Quality Accounts for 2010/2011
PATIENT SAFETY
CLINICAL EFFECTIVENESS
PATIENT EXPERIENCE
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ABOUT THIS DOCUMENT
ABOUT THIS DOCUMENT
What are Quality Accounts and why are they important to you?
South Devon Healthcare NHS Foundation Trust is committed to providing high
quality services to our patients and ensuring that we put quality at the centre of all
that we do.
Our 2010/11 Quality Accounts are an annual report of:
• How we have performed over the last year against the quality improvement
priorities which we laid out in our 2009/10 Quality Accounts.
• Our priorities for the coming year (2011/12).
• How well we are doing compared to other similar hospitals.
• Statements about the quality of NHS services provided.
• How we have engaged staff, patients, commissioners, Governors, Local
Involvement Networks (LINKs) and local Oversee Scrutiny Committees (OSCs) in
deciding our priorities for the forthcoming year.
• Statements about quality provided by our Commissioners, Governors, OSCs, LINKs
and Trust Directors.
If you would like to know more information about the quality of services that are
delivered at Torbay Hospital, further information is available on our website
www.sdhct.nhs.uk
If you need the document in a different format?
This document is also available in large print, audio, braille and
other languages on request. Please contact the Communications
team on 01803 656720
Getting involved
We would like to hear your views on our Quality Accounts. If you are interested
in commenting or seeing how you can get involved in providing input into the
Trust’s future quality improvement priorities, please contact
susan.martin@nhs.net or telephone 01803 655701.
Your views do make a difference.
Design and photography (Cover, 3, 12 and 32) NADOLSKi 01392 496200
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
Our website is at www.sdhct.nhs.uk
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Introduction and statement of quality from the Chief Executive
2
Priorities for improvement - looking back 2010/11
3
- looking forward 2011/12
CONTENTS
CONTENTS
12
Statements of assurance from the Board
16
Our performance in 2010/11 and other quality initiatives
32
Annex 1
Engagement in the 2010/11 Quality Accounts
41
Statements from Commissioners, Governors, OSCs, LINKs
42
Statement of Directors’ responsibilities in respect of the Accounts
47
Annex 2
Quality indicators proforma used by clinical teams
Our website is at www.sdhct.nhs.uk
48
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
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INTRODUCTION & STATEMENT OF QUALITY FROM THE CHIEF EXECUTIVE
INTRODUCTION & STATEMENT OF QUALITY
FROM THE CHIEF EXECUTIVE
Welcome to this year’s South Devon Healthcare NHS
Foundation Trust Quality Accounts. This report aims to build
on our first Quality Accounts and details what progress we
have made in 2010 against our quality improvement
priorities and our plans for 2011/12.
At South Devon, we believe that quality is central to how
we work and to the services we deliver. Clinicians,
managers and staff work together to ensure that we
continuously drive up quality.
Key to this is:• Improving the way we work. We have embedded into our organisation a
continuous improvement programme which is driven by clinical teams and focuses
on delivering real quality improvements for our patients.
• Listening and acting on feedback from our members, governors, patients, their
carers and families to improve their experience whilst at Torbay Hospital.
• Improving our standards of care and delivering better patient outcomes.
Throughout the year we review our services and clinical practice. We review new
national clinical standards and guidance and participate in clinical trials and health
care research.
• Supporting our dedicated staff at all levels by offering a comprehensive
programme of education and development.
• Working closely with our partner organisations including commissioners, local
authorities and other health and social care organisations to share learning and
best practice and strive for excellence in all that we do.
We know that everyone can make a difference to delivering high quality health care
and that everyone has a role to play. The information in this report provides just a
small proportion of the work we are involved in.
I hope you will take time to read this year’s Quality Accounts.
I confirm that, to the best of my knowledge, the information in this document is
accurate.
Paula Vasco-Knight
Chief Executive
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Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
Our website is at www.sdhct.nhs.uk
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PRIORITIES FOR IMPROVEMENT / 2010/11
PRIORITIES
FOR IMPROVEMENT
Looking back: 2010/11
In our 2009/10 Quality Accounts
we reported that we would focus
on three priority areas for quality
improvement in 2010/11. Some
of these areas for improvement
have been nationally driven, such
as reducing the risk of patients
developing blood clots whilst in
hospital. Others, such as
improving information at
discharge, have been driven
locally.
Our website is at www.sdhct.nhs.uk
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
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Patient safety
PRIORITIES FOR IMPROVEMENT / 2010/11 / PATIENT SAFETY
Priority 1: Reduce the risk of patients who are admitted to hospital subsequently
developing a blood clot (thrombus) in a vein.
Blood clots most commonly form in the deep veins of
the leg or pelvis (deep vein thrombosis), but can also
break up and travel to the lungs where they may
lodge and cause pulmonary embolism. The
development of a blood clot requires immediate
action.
From the data collected in 2010/11, on average 95%
of patients were given appropriate treatment and
89% of patients were risk assessed on admission.
Nationally the NHS target for risk assessment on
admission is 90%. We have made excellent progress
in our first year.
Therefore it is important that all patients are assessed
for the risk and are given appropriate preventative
treatment.
In addition we have reviewed our patient information
leaflets covering blood clots. These revised leaflets
are now available at the bedside.
Over the last year we have been working towards
ensuring that at least 95% (local target) of adult
patients admitted are both assessed and given the
appropriate preventative treatment, when required.
In 2011/12 we will continue to embed further the
processes developed over the last year to improve
patient safety, monitoring our performance against
the national and local targets.
The information is recorded on a patient’s drug chart
and compliance against the standard is measured
through monthly audits which are undertaken by a
doctor and a pharmacist. This is particularly valuable
as it allows everyone to share their learning and use
this to further improve practice.
Our progress since setting up new auditing processes
in 2010/11 is shown below.
Venous thromboembolism risk assessment 2010/11
100%
95%
90%
85%
80%
75%
0%
Apr
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Risk assessment on admission
Appropriate treatment
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Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
Our website is at www.sdhct.nhs.uk
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Clinical effectiveness
Care planning summaries are essentially clinical
reports written by a doctor when a patient is due to
leave hospital. A care planning summary includes
what the patient was admitted for, what treatment
they received, any medication taken home and
whether any follow up was required. GPs and other
health care professionals need timely access to this
information to ensure they can provide patients with
effective follow up care.
“
THE IMPROVEMENT IN CARE PLANNING
SUMMARIES HAS BEEN NOTICEABLE, IN BOTH
THE TIMELINESS AND THE QUALITY OF THE
INFORMATION. WITH THE REDUCTION OF
LENGTH OF STAY AND THE SHARING OF
PATIENT CARE IT IS VITAL THAT THIS WORK IS
Currently, Torbay Hospital discharges in the region of
37,500 inpatients a year. This can equate to over
3,000 care planning summaries every month. The
Trust has developed an electronic method of
capturing information during a patient’s stay which
becomes the care planning summary. The summary is
emailed to a GP practice after the patient has been
discharged. This ensures that the information sent is
secure, provided in a consistent format and can be
sent in a timely manner.
DEVELOPED FURTHER. PRODUCING A CARE
Over the last year we have been working towards a
local target of ensuring that 95% of patients receive
a care planning summary and that as our processes
and learning have improved, more care planning
summaries can be sent within 24 hours.
The feedback from GPs since starting this work in
2010/11 has been positive.
PLANNING SUMMARY AT THE TIME OF
DISCHARGE FROM THE EMERGENCY
ADMISSIONS UNIT HAS BEEN EXTREMELY
HELPFUL AND ALSO WHEN PATIENTS ARE
DISCHARGED TO ANOTHER CARE SETTING.
Feedback from a South Devon GP
“
Our progress over the last year is shown below. By
the end of the year over 95% of patients discharged
received a summary.
PRIORITIES FOR IMPROVEMENT / 2010/11 / CLINICAL EFFECTIVENESS
Priority 2: Improve our written and electronic information to general
practitioners (GPs) and other health care organisations with a focus on ensuring
that, as patients are discharged from hospital, a care planning summary is
produced and this is sent out promptly.
Care planning summaries completed 2010/11
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Apr
May
Jun
Jul
Aug
Sep
Local target
Our website is at www.sdhct.nhs.uk
Oct
Nov
Dec
Jan
Feb
Mar
Actual
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
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Clinical effectiveness
continued
PRIORITIES FOR IMPROVEMENT / 2010/11 / CLINICAL EFFECTIVENESS
Completing care planning summaries within 24
hours has proved to be a significant challenge.
Although we have made improvement throughout
the year, sustaining performance on every ward all
the time has been difficult.
WE WILL CONTINUE TO WORK WITH OUR
CLINICAL TEAMS NEXT YEAR WITH A FOCUS
ON THE 24 HOUR TARGET (80%) AGREED
WITH OUR COMMISSIONERS. THIS TARGET
Over the last year we have learnt that as trainee
doctors rotate through their posts from one
organisation to the next there is a dip in performance
as the new doctors learn our new systems. Also, we
have seen a dip as a result of treating much higher
numbers of patients over the winter months. We
have been working with clinical teams to address
these issues.
WILL BE MONITORED AND REPORTED TO THE
TRUST BOARD AND TO OUR
COMMISSIONERS. WE WILL ALSO UPDATE
STAFF AND PATIENTS REGARDING PROGRESS
INCLUDING MAKING INFORMATION
AVAILABLE ON OUR PUBLIC WEBSITE
WWW.SDHCT.NHS.UK.
We will continue to work with our clinical teams next
year with a focus on the 24 hour target (80%)
agreed with our commissioners. This target will be
monitored and reported to the Trust Board and to
our commissioners. We will also update staff and
patients regarding progress including making
information available on our public website
www.sdhct.nhs.uk.
Care planning summaries completed within 24 hours 2010/11
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Apr
May
Jun
Jul
Aug
Sep
Oct
Internal target
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Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
Nov
Dec
Jan
Feb
Mar
Actual
Our website is at www.sdhct.nhs.uk
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Patient experience
• Improving appointment information and information on medication at discharge.
• Improving the experience of patients with dementia and learning disabilities.
• Improving ambulance turnarounds times and reducing the amount of time
patients therefore have to wait to be admitted when they present as an
emergency.
By the end of 2010/11, the aim has been to improve the overall experience of
patients being treated at Torbay Hospital.
Improving the appointment process including patient letters and appointment times.
Over the last year the Trust has undertaken a major
piece of work to redesign services to improve the
appointment process. We have transferred the
printing of most of the outpatient appointment
letters to a third party mailing company to print,
package and post. The project started in December
2010 and to date we have sent approximately
43,000 letters by third party mailing.
The Hospital now has the ability to create letters for a
wide range of clinical specialities in large fonts and
coloured paper for patients with visual impairments
and dementia. Also we are now able to provide
letters in an appropriate style for patients with
learning disabilities. Previously letters were only able
to be sent in a larger font for patients attending one
clinic in Ophthalmology.
During 2010/11 we were also updating out patient
information leaflets into the corporate standard and
were ensuring the information was available in an
easy read format. By standardising and sending
documents via third party mailing we can ensure the
quality of the information sent is improved.
Our website is at www.sdhct.nhs.uk
In 2011/12 we will continue to build on this work
and have already started developing new maps and
directions which we can send out to help patients
attending the hospital. We know from our patient
survey feedback which are the areas of the hospital
that patients find difficult to locate. These
maps/directions will be prioritised.
In 2010/11 we also completed the development of
our ‘patient access centres’. These centres have been
developed to ensure outpatient appointments can be
more effectively managed. Patients are now able to
contact the Trust more easily as:
PRIORITIES FOR IMPROVEMENT / 2010/11 / PATIENT EXPERIENCE
Priority 3: Improve our overall communications with patients. This will include:
• There are dedicated numbers for each clinical area.
• There is better phone functionality including
informing a person how long they will need to
wait before the phone is answered.
Since its implementation in March 2011 we are now
handling over 90% of calls within one minute.
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
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Patient experience
continued
PRIORITIES FOR IMPROVEMENT / 2010/11 / PATIENT EXPERIENCE
Improving information about medication at discharge
In our 2009/10 NHS Inpatient survey two areas
around medication were identified as in need of
improvement. These were namely receiving clear
written information on medicines and being provided
with information on what a patient should do after
leaving hospital.
The preliminary results of the 2010 NHS Inpatient
survey indicates we have made substantial
improvement from the previous year.
In 2010/11 we concentrated on developing a range
of patient information leaflets about common
medication such as pain control, antibiotics and
anticoagulants. We also developed a discharge
information pack for patients. This pack includes
appropriate leaflets relating to the patient’s condition
as well as the Leaving Hospital leaflet. The pack also
contains a discharge information checklist which a
nurse completes with a patient. The checklist is a
record of information detailing follow up
appointments, medication and pain relief.
NHS Adult Inpatient Survey*
Average Score 2009
Average Score 2010
Q62
Were you given written information about
what you should do after leaving hospital?
53
68
Q64
Did a member of staff tell you about
medication side effects to watch for?
47
53
Q66
Were you given clear written information
about your medicines?
72
76
*NHS Adult Inpatient Survey results published at www.cqc.org.uk. With regards to Q62, 64 & 66. The higher the score the
better. For further information about the data and benchmarking see website.
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Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
Our website is at www.sdhct.nhs.uk
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Patient experience
continued
“
I WAS ASKED ON A COUPLE OF OCCASIONS
ABOUT MY SISTER’S QUALITY OF LIFE. IT IS
MOST IMPORTANT THAT PEOPLE APPRECIATE
THAT ALTHOUGH SOMEONE WITH SEVERE
LEARNING DISABILITIES MAY HAVE A
DIFFERENT WAY OF LIFE TO THEM; IT IS JUST
AS RICH AND PRECIOUS. I THINK MY SISTER’S
CALVERT TRUST PICTURE WAS AN
IMPORTANT SYMBOL OF HER QUALITY OF
LIFE AND PROVED A USEFUL TOOL FOR STAFF
TO COMMUNICATE WITH MY SISTER. MAYBE
SEVERELY DISABLED PEOPLE SHOULD BE
Patients with a learning disability or dementia should
expect to receive the same quality of care as anyone
else. Research shows that this is not always the case
and nationally work has been ongoing to improve
the standards of care for these groups of patients.
At South Devon we have a high elderly population
(over 40% of our inpatients are over 65) and we
know that about 7% of our patients have some form
of disability.
In autumn 2010 we took part in a regional peer
review of our services to ascertain our ability to meet
the needs of people with learning disabilities. This
process included setting a baseline of our existing
performance, identification of innovative practice and
an action plan. This plan is being monitored within
the Trust and shared with our commissioners and
through our Patient Experience and Community
Partnership Governance Group.
Work completed this year includes broadening the
range of easy-read information. We now have easyread patient menus, patient surveys, and information
on medication. We are currently working with a
learning disabilities group to translate more of our
patient information leaflets into picture format. The
current draft of ‘Coming into hospital for an
operation’ is with the local Torbay and Teignbridge
learning disability teams for comment.
We have also been adapting our safety monitoring
systems to ensure we can fully capture information
such as near misses, incidents, and complaints from
Our website is at www.sdhct.nhs.uk
ENCOURAGED TO BRING IN SOMETHING
WHICH HELPS TO DEFINE THEM.
Feedback from a relative regarding a patient
with a learning disability
“
patients with a learning disability. This allows us to
see trends and identify more easily any issues and act
on them more quickly.
PRIORITIES FOR IMPROVEMENT / 2010/11 / PATIENT EXPERIENCE
Improving the experience of patients with dementia and learning disabilities
We now have patient profiles for patients with a
learning disability. A patient profile is a summary of a
basic nursing assessment to advise any health care
professional what information is important to deliver
a high quality service to the patient. It covers
activities of daily living and is always available to
staff. Crucially the profile is created with the patient
themselves and/or their carer. Above is an extract
from a patient’s story and we have used this
feedback to improve the patient’s profile.
Dementia, as noted, has also been a key area of
work for us in 2010/11. Within the hospital, a small
clinical team has been leading on work to improve
standards of dementia care. As part of this we are
adopting the eight South West NHS Standards of
Dementia Care. In February 2011 we undertook a
self assessment against the standards and now have
an action plan to carry forward into 2011/12. In
autumn 2011 we will be peer reviewed to see what
progress we have made.
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
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Patient experience
continued
PRIORITIES FOR IMPROVEMENT / 2010/11 / PATIENT EXPERIENCE
Improving the experience of patients with dementia and learning disabilities
In 2010/11 our dementia nurse specialist set up and
ran a number of innovative educational programmes.
These have been shared with other health and social
care organisations and Plymouth University. More
information can be found at SW Dementia
Partnership website
(www.southwestdementiapartnership.org.uk).
As with learning disabilities, we have started to
improve the style of literature for patients with
dementia. This includes information about dementia
services at South Devon Healthcare NHS Foundation
Trust.
We have also ensured that there are now ward
champions for dementia who can provide support,
advice and guidance and continue to improve the
ward environment for patients with dementia. This
includes simple things such as dementia friendly
crockery and ensuring clocks are visible. In 2011/12
we will continue to improve the ward environment
through introducing better lighting and signage for
patients with dementia.
PERSONALISING MY ENVIRONMENT
THE TRUST IS AWARE THAT HOSPITALS CAN
BE A FRIGHTENING PLACE FOR A PERSON
WITH DEMENTIA OR CONFUSION. FAMILIAR
OBJECTS CAN HELP A PERSON SETTLE AND
CARERS ARE ENCOURAGED TO BRING IN
FAVOURITE OBJECTS SUCH AS
PHOTOGRAPHS OF THEIR FAMILY OR PETS,
MUSIC AND CLOTHING.
Improving ambulance turnaround times
A key area of improvement for us in the last 12
months has been to reduce the amount of time
patients have to wait to be admitted because of the
time it can take someone to transfer from an
ambulance to our Emergency Department.
A snapshot of our progress is shown below.
We have worked closely with our colleagues at the
South West Ambulance Service NHS Trust (SWAST) to
ensure we have concise and accurate handovers. This
allows rapid assessment and appropriate allocation of
patients, enabling the crews to turnaround that
much quicker.
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continued
We have also emphasised the importance of not
detaining crews unnecessarily as this takes them
away from other vital duties.
We are now one of the higher performing Trusts in
the South West region. Based on SWAST data at the
end of the 2010/11, we were ranked fifth out of the
12 main hospitals in the south west region.
Handover times
April 2010
March 2011
<15 minutes
76%
87%
>15 minutes
20%
12%
>30 minutes
4%
1%
Total handovers
1988
2021
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
Our website is at www.sdhct.nhs.uk
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Patient experience
continued
Over the last year the aim has been to monitor
whether patients perceive their overall care to have
improved and to measure ourselves against our 2009
NHS inpatient survey.
Currently all hospitals in England participate in an
inpatient survey which is used to inform us about
how we are performing in relation to our patients’
experience. Results are not fully available until nine
months later. In 2010/11 we focused on setting up
internal systems to collect and act on patient
feedback every month.
This ‘real time’ survey is undertaken when patients
are due for discharge and is conducted by trained
members of the ‘Working with Us Panel’ who are
made up of Foundation Trust members’ volunteers.
The results are shared with ward teams and with the
Patient Experience and Community Partnership
Governance Group. From this feedback,
improvements are suggested monitored and
reviewed. This ensures that there is a cycle of
continuous improvement.
We also have robust systems in place to learn from
complaints and incidents within the hospital and
ensure we make changes to improve the quality of
care we provide. All complaints and incidents are
captured on our Trust safeguard system and are
investigated. On a quarterly basis the Patient Services
team provide examples to the Trust of where a
change has been made as a result of patient
feedback. Some examples over the last year include:
Patient survey feedback 2010/11
‘Overall, how would you rate the care you received?’
• A deaf patient fed back that they wanted to cancel
an appointment at the last minute and there was
no method of contacting the Trust quickly. As a
result, we now have a text phone for appointments
and all appointment letters include information
about this facility. We are also looking at
introducing email appointments.
• When a patient attended pre assessment at the
hospital she had to go to a number of different
departments which was very confusing and time
consuming. Due to patient feedback, the Day
Surgery Unit now undertakes all assessments
within one location.
The Patient Safety Committee also receive reports
from each of the different clinical specialities on the
number of incidents and adverse events reported and
the learning and actions undertaken as a result. The
Committee made up of Senior Clinical Leads,
Commissioners and GPs all have the opportunity to
question the reports and recommend further actions,
if appropriate.
Over the last year we have consistently performed
above our 2009 NHS inpatient survey baseline. This
has been as a result of the work undertaken on
setting up real time feedback systems and acting on
it, as well as our other quality improvement work that
has been described already.
PRIORITIES FOR IMPROVEMENT / 2010/11 / PATIENT EXPERIENCE
Improving the overall experience for patients
In 2011/12 we will continue to collect real time
patient feedback and act on what our patients are
telling us. We will also use our 2011/12 quality
improvement priorities to improve our patients’
experience at the Trust.
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
May
Jun
Jul
Aug
Sep
Current rating - Excellent
Our website is at www.sdhct.nhs.uk
Oct
Nov
Dec
Jan
Feb
Mar
2009 In-Pt Survey - Excellent
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
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PRIORITIES FOR IMPROVEMENT / 2011/12
PRIORITIES
FOR IMPROVEMENT
Looking forward: 2011/12
The Trust has identified five priorities for 2011/12. These have been agreed
through discussions with our clinical teams, receiving feedback from our
patients and their carers and families. We have taken into account new best
practice and national guidance and have met with key stakeholders to agree the
priority areas for 2011/12. More information on our engagement process this
year is detailed in Annex 1.
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Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
Our website is at www.sdhct.nhs.uk
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Patient safety
Intentional rounding is a proven practical method to
reduce falls and is also starting to be used as part of
pressure ulcer prevention and supporting nutritional
needs. Instead of waiting for a patient to buzz for
help, with intentional rounding nurses take the
initiative and visit the patient’s bedside every hour to
do whatever the patients needs. Critically, it reminds
the patient that the nurse has time and can support
them with any request.
Compliance will be measured through undertaking
monthly audits on the designated wards. Our
progress towards the 90% target will be monitored
monthly and reported quarterly through our Patient
Safety Governance Group and to our partners,
including commissioners.
This year the Trust will implement intentional
rounding initially on two wards and monitor its
impact. We will test processes during the year to
ensure that it can be rolled out further onto other
wards in the hospital.
Priority 2: To improve the wards using the ‘productive ward’ methodology.
The Productive Ward/Releasing Time to Care project
focuses on improving ward processes and
environments to help doctors, nurses and therapists
spend more time on patient care thereby improving
safety and efficiency.
The project is overseen by the Ward Improvement
Project Board (WIPB) which is chaired by the Director
of Nursing and Governance. The measures are locally
agreed and the time released from the improvement
work is reinvested in the safety agenda.
The productive ward project is based on work by the
NHS Institute for Innovation and Improvement and is
proven to release time back to direct patient care by
eliminating waste.
In 2010/11 we started piloting a number of the
modules and already our staff are telling us that: “It helps me focus on the task in hand” and “The
changes have been sustained.”
PRIORITIES FOR IMPROVEMENT / 2011/12 / PATIENT SAFETY
Priority 1: To undertake intentional rounding on identified high risk patients of
falls, malnutrition or pressure sores, within the first 24 hour period, with the aim
of achieving 90% compliance.
The aim is that by spring 2012, 12 out of 18 wards
will have been involved in the project. They will look
at ward systems and processes such as the ward
environment, patient observations, drugs
administration, handover processes and nursing
procedures.
Our website is at www.sdhct.nhs.uk
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
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PRIORITIES FOR IMPROVEMENT / 2011/12 / CLINICAL EFFECTIVENESS
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Clinical effectiveness
Priority 3: To embed ‘enhanced recovery’ across Torbay Hospital
Enhanced recovery is a proven method to improve
patient outcomes through a range of measures that
include careful preparation for surgery, with
anaesthetic and surgical techniques that minimise the
disruption to the patient’s normal bodily functions.
This results in a more rapid recovery after surgery.
Enhanced recovery aims to ensure that patients
always receive the optimum and most effective care
at the right time and that the patients are more
active participants in their own treatment.
Torbay Hospital has led the field nationally in
enhanced recovery in a number of surgical
procedures including colorectal and orthopaedics.
In 2011/12 the aim is to embed enhanced recovery
across all clinical specialities at Torbay Hospital.
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
We will measure our progress through patient
feedback, length of stay within the hospital, readmission rates and also whether the patient was
admitted on the day of surgery. Our aim is to ensure
that more than 50% of those patients on an
enhanced recovery surgical pathway are discharged
on or before their intended discharge day.
Progress will be monitored through our Continuous
Improvement Programme Board chaired by our Chief
Executive. Information will also be shared with our
commissioners and our health & social care
community.
Our website is at www.sdhct.nhs.uk
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Patient Experience
In February 2011 the Health Ombudsman published
a detailed and damming report on the National
Health Service’s care and compassion towards ten
older people. Whilst none of the investigations
related to patients at Torbay Hospital, there are
always opportunities to improve the experience of
patients and we aim build on last year’s patient
experience work which is documented in these
Quality Accounts.
We will use a range of tools and techniques to
measure care and compassion towards older people.
This includes undertaking observations of care,
continuing to capture and share patient stories as
well as learning from real time patient feedback and
patient complaints. We will be supported in this work
by our Foundation Trust members who will bring
‘fresh eyes’ to the situation. We will also review the
national and local data from the various 2010/11
patient and staff surveys including those published by
partner organisations such as the Local Involvement
Networks (LINKs).
We aim to learn from these findings and act on them
across the organisation. We will also use the results
of the next National Inpatient Survey as one of the
methods to measure our improvement against.
Oversight of the implementation of
recommendations will be provided through our
Patient Experience and Community Partnerships
Governance Group chaired by one of our Non
Executive Directors.
Priority 5: To monitor compliance and outcomes against the community wide
End of Life Care Rapid Discharge Pathway.
The aim of the national End of Life Care Strategy is
to provide people approaching the end of their life
with more choice about where they would like to
die. To be effective, this needs to be managed and
monitored across the South Devon health
community. At Torbay Hospital we have a rapid
discharge pathway for patients in the last few days of
life which captures what patients will need to be
effectively supported at home if that is their wish.
We will monitor the number of patients referred for
rapid discharge and identify those that work well to
get patients home and also those that stop us
discharging patients home in their last few days.
Looking at the information on each patient in detail
will allow us to find ways to improve and build
services for the future.
Our website is at www.sdhct.nhs.uk
PRIORITIES FOR IMPROVEMENT / 2011/12 / PATIENT EXPERIENCE
Priority 4: To measure care and compassion of older people in Torbay Hospital in
response to the 2011 Health Ombudsman report highlighting the following areas
of dignity, healthcare associated infections, nutrition, personal care and discharge
from hospital.
The Hospital Palliative Care Team will also provide
quarterly reports to the Patient Experience and
Community Partnerships Governance Group
including an analysis of their findings, subsequent
recommendations and actions they are taking
forward to improve care.
The Trust will also report progress in its 2011/12
Quality Accounts. In year progress will be provided
through the quarterly Foundation Trust member’s
newsletter, the weekly staff newsletter, Trust Board
reports and the Trust internet site. We will also share
information with our partner organisations and key
stakeholders such as LINKs which can be
disseminated into their own publications.
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
15
>
Statements of assurance from the Board
STATEMENTS OF ASSURANCE FROM THE BOARD
Review of services
Participation in clinical audits
During 2010/11 South Devon Healthcare NHS
Foundation Trust provided and/or sub-contracted 47
NHS services (as per schedule two of its Terms of
Authorisation).
During 2010/11, 39 national clinical audits and 4
national confidential enquiries covered NHS services
that South Devon Healthcare NHS Foundation Trust
provides.
South Devon Healthcare NHS Foundation Trust has
reviewed all the data available to them on the quality
of care in 47 of these NHS services.
During that period South Devon Healthcare NHS
Foundation Trust participated in 90% national clinical
audits and 100% national confidential enquiries of
the national clinical audits and national confidential
enquiries which it was eligible to participate in.
The income generated by the NHS services reviewed
in 2010/11 represents 86% of the total income
generated from the provision of NHS services by
South Devon Healthcare NHS Foundation Trust for
2010/11.
The national clinical audits and national confidential
enquiries that South Devon Healthcare NHS
Foundation Trust was eligible to participate in during
2010/11 are as follows:
South Devon Healthcare NHS Foundation Trust eligibility: 2010/11
Acute myocardial infarction and other ACS (MINAP)
Acute stroke (SINAP)
Adult asthma (BTS)
Adult community acquired pneumonia (BTS)
Bowel cancer audit (NBOCAP)
Bronchiectasis (BTS)
Cardiac arrest procedure (NCEPOD)
Carotid interventions (Carotid Intervention Audit)
Centre for Maternal and Child Enquiries (CMACE) – perinatal mortality
COPD (BTS/European Audit)
Coronary angioplasty: (NICOR Adult Cardiac Intervention Audit ) – BCIS
Data for head and neck oncology (DAHNO)
Diabetes (RCPH National Paediatric Diabetes Audit)
Emergency use of oxygen (BTS)
Falls and non-hip fractures (National Falls and Bone Health)
Familial hypercholesterolaemia (National clinical audit of management of FH)
Feverish children (CEM)
Heart failure audit
Heavy menstrual bleeding (HMB) (RCOG)
Hip fracture (NHFD)
Hip, knee and ankle replacements (NJR)
ICNARC: adult critical care (Case Mix Programme)
ICNARC: cardiac arrest (National Cardiac Arrest Audit)
Lung cancer (National Lung Cancer Audit)
National continence audit
National neonatal audit programme (NNAP)
Non invasive ventilation (NIV) Adults (BTS)
16
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
Our website is at www.sdhct.nhs.uk
continued
continued
O negative blood use (Comparative Audit of Blood Transfusion)
Paediatric asthma (BTS)
Paediatric pneumonia (BTS)
Parenteral nutrition (NCEPOD)
Parkinson’s disease (Parkinson’s UK)
Peri-operative care (NCEPOD)
Peripheral vascular surgery (VSGBI Vascular Surgery Database)
Platelet use (Comparative Audit of Blood Transfusion)
Pleural procedures (BTS)
Potential donor audit (NHS B&T)
Renal colic (CEM)
Severe trauma (TARN)
Stroke care (National Sentinel Stroke Audit}
Surgery in the elderly (NCEPOD)
Ulcerative colitis and Crohn's disease (National IBD Audit)
Vital signs in majors (CEM)
STATEMENTS OF ASSURANCE FROM THE BOARD
South Devon Healthcare NHS Foundation Trust eligibility: 2010/11
>
Statements of assurance from the Board
The national clinical audits and national confidential
enquiries that South Devon Healthcare NHS
Foundation Trust participated in during 2010/11 are
as follows:
South Devon Healthcare NHS Foundation Trust participation: 2010/11
Acute myocardial infarction and other ACS (MINAP)
Acute stroke (SINAP)
Adult asthma (BTS)
Adult community acquired pneumonia (BTS)
Bowel cancer audit (NBOCAP)
Cardiac arrest procedure (NCEPOD)
Carotid interventions (Carotid Intervention Audit)
Centre for Maternal and Child Enquiries (CMACE) – Perinatal Mortality
COPD (BTS/European Audit)
Coronary angioplasty: (NICOR Adult Cardiac Intervention Audit ) – BCIS
Data for head and neck oncology (DAHNO)
Diabetes (RCPH National Paediatric Diabetes Audit)
Emergency use of oxygen (BTS)
Falls and non-hip fractures (National Falls and Bone Health)
Feverish children (CEM)
Heart failure audit
Heavy menstrual bleeding (HMB) (RCOG)
Hip fracture (NHFD)
Hip, knee and ankle replacements (NJR)
Our website is at www.sdhct.nhs.uk
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
17
>
Statements of assurance from the Board
continued
STATEMENTS OF ASSURANCE FROM THE BOARD
South Devon Healthcare NHS Foundation Trust participation: 2010/11
continued
ICNARC: adult critical care (Case Mix Programme)
ICNARC: cardiac arrest (National Cardiac Arrest Audit)
Lung cancer (National Lung Cancer Audit)
National continence audit
National neonatal audit programme (NNAP)
Non invasive ventilation (NIV) Adults (BTS)
O negative blood use (Comparative Audit of Blood Transfusion)
Paediatric asthma (BTS)
Paediatric pneumonia (BTS)
Parenteral nutrition (NCEPOD)
Peri-operative care (NCEPOD)
Peripheral vascular surgery (VSGBI Vascular Surgery Database)
Platelet use (Comparative Audit of Blood Transfusion
Potential donor audit (NHS B&T)
Renal colic (CEM)
Severe trauma (TARN)
Stroke care (National Sentinel Stroke Audit)
Surgery in the elderly (NCEPOD)
Ulcerative colitis and Crohn's disease (National IBD Audit)
Vital signs in majors (CEM)
The national clinical audits and national confidential
enquiries that South Devon Healthcare NHS
Foundation Trust participated in, and for which data
collection was completed during 2010/11, are listed
opposite alongside the number of cases submitted to
each audit or enquiry as a percentage of the number
of registered cases required by the terms of that
audit or enquiry.
18
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
Our website is at www.sdhct.nhs.uk
continued
Cases submitted
% Cases
Acute myocardial infarction and other ACS (MINAP)
459
100%
Acute stroke (SINAP)
792
100%
Adult asthma (BTS)
24
160%
Adult community acquired pneumonia (BTS)
78
390%
160
100%
3
Tbc
Carotid interventions (Carotid Intervention Audit)
20
100%
Centre for Maternal and Child Enquiries– Perinatal Mortality
tbc
Tbc
Continence audit
40
145%
COPD (BTS/European Audit)
60
100%
253
100%
38
100%
116
100%
4
40%
Falls and non-hip fractures (National Falls and Bone Health
60
100%
Feverish children (CEM)
50
100%
369
153%
tbc
Tbc
228
70%
tbc
tbc
712
100%
3
100%
188
100%
National neonatal audit programme (NNAP)
tbc
tbc
Non invasive ventilation (NIV) Adults (BTS)
17
100%
O negative blood use (Comparative Audit of Blood Transfusion)
21
53%
Paediatric asthma (BTS)
17
tbc
Paediatric pneumonia (BTS)
tbc
tbc
Parenteral nutrition(NCEPOD)
13
100%
Peri-operative care (NCEPOD)
6
100%
51
100%
8
20%
Potential donor audit (NHS B&T)
tbc
tbc
Renal colic (CEM)
42
84%
125
48%
Stroke care (National Sentinel Stroke Audit)
65
94%
Surgery in the elderly (NCEPOD)
12
100%
Ulcerative colitis and Crohn's disease (National IBD Audit)
tbc
Tbc
Vital signs in majors (CEM)
50
100%
Bowel cancer audit (NBOCAP)
Cardiac arrest (NCEPOD)
Coronary angioplasty (NICOR Adult Cardiac Intervention Audit)
Data for head and neck oncology (DAHNO)
Diabetes (RCPH National Paediatric Diabetes Audit)
Emergency use of oxygen (BTS)
Heart failure audit
Heavy menstrual bleeding (HMB) (RCOG)
Hip fracture (NHFD)
Hip, knee and ankle replacements (NJR)
ICNARC: adult critical care (Case Mix Programme)
ICNARC: cardiac arrest (National Cardiac Arrest Audit)
Lung cancer (National Lung Cancer Audit)
Peripheral vascular surgery (VSGBI)
Platelet use (Comparative Audit of Blood Transfusion)
Severe trauma (TARN)
Our website is at www.sdhct.nhs.uk
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
STATEMENTS OF ASSURANCE FROM THE BOARD
South Devon Healthcare NHS Foundation Trust
participation: 2010/11
>
Statements of assurance from the Board
19
>
Statements of assurance from the Board
continued
STATEMENTS OF ASSURANCE FROM THE BOARD
The reports of 13 national clinical audits were
reviewed by the provider in 2010/11 and South
Devon Healthcare NHS Foundation Trust intends to
take the following actions to improve the quality of
healthcare provided.
Ref
Recommendations / actions
N0009
National continence audit
The Assistant Director of Commissioning will assign a commissioning lead to this area – mid April 2011.
Either the Urology or Colorectal/Gastrointestinal Clinical Commissioning Group will be tasked with setting up a Task and
Finish group to do the following:
•
•
•
•
To scope current service provision in line with National Institute of Clinical Excellence (NICE) guidance
To identify gaps and develop recommendations
To produce an action plan for implementing the recommendations
To implement the actions in a timely manner (by 31st March 2012)
The action plan will be monitored by the agreed Clinical Commissioning Group at each of their meetings and assurance
provided to CQIPS and intervals to be agreed with CQIPS.
N0026
Severe trauma (TARN)
•
•
•
•
Reduce time to x-ray to less than 1 hour in cases of serious or severe chest trauma.
Recommend further audit of limb fractures to assure good outcomes from more junior staff.
Increase the percentage of trauma team activations for patients meeting major trauma criteria.
Discuss, via the Trauma Review Group, how we can CT scan multiple injured patients earlier and whilst still being
actively resuscitated.
• Increase the use of trauma proformas in all trauma cases admitted to the resuscitation room.
N0027
Stroke care (National Sentinel Stroke Audit)
Criterion 1 - 90% patients to spend 90% of time on a stroke unit
• Data from vital signs dashboard indicate 60-80% but affected by ward closures. Further ward staff being trained to
co-ordinate beds to increase cover over the week.
Criterion 10 – Direct admissions to stroke unit
• Continue to roll out new protocol for direct admissions to the stroke unit (introduced in February 2011). Vital signs
data for this indicator 86% so far for April 2011.
Criterion 12 – document discussions with patients/relatives
• Ensure consultants and juniors document discussions re diagnosis in notes. Tick box to be added to multi-disciplinary
team sheet re-diagnosis been discussed and documented. Ward round reminder.
N0030
Adult asthma (BTS)
The 2010 audit shows that Torbay performs well in all domains and exceeds national standards in several areas. No
action plan required.
N0031
Ulcerative colitis and Crohn's disease (National IBD Audit)
Waiting report.
N0033
Peripheral vascular surgery (VSGBI Vascular Surgery Database)
No actions required
20
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
Our website is at www.sdhct.nhs.uk
National neonatal audit programme (NNAP)
Waiting report.
N0037
Emergency use of oxygen (BTS)
• Continue to participate in the national audit and participate in education re oxygen prescription.
N0039
Heart failure audit
• Ensure patients admitted with heart failure are seen/assessed by cardiology/specialist.
• Consider appointing a nurse specialist
Miscoding of Congested Cardiac Failure
• Improve through use of inpatient B-type natriuretic peptide and provide better access to echocardiograms prior to
discharge.
• Review discharge coding criteria
N0041
Paediatric asthma (BTS)
Waiting report.
N0043
Hip Fracture (NHFD)
STATEMENTS OF ASSURANCE FROM THE BOARD
N0035
continued
>
Statements of assurance from the Board
• Improve the quality of data entered into the national hip fracture database (NHFD).
• Ensure that bone health assessment and appropriate initiation of secondary prevention occurs in >90% of fractured
neck of femurs.
• Start specialist falls assessment, with appropriate information sharing and referral to community falls services in >50%
of fractured neck of femurs.
• Implement the fractured neck of femur fast track pathway via clinical trauma co-ordinators to enhance performance
in Blue Book Standard 1&2.
N0044
•
•
•
•
•
Lung Cancer (National Lung Cancer Audit)
Improve communication with Peninsula Cancer Network at network site specific group.
Ensure core multi-disciplinary team members attend communication skills training.
Improve GP notification of cancer diagnosis.
Survey nurse led clinic regarding patient and carer experience.
Track stage and performance score at presentation and also track survival.
N0049
Coronary Angioplasty: (NICOR Adult Cardiac Intervention Audit ) – BCIS
No actions required.
The report of one national confidential enquiry was
reviewed by the provider in 2010/11 and South
Devon Healthcare NHS Foundation Trust intends to
take the following actions to improve the quality of
healthcare provided.
NCEPOD Elective & emergency surgery in the elderly: an age old problem
• Report & recommendations received by Patient Safety Committee
• Actions being taken forward by Department of Medicine & Surgery
Our website is at www.sdhct.nhs.uk
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
21
>
Statements of assurance from the Board
continued
STATEMENTS OF ASSURANCE FROM THE BOARD
The reports of 46 local clinical audits were reviewed
by the Trust in 2010/11 and South Devon Healthcare
NHS Foundation Trust intends to take the following
actions to improve the quality of healthcare provided.
Ref
Recommendations / actions
5603
Intensive Care Unit (ICU) re-admissions
• Assess the risk of re-admission prior to discharge through introducing a form.
5634
Falls in general surgery
• Educate ward staff (through induction training) that all patients over 75 years, who fall, must have a specialist falls
assessment done.
• Introduce falls care pathway to support risk assessment process, so as to educate staff on how to manage falls.
• Educate staff that high to moderate risk patients on initial assessment should be referred to Falls Clinic for specialist
falls assessment.
5684
Fertility
• Reduce BMI cut off level for treatment/ investigations at Torbay from 45 to 35.
• Review the use of notes and documentation.
• Set up an active registry for patients using Clomid.
5687
Femoral artery puncture
• Produce protocol for prescribing of anti-platelet therapy for patients.
5764
•
•
•
•
•
•
•
Publish "What is postural hypotension" leaflet.
Consider the introduction of warning triangles relating to falls on patients’ wipe-boards.
Devise and standardise a ‘smarter’ falls assessment tool.
Develop a falls prevention leaflet for patients and carers.
Email monthly safety crosses indicating falls.
Send details to wards in community hospitals information regarding ‘Intentional rounding’ and new slippers.
Share and discuss information with the Productive Community Hospital Ward Lead.
5768
•
•
•
•
Falls in community hospitals
Enhanced recovery for total hip and knee replacement (TKR and THR)
Introduce 'Joint School' to better inform patients of rapid recovery process.
Produce rapid recovery patient information pack.
Pre-select patient groups for pre-operative assessment and consent.
Investigate new gymnasium/physiotherapy space for patients.
5774
Consent to chemotherapy and radiotherapy
• Investigate the potential of using treatment specific consent forms.
• Revise the format of the cancer service consent form.
22
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
Our website is at www.sdhct.nhs.uk
Diabetic foot care
• Ensure a care plan for each patient is recorded in the GP practice notes.
• Develop a systematic method of recording examination findings carried out by community podiatry (checklist for foot
examination).
• Encourage the use of the Texas Wound Score to aid the referral system from GP surgery to community podiatry and
the hospital.
• Develop a standardised assessment of patients for the hospital podiatry department.
• Revise the assessment proforma to include short and long term management, date of referral, information given to
patient and documentation to confirm wound photographed.
• Review system for foot examinations carried out by the GP.
• Inform GP practices to record at risk patients as part of their coding system.
5797
Management of malignant spinal cord compression
• Educate healthcare professionals emphasising the importance of early recognition of malignant spinal cord
compression, appropriate steroid prescribing and timely imaging requesting.
• Educate patients regarding symptoms and signs of malignant spinal cord compression.
• Highlight guidelines to health care professionals for the management of malignant spinal cord compression.
• Review current guidelines prior to new NICE guidance (NICE Metastatic Spinal Cord Compression clinical guideline
2008)
5813
Intravitreal antiVEGF agents for wet age-related macular degeneration (ARMD)
STATEMENTS OF ASSURANCE FROM THE BOARD
5783
continued
>
Statements of assurance from the Board
• Identify way to capture data electronically to participate in a benchmarking process. In the interim develop a
prospective proforma to collect the data. (This will be shared with the four other regional centres.)
• Set up a critical incident book and report systemic complications which may be currently under reported. Develop a
questionnaire to monitor performance.
• Ensure that there are improvements in the referral processes from primary care. Set up a training evening for GPs and
Optometrists.
• Ensure that patients with wet ARMD are seen by retinal specialist within two weeks of referral.
• Ensure that patients commence treatment <2 weeks from referral.
5817
Lower limb amputations
• Review patient information and produce a new patient leaflet. (This leaflet is to include information concerning falls,
care of the contra-lateral limb and phantom limb pain).
• Create new inpatient documentation for amputation patients that will be easier to use across the surgical wards.
• Provide further training and guidance on lower limb amputations to the rotational physiotherapists.
5851
Stroke care pathway
• Modify proforma and amalgamate with generic clerking proforma.
• Educate Emergency Department and Emergency Admission Unit on the stroke care pathway
5864
Bedside transfusion practice
• Educate medical and nursing staff regarding the procedure of bedside transfusion through blood transfusion
competency assessments and mandatory training sessions.
5873
Cervical screening prior to hysterectomy
• Circulate the NHSCSP guideline to all clinicians with a reminder to ask the woman for her smear history and to
document this discussion.
5874
Laparoscopic techniques for hysterectomy (IP-239)
• Give all patients undergoing Laparoscopic Hysterectomy the EIDO patient information leaflet 0908.
Our website is at www.sdhct.nhs.uk
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
23
>
Statements of assurance from the Board
STATEMENTS OF ASSURANCE FROM THE BOARD
5877
continued
Texas wound score (TWS)
• Set up team training by the specialist podiatrist for each clinical team on the texas wound score.
5886
Trauma surgery
• Finalise trauma surgery list and make it accessible.
• Appoint an anaesthetic consultant as overall Anaesthetic Trauma Lead.
• Address issues regarding operation start times.
5887
•
•
•
•
Evaluation of early warning scores for unplanned Intensive Care Unit admissions
Introduce/ launch electronic patient record system.
Source PDAs (Personal Digital Assistant) for clinicians to input observations.
Produce rapid recovery patient information pack.
Pre-select patient groups for pre-operative assessment and consent.
5900
Surgical repair of vaginal wall proplapse using mesh
• Provide an additional information letter/ leaflet in clinic letter, prior to operation as well as post procedure.
• Document QoL assessment in the notes.
• Add Pelvic Organ Prolapse Quantification (POPQ) scores to the patient’s notes.
5908
Hydration and documentation for pre-operative fractured neck of femur patients
• Amend Trust fluid balance chart.
• Feedback results to ward staff regarding fluids given across all NBM days.
• Discuss audit results & recommendations at Trauma and Orthopaedic audit meeting.
5911
Trial of instrumental delivery
• Laminate and display list including clinicians’ responsibilities regarding instrumental delivery in appropriate clinical
area.
• Document post delivery debrief in the dark purple maternity notes.
5912
Time to theatre for category one caesarean section
• Ensure Operating Department Practitioners (ODPs) take responsibility for giving pre-med to category one cases.
(This is to be added to the C-Section policy).
5913
Screening for congenital dislocation of the hip
• Amend Trust guideline that states scanning should take place between four and six weeks to scanning should take
place between five and seven weeks.
• Increase awareness of screening within the community midwives and GPs.
5920
Hygienist referral treatment plans
• Ensure that Maxillo-Facial medical staff dictate a formal letter to explain what is required from the Hygienist
• Disseminate audit results to Orthodontics department.
24
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
Our website is at www.sdhct.nhs.uk
Risks of chest drain insertion
• Improve consent in all situations, unless there are clearly documented reasons to the contrary. (A completed consent
form should be signed by the patient or next of kin.
• Develop a specific consent form for chest drain insertion.
• Ensure there is a record of insertion, reason for insertion, monitoring of chest drain, record of removal and record of
complications
• Reduce complication rate through centralising care, ensuring appropriately trained individuals undertake procedure,
using pre-insertion imaging and the use of Rocket Drains.
• Publish new protocol on the intranet.
5928
Hormonal therapies for the adjuvant treatment of oestrogen - receptor - positive breast cancer (TA-112)
• Add box to current proforma/ care pathway, indicating that history discussion has taken place and whether history
was applicable.
• Add discussion box to the MDT record after the results clinic.
5932
Isolation
• Ensure that information leaflets regarding alert organisms are readily available on all wards.
• Ensure Infection Control Surveillance Nurse provides training regarding isolation.
5933
Newer drugs for epilepsy (TA-076)
STATEMENTS OF ASSURANCE FROM THE BOARD
5922
continued
>
Statements of assurance from the Board
• Develop a history taken summary sheet which will be kept in the patient notes
• Develop a first seizure protocol in conjunction with A&E department, to ensure all patients attending with a first
seizure are referred to Epilepsy Specialist Nurse, within two weeks of seizure.
5938
Management of patients with clostridium difficile
• Ensure the Infection Control Audit and Surveillance Nurse provides education regarding the management of
clostridium difficile to nursing staff.
• Ensure all ward managers undertake the Saving Lives care bundles and set a baseline score and report subsequent
scores quarterly to the Healthcare Acquired Infection Group.
5939
Obstetric haemorrhage - post partum haemorrhage
• Amend Trust policy to include new criteria for CNST level three.
• Highlight importance of record keeping through mandatory training.
• Discuss at Risk Review meeting consultant role in obstetric haemorrhage.
5942
Third and fourth degree tears
• Highlight importance of record keeping through mandatory training,
• Review pro-forma to ensure its relevance.
5950
Paediatric pain assessment
• Make pain assessment tool available in minors.
• Display drug dose to patient weight charts in minors.
• Provide self assessment 'paediatric analgesia passport' documentation to parents/ children on booking in.
Our website is at www.sdhct.nhs.uk
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
25
>
Statements of assurance from the Board
STATEMENTS OF ASSURANCE FROM THE BOARD
5954
continued
Paediatric eating disorders
• Add copy of the new care pathway to the patient notes on admission. This will include the re-feeding sticker which
enables observations and tests to be recorded.
(It was noted in the re-audit that daily blood tests (criterion 3) only need to be taken if the patient suffers from refeeding syndrome.)
• Develop a simple proforma to supplement the care pathways, highlighting the key actions that need to be address for
differing diagnosis of eating disorders.
5958
Paignton and Brixham community hospitals (MUST score)
• Develop nutrition update sessions for staff at community hospitals including use of section seven of the ‘Adult
Assessment and Care Plan’.
5959
Nephrotoxicity in patients with impaired renal function undergoing cardiac catheterisation or
coronary intervention
• Consider cost effectiveness - all patients to have Visipaque
• Determine/ discuss whether to use eGFR as a predictor of developing contrast induced nephropathy.
• Decide appropriate eGFR cut off and then use this is in the nephrotoxicity protocol.
5966
Screening for pulmonary hypertension
• Create a more comprehensive database of limited scleroderma patient investigations, including calendar reminders for
secretaries and ensure yearly ECHO and PFT for all patients with scleroderma regardless of symptoms.
• Ensure all investigations are carried out on the same day.
5967
Guidance on the use of Riluzole (Rilutek) for the treatment of Motor Neurone Disease (MND) (TA-020)
• Introduction of a new Motor Neurone Disease co-ordinator
• Commence regular Motor Neurone Disease care meetings at Rowcroft Hospice with Neurology and Palliative Care.
5970
Podiatry records, assessment and consent audit coordinator
• Ensure Bio-mechanical Podiatrists add full name and IHCS details on every page of "Bio booklet".
• Issue action plan "Flyer" to all staff. .
5974
Methicillin-resistant staphylococcus aureus (MRSA)
• Ensure that ward managers ensure nursing staff document in the case notes if a patients is in a side room or bed
number of where patient is being treated.
• Undertake a small prospective review of MRSA patients
5990
Prostate cancer (CG-058)
• Present findings at the Urological Multi-Disciplinary Meeting
• Amend urology prostate consent form to ensure the four indicators recommended by NICE are discussed with the
patient prior to biopsy.
6008
Breastfeeding neonates admitted to hospital with weight loss
• Promote the use of breastfeeding assessment forms through team meetings. Store alongside the various maternity
team weighing scales.
• Remind staff through team meetings and steering groups of the importance of informing the infant feeding specialist
midwife, when an infant is admitted to SCBU with weight loss.
26
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
Our website is at www.sdhct.nhs.uk
Bladder filling for radical radiology to prostate cancer
• Revise bladder filling protocol for radical radiotherapy to prostate cancer, to include specific and universal regimes for
patients during their radiotherapy before each of their treatments.
6025
Use of Meropenem in the Acute Trust
• Monitor CCU, Cromie, Dunlop and Midgley by liaising with pharmacists and removing 'restricted antibiotic' stock
• Hold a 'brain-storming' exercise with pharmacists and microbiologists on systems for controlling restricted antibiotics.
Action recommendations made.
6026
Surgical antibiotic prophylaxis
• Disseminate results & teaching session for anaesthetists on Antimicrobial prophylaxis
(There was a single occurrence of antibiotic prophylaxis for a mesh repair in this audit, although this was thought to be
necessary as the patient had an ESBL positive urine culture. SIGN (Scottish Intercollegiate Guidelines Network) do not
recommend antibiotic prophylaxis in any hernia repair. Discuss guidelines and agree way forward.)
6074
Paediatric deliberate self harm (DSH) 2010 (CG-016)
• Redesign referral and assessment to incorporate shortfalls identified in documentation.
6076
Paediatric physiotherapy goal setting
STATEMENTS OF ASSURANCE FROM THE BOARD
6015
continued
>
Statements of assurance from the Board
• Set up working party to design and introduce assessment tool that will highlight time bound short term goals and
indicate which original assessment tool was used.
• Ensure physiotherapists peer review each others note keeping and documentation (every three months).
Our website is at www.sdhct.nhs.uk
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
27
>
Statements of assurance from the Board
STATEMENTS OF ASSURANCE FROM THE BOARD
Research
The number of patients receiving NHS services
provided or sub-contracted by South Devon
Healthcare NHS Foundation Trust in 2010/11 that
were recruited during that period to participate in
research approved by a research ethics committee
was 1305.
Participation in clinical research demonstrates South
Devon Healthcare NHS Foundation Trust’s
commitment to improving the quality of care we
offer and to making our contribution to wider health
improvement. Our clinical staff stay abreast of the
latest possible treatment possibilities and active
participation in research leads to successful patient
outcomes.
South Devon Healthcare NHS Foundation Trust was
involved in conducting 298 clinical research studies in
33 medical specialties during 2010/11.
There were 71 clinical staff (as listed investigators)
participating in research approved by a research
ethics committee at South Devon Healthcare NHS
Foundation Trust during 2010/11. These staff
participated in research covering 33 of medical
specialties.
As well, in the last three years, a number of coauthored publications have resulted from our
involvement in NIHR research, which shows our
commitment to transparency and desire to improve
patient outcomes and experience across the NHS.
Our engagement with clinical research also
demonstrates South Devon Healthcare NHS
Foundation Trust commitment to testing and offering
the latest medical treatments and techniques. Here
are just a few examples of how our participating in
research improves patient care.
28
continued
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
Visual impairment study
South Devon Healthcare NHS Foundation Trust is
the first Trust in the peninsula to take part in the
MERLOT study examining the use of combination
therapy using new iRAY technology for patients
with age related macular degeneration. This is a
major cause of visual impairment in the over 50s.
Torbay is only one of seven centres selected to
recruit patients and offer patients the chance to
participate and attend treatments in two national
Centres equipped with the new technology.
Orthopaedic research
The Trust has been participating in two national
orthopaedic studies. The first comparing the
results of patients receiving arthroscopic rotator
cuff repairs with those having open repairs. The
results of this study will ensure that patients are
offered the most cost and clinically effective
surgery for their shoulder disorder.
The second study is investigating the clinical
effectiveness and cost-effectiveness of surgical
versus non-surgical treatment for displaced
fractures of the humerus. The results of this study
will ensure that surgery is only performed on
patients where it has been shown to be the most
effective management option.
Our website is at www.sdhct.nhs.uk
continued
A proportion of South Devon Healthcare NHS
Foundation Trust income in 2010/11 was conditional
on achieving quality and improvement and
innovation goals agreed between South Devon
Healthcare NHS Foundation Trust and any person or
body they entered into a contract, agreement or
arrangement with for the provision of NHS services,
through the Commissioning for Quality and
Innovation payment framework.
Further details of the agreed goals for 2010/11 and
for the following 12 month period are available
electronically at
http://www.institute.nhs.uk/world_class_commissioni
ng/pct_portal/cquin.html
In 2010/11 the value of the CQUIN payment and
income subsequently received was £2,304k. In
2011/12 the value of the CQUIN payment is £2,543k
(tbc).
Care Quality Commission
South Devon Healthcare NHS Foundation Trust is
required to register with the Care Quality
Commission and its current registration status is for: • Diagnostic and screening procedures
• Family planning services
• Management of supply of blood and blood
derived products
South Devon Healthcare NHS Foundation Trust has
no conditions on registration.
The Care Quality Commission has not taken
enforcement action against South Devon Healthcare
NHS Foundation Trust during 2010/11.South Devon
Healthcare NHS Foundation Trust has not participated
in any special reviews or investigations by the CQC in
the reporting period.
STATEMENTS OF ASSURANCE FROM THE BOARD
CQUIN payment
>
Statements of assurance from the Board
• Maternity and midwifery services
• Surgical procedures
• Transport services, triage and medical advice
provided remotely
• Treatment of disease, disorder or injury
Our website is at www.sdhct.nhs.uk
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
29
>
Statements of assurance from the Board
continued
STATEMENTS OF ASSURANCE FROM THE BOARD
Data quality
Providing data which is relevant, accurate and timely
is key to delivering high quality service and ensuring
that service improvements are driven by using robust
data and evidence based research and information.
access to a locally developed data quality dashboard
to ensure that quality data is monitored. This is
backed up by a programme of audit which includes
data quality, when measuring performance.
Currently the management of data quality is
monitored by the clinical teams themselves and also
a dedicated support team. The Trust Board has also
NHS number and general medical practice validity
South Devon Healthcare NHS Foundation Trust
submitted records during 2010/11 to the Secondary
Users 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:
The percentage of records in the published data
which included the patient’s valid General Medical
Practice Code was:
• 99.6% for admitted care
• 99.3% for accident and emergency care
• 99.9% for admitted care
• 100% for outpatient care
• 99.8% for outpatient care
• 98.1% for accident and emergency care
Information governance
South Devon Healthcare NHS Foundation Trust
Information Governance Assessment report overall
score for 2010/11 was 71% and was graded green.
30
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
Our website is at www.sdhct.nhs.uk
continued
South Devon Healthcare NHS Foundation Trust will
take the following actions to improve data quality in
2011/12:
• Improve the timeliness of data entry on all wards,
including ensuring that as patients are transferred
to wards estimated dates of discharge, consultant
information and information relating to the clinical
management of the patient is updated at the
same time and then routinely updated throughout
their patient stay.
• Improve the quality of the Trust workforce data
held on the Electronic Staff Record (ESR) system.
This includes reviewing the hierarchies currently
used to allow managers and staff to access and
review their data. Personal information will also be
reviewed to ensure it is current.
• Review and update the Information Asset Register
to ensure that all known and unknown
information assets are identified. This will ensure
that all information assets such as databases, IT
systems and health records are clearly documented
centrally within the organisation. Assurance can
then be provided to the Trust Board with regards
to their management and the maintenance of the
quality of the data held.
• Improve the management of Trust policies and
procedures to ensure they are recorded
consistently, in a standard format and are kept up
to date. In 2011/12 all policies will be transferred
to an online document management system which
will support this process.
• Act on any recommendations from the
forthcoming external audit of these Accounts. This
includes the auditors testing the data quality of
two nationally mandated performance indicators
and one local indicator agreed by the Trust
Governors. The indicators are:
• MRSA – mandatory indicator.
• Maximum waiting time of 62 days from urgent
GP referral to first treatment for all cancers –
mandatory indicator.
• Percentage of ST elevation myocardial infarction
(STEMI) patients who received primary
angioplasty within 150 minutes of call (call to
balloon time) – Governor agreed indicator on
heart attacks.
STATEMENTS OF ASSURANCE FROM THE BOARD
Data quality improvements
>
Statements of assurance from the Board
• Improve our information governance score from
71% to 85%. This includes undertaking more
detailed risk reviews of key applications and
processes. We will also improve the dissemination
of information to key stakeholders who have a
responsibility for information governance.
Clinical coding error rate
South Devon Healthcare NHS Foundation Trust was
not subject to the Payment by Results clinical coding
audit during 2010/11 by the Audit Commission.
Our website is at www.sdhct.nhs.uk
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
31
>
OUR PERFORMANCE IN 2010/11 AND OTHER QUALITY INITIATIVES
32
OUR PERFORMANCE
IN 2010/11 AND
OTHER QUALITY
INITIATIVES
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
Our website is at www.sdhct.nhs.uk
>
Performance
Torbay Hospital has been a Foundation Trust since
2007. Its principal activities are providing a range of
acute services including accident and emergency,
maternity, paediatrics and a range of medical and
surgical services. South Devon Healthcare NHS
Foundation Trust is recognised as a leading trust in
areas such as day surgery and integrated care.
The clinical teams, the Trust Executive and the Trust
Board work closely with primary care and community
services across South Devon to ensure that care is
provided as seamlessly as possible. There are many
mechanisms in place to ensure that there is an
integrated approach. Our governance groups
typically include a non executive director chair, clinical
& management leads, a governor representative, a
commissioner and where appropriate a lay
representative. The Trust has regular Board to Board
meetings with Torbay Care Trust who provide our
community based services. Clinical teams also work
with clinical colleagues across South Devon through
clinical commissioning groups and through day to
day contact.
Good governance and sound financial management
is at the heart of ensuring we are performing well.
Monitor, the independent regulator for Foundation
Trusts, rates us on this. Since 2007 we have
maintained a low risk rating.
We also monitor and report against a range of
quality and performance indicators. These include
metrics drawn from Monitor requirements, the NHS
operating framework and the NICE quality standards,
as and when they are published and implemented.
Information and data is collated and published to the
Trust Board through a variety of mechanisms. This
includes a Trust safety scorecard, an integrated
performance dashboard and a data quality
dashboard. Creating dashboards allows us to easily
visualize information, track trends and measure our
performance against a range of targets or standards.
Any quality and performance indicators which are
marked amber or red are reviewed and an action
plan agreed.
Over the last year the hospital has also developed a
Quality Accounts proforma. This innovative form is
used by clinical teams to support them in developing
services and reviewing care. The proforma supports
staff in ensuring that everyone places quality at the
centre of care. (See Annex 2 for sample proforma.)
OUR PERFORMANCE IN 2010/11 AND OTHER QUALITY INITIATIVES
Overview
Monitor - Risk ratings at a glance – 2010/11
Finance
1 2 3 4 5
KEY
1= Highest risk
5= Lowest risk
Governance
Red = Highest risk
Green= lowest risk
Downloaded April 11 from Monitor website
Our website is at www.sdhct.nhs.uk
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
33
>
OUR PERFORMANCE IN 2010/11 AND OTHER QUALITY INITIATIVES / PATIENT SAFETY
34
Our performance against our key quality objectives
Patient safety
The national indicators outlined in the 2009/10
Quality Accounts have been reported again this year
and are shown in the table below. They continue to
reflect the focus on reducing hospital acquired
infections. This year, from our range of quality
indicators which we monitor internally, we have also
included never events. These indicators are nationally
recognised measures of patient safety.
Indicator
Data source
Number of methicillin-resistant
Staphylococcus aureus
bacteraemia reports1
Health Protection
Agency (2b)
Number of clostridium difficile
cases1
Health Protection
Agency (6a)
Level of hand hygiene
compliance
Venous thromboembolism rates are being monitored
as part of our ongoing quality improvement work
and reported as part of our CQUIN target and
through our Safer Patient Initiative dashboard.
National standard
or average 10/11
2010/11
2009/10
2008/9
3
1
2
3
67
26
28
34
Trust Audit
95%
90%
94%
83%
Percentage of staff saying
hand washing materials are
always available
NHS Staff survey
(KF19)
67%
63%
61%
72%
Number of never events
Trust Safeguard
database
0
0
n/a
n/a
(1) MRSA and C difficile data has changed from the 09/10 Quality Accounts. We have adjusted the figures to reflect only our
hospital rates & cases.
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
Our website is at www.sdhct.nhs.uk
>
Our performance against our key quality objectives
This year we have reported on the same quality
indicators as in our first Quality Accounts. We have
also included sickness absence rates and whether
staff would recommend the Trust as a place to work
or receive treatment. Typically, we judge the quality
of care received on the standards we ourselves would
expect. Therefore, this is an additional useful
indicator of quality.
The Trust uses a combination of staff and patient
measures to measure patient experience. A range of
this information is collected, collated, reported and
actioned through three governance work groups
(safety, patient experience and workforce). This
includes quarterly complaints reports and actions,
feedback from individual services regarding their
patients’ experience and actions from local and
national surveys.
Staff views are also a valuable indicator of the quality
of care being offered. The NHS annual staff survey
and staff workforce data all offer the Trust insight
into how the staff view their organisation and the
work they perform in it.
2010/11
2009/10
2008/9
n/a
80
82
81
Trust Safeguard
n/a
170
229
307
Staff job satisfaction3
NHS Staff Survey
(KF32)
3.48
3.50
3.55
3.62
Staff recommendation of the
trust as a place to work or
receive treatment3
NHS Staff Survey
(KF34)
3.52
3.57
3.75
n/a
Annual staff sickness absence
rate
Electronic Staff
Record
4.5%
3.77%
3.53%
4.38%
Indicator
Data source
National standard
or average 10/11
Overall rating of care received1
NHS inpatient survey
(Q74)
Number of patient complaints2
(1) NHS Inpatient survey reports data including confidence levels for each measure. This informs the Trust as to the reliability of
the data. The indicator Q74 has a confidence level of 78 lower and 82 upper. This suggests that if the survey was repeated the
possible average score may have been in a different place. This is important as a standard of 81 would place the Trust in the top
20% of performing trusts.
NHS Inpatient results are published in subsequent years to the data collection period. For the purpose of this report the
published 2010/11 data is the 2009 Inpatient survey.
OUR PERFORMANCE IN 2010/11 AND OTHER QUALITY INITIATIVES / PATIENT EXPERIENCE
Patient experience
(2) Safeguard is our Trust complaints management system. To ensure consistency of reporting the figures from this database
have been used for reporting from 2008/9 onwards in this year’s Quality Accounts.
(3) Both NHS staff survey questions are rated on a scale of 1-5. (1= Most dissatisfied/unlikely to recommend and 5=Most likely
to recommend/most satisfied)
Our website is at www.sdhct.nhs.uk
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
35
>
OUR PERFORMANCE IN 2010/11 AND OTHER QUALITY INITIATIVES / CLINICAL EFFECTIVENESS
36
Our performance against our key quality objectives
Clinical effectiveness
Clinical effectiveness is informed through using a
broad range of indicators including the hospitalised
standardised mortality rate (HSMR) and compliance
with national and local standards such as clinical
audits. Timeliness is important and waiting time
information is collected on a daily basis and some
new metrics such as care planning summaries have
been introduced this year and will be collected as a
matter of course.
Clinical quality is also measured in part through
metrics such as re-admission rates and length of stay.
For the purpose of the Quality Accounts we have
changed the table this year to provide a broader
picture of quality. It also complements well with the
data reported in the next section.
2010/11
2009/10
2008/9
100
85.3
95.0
97.8
Dr Foster
4.4
3.4
3.6
3.6
Day case rate1
Dr Foster
87.6%
89.8%
89.2%
87.8%
Re-admission rate1
Dr Foster
6.2%
7.3%
6.9%
6.6%
Indicator
Data source
HSMR
Dr Foster
Length of stay (days)1
National standard
or average 10/11
(1) Dr Foster peer average by case mix & volume
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
Our website is at www.sdhct.nhs.uk
>
Our performance against key national priorities
We are required to report to Monitor quarterly on a
range of targets/indicators. Our performance over
the last 12 months is shown below.
Indicator/Target
C.difficile year on year reduction
MRSA - Meeting the MRSA objective
All cancers: 31 day wait for second or
subsequent treatment
All cancers: 62 day wait for first
treatment
4 hours in A+E from arrival to
admission transfer or discharge
All cancers: 31 day wait for first
treatment from diagnosis
All cancers: two week wait from
referral to first seen date
Thrombolysis within 60 minutes (where
this is the preferred local treatment)1
Screening for all elective in-patient for
MRSA
Self certification against compliance
with requirements regarding access to
healthcare for people with a learning
disability
Q1
Q2
Q3
Q4
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Achieved
Achieved
Achieved
Achieved
Achieved
Achieved
Achieved
Achieved
Achieved
Achieved
Achieved
Achieved
Achieved
Achieved
Underachieved
5 out of 9 met
Achieved
Achieved
Not applicable
5 or less
Achieved
Achieved
Achieved
Achieved
Achieved
Achieved
Achieved
Achieved
Achieved
Underachieved
4 out of 6 met
Achieved
Achieved
Achieved
Achieved
Achieved
Achieved
Achieved
Achieved
Achieved
Not applicable
5 or less
Achieved
OUR PERFORMANCE IN 2010/11 AND OTHER QUALITY INITIATIVES
Monitor
Achieved
(1) Thrombolysis is no longer the preferred local treatment hence the number of cases have fallen in some quarters to below the
minimum threshold of 5 cases in a quarter to be relevant.
Our website is at www.sdhct.nhs.uk
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
37
>
Our performance against key national priorities
OUR PERFORMANCE IN 2010/11 AND OTHER QUALITY INITIATIVES
NHS Operating Framework and local priorities
Indicator/Target
2010/11
Referral to treatment times
18 wk RTT (Admitted) - target 90% of patient pathways
18 wk RTT - by specialty (Admitted)
18 wk RTT (Non-Admitted) - target 95% patient pathways
18 wk RTT - by specialty (Non-Admitted)
•
•
•
•
Achieved
Achieved
Achieved
Underachieved - note 1
Cancers diagnosis to treatment waiting times
First definitive treatment within 1 month
Subsequent surgery within 1 month
Subsequent drug treatment within 1 month
Subsequent treatment in radiotherapy or any other treatment within 1 month
•
•
•
•
Achieved
Achieved
Achieved
Achieved
Cancer urgent referral to treatment waiting times
Within 62 days of GP or dentist urgent referral for suspected cancer
Within 62 days of urgent referral from the national screening service
Within 62 days of urgent referral from a consultant for suspected cancer
•
•
•
Achieved
Achieved
Achieved
Cancer urgent referral to first outpatient appointment waiting times
Within 2 weeks when urgently referred by their GP or dentist with suspected cancer.
Within 2 weeks when urgently referred with any breast symptom except suspected cancer.
•
•
Achieved
Achieved
Other National and local priorities
Diagnostic tests longer than the 6 week standard - local target maintain 09/10 level
Patients waiting longer than three months (13 weeks) for revascularisation
Time to reperfusion for patients who have had a heart attack (call to needle)
Primary PCI within 150 minutes of calling.
Total time in A&E+MIU – 4hrs - target 98%
Delayed transfers of care - target < 2%
Stroke care - 80% of patients spending 90% of hospital stay on dedicated stroke unit
TIA
Incidence of Clostridium Difficile (Acute Trust only)
Incidence of MRSA( Acute Trust only)
Maternity data quality
Smoking during pregnancy
Breastfeeding initiation rates (% initiated breast feeding)
Cancelled operations on the day of surgery - target < 0.8% of all elective admissions
38
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Underachieved - note 2
Achieved
Underachieved - note 3
Achieved
Achieved
Achieved
Underachieved - note 4
Achieved
Achieved
Achieved
Achieved
Achieved
Underachieved - note 5
Underachieved - note 6
Our website is at www.sdhct.nhs.uk
continued
Indicator/Target
2010/11
Other National and local priorities
Breaches of the 28 day guarantee to readmit patients cancelled on the day
Rapid access chest pain clinic waiting times: seen in 2 weeks
•
•
•
•
•
•
•
•
•
Achieved
Achieved
Achieved
Ethnic coding data quality
Achieved
Breast cancer screening
Achieved
Access to GUM clinics – offered
Achieved
Chlamydia screening
Achieved
12 week maternity appointments
Percentage of ST elevation myocardial infarction (STEMI) patients who received primary
angioplasty within 150 minutes of call (call to balloon time).
Achieved
Achieved
Diabetic retinopathy screening
Note 1 - At a specialty level in each quarter of 2010-11 one specialty failed to meet the national standard of 95% for non
admitted referral to treatment
Note 2 - Patients waiting greater than 6 weeks for a diagnostic test in 2010-11 monthly waiting time census reported 166
patients waiting over 6 weeks. This is an increase on the previous year, however comparative performance remains good against
SHA performance.
Note 3 - 22 patient were eligible against the criteria for call to needle measurement with 61% receiving thrombolysis treatment
within 60 minutes from initial call for help.
OUR PERFORMANCE IN 2010/11 AND OTHER QUALITY INITIATIVES
NHS Operating Framework and local priorities
continued
>
Our performance against key national priorities
Note 4 - The national standard has not been met with and an average of 70% for the year being recorded against the 80%
target. Clinical pathway changes and operational controls have been implemented and the Trust is now on track to deliver the
80% standard and is in the top 3 trusts in the SW Strategic Health Authority area against this measure.
Note 5 - This is the first year that a year on year improvement has not been achieved.
Note 6 - There has been an overall improvement on the previous year (402) with a total this year of 344 patient recorded as
having operations cancelled on the day of surgery (0.97% of all elective admissions). Work is ongoing to reduce these
cancellations to a minimum.
Our website is at www.sdhct.nhs.uk
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
39
>
Other quality improvement initiatives in 2010/11
OUR PERFORMANCE IN 2010/11 AND OTHER QUALITY INITIATIVES
Looking back over the last year, the Trust has continued to build and develop the
quality of its services. More information can be found in the Trust’s 2010/11
annual report and annual review. Below are just a few of the highlights from
2010/11.
Developing a sustainability strategy
Endoscopy Unit opens its doors
The Trust has recently approved a new Sustainability
Strategy which offers many benefits to the people of
South Devon including:-
Towards the end of the year, Torbay reopened its
newly refurbished Endoscopy Unit to South Devon
patients. The unit which caters for approximately
6,500 patients each year now has vastly improved
waiting areas, consultation rooms as well as single
sex recovery areas. The aim has been to improve the
overall experience of patients, with a particular focus
on improving privacy and dignity. The feedback to
date has been extremely positive.
• saving money through efficiencies around fuel and
energy consumption
• contributing to the local economy e.g. by
reducing ‘air/road miles’ and supporting local
businesses
• promoting health and wellbeing across the
community
• creating a sustainable organisation.
In 2010/11 several public awareness events were
held in the Hospital with the themes of energy use,
community partnerships and recycling. Also transport
links have continued to be important with the Trust
continuing to promote cycling, using public transport
and car sharing. Patient parking has continued to be
improved with better patient and visitor drop off
facilities and new disabled parking outside the front
entrance of the hospital. The Trust continues to work
closely with the Council and the local community and
supports Torbay Council’s park and ride proposals.
Stroke services continue to improve
The Trust continues to focus on improving stroke
services through implementing the NICE quality
stroke standards. The patient pathway continues to
be improved with a steady increase in the number of
direct admissions to the Stroke Unit. There is also
active work ongoing reviewing and improving our
out of hours service. The Board receives regular
reports regarding improvement and compliance
against the standards.
‘TEA’ campaign gains nationally recognition
The Trust launched its Take Early Action (TEA)
campaign in 2010/11. Designed by the Hospital’s
Cancer Services team, the aim of the programme is
to help patients recognise the early signs of
neutropenic sepsis following chemotherapy and to
seek appropriate care.
As a result of the work undertaken, the team have
been recognised at the national Patient Safety
Awards. The awards recognise best practice projects
and initiatives that have been developed by NHS
organisations across the country.
40
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
Our website is at www.sdhct.nhs.uk
>
Annex 1
Prior to the publication of the 2010/11 Quality
Accounts we have shared this document with:
• Our Trust governors and commissioners
• Torbay & Devon LINKs
• Torbay and Devon County Council’s Health
Overview and Scrutiny Committee.
This year’s Quality Accounts has benefitted from a
wider consultation process and greater engagement
with our community in choosing the 2011/12 priority
areas. We have had greater input from directors,
clinicians and their clinical teams. We have taken
information reported through our governance
processes and feedback from local and national
surveys to build a picture of priority areas for the
coming year.
Quality Accounts
mandated content
The development of CQUIN’s has been clinically led
and the 2011/12 continuous improvement projects
have been driven as part of our annual business
planning process with each service area.
In March 2011 the Trust held its first Quality
Accounts Engagement event inviting key
stakeholders including the OSCs, LINKs,
commissioners and Trust governors to come together
and recommend the priority areas to be included in
these Quality Accounts. (See diagram below).
CQUINS, CIP, Peer Reviews,
NICE Quality Standards,
Governance work streams
etc.
Local & national inpatient
surveys & feedback, LINK
surveys, Trust Members’
survey etc
Organisational Quality Improvement Long List (Feb 2011)
ANNEX 1 ENGAGEMENT IN DEVELOPING THE QUALITY ACCOUNTS
Engagement in developing the Quality Accounts
Quality Accounts Shortlist - Engagement Event & Recommendations (Mar 2011)
OSC, Commissioners,LINKs, Governors, Trust Directors
Board sign off of recommendations (April 2011)
Quality Accounts priorities 2011/12
Our website is at www.sdhct.nhs.uk
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
41
>
Annex 1
ANNEX 1 STATEMENTS FROM GOVERNORS, OSC, LINKs AND COMMISSIONERS
Statements from Commissioners, Governors, OSCs and LINKs
Commissioners
Torbay Care Trust, as lead commissioner for South Devon Healthcare NHS Foundation Trust
(SDHFT) is pleased to provide a statement for inclusion in this Quality Accounts. Torbay Care
Trust has taken reasonable steps to corroborate the accuracy of data provided within this
Quality Accounts and considers it contains accurate information in relation to the services
provided.
Information contained accords with data received throughout the year in question, and
which is considered within regular Performance & Contracting and Quality Review meetings.
Looking Back
Priority 1 for patient safety last year was to improve the percentage of those patients admitted to
hospital who had a risk assessment for VTE, and who then received the appropriate treatment. The
Trust reports that on average 89% of admitted patients were risk assessed for VTE, which was below
their target of 95%. However this should be considered in light of the National target of 90%. This
target for improvement is a national safety improvement initiative and will remain as part of the
incentive scheme for next year.
For Priority 2, the Trust experienced significant challenges in achieving the planned improvements in
care planning summaries being sent to GPs within 24 hours of discharge. We understand and
acknowledge the difficulties faced in achieving the CQUIN target of 80% and we look forward to
supporting SDHFT over the coming year to achieve the goal, which is continued through the incentive
scheme into 2011/12.
Priority 3 set out to improve overall communication with patients and improved patient experience.
The commissioners are very pleased to see the substantial improvement the Trust has made in the
areas of patient experience outlined in last year’s Quality Accounts. Of particular note are the greatly
improved Ambulance Turnaround times where they are now one of the best performing hospitals in
the South West. The Trust should be congratulated for their work in this area, which has involved not
only a change in processes but a real cultural shift to improve the experience and safety of patients.
The looking back section of the quality review concentrates on celebrating successes and the excellent
work the Trust has done, which is commendable. Commissioners are particularly pleased to note the
Trusts work on learning from complaints and incidents which demonstrates their development of a
culture which learns from experience.
Looking forward to 2011/12
Torbay Care Trust has worked very closely with SDHFT to identify those areas which will be prioritised
for the next year. As commissioners we are pleased to support initiatives that will improve pressure
ulcer prevention, avoidance of malnutrition and dehydration, and of falls – all of which are detrimental
to patient health and experience. The productive ward initiative is designed to allow nurses time to
care, and this is very important within a busy acute hospital so that care and compassion is strongly
aligned with efficient ward systems and processes.
‘Enhanced recovery’ is an initiative which is fully supported by Torbay Care Trust and which will offer
both improved outcomes for patients as well as a better experience of care. The commissioners will be
working with and supporting the Trust to achieve the best possible outcomes over the next year.
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Annex 1
Commissioners continued
The Care and Compassion report by the Health Ombudsman highlighted issues of patient experience
for older patients. SDHFT will use the learning from that report to ensure that patients in their care are
well treated and have a good experience of care. They plan to use various methods to collect feedback
and to learn from this, to continuously improve care. The commissioners are fully supportive of this
initiative.
Plans to work across the health community to improve the experience of patients at the end of their life
who wish to die at home are very welcome and the commissioners look forward to working with the
Trust to support partnership working in this important area.
SDHFT has worked hard to ensure that the dignity of patients is protected at all times and particularly
to ensure that the standards for Eliminating Mixed Sex Accommodation are adhered to. The numbers
of breaches of these standards has reduced dramatically, thanks to the hard work of staff at all levels,
and the commissioners commend the Trust for their concentration on this initiative. We will continue to
support the Trust through the coming year as they complete their action plan for ensuring all areas of
the hospital can provide the required separation of male and female patients, when that is desirable.
The Trust continues to ensure that there is a culture of patient safety, demonstrating the importance of
safety through leadership and participation in both national and local improvement programmes. There
have been no Never Events, and where serious incidents do occur, the Trust has signed up to the NPSA
framework for reporting and investigating and learning from incidents. This effort has helped underpin
the performance of the Trust against several key national and local quality priorities, including reduced
infection rates.
The Trust’s record of involvement in national audit and its own audit programme is commendable and it
is assuring to see the organisational willingness to undertake clinical audit and re-audit, improving
many areas of care as a result. Audit participation, particularly in national audits is very time consuming,
and the commissioners appreciate the high level of involvement notwithstanding.
The Trust is to be commended on this year’s focus on internal quality governance arrangements which
are designed to ensure each clinical team understands and is involved in improving quality of care and
patient experience, thus embedding the culture of quality throughout the organisation.
ANNEX 1 STATEMENTS FROM GOVERNORS, OSC, LINKs AND COMMISSIONERS
Statements from Commissioners, Governors, OSCs and LINKs
The commissioners were very pleased about the inclusive way in which the Trust worked with the OSC,
LINKs and the commissioners to promote discussion about the priorities for next year and to allow
those partner agencies to be involved in the whole process of selecting quality priorities for our local
population.
Our website is at www.sdhct.nhs.uk
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ANNEX 1 STATEMENTS FROM GOVERNORS, OSC, LINKs AND COMMISSIONERS
Statements from Commissioners, Governors, OSCs and LINKs
South Devon Healthcare NHS Foundation Trust Governors
The governors of South Devon Healthcare Foundation Trust (the Trust) have always played a strong
part in holding the Board of Directors to account, seeking to assure themselves that the Trust is well
run, with emphasis on patient safety and a good patient experience. The only change in the past year
has been to put greater emphasis on quality.
The Trust’s operations are overseen by five Governance Working Groups (Workstreams), each chaired
by a Non-Executive Director and including those Executive Directors responsible for delivery. Each
Workstream has a governor observer who, though not a voting member, can contribute to the
business and is required to report any issues and concerns back to the Governance Board. Similarly,
there is a governor observer at the Audit and Assurance Committee (currently the Lead Governor).
There are also governor representatives on the Equality and Diversity panel and the Communications
group. Individual governors have been able to take part in activities such as a Patient Environment
Action Team review and to observe an Adverse Events meeting. These have given good assurance that
lessons are learned, and improvements put in place, when deficiencies or errors are found. The
‘Working with Us’ panel was set up to provide governors, and the membership at large, with an
opportunity to review the patient experience, including discharge interviews with patients.
Some of the governors’ advice to the Board of Directors comes from members’ completion of a
carefully prepared questionnaire, the results of which are read and analysed by the elected governors
for the three member constituencies (South Hams and East Plymouth, Teignbridge and Torbay).
Constant effort is made to develop still further the range of interaction with members; a recent and
well-supported initiative has been ‘Medicine for Members’ presentations. This will continue next year.
Following the introduction of Quality Accounts into the Trust’s annual reporting, the external auditors
identified the need for governor involvement in the accounts for 2010-11. At the request of the
Chairman of the Board, a group of governors was set up to look at quality and compliance matters.
The Care Quality Commission (CQC) governors’ group is currently composed of interested volunteers
and has no formal status. It includes constituency and staff governors and aims to be competent to
assess whether or not the Trust takes quality seriously in everything it does.
Through a series of meetings and presentations the group has become aware of CQC values and of
the mechanisms within the Trust for compliance with stated CQC standards in the areas for which the
Trust has been registered. Activities have been reported back to full Governance Board meetings. In
March 2011 the group joined other stakeholders at a Quality Accounts engagement event. This was
held to discuss and identify priorities for areas of improvement for 2011-12 (those selected are
outlined in the Quality Accounts above). Governors played a significant part in this meeting and had
the particular responsibility for selecting one indicator where the quality of data capture will be looked
at in detail. The choice of ‘call to balloon time’ in connection with ST elevated myocardial infarction
(heart attack) was made because we felt this to be so relevant to our catchment area with its high
proportion of pensioners.
In 2011 the CQC group is likely to be formalised into a full governors’ committee with terms of
reference, a largely elected membership and better links with Workstreams. The governors are able to
confirm receiving sufficient assurance during 2010-11 to report that the Trust has high regard for the
importance of improving quality standards in all the areas for which it is registered and will continue to
strive for excellence.
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Torbay Health Scrutiny Board & Devon County Council’s Health
and Adults’ Services Scrutiny Committee
This is the statement from Torbay Health Scrutiny Board, including a commentary from Devon
County Council’s Health and Adults’ Services Scrutiny Committee.
Due to Council elections, Torbay Health Scrutiny Board has not been able to consider South Devon
Healthcare NHS Foundation Trust’s Quality Accounts for 2010/11. However, the document has been
considered by the Chair and Vice-chair of the Board who welcome the comprehensive information on
the quality of care and services included in the report and believe that, based on the knowledge they
have of the provider, this Account is an accurate and fair interpretation of the healthcare services
provided. Demonstrable progress in addressing the Trust’s three priority areas for quality improvements
in 2010/11 is pleasing. During 2010/11 the Torbay Health Scrutiny Board looked at ambulance
handover delays and, while appreciating evidence of an initial significant improvement, the Board
resolved to continue to monitor the position; minimising the time that ambulance crews have to spend
at the hospital and that patients have to wait to be admitted continues to be a key area of
improvement in 2011/12.
Although not directly related to healthcare quality, patient and visitor parking remains a local healthcare
issue of concern (notwithstanding the measures described within the Quality Accounts under
‘Developing a sustainable strategy’).
The engagement process pursued by the Trust with Overview and Scrutiny in relation to the production
of the Quality Accounts for 2010/11 is commended and reflects the positive ongoing engagement of
the Trust to the OSC. In accordance with Department of Health guidance, Overview and Scrutiny would
welcome early discussions around the proposed content of a Quality Account and an opportunity to
review early drafts. A Quality Account is intended to be a report to the public on the quality of service
of a healthcare provider and OSC endorse the publication of a more accessible, user-friendly version of
the report for 2010/11.
Devon County Council’s Health and Adults’ Services Scrutiny Committee (SC) determined to contribute
to the commentary of Torbay Council’s Health Scrutiny Board on the Southern Devon Healthcare NHS
Foundation Trust Quality Accounts 2011-12. All references in this commentary relate to the reporting
period 1 April 2010 to 31 March 2011 and pertain only to the Trust’s relationship with the SC.
ANNEX 1 STATEMENTS FROM GOVERNORS, OSC, LINKs AND COMMISSIONERS
Statements from Commissioners, Governors, OSCs and LINKs
At the Trust’s initiative, the SC’s Chairman and Vice-Chairman met the Trust’s Chairman and Deputy
Chief Executive in May 2010 and in March 2011, they joined Torbay Council’s and the Trust’s
discussions to determine the Trust’s reporting priorities for the 2010-11 Quality Accounts. The SC would
therefore like to highlight and commend the Trust’s proactive approach in cross-local authority
boundary working and the openness and transparency of its operations.
Our website is at www.sdhct.nhs.uk
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ANNEX 1 STATEMENTS FROM GOVERNORS, OSC, LINKs AND COMMISSIONERS
Statements from Commissioners, Governors, OSCs and LINKs
Torbay LINK
Thank you for your copy of the Quality Accounts for 2010- 2011. The Link would like to praise South
Devon Healthcare Trust in achieving improvements in many areas through this difficult period.
The overall presentation of the report is greatly improved from previous year.
Following consultation with Link members and other participating groups, we would like to comment
as follows:
Main points raised:
•
•
•
•
•
•
•
•
Quality Accounts title – not patient friendly.
Not easy to read – although improvement since last year, still very professional approach
Links and their involvement not included in the introduction
Link has not been involved in the development of the report.
No evidence that Link has been consulted regarding the priorities being set for the future
Clear evidence not always apparent in report and some ambiguities in the statistics reported.
National Audit results are hidden at the back of the report.
Telephone call – it was good to see over 90% handled within one minute, query raised on how
South Devon Health Care Trust monitor calls and if the figures provided were based on calls
answered or a combined figure of calls answered/unanswered.
• Noted that complaints were down – this is good, but less people were satisfied as recorded (to
clarify)
• Trust has set 5 priorities for 2011-2012 – Link would have appreciated being included in this process
throughout the year.
• Link would like to see more detail on patient engagement in reaching these priorities and more
information on quality indicators.
Suggestions and recommendations were put forward
• CPS data quoted, no comparative data to see improvement over previous year.
• Glossary of terms and abbreviations should be presented on initial pages
• The Link would like to see improved working relationships with the Hospital Board and other
committees.
• Hospital appointments – understand previously target driven, however patients wishing to make
multiple appointments with difference departments need to have 24hr break in process.
Hope you find the above information constructive and look forward to working with South Devon
Health Care Trust in the coming year.
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The directors are required under the Health Act 2009
and the National Health Service (Quality Accounts)
Regulations 2010 to prepare Quality Accounts for
each financial year. Monitor has issued guidance to
NHS foundation trust boards on the form and
content of annual quality reports (which incorporate
the above legal requirements) and on the
arrangements that foundation trust boards should
put in place to support the data quality for the
preparation of the Quality Accounts.
In preparing the Quality Accounts, directors are
required to take steps to satisfy themselves that:
• the content of the Quality Accounts meets the
requirements set out in the NHS Foundation Trust
Annual Reporting Manual;
• the content of the Quality Report is not
inconsistent with internal and external sources of
information including:
• Board minutes and papers for the period April
2010 to June 2011;
• Papers relating to Quality reported to the Board
over the period April 2010 to June 2011;
• Feedback from the commissioners dated
26/05/2011;
• Feedback from governors dated 17/05/2011;
• Feedback from OSCs dated 05/05/2011;
• Feedback from LINKs dated 25/05/2011;
• The trust’s complaints report published under
regulation 18 of the Local Authority Social
Services and NHS Complaints Regulations 2009,
dated November 2010;
• The 2009 national inpatient survey 19/05/2010;
• The 2010 national staff survey 16/03/2011;
• The Head of Internal Audit annual opinion over
the trust’s control environment dated
01/06/2011;
• Care Quality Commission quality and risk
profiles dated April 2011;
• the Quality Accounts presents a balanced picture
of the NHS foundation trust’s performance over
the period covered;
• the performance information reported in the
Quality Accounts is reliable and accurate;
• there are proper internal controls over the
collection and reporting of the measures of
performance included in the Quality Accounts, 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 Accounts is
robust and reliable, conforms to specified data
quality standards and prescribed definitions, is
subject to appropriate scrutiny and review; and the
Quality Accounts has been prepared in accordance
with Monitor’s annual reporting guidance (which
incorporates the Quality Accounts regulations)
(published at www.monitornhsft.gov.uk/annualreportingmanual) as well as
the standards to support data quality for the
preparation of the Quality Accounts (available at
www.monitor-nhsft.gov.uk/
annualreportingmanual)).
ANNEX 1 STATEMENT OF DIRECTOR'S RESPONSIBILITIES
Statement of Directors' Responsibilities
The directors confirm to the best of their knowledge
and belief they have complied with the above
requirements in preparing the Quality Accounts.
By order of the Board
01.06.2011
Peter Hildrew, Chairman
01.06.2011
Paula Vasco-Knight, Chief Executive
Our website is at www.sdhct.nhs.uk
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QUALITY INDICATORS - SAMPLE OF A PROFORMA FOR OUR EMERGENCY DEPARTMENT
Quality indicators - Sample of a proforma for our Emergency Department
Mandatory indicators
Dimension
SAFETY
Metric
INCIDENT REPORTING
NEVER EVENTS
INFECTION RATES
Indicator
Number of Serious Untoward Incidents
Number of Never Events
No. of C-Diff incidents & MRSA
Bacteraemias
Results from the Saving
IN HOSPITAL VTE
Speciality compliance with VTE
assessment & prophylaxis
EFFECTIVENESS
MORTALITY
HSMR
COMPLIANCE WITH NATIONAL
LOCAL STANDARDS
NICE TAG compliance and audit
Compliance with national audits &
specialty peer reviews
Involvement with NCEPOD surveys
Involvement with NPSA Alerts
TIMELINESS
No of Care Planningy Summaries within
24 hours
CLINICAL QUALITY
No of eligible patients recruited to
national clinical trials
Re-admission rate
EXPERIENCE
PATIENT SATISFACTION
Complaints received
Actions completed following
Patient surveys
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Emergency Dept indicators
Dimension
SAFETY
Metric
Indicator
COMMUNICATION
Safety Briefings
MDT Board Rounds/Acute Physicians
TIMELINESS
MDT CIWA-AR Tool
VULNERABLE PATIENT GROUP
Nurse Education
SAVING LIVES
Venflon Documentation
EFFECTIVENESS
PRODUCTIVE WARD
RTC/Medicines Management.
NETWORKING
Domestic Violence
MARAC
ARID
CARE OF THE FAMILY
Safeguarding Children
CLINICAL QUALITY
Named Nursing Benchmarking
Nurse Training / Development
EXPERIENCE
PATIENT SATISFACTION
QUALITY INDICATORS - SAMPLE OF A PROFORMA FOR OUR EMERGENCY DEPARTMENT
Quality indicators - Sample of a proforma for our Emergency Department
Feedback Forms/Observations of Care
Single Sex Accommodation
Our website is at www.sdhct.nhs.uk
Quality Accounts for 2010/11 / South Devon Healthcare NHS Foundation Trust
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Available in large print on request
South Devon Healthcare NHS Foundation Trust
Headquarters
Hengrave House
Lawes Bridge
Torquay
TQ2 7AA
Switchboard: 01803 614567
HQ Fax: 01803 616334
www.sdhct.nhs.uk