RCHT Quality Accounts 2014-15 V5.16
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CONTENTS PAGE
Contents
Part 1: Chairman and Chief Executive’s statement on behalf
of the Trust Board
Page
4
Part 2: Priorities for Improvement
A. Review of 2014/15 priorities for improvement
Patient Safety
Reduction in our Dr Foster Hospital Standardised Mortality
Ratio
Seven day working
Implementation of the CQC recommendations in relation to
patient records
Clinical Effectiveness
Improvement in National Staff Survey Results /
Improvement in Staff Engagement and Wellbeing
Implementation of three new patient pathways
Patient Experience
Improve discharge arrangements for patients
B. Priorities for improvement 2015/16
Patient Safety
Compliance with the Sepsis 6 pathway
Clinical Effectiveness
Improvements in stroke performance
Continue to reduce our Dr Foster Hospital Standardised
Mortality Ratio
Further strengthening of 7 day working
Patient Experience
Response to the national staff survey results
C. Board statements of assurance
Review of our performance 2014/15
National priorities and existing commitments
Incident reporting, enabling effective learning, and Never
Events
Participation in Clinical Audits
Research and Development
Commissioning for Quality and Innovation (CQUIN)
How the NHS regulator, the Care Quality
Commission, views the quality of our services
Data Quality
Information Governance Toolkit attainment levels
Clinical Coding Error Rate
National Quality Indicators
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Part 3: Review of the Trust’s quality performance
Patient Safety
Venous Thrombo-Embolism (VTE) exemplar centre status
The patient blood management (PBM) programme/ blood
conservation service
Human Factors Training Initiative
Critical Care Outreach Team development
Clinical Effectiveness
Antibiotic Stewardship
Acute Kidney Injury
Cornwall Bowel Cancer Screening Programme
Clinical Oncology (Radiotherapy)
Ambulatory Emergency Care Unit
Patient Experience
National Emergency Department Survey 2014
National Inpatient Survey 2014
National Cancer Survey 2014
Outpatients Survey 2014
Day Case Survey 2014
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Involvement and Stakeholder Engagement
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Statements from Healthwatch, Health and Wellbeing Boards and
Clinical Commissioning Groups
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Statement of Directors' Responsibilities in Respect of the Quality
Account
Independent Auditors’ Report
Glossary
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Royal Cornwall Hospitals NHS Trust
Quality Accounts 2014/15
PART 1 Chairman and Chief Executive’s statement on behalf of the Trust
Board
Welcome to this year’s Royal Cornwall Hospitals NHS Trust Quality Accounts.
The report builds on last year’s quality accounts identifying our performance in
2014/15 and our improvement plans for 2015/16.
Following our planned inspection in January 2014 by the Care Quality
Commission, we have acted on all the recommendations and look forward to
achieving a “Good” assessment, leading to the ambition of being rated
“Outstanding". The Trust continues to work towards being authorised as a
Foundation Trust and continues to be the preferred provider of acute services
for the people of Cornwall and the Isles of Scilly.
‘Our plans 2012 – 2017’ published in July 2012 outlines our commitment to the
delivery of excellent patient care.
The information within this year’s quality accounts provides a good insight into
the progress made against our objectives. Particular highlights are:






Reduction of the Trust’s Dr Foster Hospital Standardised Mortality
Ratio (HSMR)
Increase in the services available over seven days
Implementation of the CQC recommendations in relation to patient
records
Improvement in Staff Engagement and Wellbeing
Introduction of three new patient pathways (Chest pain, Heart
failure, Respiratory disease)
Improve discharge arrangements for patients
Initiatives for 2015/16 are:
 Compliance with the Sepsis 6 pathway
 Improvements in stroke performance
 Continue to reduce in-hospital mortality
 Further strengthening of 7 day working
 Responding in full to the national staff survey
We are pleased to publish our fifth quality accounts and to confirm our
personal commitment to providing high quality health care which is safe and
effective for the people of Cornwall and the Isles of Scilly.
To the best of our knowledge the information in these quality accounts is
accurate.
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Bill Shields
Chief Executive
RCHT Quality Accounts 2014-15 V5.16
Angela Ballatti
Trust Chairman
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PART 2 PRIORITIES FOR IMPROVEMENT
A. Review of 2014/15 priorities for improvement
Patient Safety
Reduction in our Dr Foster Hospital Standardised Mortality Ratio (HSMR)
Measurements of survival from hospital admissions are an important marker of
the quality of care provided. Comparative national data is published as a
Hospital Standardised Mortality Ratio (HSMR), taking into account variations in
local populations. Safer patient care will reduce mortality (as measured by the
HSMR). It is, however, reliant on data which is accurate and consistent to
ensure valid comparisons.
‘The Hospital Standardised Mortality Ratio is the ratio of observed deaths to
expected deaths for a basket of 56 diagnosis groups which represent
approximately 80% of in hospital deaths. It is a subset of all and represents
about 35% of admitted patient activity’
During 2014/15 the Trust has implemented a number of initiatives to reduce its
mortality rates:
 An action plan is in place to reduce avoidable deaths in the hospital,
monitored by Trust Management Committee-Governance. Issues
related to deaths from non-elective weekend admissions are addressed
within the action plan.

Out of Hours including weekend working:
o Additional senior nursing and medical cover in place at
weekends, together with additional junior doctor out of hours
cover
o Increased access to diagnostics
o Critical Care Outreach resources increased to allow extended out
of hour cover

Handover Process
o A hospital wide handover occurs every night at 21:00 hours led
by the Medical SPR, and at 08:00 hours led by the MAU
Consultant
o The 21:00 hours handover has been reconfigured to include:
 A systematic discussion of ward patients identified as
being “at risk” i.e. having high NEWS scores, requiring 1:1
care in line with Safer Observations of Care Policy,
undergoing psychiatric assessment/sectioning
 Involvement of surgery and critical care services
 ‘Safety of the Hospital’ discussion with Emergency
Department Co-ordinator / Hospital at Night Nurse
o The morning handover now includes a hand back of patients who
have become unwell overnight
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
Care Bundles
o Care bundles have been introduced for Sepsis (Sepsis 6) and
Pneumonia

Mortality review process
o A revised mortality review process is in place; to date 98% of
deaths that occurred between 1 January 2014 and 31 January
2015 have been reviewed
o The membership of the Mortality Review Committee has been
extended to include improved senior nurses and therapists, junior
medical staff and a member of the clinical coding team. The
committee is now chaired by the Deputy Medical Director. From
June 2015 one of the Trust’s Patient Ambassadors has agreed to
become a member of the group
o A monthly newsletter has been developed which highlights key
Dr Foster data and learning points from mortality review. This is
sent to all senior medical, nursing and management staff
HSMR: High risk areas identified in 2013/14:
 Non-elective weekend admissions –see above
 Syncope – continues to be reviewed. MAU admission proforma has
been amended to aid documentation and coding of initial diagnosis
 Septicaemia – revised NEWS charts now includes Sepsis triggers,
audits planned and in progress
 Rehabilitation – changes to the recording of acute stroke patients should
address this alert
 Pneumonia – care bundles have been introduced
HSMR: Current performance:
 The HSMR for the year ending December 2014 is 106.74 - higher than
expected; this relates to a higher than expected relative risk in February
2014
 The HSMR for non-elective weekend admissions for the year ending
December 2014 is 108.21 – as expected
All alerts raised by Dr Foster are reviewed by specialty clinical teams to
address any concerns in patient care. The alerts are also reviewed by the
clinical coding team for both clinical coding and other data errors.
Due to the importance of this indicator the Trust has identified further
improvement opportunities for 2015/16. Please see page 14 for further
information.
Seven day working
The Trust has established a task and finish group with regard to the move to 7
day working in the context of the 10 clinical standards indicators to describe
the standard of urgent and emergency care that patients should expect to
receive 7 days a week. These include:
1. Patient experience
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2. Time to first consultant review
3. Multi-disciplinary team (MDT) review
4. Shift handovers
5. Diagnostics
6. Intervention/key services
7. Mental health
8. On-going review
9. Transfer to community, primary and social care
10. Quality improvement
Extension of the critical care outreach service has been in place from January
2015.
Extended pharmacy services over 7 days commenced 1 September 2014 for a
6 month period. Operating hours increased to 17:00 hours on Saturdays and
Sundays. The initiative was supported through additional hours however; the
intention is to establish this as part of core business subject to service redesign
and financial investment.
Implementation of weekend inpatient therapies to provide consistency of
rehabilitation intervention across 7 days commenced in September 2014. Our
aim is to reduce length of stay and to improve patient flow with an emphasis on
achieving increased weekend discharge rates.
Clinical Imaging:
 Community X-ray facilities extended opening weekday and evenings
08:00-17:00
 Ultrasound – weekend inpatients’ service at the Royal Cornwall Hospital
in place from September 2014
 CT – Sunday inpatient service at the Royal Cornwall Hospital in place
from October 2014
The Trust has submitted a comprehensive self-assessment and will identify
priorities for the coming year.
Due to the importance of this initiative the Trust has identified further
improvement opportunities for 2015/16. Please see page 15 for further
information.
Implementation of the CQC recommendations in relation to patient
records
During August and September 2014,136 secure patient record trolleys were
delivered to the in-patient ward areas.
A final audit was conducted in February 2015 and the results showed that
patient records continue to be stored in secure lockable trolleys and are no
longer visible to people visiting the ward; this is an improvement on the open
style trolleys compared to when the CQC visited in January 2014.
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Out of the 124 trolleys audited, there were no trolley doors left open and
unattended: which compared to the results in the last audit, now means that
these trolleys are being used how they were intended and ensures compliance
with the security of information. It was noted that 44 trolley doors were not
locked, only closed, however the trolleys located behind the Nurse’s station
should be considered to be secure.
In 11 out of the 37 wards audited, information continued to be left unattended.
As mobile devices are being more actively used on the wards, this is an area
that now needs focusing on: information was visible on a number of devices. It
must be recognised, however, that there needs to be a balance in keeping
information safe and secure to comply with information governance standards,
but still allowing healthcare professionals deliver quality care and use
information at the point of care in a timely manner. Consideration is being
given to the use of post-it notes, raised through the Peninsula Medical
Students as part of their Special Study Unit within Health Informatics. The
proposal is that post-it notes are placed upon PC screens, notes and
information left unattended, as a warning that anyone could have
seen/accessed the information.
The biggest area of improvement is where office doors were being left open,
unlocked and unattended where there were records present.
Recommendations from the last audit were taken on board and some doors
have now been fitted with either swipe card access or key code pads. On this
particular audit there were 4 doors left open and unattended.
There has been a noted increase in areas of good practice where the
governance of patient information is very good.
All SwiftPlus whiteboards were up to date and icons were being used as well
as the NEWS and Clinically Stable columns.
The ‘Spot Check’ short audits of clinical records commenced in February; initial
results show areas that are good in terms of recording within the record are:
 Diagnosis
 Clear plan in place
 Allergies recorded
However, there are some areas that still need some improvement, although
these areas are showing signs of awareness now:
 Location of the patient
 Date and time
 Legible and signed
Clinical Effectiveness
Improvement in National Staff Survey Results / Improvement in Staff
Engagement and Wellbeing
The Trust has implemented the ‘Managers Passport’. This competency based
passport sets out the minimum standards expected of our managers and
leaders and will build a strong foundation of management practice underpinned
by Trust values and behaviours.
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We have continued to embed the Trust values and behaviours throughout the
organisation, including utilising the Listening into Action (LiA) framework. A
dedicated LiA Lead Facilitator was deployed in order to engage clinical staff to
take ideas forward.
Due to the importance of this indicator the Trust has identified further
improvement opportunities for 2015/16. Please see page 15 for further
information.
Implementation of three new patient pathways
To improve the effectiveness of the way the Trust and local health community
see and treat patients, 3 patient pathways were implemented for the following
conditions:
 Chest pain
 Heart failure
 Respiratory disease
Chest Pain
The chest pain pathway was introduced on 6 October 2014 and the Exercise
Tolerance Test (ETT) no longer used for routine assessment of cardiac chest
pain.
To date we have received and vetted 1000 referrals:
 808 outpatients (Acute GP and GP)
 192 inpatients (MAU, ED, AEC, CIU, CDU, Grenville)
These patients have then been referred into 1 of 3 pathways or declined:
 Declined: 104
 RACPAC/RP: 657
 RACPAC/CT: 79
 RACPAC/NM: 147
(1 patient seen in cardiology outpatients first and 12 temporary rejections)
All three clinics are rapid access chest pain clinics. In the RACPAC/CT clinic
patients are seen by a chest pain nurse specialist and then a CT coronary
angiogram performed immediately after on the same day. The RAPCAC/NM
clinic patients are seen by a chest pain nurse and then a myocardial perfusion
scan is performed immediately after on the same day. The RACPAC/RP clinic
patients are seen by a chest pain nurse specialist and their case is then
discussed with a cardiologist. Patients attending these clinics will have had
their referral vetted first by a chest pain nurse who will refer them onto the most
appropriate RACPAC clinic according to their symptoms, age, risk factors and
ECG. All clinics are overseen by a cardiologist. Referrals are received from
both in hospital and GPs. Those referrals received from in hospital are patients
who have had a hospital attendance with chest pain and have found to be
Troponin T negative with a normal ECG and have been discharged home for
follow up.
The Key Performance Indicator (KPI) to reduce hospital admission by <10% is
difficult to audit due to the complexity of clinical coding for chest pain. However
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it is encouraging that 192 patients have received early discharge as a
consequence of the pathway rather than waiting for an ETT or cardiology
review as an inpatient.
The KPI regarding 70% of patients to be seen within 2 weeks from referral is at
43% overall. This is mainly due to the sudden influx of referrals to the service
since implementation of the new pathway. Additional clinic slots have been
provided to address this issue and an additional 22.5hrs (0.6WTE) in the
Funded Manpower Level (FML) as regards chest pain nurses has been made,
to meet the demands of this service.
Heart Failure
The Rapid Access Heart Failure Clinic commenced on 6 May 2014. 118
patients have been seen up to 31 October 2014 (average of 42 patients per
month). 67 patients had confirmed left ventricular systolic dysfunction (LVSD)
and a further 27 with significant cardiac pathology, implying good utilisation of
the pathway. The referral rate continues to increase.
The UltraFiltration (UF) pilot project continues with 8 patients receiving therapy
to date (December 2014). Recently published NICE guidelines (CG 187) state
that UF could be considered for patients with confirmed diuretic resistance.
The Heart Function care bundle is now available and will be audited in the next
few months.
The Heart Function Pathway has been agreed and is available on the RCHT
Clinical Guidelines electronic application.
Respiratory Disease
During 2014/15 the Trust implemented the following respiratory care pathways
/ care bundles:
 Acute Exacerbation of Chronic Obstructive Pulmonary Disease (COPD)
 Hospital Management of Community Acquired Pneumonia (CAP)
 Lower Respiratory Tract Infection
Monthly spot check audits of all inpatients on Wellington, MAU and
Respiratory/General medical beds on Roskear ward were undertaken between
November 2014 and April 2015.
Patient Experience
Improve discharge arrangements for patients
ECIST (The National Emergency Care Intensive Support Team) and local
commissioners have overseen a substantial piece of work that has revised the
operational flow of patients in the Trust. During the planned whole-system
‘Spring to Green’ initiative a number of the developments were embedded into
practice from pilot areas to the entire Trust. The redesigned pathways for
simple and complex discharges have been informed by working with partners
and patient representative groups e.g. Healthwatch Cornwall ensuring a
patient-centred approach.
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Work on accessing other provider information in clinical areas progresses to
support early intervention.
Work involving the discharge checklist is two-fold. We have a revised day of
discharge checklist being robustly used in practice and the principles of the
NHS England 'Discharge Checklist' have been captured in the redesign of
these new pathways.
The Spring to Green initiative enabled all partners to work together and
improvements to effective communications across settings has been
enhanced. A robust set of key performance indicators (pledges) were
developed and the Trust has worked hard to deliver their promises on the
numbers of simple and complex discharge it achieves each day. Quick wins
have been rolled out Trust-wide as and when they have been identified e.g.
afternoon board rounds (virtual ward rounds at our interactive ward screens),
and simplification of the electronic referral forms to social care. This work will
continue.
To further improve our patient’s discharge experience the revised discharge
information booklet ‘Getting ready to leave hospital – what you need to know’
was made available for patients and relatives in April 2015.
Initiatives for 2015/16 include:
 Establish routine practice of recording MDT set Estimated Dates of
Discharge (EDD)
 Engage Patients with their discharge arrangements
 Publish Choice documentation to all patients on admission
 Record patients Clinically Stable Date as the point at which care can
continue in another setting
 Measure EDD accuracy
 Set a daily discharge expectation
B. Priorities for improvement 2015/16
Process for agreeing the Trust’s priorities for improvement
A list of priority areas for improvement was reviewed and finalised by members
of the Trust Management Committee based on the following evidence:
 Engagement during 2014/15 with patients and the public in the
community the Trust serves
 Foundation Trust Quality Assessment
 The National Outcomes Framework
 NHS Information Centre
 Commissioning for Quality and Innovation (CQUIN) programme
 National and local patient experience surveys
 Royal Cornwall Hospitals NHS Trust Business Plans
 Intelligence from internal mechanisms for monitoring the quality of the
Trust’s services
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Patient Safety
Compliance with the Sepsis 6 pathway
Sepsis is a common and potentially life-threatening condition where the body’s
immune system goes into overdrive in response to an infection, setting off a
series of reactions that can lead to widespread inflammation, swelling and
blood clotting. This can lead to a significant decrease in blood pressure, which
can mean the blood supply to vital organs such as the brain, heart and kidneys
is reduced. Sepsis is recognised as a significant cause of mortality and
morbidity in the NHS, with around 35,000 deaths attributed to sepsis annually.
Sepsis is almost unique among acute conditions in that it affects all age
groups. Problems in achieving consistent recognition and rapid treatment are
thought to contribute to the number of preventable deaths from sepsis both
locally and nationally.
While a range of actions are recommended for rapid implementation when a
patient presents with sepsis (referred to as the ‘Sepsis Six’), rapid
administration of antibiotics is the single most crucial action that can prevent
deaths from sepsis and can be relatively easily measured and reported on.
Aim: All patients identified in MAU and ED with severe sepsis should be
treated with the Sepsis 6 pathway
Performance will be monitored by Trust Management Committee – Quality and
Safety and CQUIN processes.
KPIs:
 All patients presenting to MAU and ED with sepsis symptoms should
have a sepsis screen completed
 All patients presenting to MAU and ED with evidence of severe sepsis,
Red Flag Sepsis or Septic Shock should have been administered IV
antibiotics within an hour of presentation
Clinical Effectiveness
Improvements in stroke performance
The quarterly report of the Sentinel Stroke National Audit shows that stroke
management at RCHT remains poor overall in comparison to National criteria.
The performance criteria is banded from A (Excellent) to E (Poor) and RCHT’s
current position is E.
Direct admission to the stroke unit remains a major failure due to constraints
within the complete stroke pathway. A capacity analysis of the whole stroke
pathway is planned with support from the national network.
An action plan has been developed and shared with KCCG with agreed quality
indicators to be reported.
Aim: To ensure the Trust’s stroke patients are treated on the right ward and
receive appropriate and timely investigation and therapy assessments.
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Performance will be monitored by the Stroke Programme Board that includes
NHS Kernow Clinical Commissioning Group (KCCG) and Peninsular
Community Health, and Trust Management Committee – Quality and Safety.
KPIs:
 80% of stroke patients scanned within 1 hour of hospital arrival where
clinically indicated
 65% of all stroke patients receiving a swallow screen by an
appropriately trained healthcare professional within 4 hours of arriving in
ED
 86% of patients scanned within 12 hours of hospital arrival
 58% of patients admitted directly to the Trust’s acute stroke unit within 4
hours of hospital arrival
 81% of all stroke patients receiving a full dysphagia assessment by a
trained healthcare professional within 72 hours of admission and
following a positive swallow screen in ED
 83% of all stroke patients who spend at least 90% of their time on the
Acute Stroke Unit
Continue to reduce our Dr Foster Hospital Standardised Mortality Ratio
Following on from last year’s accounts, the Trust has identified further actions
to reduce overall mortality:
Ensuring the Trust’s data is correct
 To ensure record keeping and clinical coding accurately reflect patient
care
 Review of assignment of first consultant episodes (FCEs) to improve
accuracy of patient diagnoses
 Coding sessions as part of senior doctor mandatory training sessions to
raise awareness of the importance of clinical coding
Embedding Mortality Review in all clinical areas
 Mortality reviews in all clinical areas, with an expectation that all
specialities review 100% of deaths, approximately 10% of which will
require further in-depth review
 Mortality Review committee to review 10% of “no concern” and “
concerns” deaths
 Streamlining of feedback from Speciality Morbidity and Mortality Review
Meetings
 All learning to be disseminated through a monthly mortality newsletter
Actioning the Trust Mortality Improvement plan, to include:
 Improving consultant to consultant referral pathways
 Increasing junior doctor cover
 Improving recognition of the deteriorating patient (through the correct
use of NEWS), SBARD and simulation training
 Improving the delivery of the Sepsis 6 care bundle
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New KPIs:
 Reduction in the number of Serious Incidents declared following deaths
due to poor clinical care
 Reduction in the number of cardiac arrest calls
 Reduction in the Trust’s overall HSMR and weekend HSMR
Further strengthening of 7 day working
Following on from last year’s accounts, the Trust has identified further actions
to extend 7 day working:
 Provision of 7 day services where funded or business cases are being
developed
 Implementation of 5 clinical standards indicators as agreed with KCCG
Performance will be monitored by Trust Management Committee – Quality and
Safety and KCCG contract monitoring processes.
Patient Experience
Response to the national staff survey results
The Trust employs 5000 people, and spends £209m per annum (i.e. 60%) of
the budget on their remuneration. Our people are therefore, our most valuable
asset, whose skill, expertise and approach are critical to the delivery of high
quality, compassionate care. During 2014/15 we have experienced rising levels
of variable pay, due to the use of bank and agency staff, combined with an
increase in the number of funded vacancies.
Furthermore, despite an extensive programme of work to deliver the Our
People Strategy throughout 2014/15, the results of the 2014 Staff Survey are
poor. In particular our colleagues report:
 Feelings of dissatisfaction with the quality of work and patient care they
are able to deliver (64% v 77% national average for this score)
 Feeling insecure about raising concerns about unsafe clinical practice
(54% v 67% national average)
 Poor levels of job satisfaction (3.40 v 3.60 national average - out of a
possible score of 5.0)
 Reluctance to recommend RCHT as a place to work or receive
treatment (2.99 v 3.67 national average – out of a possible score of 5.0)
These results are however, in contrast to the 94% of patients that would
recommend our Trust. Therefore we will work to understand better which staff
groups staff feel the way they do, what the reasons are, and how we need to
change to address this. Also, more positively we recognise that, when
interviewed by the Care Quality Commission, many staff reported that change
implemented in the Trust ‘had been positive…the Trust had improved… and
staff felt proud to work there. There was a high degree of respect for the
Executive team.’
Therefore, whilst there are mixed and sometimes conflicting views across staff
groups, and between staff and patients, the Trust Board is absolutely
committed to achieve consistent improvement, in the views and perceptions of
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our staff, as ultimately this will enhance the quality of care they deliver and the
experience of our patients.
We will focus our efforts over the next 12 months to improve the way it feels to
work at Royal Cornwall Hospitals. The priority actions, aligned to the objectives
include:
Reinvigorate Listening into Action (LiA), to empower staff to make changes for
their patients and themselves. Actions:
 Deputy Chief Executive to lead the LiA programme, and the approach to
be adopted as our primary process for driving change
 Divisions to review survey outcomes and target LiA plans, to address
specific feedback concerns
 Executive to ensure all major CIP/Investment projects, promote full staff
engagement in the design of success criteria and effective solutions
Redesign our clinical structure, and implement a new multidisciplinary
leadership development programme. Actions:
 Engage our senior clinical leaders in the formulation of a new structure,
built around viable but connected clinical functions, which support good
patient flow
 Design a multidisciplinary leadership and management development
programme that leaders, managers and their teams can use to address
the particular challenges that get in the way of recommending Royal
Cornwall Hospitals Trust as a great place to work.
 Ensure all staff take part in an annual appraisal where they discuss, with
clarity, their role and contribution to delivering the Trust objectives, and
receive a personal development plan that enables them to do their jobs
effectively
Safe Staffing and Workforce Planning
As referred to above, we invest c 60% of our total resources on staff, and it is
through their effective recruitment, training, development and deployment that
we will achieve the highest standards of care. It is, therefore a priority to
ensure that resources are used to best effect and to this end we have
assessed the current systems, policies, processes and outcomes over the last
12-18 months to establish priority areas of support that will deliver a more
effective and efficient workforce.
There is variability in the management and deployment of our workforce, and
thus variability in absence levels, application of effective rostering, job planning
rules, and completion of appraisals. Improved control will reduce the need for
agency staff and enhance the quality of care provided to patients.
Pro-actively recruit, and retain our staff, to maintain safe staffing levels. Action:
 The Trust will utilise a range of local, national and international
campaigns to ensure recruitment to key posts
 Improved pro-active and innovative recruitment procedures ensuring
posts are recruited to within 8 weeks of advert
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
Improving the leadership and management skills across the
organisation to deliver the improved people related key performance
indicators
Ensure staff are deployed efficiently and minimise agency spend. Action:
 Ensure that our rosters and job plans are effectively mapped to service
delivery needs, using specific key performance indicators
 Implementation and resourcing of 65:35 qualified nurse ratios, to
support safe staffing levels, combined with sound control of funded
establishments
 Improving workforce productivity for example by, role redesign, more
effective rostering, better attendance, and developing effective
interventions regarding work related stress
 Enhance the quality and safety of our services through:
o Optimum use of current workforce related systems and
development of e-solutions
o An overall 27% reduction in our temporary workforce cost
The workforce plan, is therefore derived through the combination of workforce
modelling at service level reflecting redesign plans, recruitment plans and other
factors: consideration of service developments and proposed investments, and
finally the delivery of expected efficiencies through our cost improvement
plans.
C. Board statements of assurance
These accounts have been developed taking into regard any guidance issued
by the Secretary of State which relates to Chapter Two of the 2009 Health Act,
the National Health Service (Quality Account) Regulations 2010, the National
Health Service (Quality Account) Regulations 2011, the National Health
Service (Quality Account) Amendment Regulations 2012 (“the Regulations”)
and subsequent guidance provided by NHS England in 2013, 2014 and 2015.
During 2014/15 the Royal Cornwall Hospitals NHS Trust provided and/ or subcontracted 80 NHS services.
The Royal Cornwall Hospitals NHS Trust has reviewed all the data available to
them on the quality of care in 80 of these NHS 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 the
Royal Cornwall Hospitals NHS Trust for 2014/15.
Review of our performance 2014/15
National Priorities and Existing Commitments
As an aspirant Foundation Trust (FT) the Trust self-monitors against the
Monitor Risk Assessment Framework standards against which its performance
would be assessed if it were an FT. The Trust also receives an overall risk
rating from the NHS TDA as a non-FT; for most of the year this has been 2,
where 1 is high risk and 5 low risk. The Trust does not have the detail of this
assessment but similar factors are assessed in both frameworks.
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The Monitor risk assessment is identified for each quarter for 2014/15 in the
table below, with the detail given in the table overleaf.
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Monitor Risk Assessment Framework 2014-15
Achieved
Most likely case
Indicators
Clostridium Difficile - meeting the
Clostridium Difficile objective
Threshold
35
Timings
Q2
Q3
Q4
1.0
0.0
0.0
0.0
0.0
90%
quarterly
95%
quarterly
92%
quarterly
Various
quarterly
Comments
Achieved (after in year improvement recovered the position from Q1)
ytd
RTT admitted patients. Quarterly
assessment; target must be achieved
each month to achieve the quarter
RTT non-admitted patients. Quarterly
assessment; target must be achieved
each month to achieve the quarter
RTT incomplete pathways. Quarterly
assessment; target must be achieved
each month to achieve the quarter
Projected
Q1
1.0
1.0
1.0
Not achieved in Q2-4 as the Trust participated in the national programme aimed at reducing the number of long
waiting patients in order to improve the sustainability of the waiting list position.
0.0
0.0
0.0
0.0
Achieved
0.0
0.0
0.0
0.0
Achieved
Cancer indicators (all)
0.0
A&E: Maximum of 4 hours from arrival to
admission/ transfer/ discharge
Organisational health indicators
quarterly
n/a
quarterly
Third Party Reports
Continuity of services risk rating
n/a
quarterly
Warning notice
quarterly
Formal CQC regulatory action
TOTAL NUMBER OF CONCERNS IDENTIFIED
RCHT Quality Accounts 2014-15 V5.16
0.0
1.0
1.0
1.0
Not achieved in each quarter in 2014/15. The key actions are set out in the section below.
0.0
0.0
0.0
0.0
Achieved
0.0
n/a
0.0
Achieved (subject to Q4 confirmation)
1.0
95%
quarterly
Certification against compliance with
guidance regarding access to healthcare
for patients with a learning disability
Assurance of compliance quarterly
0.0
0.0
0.0
0.0
Achieved
0.0
1.0
1.0
1.0
0.0
0.0
0.0
0.0
1.0
1.0
1.0
1.0
3.0
4.0
4.0
4.0
The risk score associated with this indicator is the Trust's HSMR position as covered elsewhere in the Quality Accounts.
Achieved
The risk score associated with this indicator is the CQC action plan as covered elsewhere in the Quality Accounts.
Page 19 of 77
It will be seen from the table that the main performance difficulties encountered
by the Trust in 2014/15 have related largely to the proportion of patients whose
care in the Emergency Department exceeded 4 hours. The Referral to
Treatment issues have related more to the Trust’s participation in the national
programme to reduce the number of long waiting patients.
The risk scores relating to mortality and to the CQC action plan are covered in
more detail elsewhere in the Quality Accounts.
Emergency Department (ED) Access
The national ED target for over 95% of patients’ care in ED to be less than 4
hours in duration was not met for each quarter in 2014/15. The performance for
the full year was 84%. Although other factors have also contributed, the main
reason for much of the year has been medical patient flow. A number of
actions have been put in place to resolve, including:






The opening of a new medical ward
A new Ambulatory Care Unit has been opened
The Trust has worked with the KCCG (and other partners) to agree a
number of new patient pathways during the year
Expansion of services during the winter months in line with the winter
plan, including 7 day therapies and pharmacy
On-going work with Peninsula Community Health and Adult Social Care
to make sure where clinically appropriate patients are transferred to
community hospitals or return home with packages of care
Internal actions within the Emergency Department, such as increased
staffing at peak times
Referral to Treatment (RTT)/ Waiting Times
The Trust has met the national non-admitted (98% for the year verses a
standard of 95%) and incomplete (95% against a standard of 92%) standards
throughout the year. The Trust has participated in the national programmes
which have taken place during the year in which an increased number of long
waiting patients have been treated, which has meant that the admitted
standard has not been achieved in month for several months in year (89%
against a standard of 90%). The Trust remains in a strong position relatively on
the incomplete standards (i.e. a relatively small percentage of its patients still
on waiting lists are waiting more than 18 weeks). However, the Trust intends to
reduce this during 2015/16, especially in terms of the number of patients on
admitted pathways waiting over 18 weeks and this is likely to mean the
admitted standard is not achieved for part of next year.
C Difficile and MRSA
The 30 cases of C Difficile attributable to RCHT recorded in 2014/15 was
below the Trust’s tolerance of 35. 13 of these have been considered potentially
avoidable following review with KCCG. This improvement means that the
Trust’s tolerance for next year, at 23, poses a greater degree of challenge. All
control measures including root cause analysis on all cases and antibiotic
stewardship remain in place.
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There was 1 MRSA bacteraemia during the year. A root cause analysis was
undertaken and the relevant actions taken.
Venous Thromboembolism (VTE) Risk Assessments
The Trust assessed 98% of patients on admission for the risk of VTE during
2014/15. The national target of 95% was exceeded every quarter.
Delayed Transfers of Care
The level of delayed transfers of care increased slightly in 2014/15 for the
fourth year running. The Trust continues to work with key partners including
Peninsula Community Health and Adult Social Care through the Whole
Systems Resilience Network to ensure that patients are discharged in an
appropriate and timely fashion.
Indicators for Cancer
There are several indicators to which the NHS must work for cancer referral
and treatment. The data in the Monitor Risk Assessment Framework includes
standards which relate to the percentage of patients with a:
 Maximum waiting time of 2 weeks from referral to the date first seen for
all urgent suspected cancer referrals (target 93%)
 One month (31 days) wait from diagnosis to treatment:
o For subsequent treatments for all cancers (surgery 94%, drug
98%, radiotherapy 94%)
o Of all cancers (96%)
 Maximum 2 month (62 days) wait for first treatment from either:
o Urgent GP referral (85%)
o Consultant screening referral (90%)
Each of these targets was achieved on a quarterly and full year basis.
Incident Reporting, enabling effective learning, and Never Events
A high incident reporting rate is considered to be an indicator of a safe
organisation, where staff feel able to report incidents and near misses from
which they are able to continually learn and consequently reduce risk. The total
number of incidents (patient and non-patient) reported throughout the Trust
during 2014/15 was 12,396 compared to 12,478 in 2013/14.
During the period 1 April to 30 September 2014 the Trust's reporting rate for
patient safety incidents was 40.59 incidents per 1,000 bed days compared to a
median of 35.1 for Acute (non-specialist) organisations in England.
The Trust reported 82 Serious Incidents during 2014/15.
The Trust has an approved process for managing all incidents, including those
classified as 'Never Events' by the National Patient Safety Agency (NPSA).
During the period 1 April 2014 to 31 March 2015, 3 Never Events occurred at
the Trust. These are listed below by category and date:
1. Incorrect Cardiac Implantable Electronic Device (CIED) implanted (April
2014)
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2. Wrong site surgery: local excision of incorrect area of low-grade Ductal
Carcinoma In-Situ (DCIS) (April 2014)
3. Retained swab following insertion of pacemaker (June 2014)
The incidents were investigated in line with the Trust's Serious Incident Policy
to identify the root cause and immediate actions taken as a result of the
investigation:
1. Incorrect Cardiac Implantable Electronic Device (CIED) implanted. New
signage on storage cupboards in place to differentiate MRI conditional
and non MRI compatible products. The WHO checklist has been
modified to include specific questions on CIED requirements.
2. Wrong site surgery. Different marker clips are now used when
undertaking breast biopsies, which are documented on the WHO
checklist. Following surgery the marker clips removed are now
compared with those documented to confirm correct operational site.
3. Retained foreign object post-operation. Relevant theatre practice
standards have been introduced to cardiac cath lab practice. A specific
WHO checklist has been developed in collaboration with staff and
clinicians.
During 2014/15 the Trust put in place processes to improve the quality of root
cause analysis investigations of Serious Incidents. As a consequence of this
the Trust failed to complete these investigations in line with national
timescales. Following a further review and the establishment of an Executive
Serious Incident Panel (ESIP) led by the Medical Director, the backlog of
investigations were subsequently completed by the middle of February 2015;
this performance has been sustained going into 2015/16.
Participation in Clinical Audits
During 2014/15, 32 national clinical audits and 6 national confidential enquiries
covered NHS services that the Royal Cornwall Hospitals NHS Trust provides.
During that period the Royal Cornwall Hospitals NHS Trust participated in
100% of national clinical audits and 100% of national confidential enquiries of
the national clinical audits and national confidential enquiries which it was
eligible to participate in.
 100% participation in the National Clinical Audit and Patient Outcomes
Programme (NCAPOP)
 100% participation in “other national clinical audits”
The national clinical audits and national confidential enquiries that the Royal
Cornwall Hospitals NHS Trust was eligible to participate in, and for which data
was collected in 2014/15, are listed below alongside the number of registered
cases required by the terms of that audit or enquiry.
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Audit/Confidential Enquires
Acronym
Participation
National Confidential Enquiries
Gastrointestinal Haemorrhage
yes
(NCEPOD)
Lower Limb Amputation
yes
(NCEPOD)
Sepsis (NCEPOD)
yes
Tracheostomy Care (NCEPOD)
yes
Elective surgery (National PROMs
yes
Programme)
Percentage or number
of cases submitted
100%
100%
100%
100%
75% (February 2015
update of 2013-14
data)
100%
Maternal, Newborn and Infant
MBRRAC
yes
Clinical Outcome Review
E-UK
Programme
National Confidential Inquiry into
NCISH
not applicable
Suicide and Homicide for people
with Mental Illness
National Clinical Audit & Outcomes Programme (NCAPOP)
Acute Coronary Syndrome or
MINAP
yes
40% (1030 records).
Acute Myocardial Infarction
95%+ of high focus
cases.
Bowel Cancer
NBOCAP
yes
100% (310 records)
Cardiac Rhythm Management
CRM
Coronary Angioplasty/National
Audit of PCI
Diabetes (Adult)
Diabetes (Paediatric)
Epilepsy 12 audit (Childhood
Epilepsy)
Falls and Fragility Fractures Audit
Programme Hip Fracture Database
Head and Neck Oncology
Inflammatory Bowel Disease
Programme
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NPDA
yes
100% (630 records)
yes
100% (820 records)
partial
79% of records
covering 2013/14 for
the outpatient element
submitted. 2014/15
records will be
submitted before the
completion date in July.
100% participation in
the Diabetic Pregnancy
audit
Data collection period
closes June 2015
yes
yes
50% (39 cases).
FFFAP
yes
100%
DAHO
yes
100% (80 cases)
IBD
yes
Biological Therapies
only 2 records
Page 23 of 77
Lung Cancer
NLCA
yes
100% (230 cases)
National Chronic Obstructive
Pulmonary Disease Audit
Programme
National Emergency Laparotomy
Audit (NELA)
National Heart Failure Audit
COPD
yes
49%
NELA
yes
100%
yes
100%
yes
95%
National Prostate Cancer Audit
yes
100%
National Vascular Registry
yes
100%
NNAP
yes
100%
NAOGC
yes
100% (190 cases)
National Joint Registry
Neonatal Intensive and Special
Care
Oesophago-gastric Cancer
NJR
Rheumatoid and Early
yes
Inflammatory Arthritis
Sentinel Stroke National Audit
SSNAP
yes
Programme (SSNAP)
Congenital Heart Disease
CHD
not applicable
(Paediatric cardiac surgery)
National Adult Cardiac Surgery
not applicable
Audit
Paediatric Intensive Care Audit
PICANet
not applicable
Network
Other National Clinical Audits
Adult Community Acquired
yes
Pneumonia
Case Mix Programme (CMP)
yes
Fitting child (care in emergency
departments)
Major Trauma: The Trauma Audit
& Research Network (TARN)
Mental health (care in emergency
departments)
National Cardiac Arrest Audit
(NCAA)
NCAA
100% (720 records)
Data collection period
closes end May 2015
100%
yes
100%
yes
67%
yes
94%
yes
Local data submission
started in February
2015
100%
National Comparative Audit of
Blood Transfusion programme
yes
Non-Invasive Ventilation - adults
yes
Older people (care in emergency
departments)
yes
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less than 5%
Data collection period
closes end January
2016
80%
Page 24 of 77
Pleural Procedure
yes
Renal replacement therapy (Renal
Registry)
National Audit of Intermediate Care
yes
Prescribing Observatory for Mental
Health
Pulmonary Hypertension
(Pulmonary Hypertension Audit)
Data collection closes
end of May 2015
100%
not applicable
POMH
not applicable
not applicable
Reviewing reports of national clinical audits
The reports of 43 national clinical Audits were reviewed by the provider in
2014/15 and the Royal Cornwall Hospitals NHS Trust intends to take the
following actions to improve the quality of the healthcare provided.
Below are examples of national clinical audits reports published in 2014 and
reviewed by the Royal Cornwall Hospitals NHS Trust:
Paediatric Bronchiectasis – report published April 2014.
 Results presented in Paediatrics in June 2014
 The Trust is largely compliant with BTS guidelines
Next steps:
 Ensure that total IgE levels are checked more stringently in outpatients
 Genetic tests for ciliary dyskinesia need to be carried out in all patients.
The national team at Southampton have agreed to do some local clinics
at this Trust to achieve this
National Emergency Laparotomy Audit (NELA)
 The NELA Organisational Report for the first year was published in May
2014.
 This trust is compliant or partially compliant with 9 of the 11 core.
Standards which all acute trusts admitting emergency surgical adult
patients should achieve
 Action planning is under way to address areas where the Trust is not
fully compliant with the 11 core standards
 Patient level data collection is continuous and approximately 100% of
the estimated number of cases have been included
The Head and Neck Cancer Audit
 The ninth annual report was published in July 2014
 All data in the report is presented for the Peninsula Cancer Network for
Head and Neck
 There are no issues for this Trust. In all fields the Network are within the
deemed acceptable area
Next steps:
 One of the lower scored domains (nationally) is the amount of time
available to the Cancer Nurse Specialist to see new patients at point of
diagnosis
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
There is a demand for more Cancer Nurse Specialist support in Head
and Neck
National Chronic Obstructive Pulmonary Disease (COPD) Programme:
 The National report was published in November 2014
 Site level results are compared with the national results and where
possible with results of the previous audit in 2008
 Nationally there has been a 13% increase in the median number of
COPD admissions per Unit since 2008
Planned local actions:
 Respiratory pathways
 Seven day respiratory working (6th chest physician)
 Business case for respiratory nurse for inpatient reviews
 Better integration through the respiratory network
National Diabetes in Pregnancy Audit
 The first report was published in October 2014
 The report was discussed at the Diabetes Team meeting and the
Perinatal Audit meeting
 An on-going process of data collection on the pregnancy outcomes of
women with pre-existing Type 1 and Type 2 Diabetes
 Data from 1704 pregnancies was collected nationally
Planned local actions:
 Engage with Primary Care to improve the uptake of preconception
counselling
 Investigate the reasons for higher than average Neonatal Unit
admissions
National Comparative Audit of Blood Transfusion
 The 2014 report of the Audit of Patient Information & Consent was
published in July 2014
 An audit of the extent to which patients undergoing blood transfusion
are involved in the decision to transfuse are provided with sufficient
information to allow them to make an informed choice
 Results show that improvements can be made in areas of policy,
training and practice, for example, the discussion of risks, benefits and
alternatives to transfusion
Planned local actions:
 Results were discussed at the Hospital Transfusion Committee in July
2014
 Since July a section for consent has been added to the transfusion form
and this is also part of mandatory training
On the Right Trach? NCEPOD Report on Tracheostomy Care
 The NCEPOD report was published in June 2014
 Highlights the process of care for patients who undergo a tracheostomy
or a laryngectomy
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
Details of the key national recommendations were reported to Trust
Management Committee (Governance) in August 2014
 Results reviewed at Critical Care multi-disciplinary Governance and
Business meetings within Critical Care
 Report and recommendations have been forwarded to the ward
managers for other areas within the Trust where patients with a
tracheostomy may be nursed on a regular basis
 The Trust already meets most of the recommendations
Planned local actions:
 Explore development of a procedure specific WHO checklist
 Datix any unplanned tube changes
 Unplanned and night time critical care discharge. Unfortunately
difficulties with patient flow and ward bed availability means that our
night time discharge rates are very high
Reviewing Reports of local clinical audits
The reports of 141 local clinical audits were reviewed by the provider in
2014/15 and the Royal Cornwall Hospitals NHS Trust intends to take the
following actions to improve the quality of healthcare provided.
Local clinical audits are reviewed at Divisional and Specialty audit and
governance meetings. Examples of actions resulting from local clinical audits
are listed below.
Bariatric Surgery Re-Audit
Results presented at the Surgical Audit Meeting in May 2014 and at the
NCEPOD conference June 2014
Actions:
 This re-audit shows there have been improvements to the bariatric
service, including the introduction of a 2 stage consent process in
January 2013
 Pending the results of an independent review into the psychology
service, as a stopgap measure, a temporary appointment of a part time
psychologist was made. This has since become a permanent role
Bacterial contamination in cell salvage blood at caesarean section
Results presented at Peninsula Obstetric Meeting and the Obstetric
Anaesthetists Association OAA meeting in Dublin in May 2014.
Actions:
 As women who received allogeneic blood had a higher rate infection continue to improve the drive to conserve blood in maternity and avoid
blood transfusions when there is possible infection
Assessment of urinary incontinence before and after incontinence surgery: are
we following guidance?
Results presented at the Obstetrics & Gynaecology Audit Meeting in April
2014. This audit is against NICE Clinical Guidelines.
Actions:
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
Validated questionnaires to be introduced at pre-op and at 1 year and
yearly thereafter to assess symptoms
To identify patient groups with long length of stay so we can focus resources
and pathway development on the right group
Results shared with Chief Operating Officer & Divisional Governance Leads
Results:
 Infection is the most significant cause for prolonged patient stay at
RCHT
 The second most frequent cause of prolonged stay is due to a cardiac
diagnosis on admission or cardiac complication during admission for
another reason
Audit into discharges and follow up of patients on the Critical Care Unit
Presented at the Critical Care Governance meeting July 2014.
Actions:
 The department are going to use the data in putting forward a case for
increasing the outreach service in the unit
Ward level compliance with oral diet safe swallow recommendations for
patients presenting with oropharyngeal dysphagia
Presented at Therapy Clinical Governance Forum August 2014.
Actions:
 To support ward based training to improve dysphagia awareness
 To pilot ‘Supported Feeding for Patients’ with Dysphagia’ training via
healthcare assistants training programme on Phoenix ward
Golden hour in paediatric sepsis and septic shock: are we meeting the targets
Multidisciplinary - Emergency Department, Child health; Anaesthesia & Critical
Care. Presented at Regional Paediatric Intensive Care Unit meeting in
September 2014.
Results:
 High standard of care delivered at RCHT vs gold standards
 Creation of ‘golden hour’ clinical flow-chart & guideline (incorporating
Sepsis 6)
 On-going education
Management of petechial rashes in children and young people under 16s
Presented at a Paediatric Audit Day in September 2014.
Results:
 Create petechial rash management proforma – including blood tests
needed
 When taking referrals remind clinicians to give pre-hospital antibiotics if
indicated
 Make sure patients are kept for the minimum observation time
 Clearly document reasons why NICE guidelines are not followed
Referral guidelines for CT Sinuses
Presented at ENT Governance Meeting in October 2014.
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Results:
 90% of patients having CT sinuses at RCHT have clear and appropriate
indications for this investigation
 This compares favourably when looked at against regional
benchmarking partners. No changes to practice needed
When are advanced colorectal cancer (CRC) patients fit for adjuvant
chemotherapy after surgical resection and what are the factors affecting their
fitness for postoperative chemotherapy?
Presented to Peninsula Medical School students in November 2014.
Results:
 Patients who had laparoscopic resections were fit for Adjuvant
Chemotherapy (AC) around 8 days earlier than those who underwent
open or emergency resections
 Patients who had laparoscopic surgery had longer overall survival and
cancer-specific survival over an 8-year period
 A higher percentage of patients who had open resections received AC
than those that had laparoscopic surgery.
Audit of perioperative glycaemic monitoring/control in diabetes patients
Presented at Anaesthetics Governance Meeting in October 2014.
Results:
 Governance Forum acknowledged significant obstruction to quality
diabetic care was workload and task compression for stretched nursing
teams
 Developments under way: earlier patient admission times and funded
nursing resource to admit in safe, quality fashion
TA258 (June 12) Erlotinib for the first-line treatment of locally advanced or
metastatic EGFR-TK mutation-positive non-small cell lung cancer
Presented at Oncology Audit Meeting in November 2014.
Results:
 Confirms compliance. No actions identified
Audit of trauma CT
Presented at Radiology & ED Governance meeting in December 2014.
Results:
 Radiology - Registrars to hold trauma bleep (for alert to trauma only)
decision to be confirmed
 Radiology - Improved use of trauma CT primary report and timeliness of
report
 Emergency Department to consider improvements for safe transfer of
unstable patients
Neutropenic sepsis audit/door to needle time
Presented at Oncology Audit Meeting in November 2014.
Results:
 Education drive in ED
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

Discussions with Ambulance Service regarding antibiotics being
administered pre admission
Sepsis boxes in all areas to trial hastening the process
Research and Development
The number of patients receiving NHS services provided or sub-contracted by
the Royal Cornwall Hospitals NHS Trust in 2014/15 that were recruited during
that period to participate in research approved by a research ethics committee,
was 2,586. This represents a greater than 65% increase on recruitment in
2013/14 – a massive achievement by the Research, Development and
Innovation (RD&I) team and the investigators who lead the studies.
RD&I activity contributes to patients receiving evidence based care and
improves the effectiveness of practice. Working collaboratively with the
Cornwall Partnership Foundation NHS Trust, KCCG and private providers of
healthcare in Cornwall research activity increases the standard of care, allows
opportunities for development for staff within the NHS and allows patients the
chance to receive innovative and life changing treatments that might not
otherwise have been available. These include a haemophilia patient receiving
the first ever dose of a drug in a phase 1 commercial study.
The RD&I Department continues to strengthen its ties with industry, working
directly with pharmaceutical and biotechnology companies and contract
research organisations such as Quintiles and Parexel. The increasing income
from external sources is re-invested into the RD&I team and has helped ensure
the patients who link to trials get access to the latest drugs, therapies and
medical devices. RD&I currently support over 250 open and recruiting studies,
with many more in follow up.
The graph below shows the recruitment activity this year across all RD&I
teams.
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The chart overleaf shows the recruitment by specialty area:
RD&I continues to work as a member organisation with the South West
Peninsula Clinical Research Network and works to ensure all studies are
conducted in accordance with the Department of Health’s Research
Governance Framework for Health and Social Care (2005, 2nd Ed.) and that
clinical trials involving an investigatory medicinal product are conducted in
accordance with the Medicines for Human Use (Clinical Trials) Regulations
2004 (MHRA) and subsequent amendments. Risk assessment and feasibility
are conducted at an early stage in the approvals process. Systems for
identifying delays in giving NHS permissions have been developed and RCHT
is working to a target of less than 15 days to open a study.
In the last year, with the support of partners in the South West, RD&I have
helped local researchers develop grant applications to fund a range of
innovative projects that have a direct benefit for patients at RCHT which, in
turn, will provide national guidelines for the care of patients. These projects
include the work of a Consultant Surgeon in devising a safer way to re-use
patient’s own blood instead of donated blood for gynaecological operations.
This study has been re-submitted to the grant giving body and we are hopeful
that it will be funded this year.
SUBLIME, the study developed by the breast cancer surgical team,
investigating a novel approach to anaesthetic infusion for pain and shoulder
function following mastectomy, has been extended to include patients at York
Hospital Foundation NHS Trust and is nearing its recruitment target. 140
patients have been recruited to the study so far at both sites and the team are
confident of reaching their target of 160 by the end of October.
The REACH Hear Failure (HF) team are investigating the feasibility of a homebased, nurse facilitated heart failure manual for patients with heart failure and
RCHT Quality Accounts 2014-15 V5.16
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their caregivers and have this year completed the feasibility study to assess
how the main study will run, and have started recruitment into the main trial.
Commissioning for Quality and Innovation (CQUIN)
The CQUIN framework is a national scheme that incentivises providers and
commissioners to work together to raise quality and develop innovative
approaches to healthcare provision. It does so by making a proportion of
providers’ income conditional on the achievement - or progress towards
achievement – of jointly agreed goals. These are a mixture of nationally
mandated and locally agreed quality improvement and innovation goals.
CQUIN framework 2014/15
For 2014/15, the proportion of income linked to CQUIN goals remained
unchanged at 2.5%, equal to approximately £6.5 million. Of this, about £5.5
million relates to goals set by our principal commissioner, KCCG, in
association with a number of minor commissioning bodies. The balance of
almost £1 million is attached to the goals set by NHS England, our other main
commissioner.
This year, we have had 3 nationally mandated CQUIN goals, accounting for
around 20% of the programme, a smaller proportion than in previous years.
1. The Friends and Family Test: entered its second year with a set of
more challenging targets. The scope of the test has been further
extended to cover outpatient and day case departments and also staff.
2. Safety Thermometer: whilst all the original Safety Thermometer harms
continued to be measured across the year, this year’s CQUIN goal
concentrated on just one of them – pressure ulcers, requiring us to
reduce their prevalence by 40%.
3. Dementia: as in 2013/14, the effort this year has been directed towards
embedding the FAIR process (Finding people with dementia, Assessing
and Investigating their symptoms and Referring for support) into our day
to day business.
Continuing the main theme of last year’s goals and in line with the very high
level of focus on these areas at all levels of the service, KCCG attached the
majority of its CQUIN funding to three goals aimed at improving unscheduled
and emergency care by improving patient flows through our hospitals.
NHS England continued the national dashboards programme but also included
3 goals aimed at improving patient access to public health screening
programmes, ensuring that hepatitis C patients’ therapy is optimally provided
and analysing the level and range of specialised endocrinology conditions that
our endocrinology team is called upon to treat.
Our performance against all of the CQUIN goals is shown in our scorecard
overleaf. Some of the more complex goals had paid milestones occurring
during quarters rather than at the end of quarters and many of the goals had
RCHT Quality Accounts 2014-15 V5.16
Page 32 of 77
non-numerical targets. Where this was the case, we have used simple ticks at
the quarter ends to indicate whether or not we achieved our targets in those
periods.
Royal Cornwall Hospitals NHS Trust
Q1
CQUIN SCORECARD 2014 - 2015
Yellow cells indicate paid milestones
NATIONAL
1
Q3
Q4
Patient Experience - the Friends & Family Test
1(a) Implementation of the staff FFT from April
2014 (30% of CQUIN value).
Target
1(b) Early implementation of the patient FFT in
outpatient and day case departments by 1
October 2014 (15% of CQUIN value).
Target
2(a) For acute inpatient services, achievement of
either:
1. a Q1 baseline response rate >= 25% &, by Q4,
both (a) >Q1 & (b) >=30%; or
2. maintaining a response rate >30%.
2(b) For ED, achievement of either:
1. a Q1 baseline response rate >= 15% &, by Q4,
both (a) >Q1 & (b) >=20%; or
2. maintaining a response rate >20%.
(15% of CQUIN value for 2(a) & 2(b) combined)
2
NHS Safety Thermometer
NATIONAL
3. Increase in the response rate in inpatient
services to 40% or more for the month of March
2015. (40% of CQUIN value).
40% reduction in the prevalence of pressure
ulcers, measured by the median of the last 5
months of 2014-2015 compared to the 20132014 October to March median (5.01%).
3
Dementia Awareness & Diagnosis
NATIONAL
Q2
Actual


Actual
Target
>=25%
Actual
31.8%
Target
>=15%
Actual
18.7%
>=30%
31.0%
25.5%
40.10%
>=20%
11.7%
14.3%
22.70%
Target
>=40%
Actual
52.40%
Target
<=2.7%
Actual
3.97%
3(a) i. To undertake case finding for patients
aged 75 and over, admitted as an emergency for
>72 hours, achieving a minimum of 90% of the
target cohort for each quarter taken as a whole.
Target
90%
90.0%
90.0%
90.0%
Actual
94.9%
95.6%
92.03%
98.68%
3(a) ii. To ensure that identified patients are
assessed appropriately, achieving a minimum of
90% of the patients identified in 3(a) i above for
each quarter taken as a whole.
Target
90%
90.0%
90.0%
90.0%
Actual
100%
100%
100%
100%
Target
90%
90.0%
90.0%
90.0%
3(a) iii. To ensure that a minimum of 90% of the
patients assessed at 3(a) ii are referred to
RCHT Quality Accounts 2014-15 V5.16
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specialist services, counting each quarter as a
whole.
KCCG
4
Actual
3(b) i. To confirm the lead clinician and planned
2014-2015 training programme for dementia.
3(b) ii. To deliver the 2014-2015 planned training
programme.
Target
3(c) To undertake a monthly audit of carers of
people with dementia, to test whether they feel
supported, and to report the results to the
Board.
Target
Actual
Actual
100%
100%
100%
100%
31-Mar


31-Mar


Urgent Care Specialties
4.1 Cardiology Chest Pain
Development, implementation and improved
delivery of a cardiology chest pain pathway as
documented in the CQC Action Plan.
Target
4.2 Cardiology Heart Function Pathway
Development, implementation and improved
delivery of a cardiology heart function pathway
as documented in the CQC Action Plan.
Target
4.3 ED Triage
In conjunction with the Acute GP Service,
development and implementation of shared
pathways.
Target
4.4 Neurology Headache Pathway
Development, implementation and improved
delivery of a Neurology Headache Pathway as
documented in the CQC Action Plan.
Target
4.5 Respiratory Pathway
Development, implementation and improved
delivery of a Respiratory Pathway as
documented in the CQC Action Plan.
Target
KCCG
Frailty Pathway
Development, implementation and improved
delivery of a Frailty Pathway as documented in
the CQC Action Plan.
6
CQC Action Plan
KCCG
5
7.1 Estimated Date of Discharge (EDD)
Increasing the proportion of patients with an
EDD and improving compliance in terms of
discharges on or before EDDs.
7.2 Timely Discharges
Increase % of (a) RCHT medical ward discharges
RCHT Quality Accounts 2014-15 V5.16
Actual
Actual
Actual










Actual
Actual









Target
Actual
Target
Actual
Target
Page 34 of 77
7
Quarter 1 Mediation Arrangement
KCCG
before 1pm and (b) home transport bookings at
least the day before, to 30% in both cases.
Patients' Records
Audit compliance with the CQC Action Plan
standards of (a) the delivery of nursing
observations (incl. care rounds) and (b) records
security and confidentiality.
To implement the routine use of clinical
dashboards in
- Radiotherapy
- Renal Replacement Therapy
- Cystic Fibrosis
- Haemophilia
- Neonatal Intensive Care
9
Endocrinology
Establish a working group to (a) audit
identification of specialised endocrinology in
OPD (b) generate proposals for coding solutions
(c) pilot a process for OP diagnostic coding in
Specialised Endocrinology.
NHSE
10
NHSE
11


50%
achieved
50%
achieved
Target
Actual

Target
No
target
set
Quality Dashboards
NHSE
NHSE
8
Actual
No
target
set

Actual

Target
Actual

Target
No
target
set


Public Health Screening Programmes
Ensure screening is accessible to all within the
eligible population and reduce the potential for
health inequalities.

Actual

Hepatitis C MDT
Target
Ensure that 85% of patients receiving therapy for
hepatitis C are discussed at MDT.
Actual

How the NHS regulator, the Care Quality Commission, views the quality
of our services
Registration with the Care Quality Commission Essential Standards of
Quality and Safety
The Royal Cornwall Hospitals NHS Trust is required to register with the Care
Quality Commission and its current registration status is unconditional.
RCHT Quality Accounts 2014-15 V5.16
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
The Care Quality Commission has not taken any enforcement action against
the Royal Cornwall Hospitals NHS Trust during 2014/15.
The Trust is currently rated as ‘requires improvement’ following the Care
Quality Commission’s (CQC) planned review visit in January 2014. Following
closure of the Trust’s action plan the Trust is anticipating a follow up visit by the
CQC in 2015/16.
Care Quality Commission Planned Review Visits
The Trust received a routine planned visit from the CQC in January 2015 as
part of the CQC’s review of Safeguarding and Looked After Children Services.
This was an overarching review of all health and social care providers in
Cornwall. As the lead organisation KCCG co-ordinated the visit. A copy of the
report has not been received in time for the production of these accounts.
NHS provider periodic review
The CQC did not visit the Trust in 2014/15 as part of its periodic review
programme.
Data Quality
The Data Quality Strategy has now been merged with the Records
Management Strategy and has been renamed as The Records, Information and
Data Quality Strategy. The Strategy is currently with a variety of appropriate
groups and individuals for consultation. The Board continues to receive
assurance on data quality through the Trust’s Integrated Governance and
Assurance Framework. The Data Quality Assurance Committee continues to
meet and report to the Information Governance Committee where the Data
Quality Dashboard is discussed. It was noted that a number of critical clinical
systems had been reporting a high level of good data quality and the Records
Services, PAS & Data Quality Manager reported that a review of their criteria
was to take place with those Information Asset Owners to agree a new sub-set
of criteria to manage within their systems. Areas are still being highlighted
where improvement needs to be made, and this is largely within the inpatient
setting in the Patient Administration System and Real Time Bed Management
recording. All Information Asset Owners provided risk assessments on their
systems for 2014, in preparation for the Information Governance Toolkit review.
The Royal Cornwall Hospitals NHS Trust submitted records during 2014/15 to
the Secondary Uses service for inclusion in the Hospital Episode Statistics
which are included in the latest published data. The percentage of records in
the published data which included the patient’s valid NHS number was:
 99.7% for admitted patient care
 99.9% for outpatient care
 97.4% for accident and emergency care
The percentage of records in the published data which included the patient’s
valid General Medical Practice Code was:
 98.7% for admitted patient care
 98.8% for outpatient care
 99.4% for accident and emergency care
RCHT Quality Accounts 2014-15 V5.16
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Information Governance Toolkit attainment levels
The Royal Cornwall Hospitals NHS Trust Information Governance Assessment
Report overall score for 2014/15 was 73% and was graded Green.
Clinical Coding Error Rate
The Royal Cornwall Hospital NHS Trust was not subject to a Payment by
Results (PbR) clinical coding audit during the reporting period by the Audit
Commission.
The Trust undertook an annual clinical coding Information Governance Audit
(IG toolkit 505). Results of this audit showed an improvement in primary &
secondary diagnosis coding accuracy compared to the 2013/14 IG clinical
coding audit. Primary procedure coding accuracy had also improved.
%Coded Accurately
Primary
Diagnosis
Secondary
Diagnosis
Primary
Procedure
Secondary
Procedure
% Coder
Error
2014/15
2013/14
2014/15
2013/14
93%
90.5%
6%
91.4%
90.7%
96.6%
96.4%
% Non-Coder Error
IG
Level
2014/15
2013/14
2014/15
2013/14
8%
1%
1.5%
IG Level 2
IG level 2
7.6%
8.1%
1%
1.2%
IG Level 3
IG level 3
96.4%
3.4%
3.6%
0%
0%
IG Level 3
IG level 3
95.3%
2.5%
3.4%
1.1%
1.3%
IG Level 3
IG level 3
All recommendations from the 2014/15 IG clinical coding audit have been
followed-up and actioned.
National Quality Indicators.
Where possible the national data reflects acute trusts only.
The value and banding of the summary hospital-level mortality indicator (“SHMI”)
for the trust
April 2013 – March 2014
July 2013 – June 2014
National Data
National Data
RCHT
RCHT
average lowest highest
average
lowest highest
1.08
1.06
1.00
0.54
1.20
(Band 2 ‘as 1.00
0.54
1.20
(Band 2 ‘as
expected’)
expected’)
The percentage of patient deaths with palliative care coded at either diagnosis or
specialty level for the trust
April 2013 – March 2014
July 2013 – June 2014
National Data
RCHT
National Data
RCHT
average lowest highest
average
lowest highest
23.9
0
48.5
24.1
24.8
0
49
24.9
The Royal Cornwall Hospitals NHS Trust considers that this data is as
described for the following reasons:
 The data is validated nationally, and
 Correlates with the Trust’s internal data
RCHT Quality Accounts 2014-15 V5.16
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The Royal Cornwall Hospitals NHS Trust has taken the following actions to
improve this score and so the quality of its services, by continuing to review
both national and local mortality data ensuring that appropriate actions are
taken where indicated. For further information please refer to page 14.
The trust’s patient reported outcome measures scores for groin hernia
surgery – EQ-5D adjusted average health gain (finalised data)
April 2011 – March 2012
April 2012 – March 2013
National Data
National Data
RCHT
RCHT
average lowest
highest
average
lowest
highest
0.087
-0.002
0.143
0.072
0.085
0.014
0.153
0.101
The trust’s patient reported outcome measures scores for varicose vein
surgery – Aberdeen Varicose Vein Score adjusted average health gain (lower
scores are better) (finalised data)
April 2011 – March 2012
April 2012 – March 2013
National Data
RCHT
National Data
RCHT
average lowest
highest
average
lowest
highest
-7.896
-1.092
-13.799 -8.158
-8.426
5.174
-16.188
-9.551
The trust’s patient reported outcome measures scores for hip replacement
(primary) surgery – Oxford Hip Score adjusted average health gain (finalised
data)
April 2011 – March 2012
April 2012 – March 2013
National Data
National Data
RCHT
RCHT
average lowest
highest
average
lowest
highest
20.077
15.2
23.919 20.149 21.299
17.219
24.689 19.910
The trust’s patient reported outcome measures scores for knee replacement
(primary) surgery – Oxford Knee Score adjusted average health gain
(finalised data)
April 2011 – March 2012
April 2012 – March 2013
National Data
National Data
RCHT
RCHT
average lowest
highest
average
lowest
highest
15.148
11.0
19.582 16.283 15.996
12.461 20.444
15.880
The Royal Cornwall Hospitals NHS Trust considers that this data is as
described for the following reasons:
 The data is validated nationally, and
 Correlates with the Trust’s internal data
The Royal Cornwall Hospitals NHS Trust has taken the following actions to
improve this score and so the quality of its services, by ensuring all PROMS
data is reviewed by the relevant specialties and participating clinicians.
The percentage of patients aged 0 to 15; readmitted to a hospital which
forms part of the trust within 28 days of being discharged from a hospital
which forms part of the Trust.
April 2010 – March 2011
April 2011 – March 2012
National Data
National Data
RCHT
RCHT
lowest average
lowest
average lowest average
lowest average
10.15*
0.00
10.15*
0.00
10.15*
0.00
10.15*
0.00
RCHT Quality Accounts 2014-15 V5.16
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The percentage of patients aged 16 or over; readmitted to a hospital which
forms part of the trust within 28 days of being discharged from a hospital
which forms part of the Trust.
April 2010 – March 2011
National Data
average lowest average
11.42*
0.00
11.42*
RCHT
lowest
0.00
April 2011 – March 2012
National Data
average
lowest average
11.42*
0.00
11.42*
RCHT
lowest
0.00
The data for the above national indicator has not been refreshed on the HSCIC
indicator portal since December 2013 and therefore remains the same as the
information provided in the Trust’s 2013/14 Quality Accounts.
The Royal Cornwall Hospitals NHS Trust considers that this data is as
described for the following reasons:
 The data is validated nationally, and
 Correlates with the Trust’s internal data
The Royal Cornwall Hospitals NHS Trust intends to take the following actions
to improve this score and so the quality of its services, by working together with
the Cornwall Health and Social Care community to reduce hospital
readmissions.
*National average for all NHS Trusts in England. Lowest and highest figures relate to acute
Trusts only.
The trust’s score with regard to its responsiveness to the personal needs
of its patients. Indicator based on data from National In-patient Survey
2012-13
2013-14
National Data
National Data
RCHT
RCHT
average lowest highest
average
lowest highest
76.5
68.0
88.2
76.2
76.9
59.0
87.0
76.7
The Royal Cornwall Hospitals NHS Trust considers that this data is as
described for the following reasons:
 The data is validated nationally, and
 Correlates with the Trust’s internal data
The Royal Cornwall Hospitals NHS Trust intends to take the following actions
to improve this score and so the quality of its services, by listening and acting
upon all patient feedback.
Please refer to page 57 for further information.
The percentage of patients who were admitted to hospital and who were
risk assessed for venous thromboembolism.
July – September 2014
National Data
average lowest highest
96
86.4
100.0
RCHT
98.3
October – December 2014
National Data
average
lowest highest
96
81
100
RCHT
98
The Royal Cornwall Hospitals NHS Trust considers that this data is as
described for the following reasons:
 The data is validated nationally, and
RCHT Quality Accounts 2014-15 V5.16
Page 39 of 77
 Correlates with the Trust’s internal data
The Trust maintained its performance against this indicator between January
and March 2015.
The Royal Cornwall Hospitals NHS Trust has taken the following actions to
improve this score and so the quality of its services, by continuing to ensure all
our patients are risk assessed on admission, including targeted action where
performance is below 100%. The EMPA system includes a mandatory VTE risk
assessment.
The rate per 100,000 bed days of cases of C.difficile infection reported
within the trust amongst patients aged 2 or over
April 2012 – March 2013
April 2013 – March 2014
National Data
National Data
RCHT
RCHT
average lowest highest
average
lowest highest
17.4
0
31.2
12.2
14.7
0
37.1
18.8
The Royal Cornwall Hospitals NHS Trust considers that this data is as
described for the following reasons:
 The data is validated nationally, and
 Correlates with the Trust’s internal data
During 2014/15 the Trust reported 30 cases of C-Difficile infection against an
agreed tolerance of 35. 13 of these have been considered potentially avoidable
following review with KCCG.
The Royal Cornwall Hospitals NHS Trust intends to take the following actions
to improve this score and so the quality of its services, by continuing to review
antibiotic prescribing by hospital doctors.
Please refer to page 49 for further information.
The number of patient safety incidents reported within the trust
April 2013 – September 2013
October 2013 – March 2014
National Data
National Data
RCHT
RCHT
average lowest highest
average
lowest highest
3371
91
11573
4488
3567
119
12152
4394
The rate of patient safety incidents reported within the trust
April 2013 – September 2013
October 2013 – March 2014
National Data
National Data
RCHT
RCHT
average lowest highest
average
lowest highest
7.7
3.5
27.9
7.5
8.3
1.2
32.9
7.4
The number of such patient safety incidents that resulted in severe harm
or death.
April 2013 – September 2013
October 2013 – March 2014
National Data
National Data
RCHT
RCHT
average lowest highest
average
lowest highest
19
0
106
23
19
0
103
29
RCHT Quality Accounts 2014-15 V5.16
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The percentage of such patient safety incidents that resulted in severe
harm or death.
April 2013 – September 2013
October 2013 – March 2014
National Data
National Data
RCHT
RCHT
average lowest highest
average
lowest highest
0.56
0
0.92
0.51
0.53
0
0.85
0.66
The Royal Cornwall Hospitals NHS Trust considers that this data is as
described for the following reasons
 The data is validated nationally, and
 Correlates with the Trust’s internal data
For the period April to September 2014 the Trust reported 4,574 patient safety
incidents to the National Reporting and Learning System (NRLS), 31 of which
resulted in serious harm or death.
The Royal Cornwall Hospitals NHS Trust intends to take the following actions
to improve this score and so the quality of its services, by continuing to
encourage a reporting and learning culture within the organisation.
The percentage of staff employed by, or under contract to, the trust
during the reporting period who would recommend the trust as a
provider of care to their family or friends.
2013
2014
National Data
National Data
RCHT
RCHT
average lowest highest
average
lowest highest
67
40
94
43
67
38
93
38
The Royal Cornwall Hospitals NHS Trust considers that this data is as
described for the following reasons
 The data is validated nationally, and
 Correlates with the Trust’s internal data
The Royal Cornwall Hospitals NHS Trust intends to take the following actions
to improve this score and so the quality of its services, by continuing with our
Listening into Action initiative and improving the health and wellbeing of our
staff.
The Trust notes the low scores on this important indicator.
Please refer to page 15 for further information.
RCHT Quality Accounts 2014-15 V5.16
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The Trust’s percentage who would recommend from a single question
survey which asks patients whether they would recommend the NHS
service they have received to friends and family who need similar
treatment or care
Inpatient Friends & Family Test
February 2015
March 2015
National Data
RCHT
National Data
RCHT
average lowest highest
average
lowest highest
95
82
100
96
94
51
100
95
Emergency Department Friends & Family Test
February 2015
March 2015
National Data
RCHT
National Data
RCHT
average lowest highest
average
lowest highest
88
53
100
87
88
55
98
88
The Royal Cornwall Hospitals NHS Trust considers that this data is as
described for the following reasons
 The data is validated nationally, and
 Correlates with the Trust’s internal data
The Royal Cornwall Hospitals NHS Trust intends to take the following actions
to improve this score and so the quality of its services by responding to the
themes identified by our patients.
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PART THREE – REVIEW OF THE TRUST’S QUALITY PERFORMANCE
Patient Safety
Venous Thrombo-Embolism (VTE) exemplar centre status
The Thrombosis Prevention and Anticoagulation Steering Committee (TPAS)
led by Dr Desmond Creagh, Consultant Haematologist and Trust VTE lead,
and with membership representation from all clinical specialties, is responsible
for the development and implementation of policy and guidelines for the
prevention and management of confirmed VTE at RCHT. The work of the
TPAS committee has ensured that an Anticoagulation/Thrombosis policy and
process for systematic VTE risk assessment and thrombo-prophylaxis
prescribing has been in place at the Trust since 1998. In 2000 the Lead
Thrombosis Nurse Practitioner initiated a rapid access clinic for the outpatient
diagnosis and management of Venous Thrombo-embolic disorders which has
in turn led to the development of a dedicated Anticoagulation and Thrombosis
Nursing Team.
Over the last 2 years the Thrombosis Nursing Team at RCHT has greatly
expanded its remit in order to address nationally recognised issues of VTE
care. There has been a drive to improve education in VTE prevention across
the Trust with VTE awareness now included in all mandatory training,
corporate induction and other training for key clinical staff. Since July 2013 and
in line with national reporting requirements, data on all VTE events at RCHT
has been collected to identify cases of Hospital Acquired Thrombosis (HAT).
Root Cause Analysis is completed in all cases with those identified as possibly
preventable HAT escalated to individual clinical teams for further investigation
with the support of the Thrombosis Practitioner. The learning outcomes of
these incidents are fed back to clinical teams and incorporated into education
sessions for staff to improve clinical care.
In 2013 the Electronic Prescribing and Medicines Administration (EPMA)
system was introduced to RCHT and from March 2014 VTE risk assessment
has been a mandatory process within the EPMA system. Mandatory electronic
VTE risk assessment has driven compliance within initial risk assessment to
98% and levels of 24 hour assessment to almost 90%. Data analysis of EPMA
has led to the development of real-time conflict reporting allowing the ward and
clinical teams to be supplied with daily e-reports outlining errors or conflicts in
VTE prophylaxis prescribing.
The Thrombosis Nursing Team have developed an electronic patient record for
patients with Cancer Associated Thrombosis and have worked closely with the
local Clinical Commissioning Group to implement a community/GP VTE
screening pathway for suspected Deep Vein Thrombosis (DVT) which has
greatly improved the patient journey. Currently in development is a Nurse-led
rapid response pathway for the administration of anticoagulation reversal
treatments and a VTE prevention self-assessment tool is also being piloted at
RCHT for patients who require plaster cast following lower limb injury.
The Thrombosis team at RCHT have presented at both national and
international conferences and in October 2014 supported the inaugural
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International Society on Thrombosis and Haemostasis (ISTH) World
Thrombosis Day with an interactive patient and public display within the
hospital.
As a result of the Trust’s on-going commitment to patient safety and in
recognition of the work undertaken in the delivery of effective, hospital wide
thrombo-prophylaxis and VTE prevention a submission was made to the VTE
prevention England programme for the Trust to be considered as a potential
VTE exemplar site. Following a rigorous assessment process by members of
VTE prevention England and VTE specialists from Plymouth Hospitals NHS
Trust the Royal Cornwall Hospitals Trust was awarded exemplar site status in
October 2014, joining only 21 other Trusts nationwide to be granted this
accolade.
Further information regarding the VTE prevention England programme and
VTE Exemplar Centres can be found at: http://www.vtepreventionnhsengland.org.uk/
RCHT staff and VTE Prevention England visiting team (from L-R) Obaid Kousha, F1 VTE link, Huw Rowsell, VTE CNS
Derriford Hospital,
Dr Julie Blundell, Consultant Haematologist, Professor Roopen Arya, Clinical Lead National VTE prevention programme,
Andrew McSorley, VTE CNS/Thrombosis Practitioner, Vikki Murphy, VTE link nurse SMH, Paul Upton, Director of
Transformation, Susie Matthews, Specialist Pharmacist, Carrie Dinning , Anticoagulation Nurse/DVT clinic manager, Dr Tim
Nokes, Consultant Haematologist/VTE Lead Derriford, and Helen Morrison, National VTE prevention programme manager.
RCHT Quality Accounts 2014-15 V5.16
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The patient blood management (PBM) programme/ blood conservation
service.
Blood transfusions using blood from a donor (allogeneic transfusion) carry risks
to patients and are costly. It is therefore desirable to seek transfusion
alternatives.
In 2003 a patient blood management (PBM) programme was introduced at
RCHT within elective orthopaedic surgery. The introduction of peri-operative
cell salvage (PCS), pre-assessment of patients, optimising pre-operative
haemoglobin (Hb) levels and the refining of transfusion guidelines constituted
elements of the programme.
Cell salvage involves the collection of a patient’s own blood during an
operative procedure which is then treated ready for transfusion back to the
patient if required (autologous blood transfusion). Optimisation or maximisation
of the haemoglobin in the blood is achieved through administration of iron or
Darbepoetin, a drug that increases red blood cell levels and is used to treat
anaemia (low haemoglobin levels).
Data on all primary hip arthroplasties was collected from March 2005 to
November 2012 to evaluate the impact of the patient blood management
programme. A statistical analysis was completed which demonstrated that age,
pre-operative Hb and use of PCS showed a reduction for the need of
allogeneic blood transfusions. In conjunction with this the patient’s general
health status, age, gender and requirement of a blood transfusion would
directly affect the length of stay in hospital. 7 years after the introduction of the
programme in 2005, allogeneic transfusion rates dropped to 5% and overall
average length of stay reduced to 5.7 days (previously 9.8).
A reduction in transfusion rates for orthopaedic surgery has been achieved as
a result of the evolution of the blood management programme and meticulous
surgical techniques. The PBM programme has included the introduction of preoperative optimisation of patients Hb, increased use of PCS and education
around restrictive transfusion triggers and providing transfusion alternatives.
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Development of PCS use and transfusion rates.
Length of hospital stay (days)
ABT – Allogeneic (donor blood) blood transfusion
Obstetrics has embraced patient blood management for all women who deliver
in Cornwall and at the Royal Cornwall Hospital (RCH). This includes treating
antenatal anaemia, the routine use of intra-operative cell salvage during
Caesarean section, multidisciplinary education of transfusion triggers and
alternatives to blood transfusion. The national average for transfusion of blood
to women in maternity is 3%. In 2013 the Trust transfused 0.8% of women who
delivered in Cornwall. RCH is considered one of the leading centres in
obstetric cell salvage. This reputation assisted in the award of the NIAA
(National institute of Academic Anaesthesia) grant to support research in the
innovative use of cell salvage in the delivery suite. This work is now completed
and access to the publication is currently on line, as referenced overleaf:
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http://dx.doi.org/10.1016/j.ijoa.2014.12.001
Other specialties also use blood conservation strategies. A patient with
anaemia who has a surgical procedure is more likely to require a blood
transfusion therefore all surgical patients can benefit from pre-operative
haemoglobin optimisation. Certain surgical specialties also request the use of
autologous cell salvage/infusion during procedures. General enquiries and
advice for blood conservation come from both medical and surgical areas.
Data shows that there is a notable beneficial effect on patient experience and
quality of care. The average length of stay per patient is reduced by nearly 3
days when compared to patients who have an allogeneic blood transfusion.
The fact that patients can go home sooner is good for them psychologically
and good for others as the Trust can treat more patients (it has to be said that
for the Trust there is also a cost saving per patient).
Optimisation of patients’ haemoglobin levels helps to reduce the need for a
blood transfusion. Use of intra-operative cell salvage means patients suffer
considerably fewer complications should they need a blood transfusion as they
will be, certainly initially, transfused with their own blood. In consequence, the
risk of infection is minimal; as it is the patient’s own blood that they are being
given there is no risk of rejection by the patient’s body; because the patient
receives their own blood back, if it is needed, then they heal more quickly as
the body is not compensating for the foreign cells introduced during an
allogeneic transfusion (even with blood cross matching).
Human Factor Training Initiative
In the last few years the reporting and investigation of incidents throughout the
organisation has dramatically improved and has been supported by the
implementation of processes to facilitate this. This activity has enabled us to
identify themes / root causes that underlie our incidents. Within the Surgical
Division our analysis clearly revealed that human error in the course of routine
operating lists was a significant theme despite the implementation of pathways
such as the WHO checklist designed to reduce this. We recognised that to
address this problem we needed to tackle behavior change and promote a
safety culture alongside our protocols and pathways.
We have therefore embarked on a Human Factors (HF) training programme for
all theatre staff: nurses, doctors and managers. The package is being delivered
by an external provider with experience in providing Human Factor training to
the maritime, airline and healthcare industries. We have worked with the
provider to customize the “standard package “of teaching material to our
specific needs which have been identified by our incident themes. The
programme is as follows:
 A half-day Human Factors training package to be delivered during Trust
governance half days to selected theatre groups/ surgical teams
o 5 training workshops to be delivered over 5 months, this amounts
to 50 staff trained each month during the Trust ‘governance’
sessions. Followed by  A series of in-theatre observation and debrief sessions by HF experts
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
o Knowledge of concepts introduced during the workshops is
reinforced during in-theatre team-based sessions over the next 3
weeks. 2 full days of observations allow for 4 clinical areas to be
observed for half a day each
In this manner, the majority of staff in all clinical areas would receive a
half-day training session and at least one observed in-theatre session
The training has begun and is just under halfway through. We have found that
feedback is predominantly very positive, and predictably, we have also
identified groups / individuals who are more resistant to the concept.
In the second half of the programme we intend to identify champions who will
ultimately form a Human Factors working group. Their role will be to continue
the training in the longer term throughout the organisation as we recognise that
this culture change is a long-term project that will require on-going momentum.
Critical Care Outreach Team development
A CQC visit in January 2014 highlighted the outreach service as inadequate. At
this time the service was delivered by a very experienced, highly qualified
nurse during the Monday to Friday period, 7.5 hours per day, day time hours
only. The service provided enabled the review of critical care discharges and
emergency referrals but was not robust or resilient due to the lack of allocated
staff resource. As an organisation we were requested to develop the service to
provide robust delivery of the service and support for the care of the
deteriorating patient outside the critical care area.
A business plan was agreed and during January 2015, three senior staff
nurses were employed into the role of critical care outreach. The current
service now has 2.72 Whole Time Equivalent (WTE) nurses at band 6 in
addition to the existing 1 WTE band 8, who is instrumental in the development
of skills and knowledge within this team. This has enabled the service to be
extended to cover seven days per week, 07.30 am to 19.30 pm. The overnight
service is provided by the hospital at night team with a robust handover both
written and verbal of all at risk patients. The critical care outreach team then
attend the medical meeting at 08.00am to receive information regarding
patients at risk who would benefit from critical care review during the coming
day.
The expansion of the service has seen the number of patients referred for
review increase from 22 in March 2014 to 69 in March 2015, an increase of
over 200%. The number of referrals has increased the most in medicine, 8
during March 2014 to 34 during March 2015. This is linked to an increase in
the number of critical care outreach interventions from 42 in March 2014 to 102
in March 2015. Again this has led to a positive increase in the number of
patients who are managed by the referring teams with the support of critical
care outreach without the need for admission to critical care from 42 during
March 2014 to 73 during March 2015.
The follow up of patients discharged from critical care was always included in
the critical care outreach plan, to ensure that deterioration did not occur
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following transfer back to the general ward areas. A significant increase in the
number of follow-up reviews had been enabled by the increase in the outreach
team with 106 reviews performed during March 2015 against 68 during March
2014 before the team increased in size. The service has also been able to
support 17 intra hospital transfers in March 2015 in comparison to 2 in March
2014. The support of the acutely ill patient in areas outside the critical care unit
is the focus of the team with data collected on the levels of care for patients
reviewed, again this has shown a positive increase, in March 2014 47 level 1
patients and 20 level 2 patients were supported by the outreach team, in March
2015 this had significantly risen to 129 level 1 patients and 48 level 2 patients.
Level 1 patients are at risk of their condition deteriorating, or have been
recently relocated from higher levels of care, whose needs can be met on an
acute ward with additional advice and support from the critical care team.
Level 2 patients require more detailed observation or intervention including
support for a single failing organ system or post-operative care or may have
'stepped down' from higher levels of care.
The extended outreach service has been in place for three months. The figures
clearly show an increase in outreach activity, with more patients being
supported within the ward environment without admission to the critical care
unit. In March 2015 73% of level two patients were successfully managed on
the ward area without CCU admission in comparison to 65% March 2014.
In order to continue the support of patients on the ward environment, the
outreach team intend to extend their teaching remit, offering short sessions
and workshops to ward staff. The team will also be able to expand the ability to
identify and respond to the psychological needs of patients discharged from
CCU.
The Trust Development Authority visit in February 2015 identified the improved
service but highlighted the need to go further to ensure the provision of a 24/7
service. The development of a robust handover system will move us towards a
seamless transfer of service between the critical care outreach team and
hospital at night. This will ensure there is effective 24/7 service for critically ill
patients within the ward environment.
Clinical Effectiveness
Antibiotic Stewardship
The latest RCHT antibiotic prescribing audit (22/02/2015 - 28/2/2015) showed
a further improvement, with 88% of antibiotic course prescriptions documenting
the clinical indication and 82% including a review or stop date. This latest data
is further evidence of a continuing improvement in compliance with these
standards over the past financial year. Further improvement is expected and
the current close audit, feedback and performance management process is
continuing as follows:
 Doctors who prescribe at least three antibiotic prescriptions in an audit
week receive an individual message with their own figures
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




All prescribers meeting the Trust standard (95% compliance with both
indication and stop or review date) are entered into a regular prize draw
Each Specialty Lead receives their Specialty's audit results listed by
individual doctor, and their Specialty's grouped score benchmarked
against a specialty league table
Specialty Leads (directly or via Clinical Supervisors) are asked to
address individual doctors' performance where necessary, and address
the result for their specialty as a whole
Antibiotic stewardship awareness sessions are convened for those
prescribers with the poorest audit results. The purpose is to reinforce
individual accountability, improve awareness of the serious local and
global context, and to learn of doctors' uncertainties or barriers to
complying with this
Doctors with the poorest antibiotic stewardship audit results who have
also appeared on a previous list are sent an email expressing concern
about their antibiotic prescribing. They are expected to speak with their
educational and/or clinical supervisor and attend a stewardship session.
The letter is copied to the doctor's educational and clinical supervisor,
and divisional director or governance lead
A Trustwide audit in December found 100% compliance with the restricted
antibiotic policy across all Divisions, and 99% compliance with antibiotic
guidance. Less encouraging is that only 76% of patients had a documented
antibiotic plan at 48 hours after starting treatment, and 11% still had no
evidence of review/plan by 72 hours. This result has been circulated to all
consultants as part of the continuing Trustwide Start Smart and Focus
initiative.
Total antibiotic consumption (measured as defined daily doses per 100
occupied bed days) declined year-on-year for the 3 years to end of 2013/14,
with a 16% decrease across the 3 years in total and a 5% decrease between
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2012/13 and 2013/14.
The RCHT antimicrobial audit programme exceeds the minimum standards set
out in the Start Smart Then Focus November 2014 publication (Antimicrobial
Stewardship Toolkit for English Hospitals) and based on this new guidance, the
audit programme will be revised to include a focus on duration and switching
from IV therapy and antimicrobial usage in peri-operative prophylaxis. The
Trust has completed the antimicrobial self-assessment toolkit and is compliant
with the following domains: antimicrobial management; risk assessment for
antimicrobial chemotherapy; operational delivery of antimicrobial strategy;
antimicrobial pharmacist; clinical governance assurance. An action plan is in
place to address areas requiring further development.
In response to the Department of Health and Department of Environment,
Food & Rural Affairs (DEFRA) UK five year antimicrobial resistance (AMR)
strategy, a multi-agency Cornwall Antimicrobial Resistance Group has been
established.
Acute Kidney Injury
Acute Kidney Injury (AKI) is now recognised as an important global healthcare
issue. AKI can occur in patients with acute illness who also have complex
health care issues, such as those with long term medical conditions, or patients
using certain medications. Around one in five emergency admissions into
hospital are associated with acute kidney injury (Wang et al, 2012), and up to
100,000 deaths in secondary care are associated with acute kidney injury. In
25-33% of patients with AKI it is possible that the causes of their AKI could
potentially have been prevented (National Confidential Enquiry into Patient
Outcome and Death Adding Insult to Injury 2009. Dr Steve Dickinson and Dr
Paul Johnston were study advisors in this enquiry).
The Trust’s renal team have been at the forefront of developing hospital AKI
services. The Trust cares for approximately 300 patients each month with AKI.
Since 2012 the renal team have worked closely with the clinical chemistry
department to identify in real time patients suffering from AKI in hospital. The
Trust is also working to introduce the new national biochemistry AKI
identification algorithm.
The importance of AKI has now been recognised in a national CQUIN. The
CQUIN focuses on the diagnosis and treatment of AKI. RCHT is developing a
strategy to enable us to successfully meet this CQUIN, and in doing so
improve care of patients with AKI.
An AKI Care Bundle was introduced in 2014, highlighting the essential factors
to consider when treating patients with AKI. This bundle compliments the
existing AKI guidelines (available on mobile and desktop devices), the
Hyperkalaemia management guidelines, and the Avoiding Contrast
Nephrotoxicity guidelines. Work is also underway to streamline identification of
patients at risk of AKI during admission clerking.
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The Trust’s renal team will also be presenting recent work at national and
international conferences in 2015 describing two projects led by Dr Rob Parry;
Identification of risk factors for Acute Kidney Injury (AKI) in patients admitted to
hospital as a medical emergency: Single centre observational study and An
Acute Kidney Injury Education Project reaching from secondary care to primary
care. The Trust has also been at the forefront of assessing the prevalence of
AKI in primary care, and reaching to primary care to highlight its importance
and to try to reduce its incidence.
Cornwall Bowel Cancer Screening Programme
The Cornwall Bowel Cancer Screening Team consists of 5 Specialist
Screening Practitioners, 6 Screening Colonoscopists and an Administration
Team together with Specialist Approved Radiologists and Pathologists.
Colorectal cancer is a major health problem in the UK with about 13,000
people dying per annum with an over-all five year survival rate of about 50%.
Since 2009 Cornwall has had a faecal occult blood test (FOBt) Bowel Cancer
Screening Programme in which individuals aged 60 – 74 are offered a stool
test. If the stool test is positive for blood they proceed to colonoscopy with a
view to early detection of colorectal cancer or colonic polyps which may
precede colorectal cancer.
Overall the uptake is in the region of 60% with 1.9% of individuals testing
positive for blood in the stool. Last year 54,879 people were invited for
screening. Currently the detection rate for colorectal cancer is in the region of
7% (31 new cases) for those who have a positive stool test with a further 45%
being found to have pre-malignant colonic polyps.
Screening Clinics take place in Bodmin, St. Austell, Truro and Penzance.
Colonoscopy is performed in Penzance, Truro and Bodmin Hospitals. A total of
5 colonoscopy lists on average are required a week. Approximately 900
individuals a year undergo screening colonoscopy or CT colonography to a
high standard and quality.
There were 3 adverse incidents post colonoscopy (post polypectomy bleed)
with no interventions required. The last Quality Assurance (QA) visit was in
November 2012. All key performance indicators were met and the service was
commended for “a hardworking, well integrated team delivering a high level of
service”. In addition the Quality Assurance Team was “impressed by the
dedication and the commitment shown by all staff”. The next QA visit is due in
late 2015/early 2016.
In March 2015 approval was given to commence the Bowel Scope
Programme. This is an adjunct to the existing screening programme, in which
all 55 year olds in Cornwall will be offered a single one off flexible
sigmoidoscopy with a view to early polyp detection. Both programmes have
been proven to be effective in reducing the incidence of colorectal cancer and
the long-term mortality from colorectal cancer.
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The Cornwall Bowel Cancer Screening Service has consistently met all key
performance indicators regarding timeliness and quality of service. Screening
for colorectal cancer has led to earlier detection of colorectal cancer and in the
long-term will lead to a reduction in mortality from colorectal cancer.
Clinical Oncology (Radiotherapy)
There are in excess of 1800 new referrals to the Clinical Oncology Department
each year. A similar number of courses of radiotherapy are delivered at the
Trust on the two relatively new TrueBeam Linear Accelerators.
The department operates a no-waiting list policy so is therefore often very
busy. Below are a couple of comments from patients from earlier in the year:
‘Thank you to all at Sunrise & especially the radiographers who have been so
professional and had the expertise that make patients feel safe and reassured
YET they manage so perfectly, politely, gently (humoursouly sometimes) to
make patients feel special. Thank you too for the ‘team makers’ and the
receptionist who knew my name from day 1. It was good to realise she took
the time to smile and welcome me.’
‘Excellent service throughout.’
Clinical Oncology has been successfully operating an accredited Quality
Management System since 1996.
Over the last year, the department has undergone significant changes bringing
in new equipment and techniques. Change puts any area under pressure but
Clinical Oncology has embraced the advances in technologies and this is
reflected in the report from the auditor following the last external audit in
November who stated in his report:
‘there has been a significant leap in technology in radiotherapy and the
department at the Royal Cornwall Hospital is noticeably ahead in the delivery of
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high standard complex radiotherapy with staff able and willing to take on further
responsibilities to continually improve pathways which meet and exceed breach
targets with staff probably exceeding the expectations of their grade compared
to other centres.’
During 2014/15, no non-conformances were identified by the external auditor.
This can be attributed to the dedication of the teams working across Clinical
Oncology.
Intensity Modulated Radiotherapy Therapy (IMRT) is a high precision form of
radiotherapy. The radiation shape and dose is taylored precisely to the tumour
volume. This reduces the amount of radiation received by healthy tissue and
maximises the dose to the tumour. IMRT goes hand in hand with Image
Guided Radiotherapy (IGRT). IGRT enables three dimensional images to be
taken at point of treatment delivery to ensure millimetre accuracy of the
treatment is achieved. It has only been possible to deliver these advanced
techniques with modern equipment. The Trust took delivery of its first
TrueBeam linear accelerator in 2012. Following a comprehensive
commissioning programme, this machine became clinical in August 2012 with
the department delivering its first IMRT treatment in December 2012. A second
TrueBeam went clinical in August 2014; this has enabled the department to
increase the amount of IMRT it delivers and provides a robust continuity of
service.
The Department of Health target for IMRT was set at 24%. Due to the
complexity of IMRT, RCHT planned to achieve this target by the end of 2013.
This figure was in fact achieved in August 2013, well ahead of the predicted
date, and has been exceeding this target ever since. RCHT now boasts a
rolling average in excess of 30%.
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Volumetric Arc Therapy (VMAT) is a type of IMRT without treatment beam
angles. As the gantry arcs around the patient the beam is modulated. The
gantry speed, multi-leaf collimator shapes and the dose rate change
dynamically and are used to control the intensity of the beam. This technique
involves shortened treatment times meaning less scope for patients movement
as well as a higher throughput of patients. This is the chosen technique for
RCHT and is currently used in only a handful of departments in the UK.
Ambulatory Emergency Care Unit (AEC)
The AEC which is co-located next to the Emergency Department (ED) was
opened on 17 November 2014. The unit has 9 assessment trollies and a
lounge with 6 comfy chairs. The acute GP service and the medical admission
team along with band 6 and band 7 nurses work as an integrated team.
The unit is open Monday to Friday with acute GP’s working from 08:30 through
to 19:00 and the band 6 and band 7 nurses and medical take team operating in
the AEC from 11:00 to 23:00.
On average the medical take over a 24 hour period ranges from 55 – 65
patients of which 40% are from GP and SERCO referrals during the week and
20% on weekend.
The aim of the unit is to provide a protected area for GP referred patients and
is co-located next to the X- ray department to provide rapid diagnostics and to
deem all medical patients ambulatory until proved otherwise. Hence only
patients that clearly need a medical admission ending up in a bed are
admitted.
Since opening in November on average 17 – 18 patients a day are seen by the
medical take team of which 53% are discharged the same day. It has also
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seen a significant improvement in our diagnostic times for both blood
investigations and x- ray imaging. 97% of patients seen in the AEC have their
x- rays performed in less than an hour, compared to roughly 35% when the
patients are admitted to the MAU where on average patients wait between 4
and 6 hours on MAU for x-rays. Blood investigations are also now processed at
the same speed as those of ED patients.
This has meant that patients being admitted as referrals from the GP are
receiving the same service whether they present at the Emergency
Department (ED) from a diagnostic and clinical review point of view; improving
equality in care.
Various pathways have been created to assist in the process which include
chest pain, pulmonary embolism, anaemia, cellulitis, hyperkalaemia,
community acquired pneumonia, COPD, heart failure, headache and first
seizure.
The unit has had very favourable friends and family feedback.
The AEC has improved not only the care but also the experience for medical
referred patients and improved the working environment for the medical take
team.
Patient Experience
National Emergency Department Survey 2014
During 2014, a questionnaire was sent to 850 people who had attended an
NHS Accident and Emergency Department (A&E) during February 2014.
Responses were received from 338 patients at Royal Cornwall Hospitals NHS
Trust.
Score
Theme
Comparison with other Trusts
8.0/10
Arrival at ED
6.2/10
Waiting times
8.1/10
Doctors and nurses
7.9/10
Care and treatment
8.2/10
Tests (answered by
those who had tests
only)
Hospital environment
8.6/10
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6.3/10
Leaving ED
8.5/10
Experience overall
The Emergency Department is developing an action plan to address the lowest
scoring issues emerging from the survey. This will include: identifying areas in
the survey that matter most to our patients in line with the RCHT Patient
Experience Strategy, ‘Listening to our patients’; connecting the results to the
Trust values, focusing particularly on working together and pride and
achievement; involving staff, central to this is clear, simple communications
and continuing the improvement work with the results from the Friends and
Family Test.
National Inpatient Survey 2014
Between September 2014 and January 2015 a questionnaire was sent to
patients who had been admitted as an inpatient during June, July or August
2014 for each NHS Trust in England. A core sample of 850 patients was
included from each Trust. Responses were received from 414 of the Trust’s
patients who were admitted during July 2014.
The Trust’s scores compared to other NHS Trusts:
Score
8.6/10
Theme
The Emergency/A&E
Department
8.1/10
Waiting list and planned
admissions
7.3/10
Waiting to get to a bed on a
ward
8.0/10
The hospital and ward
8.6/10
Doctors
8.3/10
Nurses
7.6/10
Care and treatment
8.4/10
Operations and procedures
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Comparison with other Trusts
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7.3/10
Leaving hospital
5.4/10
Overall views of care and
services
8.0/10
Overall experiences
Each score is based on a series of questions; 60 in total. Of these
 26 scores have increased (43%) – one significantly
 10 scores have remained the same (17%)
 22 scores have decreased (37%) – two significantly
 2 (3%) questions were new this year
The Trust’s Patient Experience Manager will be leading a working group to
develop a robust action plan in response to the findings.
National Cancer Survey 2014
The results of the Cancer Survey 2014 have been positive. Detailed results are
provided for each Tumour Group. These have been shared with the relevant
MDTs and – as successfully implemented for the 2013 Survey – each MDT
has developed 5 “pledges” for improvement. The pledges will be incorporated
into an overall action plan, monitored by Cancer Services.
614 RCHT patients responded to the survey.
The questions in the survey have been summarised as the percentage of
patients who reported a positive experience.

RCHT were in the highest 20% of scores for 25 of the 63 questions
compared across all Trusts.
 RCHT were in the lowest 20% of scores for 2 of these 63 questions.
Three questions had statistically significant different scores (one increased and
two decreased) compared to the 2013 survey.
Some of the areas where patients have shown a significantly increased level of
satisfaction are:
 Staff gave complete explanation of what would be done.
 Received understandable answers to important questions all/most of the
time.
 Patient did not feel that they were treated as a set of symptoms.
 Patient’s family definitely had time to talk to the doctor.
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Comparison to 2013 results – statistically significant changes:
Question
2013
Score
2014
Score
Hospital staff told patient they could get
free prescriptions
Family definitely given all information
needed to help care at home
Patient definitely given enough care
from health or social services
75%
83%
Highest
Trust
Score
93%
70%
61%
80%
74%
63%
85%
Outpatient Survey 2014
A survey of outpatients was commissioned from the Picker Institute Europe.
839 patients were eligible for the survey, of which 441 returned a completed
questionnaire, giving a response rate of 53%. Picker compared the results
against those from their 2011 survey of 74 Trusts nationwide.
The survey showed that the Trust is:
Significantly BETTER than average on 34 questions
Significantly WORSE than average on 2 questions
The scores were average on 38 questions
Examples of where the Trust’s results were significantly
better than the ‘Picker average’ are (lower scores are better):
Trust
Average
Staff did not explain what would happen during the test
16%
24%
Dr did not fully explain reason for treatment/action
16%
21%
Dr did not always give clear answers to questions
19%
26%
Not always treated with respect and dignity
8%
12%
Results were significantly worse than the ‘Picker average’ for the following
questions:
Trust
Average
No leaflets or posters about hand washing
11 %
6% %
Hand-wash gels not available or empty
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10 %
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The Outpatient lead has developed an action plan to address the worst scoring
issues which include: Hand washing; patient letters; doctors’ communications;
choice of appointment time and reception culture.
Day Case Survey 2014
The Picker Institute was commissioned by 10 trusts to undertake the Day Case
Survey 2014. 837 patients were eligible for the survey, of which 456 returned a
completed questionnaire.
The survey showed that the Trust is:
Significantly BETTER than average on 17 questions
Significantly WORSE than average on 1 question
The scores were average on 50
Examples of where the Trust’s results were significantly better than the ‘Picker
average’ are (lower scores are better):
Wanted to be more involved in decisions about care
Trust
19%
Average
26%
Staff did not do everything to control pain
17%
29%
Not fully told of danger signals to look out for on discharge
29%
35%
The results were significantly worse than the ‘Picker average’ for the following
question:
Trust Average
Discharge: did not receive copies of letters sent between
hospital doctors and GP
49 %
35 %
Involvement and Stakeholder Engagement
In early 2015, the Trust published its three year Communications and
Engagement Strategy and five year Patient Experience Strategy which sets out
recent success and priorities on public involvement and stakeholder
engagement.
The Patient Experience Strategy is summarised using three themes which are
underpinned by the Trust values as well as ‘our plans 2014/15’:
 Listening to the views of our patients and staff
 Learning and Improving
 Delivering excellence in patient care
As an aspirant NHS Foundation Trust, membership recruitment and
engagement continues to be the primary focus of activities. Public membership
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has increased from 5,241 to 7,353 in the past 12 months. The strategy for
recruitment and engagement is agreed by the Membership and Engagement
Committee formed of (Shadow) Governors and Trust staff. The Trust’s
(Shadow) Council of Governors is an important part of the programme to listen
and involve the wider community in our work and the (Shadow) Council
includes representatives from key stakeholder groups such as the local
councils and commissioners.
In the past 12 months, engagement activities have included an open evening
for members and the wider community to have tours of Royal Cornwall
Hospital, speak to Trust leaders and ask questions about service
developments. We have also established a series of public talks on health
topics such as diabetes, clinical research and dementia and attend all the
major local events to provide health information and listen to feedback.
Membership activity is in addition to the regular patient groups that occur within
clinical specialties such as cancer, cardiology and renal. The Trust provides a
range of regular support group meetings and opportunities for patients and
carers to ask questions and give feedback on services. One major example in
2014/15 is the involvement of patients and carers in the design of a new
cancer support and information centre in partnership with Macmillan. We have
also conducted surveys with members and the wider community to improve
outpatient services and our use of technology – and most recently to develop a
new Trust website which will be ready in early 2015/16.
In West Cornwall, we have an established West Cornwall Hospital Community
Forum involving representatives from local groups and organisations as well as
politicians to discuss issues affecting the population in West Cornwall. We also
have good relationships with the local Healthwatch leaders and regularly
discuss current issues or work with them on bespoke research such as care at
the end of life.
Listening, learning and improving from patient experience is central to the
Trust’s values and we ensure that we collect and act upon feedback from a
range of sources including online, through the Friends and Family Test, the
Kindamagic programme which obtains real time feedback from our most
vulnerable patients and the continued use of our Patient Ambassadors who
work within clinical specialties to improve services.
There are currently 13 Patient Ambassadors who continue to be actively
involved with or are planning to be involved with 35 Divisional projects.
New projects include:
 Observing and obtaining patient feedback on the newly opened
Ambulatory Emergency Care Unit
 Obtaining real time patient feedback on Wheal Coates and Pendennis
Wards
 A patient survey carried out in Clinical Imaging across all three sites
 ‘Points of Care Observations’ giving immediate feedback to the ward
manager
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Patient Ambassadors are also involved with the Complaints Review Panel, the
Clinical Cabinet, the Major Trauma Review Panel and the Executive Serious
Incident Panel.
The Kindamagic programme was undertaken in partnership with Peninsula
Community Health who provide the local community hospitals and has been
recognised nationally as a positive approach to involve vulnerable patients with
communicative or cognitive impairment.
In the past 12 months, the Trust has also continued to have an open dialogue
with commissioners, health and social care partners, GPs and MPs on future
service developments. The Trust has now established a regular series of talks
with local GPs on clinical topics and service improvements. A summary of the
Trust’s forward view on public involvement and stakeholder engagement can
be found in the Communications & Engagement Strategy and Patient
Experience Strategy on the Trust website.
Healthwatch Cornwall has reported on patient feedback comments for the
Trust from September 2013 to September 2014. The feedback shows that staff
attitude, support and quality of care has been received positively by patients
during the diagnosis/testing, clinical treatment and nursing stages of their care.
Negative feedback focuses on transport and the discharge process; however,
Healthwatch Cornwall is aware that the Trust is currently looking in detail at the
discharge pathway in order to improve the process.
Healthwatch Cornwall continues to have a monthly information stand in the
Trelawny cafe area. This stall is shared with Support, Empower, Advocate, and
Promote services (SEAP) – i.e. Complaints advocacy to promote local services
to patients, relatives and their carers.
Two ‘Enter and View’ inspections of wards have been carried out by
Healthwatch out during 2014, the results are awaited.
Healthwatch Isles of Scilly has revised the Working Agreement between the
Trust, Healthwatch Cornwall and Healthwatch Isles of Scilly. This agreement
clarifies lines of communication and expectations between the organisations;
this has now received final approval from the Patient Experience Group.
Regular liaison meetings to promote information sharing are to be reestablished between the Trust, Healthwatch Cornwall and Healthwatch Isles of
Scilly. The main issues raised by the patients on the islands are around
medical travel. These issues are brought to the relevant RCHT managers via
the Medical Travel Isles of Scilly Working Group.
Statements from Healthwatch, Health and Wellbeing Boards and Clinical
Commissioning Groups
Healthwatch Cornwall
Healthwatch Cornwall (HC) was pleased to read a thorough Quality Account
for Royal Cornwall Hospital Trust (RCHT). The Trust has openly reported some
difficult issues from last year, for example patient information being left
unattended, missing targets in regards to Cardiology and negative responses
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to the national staff survey, and this candour is welcomed by HC. There have
also been many positive changes made in the last year, which HC notes
include improved 7 day working, meeting the national non-admitted Referral to
Treatment (RTT) targets as well as the targets for RTT for cancer.
Healthwatch Cornwall (HC) has continued to work with RCHT as a critical
friend and in doing so has increased the amount of patient feedback about
RCHT significantly. This has been done through partnered outreach with SEAP
and Enter and View visits onto wards. As a result HC has been able to
accurately and intelligently inform RCHT of issues that have been voiced such
as the need to improve management of patient expectation. HC also
participated in the Spring to Green initiative that looked to increase the number
of patients discharged from a hospital setting. There were mixed views from
HC representatives on how effective this initiative was, but it did give further
insight to HC on how the Trust was trying to improve current pressures on the
system.
HC is glad to see the steps taken by RCHT to reduce Hospital Standardised
Mortality Ratio (HSMR) and the acknowledgement that the Trust has not been
as successful as it would have hoped. It is pleasing to see that HSMR will
remain as a priority for 2015 – 2016. HC is impressed to see the steps taken to
implement 7 day working and has received patient feedback to support this.
HC recognise that the implementation of 7 day working across the whole Trust
is a large piece of work, which will be continuing over the next year. HC is
disappointed to see the results of the staff survey and look to RCHT to ensure
that steps are taken to ensure that this will not affect patient treatment. The
feedback that HC receives about treatment received from health professionals
at RCHT is generally very positive. Patients state that they provide high quality
services in difficult and highly pressured situations.
HC has analysed comments collected about the discharge process at RCHT with issues arising around medication, waiting times and lack of support. HC
continues to hear similar patient’s stories. HC fully accept and understand that
a number of issues that occur are due to external organisations, but are
pleased to see the work that is currently being done to improve the situation.
HC are aware of the work that is currently going on behind the scenes to
improve patient experience at RCHT and the priorities for 2015 - 2016 reflect
this. Recent concerns brought to the Patient Experience Team concerning
patients with Spinal Cord Injury have been responded to quickly and positively.
HC hope that RCHT are able to conquer the current issues that face the Trust
that include Noro virus, pressures on the emergency department, bed capacity
and RTT for Cardiology. HC will continue to support the Trust in order to help it
achieve its priorities.
Healthwatch Isles of Scilly
We are pleased to comment on this Quality Account.
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Pressures in acute care have been well documented in recent months and
measures to improve patient flow are included in the report; we recognise that
this needs to be addressed in partnership across the health and care system.
We still hear about problems regarding discharge from hospital and journey
arrangements, for instance after emergency med-evacuation, but hope to see
a continued improvement through the initiatives planned for 2015/16 and
ongoing discussion with the Trust.
Comments made to Healthwatch Isles of Scilly were reported to the Trust in
the year April 2014 to March 2015. The majority of comments were about
arranging treatment and travel, and as noted this is addressed through the IOS
Medical Travel and Transport joint working group. Topics include measures to
reduce the need to travel, i.e. remote consultations where safe and
appropriate, patient/treatment pathways, local training, and utilisation of local
skills and facilities. There has been some progress in this direction and we
would be pleased to see more initiatives to reduce the need to travel in
2015/16.
Comments about treatment and care at Royal Cornwall Hospitals Trust
hospitals and clinics are generally positive.
There has been a vacancy in the resident midwife post for most of the year,
and while we consider that there is a need to review the current service level,
we commend the Trust for maintaining cover throughout this period and for its
response to issues as they arose.
We look forward to the re-introduction of regular liaison with Healthwatch as
routine contact was very useful in the past. However, we have good lines of
contact with key personnel and have been well assisted by the PPI Manager in
our communications with the Trust.
Cornwall Health and Overview Scrutiny Committee
Cornwall Council’s Health and Social Care Scrutiny Committee agreed to
comment on the Quality Account 2014 -2015 of Royal Cornwall Hospital Trust
(RCHT). All references in this commentary relate to the period 1 April 2014 to
the date of this statement.
Royal Cornwall Hospital Trust has engaged with the Committee throughout the
year and has consistently produced information when requested by the
Committee. They are represented at all meetings.
The Committee believes that the Quality Account is a good reflection of the
services provided by the Trust, and provides comprehensive coverage of the
provider’s services.
Of the priorities set last year, it is recognised that progress has been made to
improve, and the Committee is reassured that this work will be continued.
The Committee has been monitoring the numbers of backlogged outpatient
appointments and the number of cancelled operations within the Trust, along
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with other acute trusts locally, and this something that will remain on
Committee agendas. Cancelled operations are a matter of ongoing public
concern.
It is recognised that there is enormous strain on the whole health system and
economy within Cornwall. There has been heightened concern following the
'black' alerts placed on the trust over winter, of the performance of the Accident
and Emergency Department, and the utilisation of both West Cornwall Hospital
and St Michael's Hospital.
Royal Cornwall Hospital forms a large part of the reliance of the system to
ongoing pressures and the Committee will be seeking reassurance that there
are improvements in all areas, including RCHT, in the coming year.
The Committee looks forward to continued partnership working with the Trust
in 2015-16.
The Isles of Scilly Health and Overview Scrutiny Committee
The Isles of Scilly Health and Overview Scrutiny Committee is grateful for the
opportunity to comment on the Quality Accounts.
We commend the on-going work done by the Trust with the group led by the
Healthwatch Isles of Scilly to mitigate the difficulties of discharge and transport
arrangements for our community. Nevertheless there are still areas of concern
in this area.
We congratulate the Trust on the work done in such areas as VTE, PBM and
AKI.
We share the Trusts concerns raised by the poor results of the staff surveys
and we are hopeful that these issues can be resolved by the steps outlined in
the Accounts.
We are disappointed that there is no mention of the midwifery service to the
islands in the report. We are heartened that this post is now filled, but this
committee considers that the provision of one part time practitioner does not
mitigate the inherent risk.
We look forward to continued engagement with the Trust to maximise health
and care resources on the island to provide the best services for islanders.
NHS Kernow Clinical Commissioning Group
NHS Kernow is pleased to have the opportunity to comment on the Quality
Account 2014/15 for the Royal Cornwall Hospitals Trust (RCHT), and
welcomes the approach the Trust has shown in developing and setting out its
plans for quality improvement. There are routine processes in place with RCHT
to agree, monitor and review the quality of services throughout the year
covering the key quality domains of safety, effectiveness and experience of
care.
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The Quality Account presents an overview of a wide range of quality
improvement work being undertaken. We are pleased to see the Board’s
ambition to achieving a Care Quality Commission assessment of “Outstanding”
but we recognise that there are significant challenges that we would like to see
the Trust address. The Board continues to exhibit commitment to quality as
demonstrated through the priorities improving Patient Safety and Experience.
The report presents a fair reflection of progress in 2014/15 and we can confirm
the information presented in the Quality Account appears to provide a
balanced account which is accurate and fairly interpreted, from the data
collected.
We note the positive improvements Royal Cornwall Hospitals has made in:
Patient Safety
 Review of the clinical staffing at the weekend to support patient safety;
 Progress made against the 7 working day clinical standards which
includes the expansion of the outreach service, 5 of the 10 standards
will be implemented this year
 Systematic approach to ensuring “at risk” patients from the whole
organisation are being discussed at the formal handovers
 Continued improvement to the Clinical Site Development Plan improving
facilities and patient environments, most notably the new older person
ward
Clinical Effectiveness
 The on-going work around reducing mortality and the development of
the Mortality Review Group which is now led by the Deputy Medical
Director that now also includes a patient representative and a general
practitioner
 Continuing to publish surgical and clinical quality outcomes
 Continued focus on the Care Quality Commission recommendations
resulting in on-going audit carried out to check improvement initiatives
such as maintenance of better record management
 Positive engagement in process mapping the discharge pathway with
clear support from Emergency Intensive Care Team
Patient Experience
 The implementation of the Acute Ambulatory Care unit has
demonstrated a positive experience for those patients admitted via this
system
 There were many ways identified how patient feedback was obtained
but it was unclear how the dignity champions were engaged and this
could be improved during 2015
NHS Kernow looks forward to working with the Trust throughout the year to
deliver high quality services to patients, especially:
 Continued Patient Safety & Patient Experience, and in particular
recognition of the importance of linking mortality reviews to business
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



planning and care pathway improvement need to be maintained in this
year with the implementation of new key performance indicators
The development of the remaining 5 clinical standards for seven days
services, and strong working relationship with partner organisations
There have been some persistent challenges with managing flow and
NHS Kernow would like to see the work on improving discharge
arrangements for patients sustained; as well as continuous strong links
through the System Resilience Group and the System Wide Senior
Operations Group
Continue to improve the quality of care through joint working between
primary and secondary care clinicians on developing patient pathways
There have been continued improvements in the management of
serious incidents and we would like to see this sustained during 2015
We are pleased to see that the priorities chosen for 2015/16 are evidence
based and have been identified with key stakeholder involvement. NHS
Kernow recognises the work undertaken in the following areas and would wish
the Trust to continue to focus on these areas although not specifically identified
as a priority:
 RCHT Safeguarding Adults team are moving safeguarding forward in
light of the care Act 2014 and the subsequent changes to the local
processes led by the council
 We would welcome the opportunity to work with RCH on any
recommendations and required actions resulting from the Care Quality
Commission service review for looked after children and child protection
arrangements (January 2015)
 How the NHS Constitution standards in the year have not always been
met and NHS Kernow would welcome the opportunity to explore what
support is required to work with you to improve delivery
Trust response to comments from third parties
The Trust is grateful to stakeholders and third party organisations that helped
to shape our Quality Account for 2014/15. All feedback and comments will be
taken into consideration as the Trust delivers on its commitment to further
improve the safety and quality of care delivered in Cornwall and the Isles of
Scilly.
Extending services into the evening and weekends continues to be a priority
for the Trust, the recognition of which is clearly noted in the comments from the
third parties. Momentum made on this in the past year will continue into
2015/16, and the Trust expects to see a reduction in in-hospital mortality as
part of its commitment to improving the safety and quality of care for patients.
The Trusts notes that its partners recognise the enormous strain on the whole
health system and economy within Cornwall. Maximising the effective use of
resources available to the Trust will continue to be a prime focus. This, along
with maintaining close and productive working and strategic relationships with
third parties is vital to providing a complete emergency, and elective, service.
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The last year saw a positive step change in the Trust understanding, acting
upon, and improving patient experience. The third party responses reflect how
important it will be for the Trust to continue their close working arrangements
with its partners and maintain this level of progress in the coming 12 months.
The Trust looks forward to a productive 2015/16, working in close partnership
with its colleagues in Health and Social care to further improve the quality of
care given to its patients.
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Statement of Directors' Responsibilities in Respect of the Quality
Account
The directors are required under the Health Act 2009, National Health Service
(Quality Accounts) Regulations 2010 and National Health Service (Quality
Account) Amendment Regulations 2011 and 2012 to prepare Quality Accounts
for each financial year. The Department of Health has issued guidance on the
form and content of annual Quality Accounts (which incorporate the above
legal requirements).
In preparing the Quality Account, directors are required to take steps to satisfy
themselves that:

the Quality Accounts presents a balanced picture of the Trust’s
performance over the period covered;

the performance information reported in the Quality Account is
reliable and accurate;

there are proper internal controls over the collection and reporting of
the measures of performance included in the Quality Account, and
these controls are subject to review to confirm that they are working
effectively in practice;

the data underpinning the measures of performance reported in the
Quality Account is robust and reliable, conforms to specified data
quality standards and prescribed definitions, is subject to appropriate
scrutiny and review; and the Quality Account has been prepared in
accordance with Department of Health guidance
The directors confirm to the best of their knowledge and belief they have
complied with the above requirements in preparing the Quality Account.
By order of the Board.
29th June 2015
29th June 2015
Angela Ballatti
Chairman
Bill Shields
Chief Executive
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Independent Auditors’ Report
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Glossary
Term
Anaemia
Bariatric
Carbon Reduction
Commitment (CRC)
Cardiac Implantable
Electronic Device
(CIED)
CARE
Care Quality
Commission (CQC)
C-Difficile
Cellulitis
Ciliary dyskinesia
Clinical Audit
Clinical Coding
Clinical
Commissioning Group
(CCG)
Colonoscopy
Commissioning for
Quality and Innovation
(CQUIN)
Community Acquired
Pneumonia (CAP)
Definition
You have fewer red blood cells than normal, OR you have
less haemoglobin than normal in each red blood cell.
In either case, a reduced amount of oxygen is carried around
in the bloodstream.
The branch of medicine that deals with the causes,
prevention, and treatment of obesity.
The scheme is designed to incentivise energy efficiency and
cut emissions in large energy users in the public and private
sectors across the UK. To help manage resources including
energy, materials and people in a more efficient and effective
way
Cardiac pacemakers and implantable cardioverter
defibrillators (also called CIEDs or cardiac implantable
electronic devices) are used to correct abnormal heart
rhythms.
Stands for: Communicate with compassion, Assist with
toileting, ensuring dignity, Relieve pain effectively, Encourage
adequate nutrition.
This regulatory organisation checks whether hospitals, care
homes and care services are meeting government standards.
A specific kind of bacterial infection that causes mild to very
severe forms of diarrhoea and colitis.
Cellulitis is a spreading bacterial infection of the skin and
tissues beneath the skin.
The immotile cilia syndrome, a condition in which poorly
functioning cilia (hairlike projections from cells) in the
respiratory tract contribute to retention of secretions and
recurrent infection.
It is a way to find out if healthcare is being provided in line
with standards and lets care providers and patients know
where their service is doing well, and where there could be
improvements.
It is a patient’s complaint, problem, diagnosis, treatment or
reason for seeking medical attention, into a coded format.
Clinically-led statutory NHS bodies responsible for the
planning and commissioning of health care services for their
local area.
Colonoscopy is a procedure that enables an examiner
(usually a gastroenterologist) to evaluate the inside of the
colon (large intestine or large bowel).
A payment framework that enables commissioners to reward
excellence by linking a proportion of providers’ income to the
achievement of local quality improvement goals.
This is defined as the presence of symptoms and signs
consistent with acute lower respiratory tract infection in
association with new radiographic shadowing for which there
RCHT Quality Accounts 2014-15 V5.16
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is no alternative explanation. This is managed as pneumonia.
A computerized tomography (CT) coronary angiogram is an
imaging test that looks at the arteries that supply your heart
CT coronary
with blood. Unlike traditional coronary angiograms, CT
angiogram
angiograms don't use a catheter threaded through your blood
vessels to your heart. Instead, it relies on a powerful X-Ray.
Deep vein thrombosis (DVT) is a blood clot in one of the deep
veins in the body. Blood clots that develop in a vein are also
Deep Vein Thrombosis
known as venous thrombosis. DVT usually occurs in a deep
(DVT)
leg vein, a larger vein that runs through the muscles of the
calf and the thigh.
Diuretic
Something that promotes the formation of urine by the kidney.
If you have ductal carcinoma in situ (DCIS), it means that
cells inside some of the ducts of your breast have started to
Ductal Carcinoma Inturn into cancer cells. These cells are all contained inside the
Situ (DCIS)
ducts and have not started to spread into the surrounding
breast tissue.
Electrocardiogram
A recording of the electrical activity of the heart. Abbreviated
(ECG)
ECG and EKG. An ECG is a simple, non-invasive procedure.
Electronic Prescribing All prescribing and administration from traditional drug cards
and Administration
are accessed by an electronic system known as EPMA.
(EPMA)
Emergency Care
Provide the NHS with specialist advice in the delivery of
Intensive Support
operational standards.
Team (ECIST)
It is a drug used to treat non-small cell lung
Erlotinib
cancer, pancreatic cancer and several other types of cancer.
Records the electrical activity of your heart whilst you
Exercise Tolerance
exercise. A method used to determine the presence of
Test (ETT)
significant coronary heart disease.
It is a single question survey which asks patients whether
Friends and Family
they would recommend the NHS service they have received
Test (FFT)
to friends and family who need similar treatment or care.
They are the national provider of information, data and IT
Health and Social Care
systems for commissioners, analysts and clinicians in health
Information Centre
and social care. HSCIC is an executive non-departmental
(HSCIC)
public body, sponsored by the Department of Health.
Hyperkalemia is the medical term that describes a potassium
Hyperkalaemia
level in your blood that's higher than normal.
These help an organisation define and measure progress
toward organisational goals. They are quantifiable
Key Performance
measurements, agreed beforehand, that reflect the critical
Indicators (KPI)
success factors of an organisation. They will differ depending
on the organisation.
Is an approach to gathering patient experience feedback for
Kindamagic
all patients regardless of their disability.
The infection below the level of the larynx and may be taken
Lower Respiratory
to include: Bronchiolitis, Bronchitis, Pneumonia,
Tract Infection
Laryngotracheobronchitis (croup)
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Medical SPR
(Specialist Registrar)
Myocardial perfusion
scan
National Confidential
Enquiries into Patient
Outcome and Death
(NCEPOD)
National Early
Warning Scores
(NEWS)
National Institute for
Health and Care
Excellence (NICE)
Never Events
Oropharyngeal
dysphagia
Patient Ambassador
Patient Reported
Outcome Measures
(PROMS)
Petechial
Pneumonia
Pressure ulcers
Pulmonary embolism
They are a doctor who is working as part of a specialty
training programme in the UK.
A myocardial perfusion scan uses a small amount of a
radioactive chemical to see how well blood flows to the
muscles of the heart (the myocardium). Some doctors call this
a 'thallium' or 'MIBI' scan. Often this scan is performed after
gentle exercise to see how the heart muscle responds under
stress.
NCEPOD's purpose is to assist in maintaining and improving
standards of medical and surgical care for the benefit of the
public by reviewing the management of patients, by
undertaking confidential surveys and research, and by
maintaining and improving the quality of patient care and by
publishing and generally making available the results of such
activities.
Early Warning Scores have been developed to facilitate early
detection of deterioration by categorising a patient’s severity
of illness and prompting nursing staff to request a medical
review at specific trigger points utilising a structured
communication tool while following a definitive escalation
plan.
The National Institute for Health and Care Excellence (NICE)
provides national guidance and advice to improve health and
social care.
Serious, largely preventable patient safety incidents that
should not occur if the available preventative measures have
been implemented.
Patients with oropharyngeal dysphagia have difficulty
transferring food from the mouth into the pharynx and
esophagus to initiate the involuntary swallowing process.
Are volunteers who work closely with staff to develop services
in order to improve patient experience.
Tools we use to measure the quality of the service we provide
for specific surgical procedures. They involve patients
completing two questionnaires at two different time points, to
see if the procedure has made a difference to their health.
A small red or purple spot caused by bleeding into the skin.
Pneumonia is an infection that inflames the air sacs in one or
both lungs. The air sacs may fill with fluid or pus (purulent
material), causing cough with phlegm or pus, fever, chills, and
difficulty breathing.
Sometimes known as bedsores or pressure sores, are a type
of injury that affect areas of the skin and underlying tissue.
They are caused when the affected area of skin is placed
under too much pressure. They can range in severity from
patches of discoloured skin to open wounds that expose the
underlying bone or muscle.
A pulmonary embolism is a blockage in the pulmonary artery,
which is the blood vessel that carries blood from the heart to
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Safety Thermometer
SBARD
Septicaemia
Serious Incidents
Sigmoidoscopy
Tracheostomy
Troponin T negative
UltraFiltration
Venous
thromboembolism
(VTE)
World Health
Organization
‘checklist’ (WHO)
the lungs.
This is a local improvement tool for measuring, monitoring
and analysing patient harms and harm free care. It provides a
quick and simple method for surveying patient harms and
analysing results so that you can measure and monitor local
improvement and harm free care over time. The safety
thermometer records pressure ulcers, falls, catheters with
urinary tract Infections and venous thromboembolisms
(VTEs).
Situation, Background, Assessment, Recommendation,
Decision.
SBARD is an easy to remember mechanism used to frame
communications and conversations.
Septicemia is bacteria in the blood (bacteremia) that often
occurs with severe infections. Also called sepsis, septicemia
is a serious, life-threatening infection that gets worse very
quickly.
A serious incident requiring investigation is defined as an
incident that occurred in relation to NHS-funded services and
care resulting in unexpected/avoidable deaths, allegations of
abuse, serious harm and such.
Sigmoidoscopy is a procedure where a doctor or nurse looks
into the rectum and sigmoid colon, using an instrument called
a sigmoidoscope.
A tracheostomy provides direct access to the trachea by
surgically making an opening in the neck usually to help the
patient breathing.
Troponins are specific proteins found in heart muscle.
Troponins T are used to diagnose myocardial infarctions
(heart attacks).
A type of filtration, sometimes conducted under pressure,
through filters with very small pores, such as those used by
an artificial kidney. It can separate large molecules from
smaller molecules in body fluids.
A blood clot within a blood vessel that blocks a vein or an
artery, obstructing or stopping the flow of blood. A blood clot
can occur anywhere in the body’s bloodstream. There are two
main types; venous thromboembolism (VTE) which is a blood
clot that develops in a vein; and arterial thrombosis which is a
blood clot that develops in an artery.
The WHO Surgical Safety Checklist was developed after
extensive consultation aiming to decrease errors and adverse
events, and increase teamwork and communication in
surgery.
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