by NCEPOD but with valid
reason.
100% case ascertainment
yes
yes
Patient identifier period
2nd May to 20th May 14
Clinical questionnaires
October 14
Organisational audit
November 14
Patient identifier
spreadsheet completed and
submitted 3rd June 14
Peer review completed 16th
Oct 2014 (4/4)
Organisational questionnaire
completed
100% case ascertainment
Acute Pancreatitis Study
yes
yes
Patient identifier
spreadsheet, period 1st
Jan 14 to 30th June 14,
deadline 13th Feb 14
(extension 24th Feb)
Clinician questionnaire
deadline tbc
Organisational
questionnaire deadline tbc
Patient identifier list
submitted 24th Feb 15
100% participation to date
Sentinel Stroke National
Audit Programme
(SSNAP)
Yes
yes
ongoing data input
April-June 2014 =88/88
(100%)
July-Sept 2014 =82/88 (93%)
Oct-Dec 2014 =87/88 (99%)
data submission for Jan-Mar
is currently not available.
National Dementia Audit
(NAD)
yes
yes - pilot for year 1
starting Jan 15, our Trust
expressed interest in
participating in the pilot
but we were not shortlisted
as one of the 10 Trusts
included. Data collection
from all hospitals will begin
from April 2016.
Falls and Fragility
Fractures audit
programme (FFFAP)
includes National Hip
Fracture database
(NHFD), Fracture liaison
service (FLS-DB) and the
National audit of inpatient
falls.
yes
Yes
ongoing data input
Older People
NCEPOD
Sepsis Study
26
Data is 100% complete to
date
Other
Women's & Children's health
Older People
Audit
Audit
Category
Total
Eligible Data Collection required
(yes/no) 2014/15
% of cases submitted to
each audit
Older people (CEM)
yes
yes
1st August 2014 to 31st
Jan 2015
100/100 cases submitted,
100% case ascertainment
Rheumatoid and early
inflammatory arthritis (new
NCAPOP topic under
development)
yes
yes
Start date 1 February 2014
Organisational data due
28th Feb 14 - extended to
31st March 14
Organisational audit
completed and submitted
3 Clinical audit forms
submitted
Maternal, newborn and
infant clinical outcome
review programme
(MBRRACE-UK),
previously listed as
Perinatal Mortality
Yes
yes
ongoing data input
17 cases reported for
2014/15 - 100% case
ascertainment
Neonatal intensive and
special care (NNAP)
Yes
yes
ongoing data input
Waiting for data submission
details
Epilepsy 12 audit
(Childhood Epilepsy)
Yes
yes
data entry April 2014- 9th
June 2014
Waiting for data submission
details
Paediatric intensive care
(PICANet)
no
not applicable
Fitting Child (CEM)
yes
yes
1st August 2014 to 31st
Jan 2015
15 eligible cases submitted,
100% case ascertainment,
(max 50 cases)
Elective surgery (National
PROMs Programme)
Yes
yes
ongoing data input
Pre-operative questionnaires
returned 805/970=83%
(77.3% in England)
Post-operative
questionnaires
497/792=62.8% (67.8% in
England)
National Audit of
Intermediate Care
yes
yes
Service user audit
(optional)
Organisational audit 27th
May 14 to 11th July 2014
Organisational audit
Completed, 100%
Pleural Procedures
yes
yes
audit open 1st June to
30th September 14, audit
period 1st June 14 to 31st
July 14
Organisational audit
completed
9 eligible Inpatient audit
completed, 100% case
ascertainment
Adherence to British
Society for Clinical
Neurophysiology (BSCN)
and Association of
Neurophysiological
Scientists (ANS)
Standards for Ulnar
Neuropathy at Elbow
(UNE) testing
yes
1st April to 9th May 2014
Audit completed and
submitted, 100% case
ascertainment
40
39 audits completed or in
progress
27
The Trust failed to submit data for the Head and
Neck Cancer audit (DAHNO) owing to resource
issues. In order to ensure that future resource issues
identified are escalated to the appropriate level in
future, portfolio management leads will ensure that
there is appropriate representation at key meetings
when audits are presented. In addition, the work to
standardise governance agendas will also ensure that
audit progress is routinely discussed at portfolio level.
Failure to submit data for the DAHNO audit meant the
Trust was unable to achieve 100% participation rate as
this was the only audit that the Trust did not take part in.
The reports of 17 national clinical audits were reviewed
by the Royal Surrey County Hospital NHS trust in
2014/15. Ten reports have not yet been published and
a further 11 reports have been sent to the respective
audit leads for development of action plans. As a result
of the audit reports that have been reviewed, the Royal
Surrey County Hospital NHS Foundation Trust intends
to take the following actions to improve the quality of
healthcare provided.
3. National Clinical audit of Inpatient
care for patients with ulcerative colitis
Improvement priorit y 1 - Bone protect ion
prescription for patients discharged on
corticosteroids
■■ Protocol completed for acute severe colitis
■■ Educating the Junior doctors on Millbridge and EAU
re bone protection for IBD patients on prednisolone
Improvement priority 2 – Stool samples sent for
Standard stool culture
■■ Educating Junior doctors for sending stool samples
for MC&S and C diff on patients presenting with an
acute flare-up of their illness
■■ Gastro Consultants fully aware of need to involve
dietician, IBD CNS and prescribe bone protection
Improvement priority 3 - Dietician and IBD Nurse
Specialist reviews on inpatient
■■ IBD CNS now full time
■■ IBD CNS has good liaison with the gastro dietician
1. Pleural Procedures audit:
Improvement priority 1 – To improve the knowledge
of Junior doctors regarding the management of
chest drains, and suturing techniques:
■■ Theoretical educational session in Emergency
admissions unit with case based discussion
■■ Simulation practical session to demonstrated
correct seldinger placement and suturing techniques
who is now a specialist dietician for gastro patients
only, so has more time to review patients and is
based on Millbridge and gastro outpatients. Gastro
dietician attends Millbridge MDT so will become
aware of patients that require dietetic input.
The reports of local clinical audits were also reviewed
in 2014/15 and action plans developed for a number of
them including antimicrobial prescribing, compliance
with WHO surgical safety checklist, medication
prescribing errors to name a few.
2. National Cardiac Arrest Audit 13/14:
Improvement priority 1 - Significant higher rate
of cardiac arrest on Mondays and Saturdays and
during the hours 05:00-07:59:
■■ A process has been agreed for review of cardiac
arrests and escalation of patients where concerns
have been identified for discussion at the M&M
meetings
28
Participation in clinical research
The number of patients receiving NHS services
provided or sub – contracted by Royal Surrey County
Hospital NHS foundation Trust in 2014/15 that were
recruited during that period to participate in research
approved by a research committee was 1391.
In April 2014 the RSCH became one of the 15 national
host sites for National Institute of Healthcare Research
(NIHR), hosting the Kent Surrey & Sussex Lead Clinical
Research Network. Although the Trust is the host for
the KSSCRN management and the KSSCRN funding
allocation, the RSCH department of RD&I will continue
to act as a member organisation and will be required
to apply for annual and contingency funding and also
fulfil all the national targets and metric the same as
every other trust within KSS. The Trust effectively acts
as a provider of services commissioned and funded by
the NIHR CRN for the support of high quality clinical
trials and studies adopted onto the national research
portfolio (‘portfolio studies’) by the RSCH.
As a member organisation the RSCH RD&I team will
continue to work and support the CRN governance
team and research delivery managers in monitoring
trial availability on the NIHR portfolio and identifying
PIs within the RSCH.
We acknowledge that the number of trials approved
this year and patients recruited have decreased this
year and this has been mainly due to resource issues
and concentrating on improved governance. This has
included the introduction of a Governance Lead/Trials
auditor and Lead Research Nurse position. Both posts
have strengthened the research infrastructure within
the RSCH, as new research areas have opened it
has prevented isolation of research staff, enabled the
standardisation of processes and allowed workforce
development.
The Trust has approved and opened 57 new trials in this
financial year. The new trials now bring the total number
of trials hosted at the hospital up to 353 of which 74 are
commercially sponsored. Of these studies 177 are still
open to patient recruitment. At the end of the financial
year a total of 1,391patients have been recruited into
trials of which 905 patients have been recruited into
78 adopted studies that are on the National Institute
of Health Research portfolio.
The Trust continues to develop its strong research
and development culture and build on strengthening
its collaborations with neighbouring trusts and
universities. The RD&I department have worked with
the University of Surrey to develop a joint research
strategy and implement the necessary research
related umbrella agreements preventing duplication
of processes, unnecessary delays with approval and
encouraging collaborative working across institutions.
RSCH promotes strategic and operational consensus
with the University of Surrey by securing trust
representation on high level strategy groups in the
University and vice versa.
This year has also seen the growth of the Strategic
Partnership with the University of Surrey through Surrey
Health Partners (SHP) leading to the development
of ten Clinical Academic Groups (CAGs). The SHP
membership includes ASPH, RSCH, University of
Surrey and The Royal Holloway University, Surrey and
Borders Partnership FT (Mental Health) and Frimley
Health (joined in January 2015). This is supporting
partnership working between the members and
bringing clinicians and academics together in Clinical
Academic Groups (CAGs) to deliver three objectives;
■■ Improved research activity and income,
■■ D eve l o p m e nt of te a c hin g a n d e du c ati o n
programmes and
■■ Applying continuous improvement principles to
improve patient care.
The current ten CAGs are Cancer, Critical Care,
Diabetes, Cardiology, Sleep, Parkinson’s and Early
intervention in Mental Health, Comparative Pathology,
Emotional Disorders in children and Primary Care.
RSCH take a leading role in shaping and thinking in the
strategic development of SHP and it is encouraging that
new Partner Trusts are recognising the value of SHP
and seeking to join. There was a successful strategy
event in January 2015 and the SHP Five Year Strategy
will be published in June 2015.
A key early objective was to formalise joint appointments
for clinicians with the Universities. RSCH lead the
Research Management Group which is a CAG subgroup, who work together to standardise processes
and procedures required to support SHP’s vision
of increasing the number of collaborative research
proposals and successful grant bids.
An HR working group will look at the pipeline of new
consultant posts across Partner Trusts so that the
University can consider how to align these new posts
to the research priorities. Another group is looking at
the financial flows and incentives in the various partner
organisations so as to meet the goal of SHP to promote
more patient trials and research impact.
In summer 2014 Surrey Cancer Research Institute”
(SCRI) was launched. It is hoped that SCRI will follow
other leading Cancer Centres both in the UK and
overseas and provides the opportunity for the Trust to
present all the excellent and active research of many
people in RSCH in one place. This will provide national
29
and international visibility enabling the Trust to raise its
profile further in cancer research and to also create a
single point of contact for external parties looking to
collaborate or develop relationships with clinicians at
the Trust. The SCRI are currently working on a website
that will promote the excellent work delivered at the
Trust, our current key successful collaborations, our
vision to develop new research areas and how external
parties can engage with SCRI. Publications from
teams will be posted on the website simultaneously as
they appear in journals, a back catalogue/archive will
also be created. Each month there has been a wellattended seminar part of a programme of education
and training with some leading speakers in the field of
cancer research.
The RSCH and the University are working to refocus
the current Clinical Research Centre (CRC) to become
a leading Clinical Research Facility. In addition to this it
is planned to apply to the National Institute for Clinical
Research (NIHR – the NHS research funding body) to
become an accredited Clinical Trials Unit (CTU) in May
2015. An accredited CTU will enable Chief Investigators
to start up multi centre home grown research across
both the network and nationally. Through the mentoring
relationship we have with Southampton University a
number of major mutli - centre trials have been set up
through the non-accredited CTU. Accreditation by the
NIHR would provide a major opportunity for the whole
of the KSS region enable CIs from across the region set
up their own trials without resorting to going out of area.
Radiotherapy
To date for year 2014-15 the Radiation Oncology
Research Team have recruited 73 patients, adding to a
total of 689 patients recruited into Radiation Oncology
Studies ; running 17 recruiting studies during this period
and being responsible for 288 patients in active followup, as well as supporting a radiotherapy element for
10 patients in complex chemotherapy trials. Feedback
from the CHKS quality assurance accreditation visit
in Oct 2014 stated the section is "well managed and
extremely active in ensuring patients have access to
the latest trials open". This year the team remained the
top recruiter for the PIT trial, after being the first site
to open to recruitment in 2012, and recruit the first 2
patients. The team have recently recruited their 66th
patient into the Import HIGH trial exceeding the original
recruitment target by 450%; a massive achievement
considering the considerable development required to
patients pathway to implement IMRT treatment delivery
to breast patients requiring work from the entire multidisciplinary team of physicists, radiographers, research
staff and clinicians. Our work on the Ideal CRT lung
trial, has led to the Royal Surrey Team being asked to
present at the national Ideal CRT trial meeting, sharing
our expertise in recruitment and reflecting that we were
the 1 of the first 2 centres to treat a patient using IMRT
and RapidARC in the trial; with our current recruitment
standing at 9 patients. The radiotherapy physicists
have also been supporting other sites with planning of
complex head and neck studies ART DECO and DeEscalate HPV and their work resulted in a significant
modification to the radiotherapy planning guidelines
for the De-Escalate trial in late 2013.
The opening of the Radiotherapy Centre Satellite unit at
East Surrey Hospital, in Sep 2014, has brought a new
era for the Radiation Oncology team, enabling patients
to receive radiotherapy treatment within trial at new
Satellite and the team are close to completing work
enabling RSCH patients local to the satellite centre to
access a radiographer lead follow-up service for trial
patients instead of having to travel to Guildford.
The rapidly increasing nuclear medicine trials portfolio
has led to the introduction of new services into clinical
practice within molecular imaging, including vulval
sentinel node imaging and localisation as part of
the Groinss-V II trial and the introduction of Xofigo®
treatments for patients with prostate cancer as direct
result of our participation in clinical trials.
Looking to 2015-16, exciting new trials such as
RAIDER may help push through cutting edge
radiotherapy techniques such as adaptive doseescalated radiotherapy, and develop emerging therapy
procedures such as the use of Yttrium-90 glass
microspheres (STOP-HCC & EPOCH trials) providing
world-class treatment for patients, and establishing
these treatments for routine clinical patients and
providing the Royal Surrey with an excellent reputation
in clinical trials involving radiation.
30
CQUIN Framework
2.5% of Royal Surrey County Hospital NHS Foundation
Trust income in 2014/15 was conditional on achieving
improvement and innovation goals agreed between
Royal Surrey County Hospital NHS Foundation Trust
and Guildford and Waverly Clinical Commissioning
Group for the provision of NHS services through the
Commissioning for Quality and Innovation payment
framework (CQUIN). Of this 0.5 % was set against
national CQUIN goals. The remaining 2% was spread
across locally agreed goals with the CCG and some
specialist goals agreed with NHS England. Further
details of the agreed goals for 2014/15 and for the
following 12 month period are available electronically
via the link below:
http://www.institute.nhs.uk/world_class_
commissioning/pct_potal/cquin.html
Local CQUIN goals included a focus on stroke
management and serious incident management and
alcohol screening. National CQUINS that the Trust was
involved in included Dementia Screening, NHS Friends
and Family test, and the Safety Thermometer.
CQC registration
Royal Surrey County Hospital NHS Foundation Trust is
required to register with the Care Quality Commission
and its current registration status is full compliance with
no conditions imposed on registration. The Care Quality
Commission has not taken enforcement action against
Royal Surrey County Hospital during 2014/15. The Care
Quality Commission has recently revised its hospital
inspection methodology and now inspects hospitals
under 5 main key domains of quality. These are
■■
■■
■■
■■
■■
Safety
Caring
Responsiveness
Effective
Well led
Royal Surrey County Hospital NHS Foundation Trust
was amongst the first to be inspected under this
new methodology in October 2013. Following this
inspection, the Trust was awarded a shadow rating of
‘Good’. Although the inspection did not impose any
condition on the Trust’s registration, it did highlight
some areas for improvement and an action plan was
jointly developed with the CQC on how these can
be taken forward. Throughout 2014/15 the Trust has
diligently worked through the action plan to ensure that
all areas that were identified for improvement during the
2013 inspection are followed through. The availability
of the CQC action plan has also informed some of the
Trust’s quality priorities.
The full CQC inspection report can be found at the
following link: http://www.cqc.org.uk
During the reporting period, Royal Surrey County
Hospital NHS Foundation Trust has also participated
in a national survey of Accident and Emergency (A&E)
departments undertaken by the CQC in December
2014. A&E is one of the eight core services that the CQC
inspects and rates in acute hospitals, and patients’
experience of care is a key aspect in determining these
ratings (CQC, 2014). Respondents were asked to rate
their overall experience of attending A&E by allocating
a score between 0 and 10 (0 being very poor, 10 being
very good). Based on this survey, the Trust was found to
be fourth among the 12 Trusts with performance better
than expected when compared to other Trusts. Further
analysis of the survey questions showed the Trust to
perform better than expected in the following areas:
■■
■■
■■
■■
Nutrition and hydration
pain relief
compassionate care and
emotional support
31
Data quality
During the course of the year we discovered some
issues with the recording of RTT data and consequently
engaged the Department of Heath intensive support
team known as IMAS to conduct a review of our
reporting processes in this regard. At the same time,
we also alerted Monitor to the issues we had identified
as sector regulator and indeed the CQC. We are keen
to ensure good data quality and will take the necessary
steps to safeguard patients from harm resulting from
poor data quality.
■■ Providing guidance to staff on what data fields to
check to ensure the correct patient demographic
identifiers (PDIs)
■■ Monitoring on-going trends and themes via
the information governance steering group and
escalating to board as necessary
■■ Raising awareness of the importance of reporting
data quality issues so that remedial action can be
taken in a timely manner
Good quality information underpins the effective
delivery of patient care and is essential if improvements
in quality of care are to be made. Royal Surrey County
Hospital NHS Foundation Trust will be taking the
following actions to improve data quality.
Records submitted for secondary
uses services for hospital episode
statistics
NHS Number and General Medical Practice Code Validity
Royal Surrey County Hospital NHS Foundation Trust submitted records during 2014/15 to the Secondary Uses
Services for inclusion in the Hospital Episode Statistics which are included in the latest published data. The
percentage of records in the published data which included the patient’s valid NHS number is shown below:
2011/12
Inpatients
A&E
2012/13
OP
2013/14
Inpatients
A&E
OP
Inpatients
A&E
2014/15
OP
Inpatients
A&E
OP
NHS
Number
98.8
95.4 99.4
99.2
97
99.6
99.6
98.1 99.8
99.3
97.4 99.8
GM
Practice
Code
99.4
100
99.9
100
99.9
100
100
100
100
32
99.6
100
100
Information governance
assessment report
Royal Surrey County Hospital NHS Foundation Trust Information Governance Assessment Report score overall
score for 2014/15 was rated green in line with the Information Governance Toolkit (IGT) Grading Scheme.
Clinical coding error rate
Clinical coding is the translation of medical terminology as written by clinicians to describe a patient’s complaint/
diagnosis into a coded format which is nationally and internally recognised. High quality coded clinical data is
essential when developing reliable and effective statistical analysis. Above all, data must be accurate, consistent
and comparable across time and between sources. Incomplete coding translates to loss of income for Trusts,
while inaccurate coding leads to inaccurate payment, which can impact negatively on the finances of providers
or commissioners.
Clinical coders depend on clear, accurate source of information in order to produce a true picture of hospital
activity and accurately record patient care. The coded data is important for a whole range of purposes such as:
■■ Monitoring and recording patient care provided across the NHS
■■ Research and monitoring of health trends for health service planning
■■ NHS financial planning and enabling payment by results
■■ Local and national clinical coding audit
■■ Clinical governance
Royal Surrey County Hospital NHS foundation Trust was subject to a clinical coding audit by NHS Classifications
Service Clinical Coding Approved auditors during the reporting period. Two specialities were audited: Oncology and
General Surgery. The error rate reported in the latest published audit for that period for diagnoses and treatment
coding (clinical coding) was 6.5%. Breakdown of the audit results is shown below:
Oncology:
Total from
episodes
audited
Incorrect - Incorrect – non
coder error
coder error
Total incorrect
% incorrect
Primary
diagnosis
100
2
6
8
8.00
Secondary
diagnosis
406
6
11
17
4.19
Primary
procedure
96
3
0
3
3.13
Secondary
procedure
121
4
0
4
3.31
Overall
723
15
17
32
4.43
33
Surgery:
Total from
episodes
audited
Incorrect – Incorrect – non
coder error
coder error
Total incorrect
% Incorrect
Primary
diagnosis
100
10
2
12
12.00
Secondary
diagnosis
355
18
7
25
7.04
Primary
procedure
73
3
0
3
4.11
Secondary
procedure
134
17
1
18
13.43
Overall
662
48
10
58
8.76
The clinical coding results should not be extrapolated further than the actual sample
size audited.
Recommendations arising from these audits have been included in an action plan that the hospital has developed
in response to the findings of the audit. High priority recommendations included the following:
■■ Clinical coders must utilise all relevant documentation for every admission, including referral letters and
endoscopy booklets
■■ Clinical coders need to ensure that procedures are coded onto the correct episode/ admission
■■ An in house training session for errors identified in this audit
34
NHS outcomes
framework
35
Review of performance against
mandated indicators
The NHS Outcomes Framework sets out high level national outcomes which the NHS should be aiming to improve.
The Framework provides indicators which have been chosen to measure these outcomes. An overview of the
indicators is provided in the table below. It is important to note that whilst these indicators must be included in
the Quality Accounts, the most recent available national data for the reporting period is not always for the most
recent financial year.
NHS
Outcome
Framework
Domain
Preventing
people
from dying
prematurely
Enhancing
quality
of life for
people with
long–term
conditions
Indicator
2014/15
National
Average
Top
performer
(where
applicable)
Worst
Performer
(where
applicable)
2013/14
2012/13
SHMI value and
banding (July
2013 – June 2014)
SHMI value
0.86 band 3
= lower than
expected)
1
Bart Health
NHS Trust.
SMHI value
0.81 (band 3
= lower than
expected)
South
Tyneside
NHS
Foundation
Trust. SHMI
value 1.15
(band 1 =
higher than
expected)
SHMI value
0.93 (band
2 = as
expected)
SHMI
value 0.94
(band
2 = as
expected)
(band
2 – as
expected)
% of admitted
patients whose
treatment
included palliative
care
(Apr 12 –
Mar 13)
22.4%
24.5%
The Royal Surrey County Hospital considers that this data is as described because over 18 months ago, the trust
established a mortality and morbidity process for each specialty. These meetings feed into an overarching trust wide
mortality review process meaning that there is a systematic process for mortality review. This was one of our quality
priorities two years ago and it has had a positive impact on clinical practice, and so the quality of our services.
The palliative care indicator is a contextual indicator.
We attribute our % of palliative care coded admissions to our status as a cancer centre.
Helping
people
recover
from
episodes of
ill health or
following
injury
36
Patient reported
outcome measure
for groin hernia
surgery (Apr
2013- March
2014)
51.1%
50.6%
(EQ -5D
index)
(EQ -5D
index)
Patient reported
outcome measure
for varicose vein
surgery **
**N/A this
procedure is
not carried
out in the
trust
Patient reported
outcome
measure for hip
replacement
surgery (Apr 2013
– Mar 2014)
92.7%
89.2%
(EQ -5D
index)
(EQ -5D
index)
Patient reported
outcome
measure for knee
replacement
surgery (Apr 2013
– Mar 2014)
90.6%
81.4%
(EQ -5D
index)
(EQ -5D
index)
n/a
n/a
-
53%
(EQ -5D
index)
n/a
n/a
-
89.40%
(EQ -5D
index)
n/a
n/a
-
84% (EQ
-5D index)
NHS
Outcome
Framework
Domain
Helping
people
recover
from
episodes of
ill health or
following
injury
Indicator
2014/15
% of patients
aged 0-14
readmitted to
hospital within 28
days (2002/3 –
2011/12)
10.38%
Data Release
March 2014
% of patient aged
between 15 and
over readmitted to
hospital within 28
days of discharge
(2002/3 – 2011/12)
Data Released
March 2014
National
Average
Top
performer
(where
applicable)
Worst
Performer
(where
applicable)
2013/14
2012/13
-
-
-
-
-
-
-
-
(Upper limit
of 95%
confidence
interval –
11.11% and
lower limit
of 95%
confidence
interval –
9.69%)
10.07%
(Upper limit
of 95%
confidence
interval (10.54%
lower limit
of 95%
confidence
interval
-9.61%)
The Royal Surrey County Hospital considers that the PROMS data is as described due to our high participation rate
in this national survey. This meant that we exceeded the national target in 6 out of the 8 measures for PROMS. We will
continue to build on this by continuing to increase our participation for all eligible hospital episodes.
In terms of readmission rates, we consider the data to be as described as we have been working with our local CCG to
improve links with community healthcare colleagues so that patients are better supported following discharge
Ensuring
that people
have a
positive
experience
of care
Responsiveness
to the personal
needs of patients
(CQC inpatient
survey 2013)
5.1
% of staff
who would
recommend the
provider to a
friend or relative
if they needed
treatment
87% based
on 563
responses
-
-
7.2
4.7
(score
achieved
by highest
scoring
trust)
(score
achieved
by lowest
scoring trust)
-
-
6.7
-
-
-
(Q1- 2014/15)
The Royal Surrey County Hospital considers that this data is as described for the staff recommendation of the trust
which shows a consistent picture across the years. The results shown in the narrative section below indicate the areas
where we have made an improvement and those were we need to focus on for further improvement. The Royal Surrey
County Hospital NHS Foundation Trust has developed an action plan to address these areas.
With regards the inpatient survey, like in previous years, we will be developing an action plan to address the areas of
deficiency identified in the latest survey
37
NHS
Outcome
Framework
Domain
Indicator
2014/15
% of patients who 97%
were admitted to
hospital who were
risk assessed
for venous
thromboembolism
(VTE) during the
reporting period
(2014/15)
National
Average
Top
performer
(where
applicable)
Worst
Performer
(where
applicable)
2013/14
2012/13
96%
n/a
n/a
95.6%
-
n/a
n/a
13.5
14.0
(National
target
95%)
Data release Feb
2015
Treating
and caring
for people
in a safe
environment
and
protecting
them from
avoidable
harm
The rate per
100,000 bed days
of cases of C.
Difficille infection
reported within
the trust amongst
patients aged 2 or
over (April 2013 –
Mar 2014)
29.1
Rate of patient
safety incidents
reported within
the trust and
the number and
percentage of
such patient
safety incidents
that resulted in
severe harm or
death.
1.90%
39.0
(Count
of Trust
apportioned
c. difficile
infections in
2014/15 was
21 against a
DH target of
23)
(April 2012 –
March 2013)
Count
of trust
apportioned
cases in
2013/14 was
26 against
a DH target
of 14
-
n/a
n/a
1.13%
-
Count of 120
incidents –
(see table
below)
The Royal Surrey County Hospital considers that this data is as described as infection prevention and control is a top
priority for our trust. Whilst our overall rates have consistently been below the national rate for the last 4 years, this
year the number of hospital apportioned c. difficile infections was below our national target. Since introduction of the
requirement for all c difficile cases to be assessed for a possible lapse in care, we have worked with our local CCG to
review all cases with representation from the CCG at each root cause analysis meeting.
We have achieved out target for VTE risk assessment each month and we attribute this to have a dedicated specialist
VTE nurse who proactively monitors this aspect of care, and take appropriate and timely remedial action as required.
38
Further narrative on outcome
framework indicators
Domain 1:- Preventing people from dying prematurely
Summary Hospital level Mortality Indicator (SHMI)
The SHMI reports on mortality at trust level across the NHS in England. The SHMI is the ratio between the actual
number of patients who die following hospitalisation at the trust and the number that would be expected to die
on the basis of average England figures, given the characteristics of the patients treated there. The SHMI values
for each trust are published along with bandings indicating whether a Trust’s SHMI value is ‘as expected’, ‘higher
than expected’, or ‘lower than expected’. The SHMI requires careful interpretation and should not be taken in
isolation as a headline figure of trust performance. It is best treated as a smoke alarm which warrants follow up.
The Trust’s SMHI value for the period July 2013 – June 2014 was band 3, indicating that mortality was lower than
expected. The funnel plot below shows the Trust SMHI value in relation to the national picture.
Domain 2: Enhancing quality of life for people with long term conditions
The % of deaths with palliative care coding was as follows:
Specialty level: -22.7%
Diagnosis: -22.3%
39
Domain 3: Helping people recover from episodes of ill health or following injury
Patients readmitted to hospital within 28 days of discharge
The readmission rate for Royal Surrey County Hospital NHS Foundation Trust during 2014/15 is shown below
including the rate for the previous three years.
Year
Emergency readmission rate within 28 days of discharge
2014/15
10.07%
2013/14
11.40%
2012/13
10.11%
PROMS data
Patient Reported Outcome Measures (PROMS) measures health gain in patients undergoing hip replacement,
knee replacement, varicose veins and groin hernia surgery in England based on responses to a questionnaire
before and after surgery. PROMs collect information on the effectiveness of care delivered to NHS patients as
perceived by the patients themselves, making it a particularly important indicator which adds to the wealth of
information available on the care delivered to NHS funded patients to complement existing information on the
quality of services. The table below summarises the Trust’s performance in the year 2013/14. (Please note that
this is the most current data available)
Health Gain data – Reporting period April 2013 – March 2014
EQ-5D Index*
EQ-VAS Index**
Oxford Hip/Knee
Score***
% Patients reporting
on an improvement
Trust Score National
Ave
Trust Score National
Ave
Trust Score National
Ave
Following hip
replacement surgery
92.70%
89.30%
75.20%
65.10%
98.40%
97.20%
Following knee
replacement surgery
90.65%
81.40%
55.00%
55.10%
97.10%
93.80%
Following groin hernia
surgery
51.10%
50.60%
33.50%
37.30%
N/A
N/A
Following varicose vein
surgery
N/A - varicose vein procedures no longer conducted at Royal Surrey County
Hospital NHS Foundation Trust
EQ -5D* is a health questionnaire consisting of a five dimensional system and a visual analogue scale** (EQ –VAS).
***The oxford hip/ knee is a type of hip/ knee replacement operation technique.
40
Domain 4: Ensuring that people have a
positive experience of care
Staff survey
The principal aim of the staff survey is to gather
information that will help the Trust to improve the
working lives of our staff and so help to provide better
care for patients. The staff survey provides the Trust
with a wealth of information detailing our staffs’ view
about working at the Royal Surrey County Hospital. We
are pleased to report that the 2014 staff survey results
show another year of continued good performance.
Areas to highlight include
■■ Being placed in the top 20% of acute trusts for 6
of the 29 findings
■■ Scored better than average in 9 of the 29 findings
■■ 1 area of deterioration
The Trust maintained its top 20% result in relation to
staff recommendation as a place to work or receive
treatment, connected to the CQUIN target.
The one area that the Trust deteriorated in was the %
staff witnessing potentially harmful errors, near misses
or incidents in last month. In 2013 the Trust was in
the top 20% of Trusts so this has now deteriorated to
average.
There were no changes in all other areas however; the
survey identified 3 areas that do need to be addressed:
■■ Work pressure felt by staff (3.11 when the national
average was 3.07)
■■ Staff working extra hours (76% when the national
average was 71%)
■■ Staff appraised in the last 12 months (75% when
the national average was 85%)
We recognise the correlation between staff satisfaction
and patient experience and so we will be focussing on
developing the cultural health of the organisation and
we are currently exploring a number of options on how
best we can take forward this work, recognising that a
number of our quality priorities will also feed into this
important work stream.
CQC inpatient survey
76% of staff would
recommend the hospital as
a place work to their friends
and family
NHS FFT, Q1 2014
An action plan has been developed in response to
the areas identified for improvement. The table below
shows the areas where the trust has performed
best and provides a comparison with the national
benchmark. 1281 staff at Royal Surrey County Hospital
NHS Foundation Trust took part in this survey. This is
a response rate of 40%1 which is below average for
acute trusts in England, and compares with a response
rate of 41% in this trust in the 2013 survey.
The Royal Surrey County Hospital NHS Foundation
Trust had a response rate of 54% for the CQC inpatient
survey. Of the people who were treated in A&E, over
75% stated that they received the right amount of
information about their condition and treatment.
Over half of people, 54% felt that they were definitely
involved in decisions about their care and a further 35%
felt that they were involved to some extent. We will be
working on improving patient engagement as one of
our priorities this year.
Within the same survey, 75% of people felt that they
were given enough privacy when examined and treated
in A&E. The Trust scored equally well in regards to
people feeling safe in hospital with 98% of people
reporting that they did not feel threatened by other
patients or visitors. However a disappointing 19% felt
that the food offered in hospital was poor. We have
been working with our catering team to improve the
food offered to patient admitted within the hospital.
Other areas for improvement that were highlighted
were that 78% of people reported that doctors talked
in front of them as if they were not there.
87% of staff would
recommend the hospital as
a place to receive treatment
to their friends and family
NHS FFT, Q1 2014
41
Domain 5: Treating and caring for people in a safe environment and protecting them
from avoidable harm
VTE assessments for admitted patients
During the reporting period, Royal Surrey County Hospital NHS Foundation Trust has consistently achieved the
target of 95% for VTE risk assessments for admitted patients each month as shown in the chart below. Improvement
work on VTE has continued throughout the year with focus directed at ensuring sustained and improved quality
in completion of the documentation.
100
95
M
ar
ch
ry
ua
br
Fe
ar
nu
Ja
be
m
y
r
r
ce
De
em
be
er
ov
N
ct
ob
r
O
be
em
pt
Se
Au
gu
st
ly
Ju
ne
Ju
ay
M
Ap
ril
90
MRSA and C diff rates
Below are the rates for MRSA and Clostridium Difficile infection for the Royal Surrey County Hospital as published
by the Public Health England (PHE).
MRSA bacteraemia rates April 08–March 2014,
per 100,000 bed days (acute Trust attributable)
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
Apr 08–Mar 09 Apr 09–Mar 10 Apr 10–Mar 11 Apr 11–Mar 12 Apr 12–Mar 13 Apr 13–Mar 14
RSCH MRSA bacteraemia rate per 100,000 bed days (Acute Trust Assigned)
National MRSA bacteraemia rate per 100,000 bed days
42
Clostridium difficile infection rates, April 08–March 14,
per 100,000 bed days (acute Trust apportioned)
60
50
40
30
20
10
0
Apr 08–Mar 09 Apr 09–Mar 10 Apr 10–Mar 11 Apr 11–Mar 12 Apr 12–Mar 13 Apr 13–Mar 14
RSCH CDI rate per 100,000 bed days (acute Trust apportioned)
National CDI rate per 100,000 bed days
■■ Number of patient safety incidents and % resulting in severe harm /death
The table below shows the number of patient safety incidents reported each month during the reporting period and
a breakdown by severity grading for these, including the proportion of incidents resulting in severe harm or death.
1 - Low
Total
2 - Minor
%
Total
3 - Moderate
4 - Major
5Catastrophic
%
Total
%
Total
%
Total
%
Total
April 2014
171 38.0%
222 49.3%
50
11.1%
5
1.1%
2
0.4%
450
May 2014
237 43.9%
233
43.1%
64
11.9%
5
0.9%
1
0.2%
540
June 2014
239 40.2%
264 44.4%
78
13.1%
13
2.2%
0
0.0%
594
July 2014
235 39.8%
279
47.2%
62 10.5%
15
2.5%
0
0.0%
591
August 2014
246
44.1%
233 41.8%
72 12.9%
7
1.3%
0
0.0%
558
September 2014
276 44.8%
254 41.2%
78 12.7%
5
0.8%
3
0.5%
616
October 2014
231
37.4%
277 44.8%
100 16.2%
10
1.6%
0
0.0%
618
November 2014
199
37.1%
276
51.4%
9.1%
12
2.2%
1
0.2%
537
December 2014
183
37.7%
232
47.8%
61 12.6%
7
1.4%
2
0.4%
485
January 2015
216 38.4%
249 44.3%
88 15.7%
9
1.6%
0
0.0%
562
February 2015
170 33.7%
249 49.4%
71
14.1%
13
2.6%
1
0.2%
504
March 2015
185 33.5%
256 46.3%
103 18.6%
9
1.6%
0
0.0%
553
2588 39.2%
3024 45.8%
876 13.3%
110
1.7%
10
0.2%
6608
Grand Total
49
The Trust utilises an electronic incident reporting systems which enables all incidents to be tracked from the point
of reporting and on-going monitoring until closure of an incident, therefore as promoting timely response to serious
incidents. The hospital has a robust and established incident management process in place. All incidents rated
moderate and above are subject to additional scrutiny by the clinical governance team.
Through this system, all incidents rated as potentially serious are flagged to senior executives on a weekly basis
and appropriate decisions taken about their investigation and or management. Where appropriate these incidents
are then subject to a detailed root cause analysis investigation. This year we have two priorities that focus on
incidents: One in relation to encouraging greater involvement of patients and relatives and the other concerned
about ensuring that patients are informed when the care they receive results in harm as defined in the duty of
candour regulations.
In line with ensuring that safety incidents are reported, we have reviewed recommendations from the Jimmy Savile
investigation as well as Sir Robert Francis’ review of whistleblowing titled ‘Freedom to Speak Up.’
43
Part 3
44
Review of quality performance
Progress made for quality priorities
2014/15
In our quality account 2014/15, we chose six areas
to focus on for our quality improvement priorities.
The following section gives a detailed account of the
progress we have made for each of the priority areas
and how the improvement work will be maintained in
the coming year. We also discuss in this section the
quality priorities that we will be taking forward into the
coming year and those that we will be retiring from
the quality accounts. It is important to remember
that even though some priorities may be retired from
the quality account, this is not to say that the work
ceases but rather that the processes and systems for
continued management of the improvement goal are
well established and can be maintained outside of the
quality accounts process
Priority 1: Responding to the
deteriorating patient – Sepsis
management
Last year, we set about to improve the way that we
manage patients presenting with sepsis. Sepsis is a
time critical medical emergency, which can occur as
part of the body’s reaction to infection. Unless treated
quickly, sepsis can progress to severe sepsis, multi –
organ failure, septic shock and ultimately death. Septic
shock has a 50% mortality rate. This quality priority
was in part driven by national interest on this aspect
of healthcare but also through our own local audits
which also confirmed this to be an area that warranted
further attention.
Given that this was recognised as a national concern,
we decided to work with other colleagues within the
NHS QUEST network on a breakthrough improvement
programme that had been developed to help enable staff
to respond to deteriorating patients. The programme
had two strands of which sepsis management was one.
We therefore set up a project team aimed at helping
staff to identify the clinical presentation of sepsis in
order to take the appropriate action to manage patients
presenting with this condition. The Trust adopted the
Sepsis 6 pathway which is a nationally recognised
care bundle for sepsis management. From that we
developed a local sepsis pathway which is currently
being implemented across the Trust. The pathway is
intended to standardise the response to sepsis and
ensuring that were patients present with suspected
sepsis, there is a systematic response to managing
these patients. At the onset of the project, we focused
on education all staff and raising awareness about
sepsis and describing the symptoms to all staff. A key
part of the education was conveying the message to
staff that early intervention was critical in reversing the
symptoms of sepsis. We there tailored the local sepsis
6 pathway to show when key interventions needed to
happen and also how to escalate when patients were
presenting with further signs of deterioration. The
sepsis pathway is shown overleaf.
Once the programme of training and education for staff
had been established, we began implementing use of
the forms primarily within our emergency department
and we wanted to measure the effectiveness of the
sepsis pathway. This has proved challenging due
to a number of issues which the project team is
working to address. One of the biggest challenges
we encountered was how we accurately measure the
time when patients receive antibiotics and also how we
identify sepsis cases retrospectively in order to have a
baseline on our performance and therefore understand
if we were making any improvement. We shared our
frustrations with colleagues across the network but
found this to be a common challenge for other sepsis
teams working on the collaborative series. However
we had determined that the key indicator for us to
focus on was the time taken to give antibiotics and so
we had been doing some targeted audits looking at
performance in this regard. We have been encouraged
by the progress we have made particularly in raising
awareness of sepsis around the Trust and in the coming
year, we will focus on capturing data to show the impact
of the work done to date. We do know however that in
the last two quarters (Q2 and Q3) there have been no
deaths picked up via the mortality audits where sepsis
was the cause of death.
An important aspect of this will be the communication
during transition in care and so through the discharge
summary, we will be able to measure the effectiveness
of our communication to colleagues in other parts of
the healthcare system.
45
The sepsis pathway
46
Priority 2: To increase the percentage of all clinical staff working in clinical areas
receiving annual infection control update to 80%
This quality priority was put forward by the council of governors with the full endorsement of the board. The aim
of the priority was to reduce infection rates and improve compliance with infection control audits through staff
receiving the appropriate on-going infection control training.
This priority was audited by KPMG in May 2014 and two key recommendations were made. These included defining
‘clinical staff’ and ‘clinical areas’. In addition, issues were also identified with completeness of records against
the Trusts ESR system and the processes required to ensure timely reports. We have made good progress in this
priority – however, there are still improvements to be made. The table below shows monthly training compliance
rate for all clinical staff by staff group.
Apr
Overall IC SaM
(3015)
63%
May June
64%
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
69%
68%
71%
71%
71%
71%
75%
74%
72%
75%
Clinical Staff Group on OLM
Add Clinical Serv
(487)
62%
63%
61%
74%
74%
72%
75%
73%
76%
73%
71%
73%
Allied Health
Professionals (352)
84%
85%
77%
77%
81%
81%
80%
76%
81%
79%
79%
84%
Healthcare
Scientists (98)
59%
64%
64%
63%
56%
63%
77%
75%
82%
71%
72%
77%
Medical & Dental
(542)
52%
52%
49%
45%
57%
59%
58%
65%
67%
69%
63%
62%
Nursing &
Midwifery (1022)
66%
70%
70%
76%
78%
76%
76%
74%
79%
80%
77%
82%
Students (2)
67%
67%
67%
67%
50%
50%
67%
0%
0%
0%
0%
0%
TOTAL CLINICAL
65%
66%
65%
68%
72%
72%
72%
72%
76%
76%
73%
76%
Actions taken to aid this progress included:
■■ Definition of Clinical - The Skills for health definition of clinical was used. This defines the clinical environment as
‘relating to the bedside of a person, the course of a person’s disease, or the direct observation and treatment
of the person”
■■ Training risk assessment to determine high and medium risk areas – this was based on numbers / clusters
of infection control alert organisms, adverse incident reports relating to infection control, audit results and
previous compliance with infection control training.
■■ Standard operating procedures for reporting on infection control training. This includes identification of staff on
OLM requiring infection control training, ensuring accurate dates of training, monthly lock down for inputting
data to allow for accurate reporting and monthly monitoring and reporting to individuals and line managers.
A monthly status report is also managed by HR which is available to all staff and includes compliance with
infection control training.
■■ Clinical training fully reviewed and now available via E-Learning. Availability of classroom based sessions have
increased and availability of departmental sessions advertised.
■■ Monthly Status report run by HR Information
●● This can be accessed by all staff and departments
●● All SaM training including Infection Control
■■ Class room based infection control sessions increased to three a month
47
As part of the progress updates presented at the quality accounts workshop, we have shown infection incidence
rates against staff’ infection control training and in the main there has not been correlations between areas with
low training compliance and incidence of infections. The table below shows our infection rate targets for the year.
Year
Training clinical staff (see below for more
detail)
Training All Staff
March 2014
64%
63%
March 2015 (numbers
not yet validated)
77%
76%
Clostridium difficile cases
MRSA bacteraemia
21 reported hospital apportioned against a
DoH limit of 23
3
Hand Hygiene compliance
Bare below the elbow
compliance
96%
99%
Apr 2014 – March 2015
(not yet validated)
Feb 2015
This priority will remain on the quality account for 2015 – 2016 where we expect to build on the improvements that
we have achieved to date and continue infection control training compliance rates.
Priority 3: To develop consultant level quality and safety dashboards
The quality priority relating to the development of a consultant level safety and quality dashboard was borne out of
a desire to improve data quality, be more transparent and engage clinicians in reviewing the quality of their data.
Therefore over the last year we have been working with colleagues at CHKS which is a specialist health information
firm, to create a dashboard showing a suite of carefully selected quality indicators at consultant level. The initial
selections of indicators that we wanted to show on the dashboard included some of the following:
Mortality data, complication rates/ misadventure rates, length of stay, readmission rate, upheld complaints, serious
incidents, statutory and mandatory training, VTE risk assessment, C diff, antimicrobial prescribing compliance,
data quality
A key part of this work has been working with consultant colleagues in order to get the appropriate level of
engagement to make the exercise worthwhile and meaningful. There have also been challenges in terms of the
availability of some the data that we wished to reflect on the dashboard which have meant that we have not been
able to progress at pace as we have taken time to seek out solutions to these technical issues. It is envisaged
however that the first wave of consultant dashboards will be available from May 2015. This is a priority that we
will be taking forward into the coming year and we expect that the information on the dashboard will evolve over
time to include more quality indicators in response to safety priorities.
48
75
0
0
Risk Adjusted Length of
Stay 2013 (Spell)
Risk Adjusted Mortality
2013 (Spell)
SHMI 2013 - In Hospital
(Spell)
2.8%
Readmissions (Spell)
Misadventure Rate (Spell)
1 : 1.8
82.9%
Day Cases - Basket of 25
(Spell)
Outpatient New to
Follow-up Ratio (OP)
53.7%
Day Cases (Spell)
9.8%
96.0
Data Quality (FCE)
Outpatient DNA Rate
(OP)
0.8%
Complication Rate Treated (Spell)
0.00%
0.3%
Complication Rate Attributed (Spell)
Mortality (Spell)
1.2
Average Length of Stay
(Spell)
Indicator
Consultant A
0
0
54
1.8%
1 : 2.2
5.9%
0.00%
0.18%
92.2%
84.3%
96.4
0.5%
0.9%
0.2
6.3
Consultant C
32
53
84
7.0%
1 : 3.0
3.9%
0.50%
66.7%
13.4%
96.8
6.0%
3.0%
Below is an example of the consultant dashboard.
Consultant B
49
Consultant D
0
0
42
1.0%
1 : 2.4
5.3%
0.00%
0.35%
85.7%
53.7%
96.0
2.1%
1.4%
0.5
Consultant E
24
47
78
3.1%
1 : 1.5
6.0%
0.30%
86.7%
61.4%
97.2
2.4%
0.7%
2.9
Consultant F
61
76
86
4.7%
1 : 2.9
6.0%
1.06%
0.21%
70.3%
65.9%
96.3
4.4%
1.5%
3.4
Consultant G
71
129
124
3.2%
1 : 2.4
5.8%
1.21%
86.0%
82.3%
96.7
3.2%
1.0%
4.2
Consultant H
0
0
94
4.0%
1 : 2.1
5.7%
0.00%
0.24%
85.8%
47.1%
97.0
7.8%
1.7%
3.5
Consultant I
44
41
95
4.7%
1 : 1.4
5.8%
0.67%
0.22%
79.3%
48.5%
96.6
4.9%
0.7%
4.5
Consultant J
42
80
95
4.2%
1 : 1.5
7.5%
0.65%
80.0%
48.1%
96.4
3.9%
2.6%
3.7
Consultant K
57
67
102
5.6%
1 : 1.7
9.1%
1.27%
81.2%
48.4%
97.1
4.1%
1.0%
5.8
Consultant L
44
58
77
4.1%
1 : 2.0
5.9%
0.65%
92.2%
76.6%
97.0
3.6%
0.8%
3.0
Consultant M
0
0
104
11.4%
1 : 0.3
7.3%
0.00%
94.3
2.9%
4.3%
6.5
0
0
67
1.3%
1 : 1.4
6.6%
0.00%
72.7%
69.3%
97.8
1.3%
1.3%
0.6
Consultant N
Priority 4: To implement new
emergency processes that will improve
clinical care pathways for patients seen
in A&E
In July 2014, we invited the Emergency Care Intensive
Support Team (ECIST) to come and review practice
within our emergency department (ED) as a means
of progress this quality priority. The ECIST team
spent 2 days on site and at the end of their visit
they offered a number of recommendations on how
we could further improve our emergency care. This
report was presented to the Executive Leadership
Team. The recommendations contained within the
report were accepted and they became the basis of
the improvements that we were going to take forward.
The recommendations were themed with a focus on
practice within the ED itself; Paediatric ED; Diagnostics;
Ward impact; EAU; Length of Stay; IT and Operational
issues including bed management and such like.
Therefore there was recognition that that implementation
of the recommendations would also necessitate
additional resources and so alongside this, a number
of new appointments were made. This included the
following:
■■ Appointment of 3 additional locum consultants
in A&E, with a view to formalising substantive
appointments. ■■ Appointment of a new Emergency Care Lead for
A&E
■■ Appointment of a Clinical Director with responsibility
to oversee all aspects of Emergency Care (A&E
and EAU).
■■ Appointment of a new Emergency Care Matron.
Another improvement ambition was to improve patient
flow between A&E minors and out of hours on site GP
service.
Alongside all of these improvements, the trust, like
all other trusts in the country has had to achieve the
nationally mandated target of seeing 95% of patients
within 4hours. Despite huge challenges that were
televised nationally, we achieved Quarter 1, 2 and 3 –
performance of 95% was achieved for each period in
line with national requirements although we narrowly
missed the target for Q4.
Plans for 2015/16
Further appointments are planned for this year including
appointing a Clinical Lead for EAU working alongside
the Clinical Lead in A&E and directly reporting to the
Clinical Director. Other plans include:
■■ To finalise the appointment of Acute Physicians in
EAU to support the emergency take teams.
■■ To amalgamate IDT, HOST, OPAL, Virgin and Social
Services into one integrated discharge team under
the leadership of an Integrated Care Lead, therefore
supporting less hand-offs, less delays and speedier
discharge.
■■ To finalise standard operating procedure within
emergency care detailing patient pathways to
support standardised consistent care.
■■ To finalise specification for an IT system which is
fit for purpose.
■■ To remodel the medical take to provide greater
comprehensive cover.
■■ To increase GP sessions within A&E and EAU as
part of clinical development work across the health
professionals.
■■ Amalgamation of A&E and EAU into one SBU
service.
■■ Focussed recruitment on nursing staff within A&E
to reduce reliance on agency which has been very
successful.
■■ Recruitment to middle grade doctor vacancies to
Due to the amount of work undertaken during the year
and the increased focus on the implementation of the
ECIST recommendations, this priority will be retired
from the quality accounts and the on- going work to
improve emergency processes will be monitored via
ELT and the resilience group.
establish a 10 WTE working rota.
A further visit from the ECIST team took place
in December 2014 and we will be implementing
recommendation from this visit throughout the coming
year. In addition we undertook three RESET projects to
improve patient flow and management of A&E including
enhancing the patient experience. These were a huge
success on both occasions expediting discharges
where appropriate by attending to potential issues to
avoid unnecessary delays, therefore freeing up much
needed beds within the hospital. This enabled us to
work with the CCG in developing a closer partnership in
managing patient discharges from EAU into community
based facilities.
50
Priority 5: Communicating with patients
and relatives
Context
Data from the Trust complaints review group
consistently demonstrates that difficulties around
communication with nursing and medical staff during
in-patient hospital stays have been a frequent factor in
both formal complaints and informal concerns flagged
via PALs, for 2013/14.
In an attempt to improve this, and to enhance patient/
relative experience of inpatient care, the Trust made
this a Quality priority for 2014/15.
Progress report
The initial focus of this piece of work was to facilitate
access of patients and their relatives to medical and
nursing staff, so that any concerns could be promptly
dealt with and any questions regarding patient care
be answered in a timely way. A pathway was devised,
stating expected timescales for responding to a request
for communication, and clarifying for patients and
relatives how they should go about setting this up,
since a common problem experienced by patients
and relatives was “not knowing who to speak to” on
the ward to get concerns addressed.
However, it quickly became clear that, as well as lack
of clarity in who should be spoken to and expectations
around timescales for this, there were a number of
associated issues which required addressing if any
meaningful impact was to be made on patient and
relative experience:
1.The majority of wards had no suitable designated
area or room which could be used for the purpose
of communicating with relatives. In practise, such
conversations were too often being undertaken in
ward offices or even in hospital corridors.
2. It was unclear that Consultants, in particular, had
time within their job plans to allow for dedicated time
to be devoted to relative’s clinics or discussions with
relatives following ward rounds, which had been
what had been envisaged.
This piece of work is not yet complete, but good
progress is being made towards it’s objectives:
1.Designated rooms for communication have been
identified in two locations within the main ward
block, and also on Onslow ward. Funding has
been identified for the refurbishment and furnishing
of these rooms; which will result in provision
of a comfortable, private environment for such
conversations.
2.An ambitious enhancement of patient information
has been developed, with input from the whole team
and the assistance of the Trust communications
department. Work to finalise this is ongoing, and it
is envisaged that by providing more comprehensive
information about the wards, as well as topics such
as expectations around discharge from hospital,
how to set up a meeting with medical or nursing
staff, as well as issues such as discussions on
DNAR orders, patients and relatives will benefit from
being better informed about ward routines. Advice
from junior doctors and nursing staff about the type
of questions they are commonly asked has been
taken, with the aim of reducing the burden of junior
doctors in answering frequently asked questions.
3.Time for communication will relatives and patients
will be factored into Consultant job planning as
required (different departments will likely have
different requirements) as part of annual job
planning.
4.
A c o m m u n i c a t i o n p a t h w a y, f a c i l i t a t i n g
communication with relatives, is being set up and
distributed; this should clarify for all concerned
expectations around facilitated communication for
patients and relatives.
It is envisaged that components of this plan be in
place with q1 of 2015/16; the exception to this might be
Consultant job planning, which overlaps with separate
project work for 2015/16, and which, due to pressure
on job plans, may be more challenging to deliver.
3.It was suggested that many of the questions
frequently asked could be addressed by augmenting
the information already given to patients and
relatives on admission.
A project team was therefore set up, with membership
from Consultants in elderly care and surgery, Portfolio
heads of nursing for Medicine and Surgery/Oncology,
the Trust communications department, junior doctors
(2), and with help from Patient’s first a project was set
up to include the issues above.
51
Priority 6: To improve the experience
of outpatients
Set as one of the quality priorities in the 12/13 quality
account we have been working on improving the
outpatients’ experience and reporting in the quality
account for the last two years. The overall vision in
outpatient management was to deliver a service that
provides patients with the best experience and to
modernize the service to support the development of
a positive reputation of the Trust in providing a high
standard of clinical care.
To achieve this we set the following standards:
Access Standards –
■■ 5 week new appointment maximum waiting time
■■ Centralised booking function for all Trust
■■ Appointments confirmed via telephone, letter, text
reminder
■■ Expanded choose and book service
■■ High utilization of capacity across 6 day week
In Clinic Standards –
■■ Clear information on travelling to the hospital and
what to expect, including providing information via
leaflets and the internet
■■ Clearer signage
■■ Redesign of environment
■■ <6% DNA rate
■■ <30 minutes wait time for appointment
Follow up and GP liaison Standards –
■■ Leaving clinic with follow – up appointment booked
■■ Quick turnaround for clinic letters
■■ Reminders via text messaging
At the same time, in 2014 calendar year we have seen
a further increase of over 10,000 patients in our main
outpatient areas alone compared to 2013, i.e. average
increase more than 800 per month, 5%
Identified areas for improvement: Ophthalmology
Outpatients service
■■ Improving physical space within ophthalmology
clinics
●● The new extension completed late 2014
●● Additional consulting rooms created
●● Larger, more comfortable waiting area for
patients
52
Clinic template redesign
Work has begun on this, with appointment centre management liaising with specialty managers/consultants to
improve templates which will ensure smoother running of clinics, whilst managing the capacity needs of the service.
Additional clinic capacity has been created to deal with this e.g. more ad-hoc Saturday and evening clinics in 2014.
Saturday clinics
25
22
Number of clinics
20
20
15
17
11
9
15
14
13
9
10
9
10
6
4
11
10
9
8
7
5
2014
19
16
10
2013
88% increase in number of Saturday
clinics compared to 2013 - (173 vs 92)
6
6
4
0
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Spet
Oct
Nov
Dec
Evening clinics
30
2013
27
146% increase in number of evening
clinics compared to 2013 - (165 vs 67)
2014
25
Number of clinics
23
20
16
15
13
12
12
15
16
12
12
11
10
9
8
7
8
6
5
4
4
4
2
4
3
2
2
0
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sept
Oct
Nov
Dec
53
Review of staffing in Outpatients
Appointment Centre and Reception
areas
A review of administration staffing was undertaken
during the year to achieve a gold standard service, to
increase booking efficiency in order to meet increased
demand. Recruitment begun in October to bolster the
appointment centre team of booking co-ordinators and
admin staff, together with a more stabilised reception
team (this will also help patients being able to book
follow-up appointment on same day). A Choose and
Book Lead has now been appointed permanently
as these referrals have greatly increased (whilst no
decrease in paper referrals).
Other improvements of note include significant
improvement in access and notes availability for patient
attendances, achieved through recruitment of extra
staff to improve service delivery.
We have also enhanced our process for managing DNA
( when patients do not attend) rates by developing an
appointment reminder system, re-contacting patients
following DNAs, phoning patients as well as sending
letters where short notice appointments made i.e. 1
week or less – currently under 5% Trustwide
■■ Average new appointment waiting time of =< 5
weeks.
■■ Current overall average appointment waiting time
of around 8 weeks
■■ Ranges from 1 week on new MSK Foot and Ankle
Pathway, to 15 weeks for Clinical Immunology and
Allergy
■■ Will be continuously monitored during 2015 and
additional capacity measures taken to meet demand
As part of our improvement plans, we had set a target
to have a maximum clinic appointment of 30minutes.
However it has not been possible to publish our
performance in this regard due to current set up of clinic
manager in different specialties. We feel that this is an
important metric and will be working to ensure that we
are able to report on this in the future.
54
Review of other quality measures
Compliance with NICE and other
National Guidance
97 national guidance documents have been received
between 1st April 2014 and 31st March 2015. Of these
37 were not applicable to the Trust. The compliance
status for the remaining 60 guidance documents, are
presented in the table and chart below.
Introduction
There are two main types of national guidance:
The first of these is guidance produced by the National
Institute for Health and Clinical Guidance (NICE),
referred to as NICE guidance
Compliance status for National Guidance received
for the period 1st April 2014 to 31st March 2015
2%
The second type of guidance is that arising from
Confidential Enquiries. Confidential Enquiries are
produced by one of 3 main bodies; National Confidential
Enquiry into Patient Outcome and Death (NCEPOD),
Confidential Inquiry into Suicides and Homicides by
people with a mental illness (CISH) and Centre for
Maternal and Child Enquiries (CMACE).
The Trust current compliance for guidance received in
2013/14 is shown below. The Trust continues to follow
up on guidance under review in the previous years as
we recognise the importance of ensuring that we have
assessed our services against all guidance received.
13%
25%
60%
Met
Partly met
Not met
Under review
Compliance status for National Guidance received
for the period 1st April 2013 to 31st March 2014
3%
Met
89%
Not met
Met
Partly met
NICE Medical Technology guidance: MTG23 The TURis system for transurethral resection of
the prostate. The Trust is not compliant with this
guidance because there is currently no funding for this
technology. The TURP syndrome is rare and complying
with this guidance would require considerable
investment, especially as the Trust uses Storz and not
Olympus equipment.
8%
Partly met
Met
The Trust is currently not compliance with 1 guidance
Not met
document that hasUnder
beenreview
reviewed:
Partly met
Not met
For the guidance that is partly met, the Trust has carried
out a gap analysis and identified actions to be taken
in order to achieve full compliance. This is monitored
via the existing governance structures within the Trust
to ensure that progress is made or where this is not
possible, issues are escalated. The chart below shows
a breakdown of compliance for 2014/15 by quarter. This
chart shows that the guidance currently under review
was received in the final 2 quarters of the year.
At times there can be a time lag from receiving the
guidance and completing the gap analysis as shown
above. This is often due to the complexity of the
particular guidance or the requirement to consider
the guidance under the local variation protocol. The
compliance picture is dynamic as the Trust continues
to follow up on all guidance received and so the above
table is updated on a quarterly basis to reflect changes
in compliance as further compliance assessments are
received.
55
Collaboration with Kent, Surrey, and Sussex Academic Health Science Network
(KSS AHSN)
The Royal Surrey County Hospital NHS Foundation Trust belongs to the KSS AHSN. The aim of the network is to
drive innovation at pace and scale that will improve care across Kent, Surrey and Sussex. There are 9 universities
within the region that offer breadth and diversity in research and teaching expertise. Through this network, we have
been involved in collaborative work focusing on particular aspects of care that are prevalent across the region,
for example pressure ulcers and medication errors.
This year the AHSN has set up the patient safety collaborative across 5 key work streams in response to the
Berwick report. These are shown below and the Trust is actively engaged in the work of the AHSN and one of the
Trust’s clinicians is co – lead for the sepsis pathway.
Indeed the Trust was nominated for the KSS award for most consistent top performer for their enhancing quality
and enhanced recovery programme, further demonstrating the Trust’s commitment to patient safety and quality
of care outcomes.
56
Compliance with Patient Safety Alerts
Ref
Alert Title
Originated By
Issue Date
Status
NHS/
PSA/W/2015/004
Managing risks during the transition
period to new ISO connectors for
medical devices.
NHS England
27/03/15
On - going
NHS/
PSA/W/2015/003
Risk of severe harm and death from
unintended interruption of noninvasive ventilation.
NHS England
13/02/15
Actions
completed
NHS/
PSA/W/2015/002
Risk of death from asphyxiation by
accidental ingestion of fluid/food
thickening powder
NHS England
05/02/15
Actions
completed
NHS/
PSA/W/2015/001
Harm from using low molecular
weight heparins when
contraindicated.
NHS England
19/01/15
Actions
completed
NHS/
PSA/W/2014/18
Risk of death and Serious Harm from
accidental ingestion of potassium
permanganate preparations.
NHS England
22/12/14
Actions
completed
NHS/
PSA/W/2014/017
Risk of death and serious harm from
delays in recognising and treating
ingestion of button batteries.
NHS England
19/12/14
Actions
completed
NHS/
PSA/W/2014/016
-016R
Risk of distress and death from
inappropriate doses of naxolone in
patients on long-term opiod/opiate
treatment.
NHS England
20/11/14
Actions
completed
NHS/
PSA/R/2014/015
Resources to support the prompt
recognition of sepsis and the rapid
initiation of treatment.
NHS England
02/09/14
Actions on
-going
NHS/
PSA/W/2014/014
Risks arising from breakdown and
failure to act on communication
during handover at the time of
discharge from secondary care.
NHS England
29/08/14
Actions
completed
NHS/
PSA/D/2014/013
Risk of inadvertently cutting in-line or
closed suction catheters.
NHS England
17/07/14
Actions
completed
NHS/
PSA/W/2014/012
Risk of Harm relating to interpretation
& action on PCR results in pregnant
women.
NHS England
23/06/14
Actions
completed
NHS/
PSA/D/2014/011
Legionella and heated birthing pools
filled in advance of labour in home
settings.
NHS England
17/06/14
Actions
completed
NHS/
PSA/D/2014/010
Standardising the early identification
of Acute Kidney Injury
NHS England
09/06/14
Actions ongoing
NHS/
PSA/W/2014/009
Risk of using vacuum & suction
drains when not clinically indicated
NHS England
06/06/14
Actions
completed
NHS/
PSA/W/2014/007
Minimising risks of omitted and
delayed medicines for patients
receiving homecare services
NHS England
10/04/14
Actions
completed
57
Achieving Excellence Programme
The Achieving Excellence Programme is our ward accreditation scheme and the vehicle by which we ensure safe
standards of care at ward level. The ambitions of the programme is to help staff and teams to understand where
they fit in helping the Trust deliver best care and to support teams to make continual improvement in their everyday
work. Each area is assessed against the BEST accreditation criteria and gaps in performance identified. The
Achieving Excellence programme will support the Trust is driving organisational transformation by teaching teams
to define’ what good looks like’ and to set appropriate measures to track their performance and identify problems.
This way of working requires a culture change and it is worthy to note that any culture change is dependent on
leaders and therefore changes in the way that leaders and managers at Royal Surrey County Hospital work will
be essential to success of the Achieving Excellence programme. All wards teams will be assessed under this
programme and progress is made publicly available as this is displayed at the front entrance of the hospital. Patients
and relatives are encouraged to speak to ward staff if they require further information about the performance of
their wards and what it means for their care and treatment.
Harm Free Care
The Trust takes part in the national monthly point prevalence survey of in- patient harm as defined by the national
Safety Thermometer. Overtime the Trust has improved its performance on this national audit and this is shown
in the following charts below:
% of National and RSCH Harm free care including Median
100%
% of patients free from All Harm (old and new)
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Mar-14 Apr-14 May-14 Jun-14
RSCH Harm Free
Care
Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15
89.91% 94.89% 92.81% 92.58% 94.33% 95.78% 93.59% 95.28% 94.51% 94.54% 95.77% 94.55% 93.56%
National Harm Free
93.60% 93.50% 93.60% 93.60% 93.08% 93.70% 93.70% 93.90% 93.90% 94.10% 93.90% 93.70% 94.00%
Care
58
RSCH Median
(94.51%)
94.51% 94.51% 94.51% 94.51% 94.51% 94.51% 94.51% 94.51% 94.51% 94.51% 94.51% 94.51% 94.51%
National Median
( 93.70%)
93.70% 93.70% 93.70% 93.70% 93.70% 93.70% 93.70% 93.70% 93.70% 93.70% 93.70% 93.70% 93.70%
The following chart shows the percentage of all inpatients that were free from all four harms
120
100
80
60
40
20
0
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Harm Free
89.91
94.89
92.81
92.58
94.56
95.78
93.59
95.28
94.51
94.54
95.77
94.55
93.56
One Harm
9.44
4.89
7.19
7.42
5.44
3.75
6.41
4.72
5.49
5.46
3.81
5.45
6.44
Two Harms
0.64
0.22
0
0
0
0.47
0
0
0
0
0.42
0
0
Three Harms
0
0
0
0
0
0
0
0
0
0
0
0
0
Four Harms
0
0
0
0
0
0
0
0
0
0
0
0
0
Pressure ulcer harm is shown below:
% of National and RSCH PU(Old and New) including Median
% of Patients with Pressure Ulcer (old and new)
7.00%
6.00%
5.00%
4.00%
3.00%
2.00%
1.00%
0.00%
Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15
Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15
RSCH PU All
6.22% 4.22% 4.86% 4.28% 2.84% 3.51% 4.27% 3.43% 2.86% 2.94% 2.54% 3.14% 3.65%
National PU All
4.60% 4.60% 4.70% 4.70% 4.50% 4.60% 4.60% 4.40% 4.40% 4.30% 4.60% 4.60% 4.50%
RSCH Median(3.51%)
3.51% 3.51% 3.51% 3.51% 3.51% 3.51% 3.51% 3.51% 3.51% 3.51% 3.51% 3.51% 3.51%
National Median (4.60%) 4.60% 4.60% 4.60% 4.60% 4.60% 4.60% 4.60% 4.60% 4.60% 4.60% 4.60% 4.60% 4.60%
59
New Pressure Ulcer harm is shown below. As shown in the chart there has been a marked decrease in the incidence
of new pressure ulcers since November 2014. It is anticipated that this will continue to decrease due to the Trust’s
involvement with the patient safety collaborative pressure damage work stream and the continued programme of
education and training of staff in relation to the management of at risk patients.
% of patients with Pressure Ulcer (new only)
% of National and RSCH PU(New) including Median
3.50%
3.00%
2.50%
2.00%
1.50%
1.00%
0.50%
0.00%
Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15
Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15
RSCH PU New
2.79% 2.67% 3.17% 0.90% 1.18% 1.64% 1.92% 1.29% 0.72% 0.21% 0.21% 0.21% 0.64%
National PU New
1.00% 1.00% 1.00% 1.00% 0.90% 1.00% 1.00% 1.00% 0.90% 0.90% 1.10% 1.00% 1.00%
RSCH Median (1.18%)
1.18% 1.18% 1.18% 1.18% 1.18% 1.18% 1.18% 1.18% 1.18% 1.18% 1.18% 1.18% 1.18%
National Median (1.00%) 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00%
Falls harm is shown below. The
Trust
has an established
falls prevention
steering
group whose membership is
% of
Patients
with Pressure
Ulcer (new
only)
multi–disciplinary. The group meets each month to consider falls trends across the hospital and to review learning
form serious incidents. Over the last year, the group has reviewed a number of technological solutions aimed at
better management of falls and through this the Trust has implemented the use of bed and chair alarm for at risk
patients. Highlighting of patients at risk of falls has also been incorporated in the Achieving Excellence programme
through the use of magnets on the ward board which serve as a prompt to all multi –disciplinary staff of those
patients identified to be at high risk.
% of National and RSCH Falls with Harm including Median
Additionally, the Trust has been working with other members of the NHS Quest network on a falls improvement
project known as SWARM which aims to improve the process of assessment of patients.
0.90%
% of Patients with Falls (with Harm)
0.80%
0.70%
0.60%
0.50%
0.40%
0.30%
0.20%
0.10%
0.00%
Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15
Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15
RSCH Falls with Harm
0.64% 0.44% 0.21% 0.45% 0.00% 0.23%
National Falls with Harm
0.80% 0.70% 0.70% 0.70% 0.70% 0.70% 0.70% 0.60% 0.70% 0.70% 0.70% 0.70% 0.60%
RSCH Median(0.21%)
0.21% 0.21% 0.21% 0.21% 0.21% 0.21% 0.21% 0.21% 0.21% 0.21% 0.21% 0.21% 0.21%
0%
0%
0%
0%
0.21% 0.21%
0%
National Median (0.70%) 0.70% 0.70% 0.70% 0.70% 0.70% 0.70% 0.70% 0.70% 0.70% 0.70% 0.70% 0.70% 0.70%
Na#onal March data is not available at the #me of Analysis 60
New VTEs vs National
2%
1.8%
1.6%
1.4%
1.2%
1%
0.8%
0.6%
0.4%
0.2%
0%
Mar-14
Apr-14
May-14
New VTEs(DVT and PE)
Jun-14
Jul-14
New DVT
Aug-14
New PE
Sep-14
Oct-14
Nov-14
National Median (New VTEs)
Dec-14
Jan-15
Feb-15
Mar-15
RSCH Median(New VTEs)
61
Trust’s performance against
some nationally set targets and
regulatory requirements
In the table below we have set out our performance against national targets and priorities over the last 3 years,
including those set out within Monitor’s compliance Framework.
National Target/
Minimum
Standard
Indicator
Monitor
Target
2012/ 13
12
(22 )21
(14) 26
(23) 21
6
(1) 2
(0) 2
(0) 3
2 week wait from referral to date
first seen for all cancers
93%
95%
95.0%
94.8%
2 week wait from referral to date
seen for symptomatic breast
patients
93%
93.7%
93.6%
93.4%
31 day wait for second or
subsequent treatment with
surgery
94%
96.6%
97.4%
97.8%
31 day wait for second or
subsequent treatment with anticancer drug treatments
98%
99.6%
99.6%
99.4%
31 day wait for second or
subsequent treatment with
radiotherapy
94%
98.9%
95.6%
95.3%
62 day wait for first treatment
from urgent GP referral for
treatment
85%
85.2%
85.5%
85.1%
62 day wait for first treatment
from consultant screening
service referral
90%
95.8%
93.8%
96.0%
% of patients waiting a
maximum of 4 hrs in A&E from
arrival to admission, transfer or
discharge
95%
94.6%
94.1%
95.18%
Number of C. Diff cases
Infection Control Number of MRSA bloodstream
infection cases
Access to
Cancer Services
A&E waiting
times
62
2013/14
2014/15
(DH target) (DH target) (DH target)
Appendices
63
Summary of Stakeholder
Involvement
During 2014/15, we have worked with colleagues from Guildford and Waverly Clinical Commissioning Group, local
Healthwatch, Surrey County Council Health Scrutiny quality account member reference group representative and
our council of governors to monitor and report on progress on the quality priorities. We facilitated three engagement
workshops aimed at discussing the quality priorities and sharing learning from across the health economy where
shared quality concerns had been identified.
This is the second year that we have held workshops aimed at looking at the quality priorities within the quality
account and we intend to strengthen this process in the coming year, with possibly a view of getting some patient
involvement in the workshops as well engaging a wider group of external stakeholders.
64
1. Statements and feedback from
external stakeholders
Statement from Guildford and Waverly CCG
3rd Floor
Dominion House
Woodbridge Road
Guildford
GU1 4PU
01483 405450
Mr. Nick Moberly,
Chief Executive Officer
Royal Surrey County Hospital NHS Foundation Trust
Egerton Road
Guildford
Surrey
GU2 7XX
21st May 2015
Dear Nick,
Re: Quality Account 2014 for Royal Surrey County Hospital NHS Foundation Trust
On behalf of the NHS Guildford and Waverley Clinical Commissioning Group (GWCCG), we have welcomed the
opportunity to comment on The Royal Surrey County Hospital NHS Foundation Trust’s 2014 draft Quality Account
which was supplied to us by your Head of Patient Safety and Quality on the 17th April 2015 and then an amended
version on the 15th May 2015.
The process of review was to share the draft versions with our Associate Commissioners and also review through
our Quality and Clinical Governance Committee to identify whether the progress reported and priorities described
concords with our own interpretation of the levels of quality at the Trust. These understandings have been attained
through regular quality surveillance and the holding of a monthly Clinical Quality Review meeting with the Senior
Management responsible for Quality and Safety at the Trust. It has also been ascertained through a number of
clinical visits we have performed throughout the year including surgical theatres and the eye clinic. Understandings
have also been ascertained through collaborative workings via the ‘Hospital Implementation Group (HIG)’.
We communicated our initial views on the quality account on the 12th May 2015. We are very pleased to confirm
that the majority of these were included in the final draft version. This included:
■■ Reference to collaborative work with Clinical Commissioning Groups in various areas including RESET and
the improvement of Accident and Emergency Department flow
■■ The expansion on the narrative about the Quality Workshop activities during the year
■■ A dedicated telephone line for enquiries (as well as email, twitter, Facebook etc.)
■■ The amendment to the manner in which mortality indicator was described
■■ To provide further details on the description of the CHKS award
■■ To increase on two quality priorities per category of safety, clinical effectiveness and experience
■■ To enhance the focus on workforce, pressure damage and quality of discharge summaries as priorities
■■ To increase the focus on the involvement with the Patient Safety Collaborative work programme
■■ To increase the focus on the actions associated with the findings of National NHS Patient Surveys
■■ To include narrative on how to improve understanding of waiting times for treatment
65
■■ To focus on the improvement of safety culture rather than performance of the survey
■■ To provide a more lay narrative of the priority 6 description
■■ To provide a reference to what actions are required to improve data submissions to DAHNO Audit
■■ To provide a greater transparency for what increase governance arrangements are required in research
■■ To include what learning is ascertained from clinical coding in Surgery
■■ To provide clarity for the tables associated with NHS Outcomes section of the report.
We would have welcomed an increased focus on the following, but understand that the Trust still considers these
priority areas and will be discussed and reviewed at various forums including our Clinical Quality meetings and
Quality Account Workshops:
■■ Mixed Sex accommodation
■■ Stroke pathway
■■ Utilisation of patient experience forum in developing clinical pathways
■■ Increased narrative on actions to address the findings of National Clinical Audits
■■ Reduction of readmission rates
In summary, we can confirm that we have no reason to believe this Quality Account is not an accurate representation
of the achievements of the organisation during 2013/14. This has been enhanced through the regular workshops
the Trust have held with Commissioners and other key stakeholders (e.g. Associate Commissioners, HealthWatch
and Health Overview and Scrutiny Committee), and the opportunity this has given us both to review, celebrate
and challenge performance in line with our statutory obligations.
We recognise the areas of strengths described in the Quality Account, and we also support the priority areas for
quality improvement. We feel these are the right and appropriate priorities for our Guildford and Waverley residents,
as well as the wider population to which the Trust serves.
We remain committed to our statutory obligation of ensuring the Trust continually improve their services, and will
ensure that all the related recommendations set down recent Governmental publications will be met – particularly
those published as a result of serious quality failures. We will continue to exercise this through our monthly Clinical
Quality Review meetings with the Trust, regular review and reporting of quality/safety to our Clinical Quality and
Governance Committee and Governing Body, contractual measures, and continued progress of our Quality
Strategy 2014-15.
The Commissioners look forward to our continued work with the Royal Surrey County Hospital NHS Foundation
Trust over the forthcoming year, particularly to ensure our commissioning intentions are met, quality and safety
is sustained, and ultimately, patients and their families/carers receive the best possible healthcare to which they
deserve.
Yours Sincerely,
Dr. Susan Tresman
Chair of the Quality and Clinical Governance
Committee and Vice Lay Chair of Governing Body
66
Vicky Stobbart
Director of Quality and Safeguarding/
Executive Nurse
Statement from Surrey Healthwatch
Regrettably, this year Surrey Healthwatch has not been able to comment on the quality accounts nor provide a
statement for inclusion in this report. This has been due to capacity issues within Surrey Healthwatch. However we
acknowledge their involvement in the RSCH quality accounts workshops throughout the year and their input has
been invaluable. We look forward to their continued involvement in the quality accounts workshops here at RSCH.
Surrey County Council Health Scrutiny committee
The Surrey Health Scrutiny Committee delegates responsibility for the overview of the Royal Surrey County Hospital
Foundation Trust’s quality reporting to two of its Members; Mr Bill Barker OBE and Mrs Pauline Searle. Through
their attendance at the Trust’s quality account workshops and Mr Barker’s role as a County Council appointed
Governor of the Trust they have developed an appreciation of its good performance on achieving its quality
priorities. In particular, access to Governing Body papers and discussions has been very valuable for reviewing
performance and tracking the proposed merger with Ashford and St. Peter’s Hospitals. The Members reported
that Trust staff are approachable, happy to respond to queries about matters of quality and that the meetings
encourage an inclusive atmosphere.
Regarding this year’s report it is clearly laid out with accessible language showing how the Trust has performed
and where it can improve. The priorities for 2014/15 and the process for evaluating and developing these points
are explained to the reader at the beginning of the report. Members have been involved in the development of
priorities for 2015/16 and will continue to input throughout the next year to ensure the improvements in patient
safety and experience are realised.
Comment received by email on May 22, 2015.
Statement from Council of Governors
Statement from the Council of Governors
Royal Surrey County Hospital NHS Foundation Trust – Quality Accounts
This year, the Governors have continued to represent the interests of the members of the hospital and the public
and to ensure their voice is heard. They have been involved in a number of activities to help improve patient
experience within the Trust. These include:
■■ Membership of a number of Committees.
■■ Patient surveys.
■■ Cleanliness audits e.g. (PLACE (Patient Led Assessment of the Care Environment).
■■ Feeding back issues of concern / praise from patients / relatives.
One of the many roles of the Patient Experience Committee is selection of the Governors’ Quality Indicator (QI)
for the year ending March 2016. This year the stretch target chosen is:
‘To increase the percentage of all clinical staff receiving annual update on infection control to 90%’
Last year, the Governors chose a similar QI which had a compliance target of 80%. Staff worked hard to achieve
this through planned training sessions or e-learning modules and achieved an increased level of compliance of
76% (from a starting position of 63%). More work will be done this year to effect the desired increase in compliance
to 90%.
Also under discussion, is the Governors’ desire to lay the foundation for next year's QI by setting up a trial indicator
i.e. ‘Eye Clinic waiting times’. After a formal trial period, this is likely to be adopted as the indicator for next year.
The Governors are always interested in feedback and if a member wishes to discuss any issue with a governor,
they may do so through the hospital website or by contacting the Company Secretary, Joanne Green on 01483
571122 ext. 2318, or by e-mail (j.green7@nhs.net).
Dr. Jan Whitby
Chairman, Patient Experience Committee.
25 May 2015
67
2. Statement of directors’
responsibility in respect of the
quality report
Under the Health Act (2009) and the National Health Service (Quality Accounts) Regulations 2010, the directors
are required 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.
In preparing the quality report, directors are required to take steps to satisfy themselves that:
■■ The content of the Quality Report meets the requirements set out in the NHS Foundation Trust Annual Reporting
Manual 2014/15 and supporting guidance
■■ The content of the Quality Report is not inconsistent with internal and external sources of information including:
●● Board minutes and papers for the period April 2014 to 27 May 2015
●● Papers relating to Quality reported to the board over the period April 2014 to 27 May 2015
●● Feedback from Commissioners dated 21 May 2015
●● Feedback from governors dated 25 May 2015
●● Feedback from local Healthwatch organisation: N/A (See statement above)
●● Feedback from Overview and Scrutiny Committee dated 22 May 2015
●● The Trust’s complaints report published under regulation 18 of the Local Authority Social Services and NHS
Complaints Regulations 2009, dated 2014/15
●● The national patient survey published May 2015
●● The national staff survey dated May 2015
●● The Head of Internal Audit’s annual opinion over the trust’s control environment dated 22 May 2015
●● CQC intelligent Monitoring Report dated May 2015
■■ The performance information reported in the quality report is reliable and accurate
■■ There are proper internal controls over the collection and reporting of the measures of performance included in
the quality report, and these controls are subject to review to confirm that they are working effectively in practice
■■ The data underpinning the measures of performance reported in the quality report is robust and reliable,
conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny
and review; and
■■ The quality report has been prepared in accordance with Monitor’s annual reporting guidance as well as the
standards to support data quality for the preparation of the Quality Report (available at www.monitor.gov.uk/
annualreportingmanual).
The directors confirm to the best of their knowledge and belief that they have complied with the above requirements
in preparing the quality report.
By order of the Board
Chairman, 27 May 2015
68
Chief Executive, 27 May 2015
3. External Audit Limited
Assurance Report
Independent auditor’s report to the Council of Governors of Royal Surrey
County Hospital NHS Foundation Trust on the Quality Report
We have been engaged by the Council of Governors of Royal Surrey County Hospital NHS Foundation Trust to
perform an independent assurance engagement in respect of Royal Surrey County Hospital NHS Foundation
Trust’s Quality Report for the year ended 31 March 2015 (the ‘Quality Report’) and certain performance indicators
contained therein.
Scope and subject matter
The indicators for the year ended 31 March 2015 subject to limited assurance consist of the following two national
priority indicators:
■■ Percentage of incomplete pathways within 18 weeks for patients on incomplete pathways (“Referral to Treatment
– incomplete pathways”)
■■ Maximum waiting time of 62 days from urgent GP referral to first treatment for all cancers (“62 day cancer waits”)
During 2014/15 the Trust identified significant weaknesses in its control environment and data quality in regard
to the “Referral to Treatment – incomplete pathways” indicator. As a result, the Department of Health’s Interim
Management and Support team (“IMAS”) have begun an investigation and this has been reported to Monitor. As a
result of these identified control weaknesses, we are unable to issue a limited assurance opinion on this indicator.
In this opinion all references to the ‘indicator’ refer to the national priority indicator: Maximum waiting time of 62
days from urgent GP referral to first treatment for all cancers.
Respective responsibilities of the directors and auditors
The directors are responsible for the content and the preparation of the Quality Report in accordance with the
criteria set out in the NHS Foundation Trust Annual Reporting Manual issued by Monitor.
Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything has come
to our attention that causes us to believe that:
■■ the Quality Report is not prepared in all material respects in line with the criteria set out in the NHS Foundation
Trust Annual Reporting Manual;
■■ the Quality Report is not consistent in all material respects with the sources specified in the Detailed Guidance
for External Assurance on Quality Reports 2014/15 (‘the Guidance’); and
■■ the indicator 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 Guidance.
We read the Quality Report and consider whether it addresses the content requirements of the NHS Foundation
Trust Annual Reporting Manual and consider the implications for our report if we become aware of any material
omissions.
■■ We read the other information contained in the Quality Report and consider whether it is materially inconsistent
with:
■■ Board minutes for the period April 2014 to May 2015;
■■ Papers relating to Quality reported to the Board over the period April 2014 to May 2015;
■■ Feedback from the Commissioners dated May 2015;
■■ Feedback from local Healthwatch organisations dated May 2015;
69
■■ The Trust’s complaints report published under regulation 18 of the Local Authority Social Services and NHS
Complaints Regulations 2009, 2014/15;
■■ The 2014/15 national patient survey;
■■ The 2014/15 national staff survey;
■■ Care Quality Commission quality and risk profiles/intelligent monitoring reports 2014/15; and
■■ The 2014/15 Head of Internal Audit’s annual opinion over the Trust’s control environment.
We consider the implications for our report if we become aware of any apparent misstatements or material
inconsistencies with those documents (collectively, the ‘documents’). Our responsibilities do not extend to any
other information.
We are in compliance with the applicable independence and competency requirements of the Institute of Chartered
Accountants in England and Wales (ICAEW) Code of Ethics. Our team comprised assurance practitioners and
relevant subject matter experts.
This report, including the conclusion, has been prepared solely for the Council of Governors of Royal Surrey County
Hospital NHS Foundation Trust as a body, to assist the Council of Governors in reporting the 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 indicator.
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 Royal Surrey County Hospital NHS Foundation Trust for our work or this report, except
where terms are expressly agreed and with our prior consent in writing.
Assurance work performed
We conducted this limited assurance engagement in accordance with International Standard on Assurance
Engagements 3000 (Revised) – ‘Assurance Engagements other than Audits or Reviews of Historical Financial
Information’, issued by the International Auditing and Assurance Standards Board (‘ISAE 3000’). Our limited
assurance procedures included:
■■ evaluating the design and implementation of the key processes and controls for managing and reporting the
indicator;
■■ making enquiries of management;
■■ testing key management controls;
■■ limited testing, on a selective basis, of the data used to calculate the indicator back to supporting documentation;
■■ comparing the content requirements of the NHS Foundation Trust Annual Reporting Manual to the categories
reported in the Quality Report; and
■■ 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.
Non-financial performance information is subject to more inherent limitations than financial information, given the
characteristics of the subject matter and the methods used for determining such information.
The absence of a significant body of established practice on which to draw allows for the selection of different,
but acceptable measurement techniques which can result in materially different measurements and can affect
comparability. The precision of different measurement techniques may also vary. Furthermore, the nature and
methods used to determine such information, as well as the measurement criteria and the precision of these
criteria, may change over time. It is important to read the quality report in the context of the criteria set out in the
NHS Foundation Trust Annual Reporting Manual.
The scope of our assurance work has not included governance over quality or the non-mandated indicator, which
was determined locally by Royal Surrey County Hospital NHS Foundation Trust.
70
Conclusion
Based on the results of our procedures, nothing has come to our attention that causes us to believe that, for the
year ended 31 March 2015:
the Quality Report is not prepared in all material respects in line with the criteria set out in the NHS Foundation
Trust Annual Reporting Manual; and
the Quality Report is not consistent in all material respects with the sources specified in the Guidance.
the indicator in the Quality Report subject to limited assurance has not been 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 Guidance.
KPMG LLP
Chartered Accountants
15 Canada Square
London
E14 5GL
28 May 2015
71
Our Trust Strategy – BESTF
Patients
Vision
Deliver the best
patient care, anywhere
Mission
Provide outstanding general
hospital and specialist cancer
services in the South East of England
Goals
Attract patients
by being the best
at what we do
Work efficiently
to make best use
of resources
Values
Safe and
excellent care
Respect
for people
Continuous
improvement
Best
outcomes
Excellent
experience
Skilled, motivated
Top
teams
productivity
P&G214
Strategies
★★
★★★
✔✔
Firm foundations
Strong
governance
Sound
finances
Robust IT &
Information
Effective
marketing
Vibrant
teaching &
research
Strong
partnerships
The Trust strategy sets out the vision of best patient care, anywhere. This means that we want our patients to
benefit from care which is as good as the very best in the NHS, and internationally. Our mission is to focus on
providing outstanding general hospital and cancer services in the south East of England – attracting patients by
being the best at what we do, and working efficiently to make best use of the resources we are given. The four
specific strategies will enable us to deliver this vision and mission:
Best Outcomes – working closely with other professionals from across the health system, our expert clinical
teams will focus on delivering the best and most up to date treatments, putting patient safety at the heart of
everything we do.
Excellent Experience – we recognise our patients have a choice, and we will strive to treat them with the courtesy
and compassion that we would expect for ourselves, ensuring that all aspects of our service are user friendly
and convenient
Skilled and Motivated Teams – our people are our most precious resource and we will enable them to deliver
our vision – empowering them to shape and lead their services, and supporting them to reach their full potential
Top Productivity – we will harness all the resources at our disposal to benefit our patients, achieving outstanding
levels of quality and productivity by continuously reviewing and improving what we do.
These strategies are built on firm foundations of strong governance, sound finances, robust IT and information,
effective marketing, vibrant teaching and research and strong partnerships. Getting these basics right will create
the stability we need to deliver our vision successfully.
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Glossary of terms and
abbreviations
Term
Explanatory note
A&E
Abbreviation for the accident and emergency department which is also sometimes
referred to as the hospital emergency department
AHSN
Refers to the Academic health science networks. These were set up in 2013 to help
transform health and healthcare by putting innovation at the heart of the NHS
BESTF
Acronym for trust strategy representing Best outcomes; Excellent experience; Skilled and
motivated teams; Top productivity; and Firm foundations
BMJ
Refers to the British medical journal.
CAG
Refers to clinical academic groups.
CAUTI
Refers to catheter associated urinary tract infection. This is one of the harms that is
measured by the safety thermometer
CCG
Refers to clinical commissioning group. CCGs were set up in 2013 following the dissolution
of primary care trusts. CCG s are clinically led statutory bodies that commission local
healthcare services
CHKS
Refers to comparative health knowledge system.
CLRN
Comprehensive local research network
CNST
Refers to clinical negligence scheme for trusts.
CQC
Refers to care quality commission who are the sector regulator for healthcare
CQGC
Refers to clinical quality governance committee
CQUIN
Refers to commissioning for quality and innovation
ECIST
Refers to emergency care intensive support team. Their remit is to support the creation of
sustainable emergency care
ELT
Refers to executive leadership team
EWS
Refers to early warning score which is a measure of rating individual patient’s risk of
deterioration
FFT
Refers to the Friends and family test. This is a national health service survey given to
patients at the point of discharge. The survey aims to ascertain patients’ experience of
healthcare by asking patients to rate the extent to which they would recommend the
hospital to their friends and family
HICC
Refers to the hospital infection control committee
HSCIC
Health and Social care information centre
IDT
Refers to intermediate discharge team.
IG
Refers to Information governance
IGT
Refers to Information governance toolkit
KPMG
Refers to the name of the internal audit company
KSSCRN
Refers to Kent, Surrey and Sussex clinical research network
NICE
National institute for health and care excellence.
NHS
Refers to national health service
PDI
Refers to patient demographics identifier
PHE
Refers to Public health England
SBU
Refers to specialty business unit
SHMI
Refers to summary hospital mortality index which is measure for
SSNAP
Sentinel Stroke national audit programme
VTE
Venous thrombo- embolism
WHO
World Health Organisation
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P&G640. Design and photography by RSCH Photography & Graphics Department