Quality Account
2014/15
Puttingpeoplefirst
212
2014/15 Quality Account contents
Section 1 – Introduction
1
Statement on quality from the chief executive
1
A guide to the structure of this report
3
How quality is embedded in the culture of North
5
Middlesex University Hospital
Quality achievements performance against
58
dying prematurely
Domain 2 – Enhancing quality of life for 61
people with long-term conditions
Domain 3 – Helping people to recover from
61
episodes of ill health or following injury
7
key national priorities in 2014/15
Quality headlines from 2014/15
Domain 1 – Preventing people from
Domain 4 – Ensuring people have a positive
67
experience of care
8
Glossary9
Domain 5 – Treating and caring for people in
70
a safe environment and protecting them from
avoidable harm
Section 2 – Priorities for improvement and
statements of assurance from the board
11
Section 3 – Annexes
73
Delivery against our quality priorities and
11
Annex 1: Statements from commissioners, 73
local Healthwatch organisations and
objectives for 2014/15
Patient safety priorities:
13
Overview and Scrutiny Committees
2014/15 performance
Annex 2: Statement of directors’ responsibilities
Patient experience priorities:
for the Quality Account
17
Annex 3: External audit assurance report
2014/15 performance
Clinical effectiveness priorities:
23
2014/15 performance
Quality priorities for 2015/16
25
Patient safety priorities for delivery in 2015/16
26
Patient experience priorities for delivery
32
in 2015/16
Clinical effectiveness priorities for delivery
36
in 2015/16
Statements of assurance from the board
40
National clinical audit participation 2014/15
41
National confidential enquiry
45
participation 2014/15
78
79
Quality Account
Section 1
Statement on quality
from the chief executive
I am delighted to introduce our Quality Account for the year 2014/15,
a year which saw the staff of North Middlesex University Hospital rise
to the challenge of embedding and delivering high quality care and the
benefits envisioned with the implementation of the Barnet, Enfield and
Haringey clinical strategy.
This Quality Account reports on the quality of
services provided by the trust throughout 2014/15
and highlights the delivery of important quality
achievements and the quality objectives we set
ourselves in last year’s Quality Account. As a result
of the implementation of the Barnet, Enfield and
Haringey (BEH) clinical strategy, and the closure of
accident and emergency and maternity services
at Chase Farm Hospital, this year saw the trust
care for 178,863 patient attendances to accident
and emergency, in comparison to 163,457 A&E
attendances during the previous year. During
2014/15 there were 5,090 babies delivered at North
Middlesex University Hospital in comparison to
4,226 in the previous year. Against this background
of rapidly expanding services, the trust underwent
a planned CQC inspection in June. This inspection
concluded that the trust provided good quality care
in surgery, intensive care, maternity and paediatrics.
Disappointingly, the CQC inspection found that the
care provided in accident and emergency, medicine,
outpatients and at end-of-life required improvement.
Since receiving this inspection report, my team
and the frontline staff of the hospital have worked
tirelessly, and with key external stakeholders such
as the CQC, our local commissioners, and the Trust
Development Authority, to implement a quality
improvement plan. I am confident that this plan is
delivering the required improvements to the quality
of care in the services identified by the CQC. The
trust will be reinspected by the CQC to check that
we have made the improvements necessary for all
our services to be classified as ‘good’.
1
This year has seen the trust implement the third year
of the patient safety strategy in order to improve
health outcomes and deliver harm-free care to our
patients. As you will read later in the report, the
trust has continued to work hard to reduce harm
caused to patients during their treatment, such as
hospital-acquired infections, injuries sustained as
a result of falls in hospital, and the management of
deteriorating patients and patients with sepsis, so
that the trust continues to provide safe care and
good standardised mortality rates.
Despite these efforts, there have been aspects of
our care which have not met the standard of care we
expect to provide all our patients. The trust reported
a “never event” in March when a patient received an
incorrect blood transfusion. The trust’s performance
during 2014/15 in terms of infection control has been
mixed. No patient-acquired an MRSA bacteraemia
infection at North Middlesex University Hospital
during the year. This is a fantastic achievement.
However, there have been 12 Clostridium difficile
infections attributable to lapses in care reported
across the trust during the year. Therefore, whilst
the trust provides good, safe care to the vast
majority of our patients, I and my team are clear,
there is no room for complacency and further
improvements to the safety of our services are
possible and this report will outline the trust’s safety
improvement plan for 2015/16 which will deliver
these continued improvements.
Quality Account
Accounts
Section 1
The trust continues to concentrate efforts on
improving the experiences for both our patients and
our staff. This report will outline the progress we have
made in improving the patient experience during
the course of 2014/15 and the patient experience
objectives that are planned for achievement in
2015/16. This year we have developed our values
and behaviours programme to embed the lessons
learned from the “in our shoes” project. This focuses
on understanding that the way our staff behave has
a tremendous impact on the care we offer to our
patients and the experience of working at North Mid.
As part of this we held our first annual staff awards
ceremony at Alexandra Palace which provided me
with an opportunity to recognise and celebrate the
outstanding achievements and commitment to our
patients of our members of staff. Continuing this
important work to improve the experiences of our
patients and staff will remain a key priority as we
move into 2015/16.
Finally, I confirm that to the best of my knowledge,
the information contained throughout this document
is accurate.
Julie Lowe
Chief executive
2
Quality Account
Section 1
A guide to the structure of this report
Quality Account and CQUINs
This document is one of the ways in which we
report on the quality of care we provide.
The report summarises our performance and
improvements against the quality priorities and
objectives that we set ourselves in 2014/15.
We have detailed how we performed in 2014/15
against the priorities and objectives we set
ourselves for patient safety, clinical effectiveness
and patient experience. We have also outlined our
quality priorities and objectives for 2015/16. We
have detailed how we will achieve and measure
our performance. The regulated statements of
assurance are included as well.
We have provided other information to review our
overall quality performance against key national
priorities and standards. One of the important
mechanisms for this reporting is the commissioning
for quality and improvement (CQUIN) framework.
As CQUINs and data gathered from CQUINs are
referred to a number of times in our Quality Account
an explanation is provided of what they are and how
they are relevant to our Quality Account.
3
The CQUIN framework was introduced in April 2009
as a national framework for locally agreed quality
improvement schemes. CQUINs are designed to
make a proportion of provider income conditional on
the achievement of ambitious quality improvement
goals and innovators.
CQUINs are intended to reward excellence and
encourage providers to drive a portfolio of quality
improvement on a continuous basis. Each year
providers and commissioners come together to
agree the details of how nations and local priorities
will be achieved and measured. An example of a
national priority is participation in the NHS “safety
thermometer” which every provider organisation
has to achieve. A local priority is to participate
in value-based commissioning locally. A series
of milestones and targets are agreed in advance
and each provider is required to submit evidence
to commissioners at regular intervals – usually
quarterly – in order to ensure that the funding
associated with the quality improvement is paid.
4
Quality Account
Section 1
How quality is embedded in the culture
of North Middlesex University Hospital
North Middlesex University Hospital has embedded
continuous quality improvement into the
organisational culture by putting in place a structure
that enables quality to be effectively measured
and monitored. This framework also enables
quality improvement initiatives to be effectively
implemented in response to external drivers such
a local commissioner initiatives or developments in
national priorities.
The trust engages with its commissioners to improve
quality via contracting and the inclusion of CQUINs
and quality requirements in the trust’s contract.
Performance against these quality requirements is
monitored by the trust and commissioners monthly
at CQRG.
This culture is underpinned by a robust quality
governance framework. Quality has been integrated
into the trust’s performance management
framework. This enables the trust board to
triangulate key quality performance data alongside
other performance metrics such as financial
performance. Furthermore our performance
management framework ensures that clinical
business units are held to account for the quality
of the services they provide. This directorate level
of scrutiny is supported by local ward level quality
dashboard reporting which enables effective
monitoring of ward and departmental level quality,
so that ward sisters and heads of department are
accountable for the quality of care provided in
their areas.
The trust has a number of quality improvement
strategies and initiatives in place to drive quality
improvement across the hospital. For example, the
trust is currently implementing a “two at the top”
programme to enhance local ward level ownership
of quality improvement interventions.
Priority
Key objective
Measure
Rating
Process and outcome
Mostly Met
Outcome
Met
Process and outcome
Mostly Met
To build on the peer review of
the London Quality Standards for
Clinical Effectiveness
London Quality Standards
emergency care to ensure that
for emergency care
we meet all the standards that
are relevant to the organisation
and within its remit
Trust-wide focus
Patient Safety
on delivering
harm free care
Patient Experience
5
Continuous improvement
in patient experience
To reduce the incidence of
unintended injury to patients.
To implement year 3 of the
patient safety strategy
To make improvements in
specific areas of patient
experience
Quality Account
Section 1
Continuous quality improvement
Patient safety
Patient experience
Clinical effectiveness
External drivers
Quality governance framework
Internal drivers
Commissioning (cquins, national and
local quality requirements)
Trust board integrated performance
report
Quality strategy
National initiatives (sign up to safety,
nhsla safety bids)
Risk and quality committee
Patient safety strategy
Cqc inspections
Patient safety group
Patient experience strategy
National patient experience surveys
Patient representative forum
Clinical audit strategy
Friends and family tests
Cbu performance meetings
Better care better value
Two at the top
Qipp
Performance management framework
6
Quality Account
Section 1
Quality achievements performance
against key national priorities in 2014/15
The financial year 2014/15 has seen North Middlesex University Hospital continue to deliver almost
total compliance with all of the key national priorities on both its quarterly and full-year targets, with the
exception of four hour A&E performance during the winter. Achievement of these priority targets gives a
clear indication that both access to services and quality around care we provide to patients is extremely
high and very safe. The table below outlines this very positive achievement.
Indicator
Target
YTD
Actual
Q1
Actual
Q2
Actual
Q3
Actual
Q4
2014–15
YR or
YE
A&E 4-hour performance (all types)
95%
95.1%
95.4%
92.0%
92.0%
93.6%
18 weeks referral to treatment (RTT) – admitted patients
90%
94.0%
93.5%
93.7%
94.4%
94.4%
18 weeks referral to treatment (RTT) – non-admitted patients
95%
97.0%
95.3%
97.1%
97.0%
97.0%
18 weeks referral to treatment (RTT) – incomplete pathways
92%
92.8%
93.7%
94.0%
95.1%
95.1%
Cancer 2 week wait – suspected cancer
93%
94.2%
93.5%
95.1%
95.4%
94.6%
Cancer 2 week wait – breast symptomatic
93%
94.2%
93.4%
94.9%
97.7%
95.0%
Cancer 31 days from decision to treat to first treatment
96%
99.5%
99.5%
99.0%
98.7%
99.2%
Cancer 31 days for subsequent treatment – anti-cancer drugs
98%
100%
100%
100%
100%
100.0%
Cancer 31 days for subsequent treatment – radiotherapy
94%
100%
100%
100%
98.3%
99.6%
Cancer 31 days for subsequent treatment – surgery
94%
100%
100%
100%
100%
100.0%
Cancer 62 days from urgent GP referral to first treatment
85%
89.1%
89.4%
92.4%
88.3%
90.1%
Cancer 62 days from NHS cancer screening service referral
90%
100%
100%
100%
100%
100.0%
Cancer 62 days from consultant upgrade
85%
97.8%
97.9%
96.8%
87.6%
96.4%
Diagnostics waiting times
99%
100%
99.3%
99.5%
99.6%
99.6%
Operations not rebooked within 28 days
0
0
0
0
0
0
Cancelled operations on the day, not rebooked
0.8%
0.5%
0.2%
0.3%
0.7%
0.4%
Maternity bookings within 13 weeks with referrals received at
< 13W
90%
98.1%
98.3%
98.9%
99.2%
98.6%
Clostridium difficile (Aged 2+) – hospital-acquired / received
19
7
2
1
2
12
MRSA bacteraemias – hospital-acquired
0
0
0
0
0
0
Mortality (SHMI) – rolling 12 months
100.0
80.1
81.2
87.6
87.4
87.4
* indicates provisional performance as at April 2015
In addition, the trust has made a number of improvements to the quality of services provided across the
hospital. The calendar below gives an overview of some of highlights of the improvements and initiatives
that we delivered to our patients during 2014/15.
7
Quality Account
Section 1
Quality headlines from 2014/15
Month
Quality headline
April 2014
North Middlesex University Hospital health bus health awareness campaign continued in April. The former
ambulance, kitted out with health screening devices and testing equipment, began a programme of visits to
schools, leisure centres and community events across Enfield and Haringey. The outreach campaign sought
to identify the health needs of local people and worked with them to improve their lifestyles and knowledge of
healthcare options. The campaign worked closely with local GPs to increase registration and reduce unnecessary
trips to the hospital’s accident and emergency (A&E) department and urgent care centre (UCC).
May
On International Nurses Day (12 May) our nurses and midwives put on a fantastic show of stalls and events in the
hospital’s main atrium. First prize for best stall went to senior nurses Cathy Fairs and ward sister Jane Horwood
of Michael Bates ward. The stall showcased their Institute of Healthcare Improvement and McKinsey project to
reduce harm to patients through better ward communications. There was also a programme of live music and
poetry performed by our staff for our new ‘Arts in the Atrium’ event.
June
Consultant geriatrician Dr Sophie Edwards, the trust’s lead on dementia, continued to raise dementia
awareness through staff and local community training across the hospital. She introduced “carers’ passports”
to make visiting easier and developed the “10 things about me” bedside cards to help staff and visitors have
conversations with dementia inpatients. She has also increased screening on admissions and introduced
massage therapy for patients. Her work received national recognition in March 2014 when she won the Kate
Granger award for campassionate care, judged by NHS England, NHS Employers and staffside.
July
Our human resources team won a national award for their recruitment campaign which attracted over 450 high
calibre staff during last year’s hospital expansion. They scooped the ‘strategic approach to recruitment’ award at
the HPMA Excellence in HR management event. The campaign successfully recruited 220 nurses and midwives,
110 healthcare assistants, 90 medical staff, and 30 scientific, technical and therapeutic staff over a six month
period by advertising online, through social media and in local job centres under the strapline ‘together we work’.
The judges praised the large-scale recruitment and the breadth of approach. The award was sponsored by the
Health Service Journal.
August
The trust opened its two fully refurbished children’s units. The new units include our paediatric assessment unit
(PAU) and paediatric day assessment unit (PDAU). The PAU sees mainly children who are admitted through our
children’s A&E department for further assessment. The PDAU sees children who need to be in the hospital for
a full day of diagnostic tests or treatment. The spacious new wards have bright new décor, furnishings, toys
and equipment.
September
Our fantastic new Macmillan Cancer Information and Support Centre officially opened in September. It’s for
cancer patients, their family and friends, and is located on level two of the hospital’s main atrium, next to the lifts.
Tottenham Hotspur FC star Ledley King was our guest of honour.
October
The trust celebrated its first Our Staff Awards ceremony at Alexandra Palace. Over 100 staff were nominated for
prizes in 10 categories and the trust recognised the dedication of 46 members of staff who had each worked at
the hospital for more than 25 years.
November
Our diabetic eye-screening service launched a mobile screening service to extend its reach to patients across
the North East London area it serves. It’s the latest improvement to the hospital’s highly praised diabetic eyescreening programme which is rated as one of the best in the country.
December
We opened a new heart catheterisation laboratory at the hospital to help hundreds of local patients with heart
problems. The lab enables diagnostic angiograms to be carried out – a procedure in which a catheter is guided
to the patient’s heart with the help of x-rays before special contrast dye is injected, creating a map of the heart’s
arteries and veins. Our cardiology team have also performed the hospital’s first cardiac stress echocardiogram in
which a patient’s heart valves are comprehensively monitored using ultrasound while they exercise.
January 2015
The trust announced the opening of the refurbished tower wards on levels 3, 5, 6, 7 and 8. All five wards,
including medicine for the elderly, respiratory, gastroenterology, renal, diabetes and endocrinology,have been
fitted with new floors, new side rooms and new four-to-a-bay areas that feel comfortable and spacious for
our patients.
February
The trust expanded its mental health team from five to 20. The team uses the RAID model of rapid
assessment interface and discharge and work closely with community mental health teams to support
discharge and follow up.
March
The trust opened its newly refurbished ambulatory care unit and day hospital in the Pymmes building. Their
completion marks the end of five years of major building work which has transformed the hospital.
Nearly all our services are now delivered from buildings that are completely new or which have been fully
modernised, including our brand new maternity unit and our expanded A&E department.
8
Quality Account
Section 1
Glossary
A&E
Accident and emergency
ACE-i
Angiotensin-converting-enzyme inhibitor
ACSAAnaesthetics clinical services accreditation awarded by the Royal College of
Anaesthetists
ANS
Association of Neurological Scientists
ARB
Angiotensin II receptor blockers
ARTAnaesthetics review team, an onsite review conducted by the Royal College of
Anaesthetists
BEH clinical strategy
The Barnet, Enfield and Haringey clinical strategy
BMI
Body mass index
BP
Blood pressure
BSCN
British Society of Clinical Neurophysiology
C.Diff
Clostridium difficile
CAD
Complication diverticulitis audit
CBU
Clinical business unit
CCG
Clinical commissioning group
CCOT
Critical care outreach team
CIA
Carotid interventions audit
CNS
Clinical nurse specialist
COE
Care of the elderly
COPD
Chronic obstructive pulmonary disease
CQC
Care Quality Commission
CQRGClinical quality review group – a monthly meeting between the trust and its
commissioners to review the quality of clinical services
CQUINs
Commissioning for quality and innovation framework
CTGCardiotocography
DAHNO
National head and neck cancer audit
DGH
District general hospital
E.Coli
Escherichia coli
ED
Emergency department
EQ-5DPatients’ self reported health on each of the five quality of life dimensions of the
descriptive system
EQ-VASPatients’ own global rating of their overall health, on a scale from 0 (worst possible
health) to 100 (best possible health)
ERS
Endoscopic retrograde sphincterotomy
FFFAP
Falls and fragility fractures audit programme
FFT
Friends and family test
FiO2
Fraction of inspired oxygen
GP
General practitioner
HCAIs
Healthcare-associated infections
HPMA
Healthcare People Management Association
HSGHysterosalpingograms
HSMR
Hospital standardised mortality ratio
IBD
Inflammatory bowel disease
ICD-10
International classification of diseases version 10
IOL
Intra-ocular lenses
IP&C
Infection prevention and control
IPCC
Infection prevention and control committee
IUAC
International Union Against Cancer
LeAD
Learning and development department
LSCS
Lower segment Caesarean section
MBRRACE
National maternal infant and newborn programme
MINAP
Myocardial infarction audit
MRI
Magnetic resonance imaging
MRSA
Meticillin-resistant staphylococcus aureusis
9
Quality Account
Section 1
MSSA
Meticillin-sensitive staphylococcus aureusis
MTS
Mental test score
NAOGC
National oesophagus-gastric cancer audit
NBOCAP
National bowel cancer audit
NCISHNational confidential inquiry into suicide and homicide for people with mental illness
NELA
National emergency laparotomy audit
NHFD
National hip fracture database
NHS
National Health Service
NHSLA
NHS Litigation Authority
NHS Safety Thermometer A system for measuring patient safety and monitoring harm-free care provided
to patients
NICE
National Institute for Health and Care Excellence
NIV
Non-invasive ventilation
NJR
National Joint Registry
NLCA
National lung cancer audit
NNAP
National neonatal audit
NOF
Neck of femur
NPDA
National paediatric diabetes audit
NPID
National pregnancy in diabetes audit
NSAIDs
Non-steroidal anti-inflammatory drugs
NTDA
National Trust Development Authority
PAC
Pre-assessment clinic
PAU
Paediatric assessment unit
PCIs
Primary coronary angiography
PDAU
Paediatric day assessment unit
PICANet
Paediatric intensive care audit
POMH
Prescribing Observatory for Mental Health
PROMs
Patient-reported outcome measures
RAIDRapid, assessment, interface and discharge mental health service model
RTTReferral to treatment, the national target is for patients to be treated within 18 weeks
of being referred
Saving lives bundleA collection of interventions and audits designed to improve infection prevention and
control practices
Sepsis six bundleA collection of interventions to improve the management of patients with
severe sepsis
SHMI
Summary hospital-level mortality indicator
SMART objectivesObjectives that are specific, measurable, achievable, relevant and time-bound
SSKIN bundleCare bundle designed to reduce the risk of patients developing pressure ulcers
SSNAP
Sentinel stroke national audit plan
TARN
Trauma audit and research network
TEDs
Thromboembolic deterrent stockings
THR
Total hip replacement
TIVA
Total intravenous anaesthesia
TKR
Total knee replacement
TNM
TNM classification of malignant tumours
UCC
Urgent care centre
UCLPUniversity College London Partners, an academic health science partnership, the
research network the trust participates in
UNE
Ulnar neuropathy at elbow
VSGBI
Vascular Society of Great Britain and Ireland
VTE
Venous thromboembolism
WHO
World Health Organisation
WTE
Whole time equivalent
10
Quality Account
Section 2
Priorities for improvement and
statements of assurance from the board
Delivery against our quality priorities and objectives for 2014/15
In last year’s quality account, the trust identified 10 key quality priorities that were aligned to improve the
safety of care, the experience of our patients and the effectiveness of our clinical services. The table below
summarises our performance against each of the quality priorities and objectives we set ourselves for
achievement during 2014/15 in last year’s quality account.
Our quality priorities and objectives for 2014/15
Safety
Priority
Key objective
Measure
2014/15 performance
1. Falls prevention
Reduce harm from patient falls
Outcome
Partially achieved
Process and outcome
Mostly achieved
Process and outcome
Mostly achieved
Process and outcome
Achieved
Process and outcome
Partially Achieved
Outcome
Partially achieved
Outcome
Partially achieved
Process and outcome
Mostly achieved
Process and outcome
Partially achieved
Process
Achieved
2. Sepsis management
3. Healthcare-associated
infections
1. End-of-life care
2. Discharge arrangements
Experience
3. Improved patient
communication and
engagement
4. Improved staff
engagement
1. NICE guidance
Launch sepsis six care bundle and
improve compliance
Reduce harm from healthcareassociated infections
Improve access to end-of-life care
service and training
Improve timeliness of patient
discharges
Improve patient satisfaction as
measured by FFT
Improved staff experience and
satisfaction
Improved compliance with relevant
NICE guidance
2. Patient-reported
Clinical effectiveness
outcome measures
Improved participation in PROMs
(PROMs)
3. Specialty level clinical
outcome measures
Identify specialty level clinical outcome
measures across the trust
A detailed analysis of our performance against each of these quality priorities follows.
11
12
Quality Account
Section 2
Patient safety priorities:
2014/15 performance
1. Falls prevention
Why have we chosen this as a priority?
Falls are a leading cause of hospital-acquired injury,
and frequently prolong or complicate hospital stays.
Falls are the most common patient safety incident
reported in hospitals. Reviews of observational
studies in acute hospitals show that fall rates can
vary from 1.3 to 8.9 falls per 1,000 bed days. The
rate of falls per 1,000 bed days is a useful measure
because it measures the relative risk of harm from
falling consistently in response to fluctuations in
clinical activity. The falls rate is calculated as the
number of falls divided by the number of bed days
multiplied by 1,000.
The falls injury rate measures the number of patient
falls that result in harm to patients versus the
number of falls which are managed or assisted,
or which do not result in any injury to patients and
constitute near misses. A breakdown of these and
the severity of harm sustained, as defined nationally,
appear below.
Priority
Objective
Despite the efforts of a multidisciplinary working
group to ensure adequate risk assessment on
admission, introduction of the ‘falls prevention
tool’ for those identified as being at risk, and the
introduction of non-slip socks, our falls rate have
not really improved during the previous 2 years.
In order to deliver a reduction in the harm caused by
patient falls we:
•Reviewed the falls policy and associated risk
assessment documentation, including launching
a new falls risk assessment proforma in the
emergency department prior to patients being
admitted. Our falls risk assessment tool has been
comprehensively reviewed to take into account
lesson learned by patient falls during 2014/15.
•Raised awareness of falls by ensuring that our
staff have adequate teaching and access to
equipment to use.
•Targeted repeat fallers and undertake root
cause analysis of such cases to implement
lessons learned.
What we acheived
Status
The trust’s monthly falls rate deteriorated from 1.974 in April
Falls prevention
Reduction in the monthly falls rate (per
2014 to 2.832 in March 2015. The average monthly falls rate
1,000 bed days)
over the first 6 months of the year was 2.369 versus 3.001 for
Not achieved
the second 6 months.
Reduction in monthly falls injury rate
Falls prevention
(including minor harm injuries such as
cuts and bruises)
The trust’s monthly falls injury rate deteriorated from 15.25 in
April 2014 to 17.72 in March 2015. The monthly average falls
injury rate deteriorated from 20.595 over the first six months to
Not achieved
21.127 over the second six months.
The trust achieved a significant improvement in reducing the
harm rate for falls resulting in moderate or severe harm during
Reduction in monthly falls injury rate
Falls prevention
for falls resulting in moderate or severe
harm (such as fractures neck of femurs)
the course of 2014/15 despite the increased monthly falls rate
outlined above. The monthly falls injury rate improved from
an average of 2.363 per month during the first six months of
2014/15, to 1.025 per month during the second six months of
the year. This was despite an increase in the number of falls that
were reported in the second six months of the year.
13
Achieved
Priority
Objective
No harm
Minor harm
Moderate harm
Permanent severe harm
Death
Falls prevention
Falls injury severity
737
176
15
0
0
Quality Account
Section 2
As a result of the partial achievement of this quality priority during 2014/15, the trust has reviewed its falls
safety workstream and will continue to focus on improving safety and the risk of patient falls as a quality
priority during 2015/16.
2. Sepsis management
Why have we chosen this as a priority?
Sepsis claims 37,000 lives in the UK annually – more
than lung cancer, breast cancer and bowel cancer
combined. Research shows that early recognition
and intervention saves lives and may save as many
as 15,000 lives in the UK annually. To achieve
this improvement requires a partnership between
patients, the public and the healthcare professions.
This partnership must start with heightened
awareness and understanding of the condition,
ability to recognise the symptoms and know when
to act and how to manage it. International evidence
based guidelines in the management of sepsis
are available, yet are delivered to fewer than one
in five patients in the UK. Failure to recognise and
intervene quickly means that there is still around 3550% mortality for hospital severe sepsis.
A re-audit in 2013 revealed little change in practice
amongst staff with poor management of all
components of the sepsis care bundle.
In 2010, an audit carried out at North Middlesex
University Hospital on medical patients admitted
via accident and emergency with signs of systemic
inflammatory response and sepsis revealed poor
management in relation to the sepsis bundle. A
considerable delay in instituting antibiotic therapy
was noted with all other components scoring badly.
Despite implementing and delivering focused sepsis
management training to A&E staff in the recognition
and management of sepsis, adverse events relating
to severe sepsis continued to be a problem.
•Improve the treatment of patients diagnosed
with sepsis by activating the sepsis treatment
pathway (sepsis six care bundle) within one hour
of diagnosis
The trust is dedicated to increasing the identification
of patients with sepsis including treatment with
the sepsis six care bundle within one hour of
diagnosis, in order to improve patient outcomes.
This will enable us to achieve greater compliance
with recognition of symptoms and the appropriate
treatment ensuring that we deliver high quality care
to people affected by sepsis. In order to achieve this
ambition, the trust committed to:
•Improve the recognition of patients presenting
with sepsis to the emergency department
•Develop guidelines that support the management
of patients
•Devise and implement a training plan to
improve staff awareness and understanding
of sepsis management.
14
Quality Account
Section 2
Priority
Objective
What we acheived
Sepsis
Launch sepsis six
Sepsis six guidelines launched across the trust in April 2014 and monitored at
management
guidelines across the trust
the Patient Safety Group
Sepsis
management
Sepsis
management
Sepsis
management
Conduct audit to assess
compliance with sepsis
six pathway
Conduct staff survey to
test understanding of
sepsis management
Embed sepsis training
for doctors, nurses and
clinical staff at induction
Status
Baseline audit completed. Initial level of compliance with sepsis six pathway
was 21%
Staff survey completed to inform training and additional interventions. Repeat
staff survey to be undertaken in April 2015
Sepsis management and sepsis six pathway included in clinical induction from
November 2014. Remains ongoing
Achieved
Achieved
Achieved
Achieved
80% of patients diagnosed
Sepsis
management
with severe sepsis to be
Baseline audit demonstrated initial compliance of 21%. Repeat audit in
managed using sepsis six
September demonstrated improved compliance to 54%.
Not achieved
pathway with particular
focus on administration of
Additional interventions including A&E screening tool developed and currently
antibiotics within 1 hour
being rolled out. Repeat audit to be undertaken in August 2015
of diagnosis
3. H
ealthcare-associated infections (HCAIs)
Why have we chosen this as a priority?
Healthcare-associated infections (HCAIs) require
treatment over and above the primary admission
diagnosis, for which a patient is admitted to
hospital. This may extend the length of stay, as
well as adding to patient distress, morbidity and
mortality. Additionally, patients are worried about
the risks of acquiring an infection while they remain
in our care. Reducing the number of avoidable
HCAIs will reduce cost per patient and promote
confidence within the service. Increasing levels
of resistance to antibiotics in some organisms
associated with HCAIs is a major concern nationally
and internationally; by having robust measures in
place for infection prevention and control, we will
minimise the risk of our patients coming into contact
with these.
15
During 2013/4, the trust exceeded its trajectory
against both MRSA bacteraemia and Clostridium
difficile. Root cause analysis investigations of these
revealed that a number of these were avoidable.
The trust, therefore, committed to reducing HCAIs in
2014/5 by:
•The trust will be within the allocated objectives
for maximum numbers of Clostridium difficile and
MRSA bloodstream infections
•Compliance with implemented control measures
will consistently be above 95%
•The trust will be continue to be fully compliant
with the Hygiene Code.
Objective
The trust will be within the allocated
Preventing
hospital-acquired
infections
objectives for maximum numbers of
C.diff and MRSA bloodstream infections
MRSA = 0
C.diff = 21
What we acheived
Quality Account
Section 2
Priority
Status
Trust has had no cases of MRSA bloodstream infection during
2014/15 so achieved this target. The trust had 12 patients who
contracted a Clostridium difficile infection that was attributed to
Achieved
lapses in care. This was within the trust’s target trajectory of 21
across 2014/15
Trustwide hand hygiene audits of all wards are conducted each
Preventing
hospital-acquired
infections
Compliance with control measures will
week and reported weekly and monthly by the IP&C team.
consistently be above 95%
Compliance exceeded 95% in 4 out of 12 months and the
Partially achieved
annualised compliance rate was 93%
Preventing
hospital-acquired
infections
Compliance with the Hygiene Code is monitored bi-monthly at
Trust to be fully compliant with the
the IPCC. The outstanding area for improvement was inclusion
Hygiene Code
of infection risk in discharge documentation which has now
Achieved
been addressed
16
Quality Account
Section 2
Patient experience priorities:
2014/15 performance
1. End-of-life care
Why have we chosen this as a priority?
Care of the dying is a fundamental core skill
for all healthcare professionals. Developing
competent skills in care of the dying is included
in undergraduate programmes for all healthcare
professionals and is an essential skill to continue
developing during ongoing professional
development. The overriding principle of care is
that all patients who are dying, and their loved
ones, should experience transparent and open
communication and receive compassionate care of
the highest standards from all health professionals
involved in their care.
We are committed to ensuring that the organisation
remains focused and efficient at enabling our staff
to deliver a responsive, coordinated approach
to patients and their relatives, as they approach
the end of life. We recognise that to achieve this
excellence in end-of-life care, we must aspire to
continuous improvement in implementation of
new guidelines, a trustwide approach to training
clinical staff and monitoring delivery of care to
realise a sustained improvement in care. The trust is
dedicated to improving the care for patients at the
end of their life by addressing timeliness of referrals
for inpatients and the overall quality of end-of-life
care delivered across the trust.
In order to improve patients’ and relatives’
experience at the end of life, the trust will increase
the number of staff trained in end-of-life care and
have agreed competencies associated with endof-life training. The aim of this is to ensure that staff
have the knowledge and skills, and demonstrate
behaviour and attitudes that enable them to deliver
high quality care when managing patients who are
approaching the end of their life.
In order to deliver this vision for the end-of-life care
the trust committed to:
•Improve appropriate and timely referrals to the
end-of-life team for end-of-life patients admitted
to the trust
•Provide competency based training for all new
clinical staff during clinical induction. All other
clinical staff deemed appropriate will receive
a competency-based training session from the
end-of-life team
•Monitor implementation of new guidelines and
the quality of care delivered.
17
Quality Account
Section 2
Priority
Objective
What we acheived
Status
We expanded the end-of-life care team during 2014/15. We have filled the
vacant clinical nurse specialist posts and recruited 0.5 WTE additional end-ofEnd-of-life care
More effective, appropriate
life consultants. New end-of-life referral guidelines were developed, published
and timely referrals with
and publicised across the trust. As a result of these developments, there were
improved review times
545 referrals to the end-of-life team, an increase of 63% in comparison to
Achieved
2013/14. Of the 545 referrals, 97% were seen by the end-of-life care team on
either the same day or next working day
End-of-life care included in mandatory induction training for clinical staff from
December 2014. In addition, two medical grand round presentations held to
launch new end-of-life clinical guidelines and five things to do for patients who
are dying. Ward based training also launched to increase attendance for existing
95% of appropriate clinical
End-of-life care
staff to received end-of-life
care training
staff. Training held on medical and surgical wards including the acute medical
unit, acute stroke unit and critical care. As a result 400 members of staff have
been trained. The trust has been appointed lead provider of end-of-life care
Achieved
training by Health Education England for North Central and East London. The
trust has devised a four tier training programme in development with UCLP
and this will be launched from May 2015. The trust has successfully bid for a
MacMillan end-of-life training facilitator which has been approved and has gone
out to advert in April 2015. And this CNS will lead this training programme
Official launch of new
End-of-life care
clinical guidelines, easily
New guidelines developed and launched at grand medical round and junior
accessible to all staff to
doctor training forum. Guidelines are available to all staff on the intranet and are
raise awareness across
displayed on each ward
Achieved
the trust
Review process for
End-of-life care
clinical incidents relating
Incident investigation process agreed and in place. No incidents reported
to the provision of end-of-
relating to end-of-life care
Achieved
life care
18
Quality Account
Section 2
2. Improved discharge arrangements
Why have we chosen this as a priority?
A review of patient flow in the trust revealed that
many patients are discharged later than expected,
creating a backlog of patients awaiting admissions.
This creates unnecessary pressure for beds within
the organisation, resulting in poor experience for
our patients from the outset. This can be improved
by a review of the discharge pathway, involving
the multidisciplinary team and engaging with
community services early in the patient’s admission.
To achieve these improvements the trust
committed to:
•Ensure that individualised discharge plans are
developed on admission in conjunction with
patients and their carers, social services and
other voluntary organisations who may be
assisting the patient
•Visually display expected discharge dates, with
regular review by the multidisciplinary teams
•Improve the pathway for nurse-led discharges
ensuring patients suitable for discharge will be
discharged irrespective of the day of the week.
19
Objective
What we acheived
Quality Account
Section 2
Priority
Status
There have been a number of initiatives implemented during 2015/15 as part of a wider
transformational programme to improve patient flow and patient experience in discharge
planning arrangements. This work has incorporated two national ‘breaking the cycle’
initiatives in January and April 2015. These are improvement events held over the course
of a week where organisations work together to optimise capacity to reset the local
health and social care system. Learning is then used from these initiatives to inform
future improvement plans. Highlights from the year include:
•Pathway review and subsequent reduction in the turnaround times for patients
awaiting rehabilitation placements.
Appropriate discharges
Improved
will be expedited in a
discharge
timely manner, including
arrangements
collaboration with relevant
community services
•Increased governance arrangements across the locality for community equipment
provision.
•On-site presence from both Haringey and Enfield social services to assist
communication and multidisciplinary working.
Partially
achieved
•Pilot expansion of the physician assistant role in ward areas to support the junior
medical workforce.
• Establishment of a discharge pharmacist role to expedite early morning discharges.
• Redesign of the early morning consultant RAG round process
A ward-level patient flow dashboard has also been developed and is used to improve
awareness of performance in early morning discharge rates and other flow-related
indicators. A new “2 at the top” ward leadership and governance model was also
launched in quarter 4 and provides a multidisciplinary framework to support the ward
manager and lead consultant in delivering improvements in patient care in their areas
Individualised discharge
Improved
care plans, including
discharge
expected dates of
arrangements
discharges, completed on
admission for every patient
Robust nurse-led discharge
Improved
pathway for non-complex
discharge
discharges, embedded
arrangements
into daily practice by all
clinical staff
Every patient will have an identified estimated date of discharge agreed within 24 hours
of admission to hospital. This is subsequently reviewed and updated as necessary on
the wards through a newly revised RAG round process. The information is recorded
and monitored on our electronic bed management system. Recently a new discharge
Achieved
information leaflet has been piloted to raise awareness of a patients expected date of
discharge and this work will continue in our 2015/16 programme of work
Work continues to develop pathways to support criteria-led discharge for patients.
This will enable nurses to safely discharge patients in a timely manner based on strict
criteria set and agreed by the named consultant. This approach is supported by the early
Partially
morning multidisciplinary reviews on the wards where consultant-led RAG rounds identify
achieved
priorities for the day including actions for discharge for those patients due to go home
that same day or next day
Initiatives for 2015/16
As a result of our partial achievement of this
objective during 2014/15, there are a number of
improvement initiatives already underway as part of
our ongoing commitment to transforming the patient
discharge pathway. These include:
•CQUIN initiatives aimed at increasing
early morning and weekend discharge
rates during 2015/16.
•Consideration of a recovery at home health care
model to support earlier supported discharge for
patients back into their home.
•Expansion of our ambulatory emergency
care unit to support admission avoidance
and treat patients where safe to do so, in
a day case model.
20
Quality Account
Section 2
3. Improved patient communication and engagement
Why have we chosen this as a priority?
We chose this priority because in 2013/14, the
trust’s Friends and Family test (FFT) scores were
below the London average and we aspire to
improve these scores in line with other similar sized
acute trusts, to ensure that our patients receive
high quality care and would recommend us as their
hospital of choice.
The FFTs ask people how likely they would be
recommend the trust to friends and family. This
provides the trust with a Friends and Family score
that enables us to benchmark how satisfied our
patients are with their experiences of using our
services, in comparison to the experiences of
patients at other trusts.
The trust also receives feedback from patients and
carers from observations and complaints. During
2013/14, our complaint responses were not always
provided in a timely manner. It is imperative that the
trust learns from complaints and that complainants
Priority
receive responses in timescales stipulated by
the trust. The trust was also aware that it did not
routinely ask people who used our services for ways
in which we could improve the patient experience.
In order to improve this, the trust committed to:
•Improve the percentage of patients who respond
to the Friends and Family question and give the
hospital a score of “very likely”
•Implement feedback from the Friends and
Family questions
•Implement “You said...we did” and display on
information boards
•Improve complaints response times from 40% to
80% of complainants within an agreed timescale
•Ask people who use our services for
their opinions on how to improve the
patient experience.
Objective
What we acheived
The trust will have implemented the FFT
From June 2014, the trust has introduced patient experience boards in all
Communication
feedback in conjunction with ‘you said,
clinical areas which display patient experience performance information
and engagement
we did’ which will assist in improving
and feedback on what has been auctioned in response to the ‘you said,
patient satisfaction scores
we did’ initiative
Status
Achieved
Inpatients surveyed improved from 57% at the start of the year in April
The trust will be able to demonstrate
Communication
and engagement
an improvement in the percentage
of patients who respond to the FFT
question resulting in the trust having a
score of “very likely”
2014 to a monthly average of 73.3% over the course of 2014/15
A&E patients surveyed deteriorated from 58% in April 2014 to a monthly
Partially
average of 37.3% over the course of 2014/15
Achieved
Maternity users deteriorated from 67% in April 2014 to a monthly
average of 30% over the course of 2014/15
Complaint response times improved fractionally from the 2013/14
Communication
and engagement
Improve complaint response rates
baseline of 40.0% to 40.6% against a target of 80%. Complaints
Not
response times improved above the baseline in seven out of 12 months
Achieved
during 2014/15
As a result of our partial achievement of this priority during 2014/15, the trust has refreshed the patient
experience group and agreed revised patient experience priorities that focus attention on improving areas of
poor patient experience identified by national patient surveys during 2015/16.
21
Quality Account
Section 2
4. Improved staff engagement
Why have we chosen this as a priority?
Triangulation of a number of key workforce indicators has revealed that amongst others, the staff survey
score for staff engagement matched the national average for acute trusts. However, our stated aim is to
be above the national average and to be an an employer of choice. It was also clear from analysis of key
performance indicators that whilst we had a reasonably good record in recruiting staff we had a relatively
high turnover rate. We therefore needed to focus on not only attracting suitable staff but also engaging
with them, listening to them, valuing and respecting their contributions, recognising when they have done
a good job, and ensuring our leaders demonstrate in practice the kind of behaviours which underpin the
above. Finally, as an aspirant foundation trust, we need to develop a membership that feels engaged
and committed to the trust and which contributes and is listened to in terms of their ideas on the
trust’s functioning.
Priority
Objective
What we acheived
Status
Average net promoter score over the course of 2014/15 = 67%
Achieved
Improved staff FFT scores that will
impact on improved patient experience.
Staff engagement
Based on last year’s performance the
target for 2014/15 was to achieve two
thirds (67%) net promoter score
Staff engagement
Staff engagement
Staff engagement
Reduction in annual staff turn over rate
from 15.9%
Annualised average turn over rate = 17.6%
Reduction in vacancy rate from 11.0%
Annualised average vacancy rate = 9.9%
Ensure our leaders demonstrate
Values and behaviours strategy action plan devised and implementation
in practice the behaviours that are
monitored at workforce committee. Implementation remains ongoing but
congruent with the trust’s values
there has been slippage against the delivery of some strategy milestones
Not
Achieved
Achieved
Partially
Achieved
As a result of the partial achievement of this priority, the trust has reviewed it values and behaviours
programme and action plan which will continue to be implemented and monitored at the trust’s workforce
committee during 2015/16.
22
Quality Account
Section 2
Clinical effectiveness priorities:
2014/15 performance
1. NICE guidance
Why have we chosen this as a priority?
During 2013/14, the audit department worked
closely with clinicians to ensure that all NICE
guidance was assessed for its relevance to North
Middlesex University Hospital. However, there
was only a gradual improvement in the response
rate from the clinicians on the initial gap analysis.
Therefore, the trust committed to completely
assessing compliance with all NICE guidance and
evidence to demonstrate either achievement of
compliance or reasons for non-compliance.
Priority
Objective
The trust therefore committed to achieve:
•100% compliance with initial gap analysis of all
NICE guidance
•Following the initial gap analysis, where the
trust is found to be non-compliant or partially
compliant, 90% of guidance will have an
action plan stating how the clinical area will
become compliant.
What we acheived
Status
Specialty audit leads have four weeks from the date of issue to conduct the
NICE guidance
100% compliance with initial gap
analysis of NICE guidance
gap analysis. However on occasion, due to the complexity of the guidance,
it requires longer than four weeks to complete the gap analysis. The
annualised monthly average was 98.75% compliance during 2014/15 and
Partially
Achieved
100% compliance was achieved during two out of 12 months
Where the trust is found to be nonNICE guidance
compliant, 90% will have an action
Annualised average is 90% with 91% compliance achieved across each of
plan to demonstrate how the clinical
the first six months of the year
Achieved
area will become compliant
2. Patient-reported outcome measures (PROMs)
Why have we chosen this as a priority?
Data received from the national centre shows
that there is a low level of patients completing the
PROMs questionnaires, particularly for hip surgery.
The trust needed to have in place a robust system
in which it can identify the patients who have
groin hernia surgery, knee replacements and
hip replacements and ensure that they have
the appropriate information that they require
and understand the importance of completing
the questionnaires.
23
In order to achieve this, the trust committed
to deliver:
•95% of patients who are eligible to take part
in the PROMs survey will have been given the
opportunity to fill out the questionnaire and their
information sent to the national team.
•If a patient declines to take part, this information
will also be recorded.
Objective
What we acheived
Quality Account
Section 2
Priority
Status
Percentage of patients undergoing Groin Hernia who completed PROMs
questionnaire = 34%
Patient-reported
95% of eligible patients to be
outcome
given opportunity to participate
measures
in PROMs questionnaires
Percentage of patients undergoing Total Hip Replacement who completed
Partially
PROMs questionnaire = 96%
Achieved
Percentage of patients undergoing Knee Replacement who completed
PROMs questionnaire = 86%
Patient-reported
Implement a system to record
outcome
patients who declined to take part
measures
in PROMs questionnaire
The trust did not implement a system to record the details of patients who
Not
declined to take part in the PROMs questionnaire
Achieved
As a result of the limited progress the trust made during 2014/15 regarding PROMs participation, most
notably for patients undergoing groin hernia surgery, the trust will continue to concentrate on PROMs as
a priority for inclusion in the 2015/16 Quality Account.
3. Clinical outcome measures
Why have we chosen this as a priority?
During 2013/14, North Middlesex University
Hospital increased in size as a result of the
implementation of the Barnet, Enfield and Haringey
clinical strategy. Whilst this did not entail the
addition of any new specialties to the services we
provide, there was a significant increase in patients
who visit the emergency department, outpatients
and inpatients. This also included a 25% increase in
the hospital’s bed base.
Priority
Objective
To identify specific clinical outcome measures for
each clinical specialty was selected as a priority
because it is imperative that the trust continues
to provide high quality care. By each specialty
identifying at least one clinical outcome, this will
assist in striving to ensure that all patients receive
the high quality care to which they are entitled.
In order to achieve this, the trust committed to
identify at least one clinical outcome measure for
each clinical specialty.
What we acheived
Status
Specialty level outcome measures have been agreed and monitoring
Clinical outcome
measures
Each specialty to identify
processes implemented to enable monitoring. Specialty level clinical
clinical outcome measure(s)
outcome performance has been added to each clinical business unit
and initiate monitoring
performance dashboard report to the bi-monthly clinical effectiveness
Achieved
group, which is chaired by the medical director
24
Quality Account
Section 2
Quality priorities for 2015/16
In identifying our quality priorities for 2015/15, we have decided to maintain the overarching objectives of
improving quality by improving the patient experience, patient safety and clinical outcomes. However we
have also been mindful to select priorities that are also aligned to the Care Quality Commission’s quality
domains of safety, effectiveness, caring, responsive and well led clinical services. When selecting our
priorities we have taken account of national priorities such as the “Sign Up to Safety” campaign and the
areas of improvement identified in the NHS outcomes framework such as healthcare-associated infections
and pressure ulcers.
We have also selected and shaped some of our priorities to specifically target the findings of our recent
CQC inspection report. In this important respect, our process for selecting this year’s priorities has
developed from last year’s process. Finally, we have taken our performance against last year’s priorities
into account, and where there remains important work to be done to achieve priorities that have been
previously identified, these have been reflected upon and updated for inclusion in this year’s quality
improvements. Our process for determining and agreeing our priorities has seen us consult internally with a
multidisciplinary team of senior clinicians, as well as the senior management team and the trust’s risk and
quality committee. We have also consulted with our commissioners, including local GP representatives,
our local commissioning support unit and our local branches of Healthwatch. Progress against the delivery
of these priorities will be reported to the risk and quality committee during the year and shared with our
external stakeholders at the clinical quality review group meeting.
As a result of this consultation process, the quality priorities for 2015/16 are:
Patient safety
Patient experience
Clinical effectiveness
Priority 1: To reduce harm to
patients by reducing and aspiring
to eliminating avoidable healthcare
associated bloodstream infections
and improving the management of
Clostridium difficile and patients
with sepsis
Priority 1: To improve patient
satisfaction as measured by
national surveys and the Friends
and Family test
Priority 1: Improved patient
participation in the patientreported outcome measures
(PROMs) questionnaires
Priority 2: Continued improvement
to end-of-life care so that North
Middlesex University Hospital
becomes an exemplar provider
Priority 2: Improved performance
against the specialty specific
clinical outcome measures
Priority 2: Reducing the harm from
patient falls
Priority 3: To continue to reduce
harm from pressure ulcers and
aspire to eliminate avoidable
hospital-acquired grade 3 and
grade 4 pressure ulcers
25
Priority 3: Improving care for
patients with dementia
Priority 3: Design and implement
an anaesthetics service
improvement plan
Quality Account
Section 2
Patient safety priorities
for delivery in 2015/16
As part of the trust’s longstanding commitment to a continuous improvement in the safety of its services,
the trust is participating in the “Sign Up to Safety” campaign that aspires to make the NHS the safest
healthcare system in the world. As part of this campaign, the trust has devised a safety improvement plan
for 2015/16 which outlines all the safety initiatives that the trust will be introducing in 2015/16 to continue
the journey to ever safer healthcare.
The trust submitted the safety improvement plan along with a bid for enabling funds to finance some of
the interventions to the NHS Litigation Authority (NHSLA). The NHSLA received 243 such bids and North
Middlesex University Hospital’s was one of only 67 successful bids and has been awarded £130,000 to
finance the introducing of a central monitoring stations for fetal heart rate monitoring in maternity that is
also accessible remotely so that on-call consultants can view CTG traces from across the trust or offsite.
The safety improvement plan can be accessed via the trust website however the following safety priorities
have been selected from the safety improvement plan for inclusion in this year’s Quality Account.
Priority 1: To reduce harm to patients by reducing and aspiring to eliminating avoidable healthcare
associated bloodstream infections and improving the management of Clostridium difficile and
patients with sepsis.
Why have we chosen this as a priority?
The trust has made significant improvements in reducing hospital-acquired blood stream infections such
as MRSA and E.Coli over the previous three years. Despite the significant increase in emergency activity
following the implementation of the Barnet, Enfield and Haringey clinical strategy in 2013/14, 2014/15 saw
the number of infections remain steady, which is indicative of a significant improvement in infection rates.
The trust wants to build on this success and aspires to provide care in which avoidable hospital-acquired
blood stream infections are eliminated.
Number of hospital-acquired bloodstream infections 2012/13 – 2014/15
MRSA bacteraemia
MSSA bacteraemia
E.coli bacteraemia
2012/13
1
12
35
2013/14
6
5
13
2014/15
0
4
18
Furthermore, the trust’s catheterisation rate
as measured on the “safety thermometer”, is
significantly higher than the national average, this
suggests that the trust could further reduce the
risk of infection by reviewing its use of urinary
catheters and bringing usage more closely in line
with the national average as reported via the
“safety thermometer”.
In addition to this, the risk of harm to patients
caused by hospital-acquired infections can be
reduced by the achievement of the trust’s allocated
objective for the maximum number of patients who
contract hospital-acquired Clostridium difficile
during 2015/16. The trust is committed to ensuring
that fewer than 34 patients contract hospitalacquired Clostridium difficile during 2015/16.
26
Quality Account
Section 2
What are we trying to improve?
What will success look like?
Our aim is to reduce mortality and improve patient
outcomes by reducing hospital-acquired infections
through the expanded use of the “saving lives”
audit tools. The trust will implement the central line
insertion and care “saving lives” bundle in oncology.
In addition, the urinary catheter care bundle and
the care bundle to reduce the risk from Clostridium
difficile will be rolled out to all relevant clinical areas
across the trust. The trust will expand its promotion
of the sepsis sixbundle, and continue the provision
of sepsis trolleys in accident and emergency so that
compliance with the sepsis six bundle improves and
becomes embedded in practice across the trust.
Success will see a continuous reduction in
infections until we have achieved our aspiration
to eliminate avoidable healthcare associated
MRSA, MSSA and E.Coli bloodstream infections.
In addition, success will see a reduction in the use
of urinary catheters until we have more closely
converged towards the national average for
urinary catheterisation as measured via the
“safety thermometer.”
In addition, the trust will seek to work with external
partners in the community to improve the infection
prevention and control practice and standards
in the local health economy. The trust will work
with commissioners to participate in whole
system working in order to support community
providers with the undertaking of communityacquired Clostridium difficile root cause analysis
investigations as required. Furthermore, the trust
will also support local commissioner initiatives
to reduce infections in the community through
engagement and participation. This will enable the
trust to positively contribute to the dissemination of
good infection prevention and control practices in
the community for our patients.
Successful delivery of this priority will result in
improved management of patients with sepsis,
improved compliance with the sepsis six bundle and
improved mortality and morbidity for patients with
sepsis. Achievement of this priority will also support
the trust’s achievement of the national sepsis
CQUIN targets for 2015/16.
Successful delivery of this priority will result in
fewer than 34 patients contract hospital-acquired
Clostridium difficile during 2015/16.
How will we monitor progress?
The implementation of the “saving lives” care
bundles and associated audits will be overseen
by the infection prevention and control committee
which is chaired by the director of nursing. The
results of this and the monitoring of the outcomes in
terms of reduced infections will also be reported to
the patient safety group.
The trust’s performance regarding the management
of patients with sepsis and reduction of Clostridium
difficile, will be monitored internally and reported
to our commissioners at the clinical quality review
group meetings.
27
Domain
Reduction in the number
of bloodstream infections
Source
Performance data from
Safety
infection prevention and
during 2015/16
control department
Number of hospital-
Performance data from
Frequency
Aim/Target
Aspire to eliminate
Monthly performance
hospital-acquired
reporting
bloodstream
infections
Quality Account
Section 2
Measure
Baseline data
See table above for
MRSA, MSSA and
E.Coli baselines
Fewer than 34
acquired Clostridium
Safety
difficile infections
infection prevention and
control department
Monthly performance
reporting
hospital-acquired
Clostridium difficile
1 in year to date
infections during
2015/16
Compliance with sepsis
six bundle
Compliance with “Saving
Lives” audit bundles
Safety
Safety
Sepsis six audit
Annual report to
patient safety group
Performance data from
IPC Audit report to
infection prevention and
infection prevention
control department
and control committee
>90%
Compliance with
To be determined in
saving lives audits
Q1 2015/16
Monthly
0
0
Monthly
0
0
Number of central line
infections and proportion
attributable to lapses
Safety
Critical care safety report to
patient safety group
in care
Number of ventilatoracquired pneumonia
attributable to lapses
Safety
Critical care safety report to
patient safety group
in care
Priority 2: Reducing the harm from patient falls
Why have we chosen this as a priority?
Patient falls continue to be the most frequently reported type of incident at North Middlesex University
Hospital. The falls rate has increased since the implementation of the Barnet, Enfield and Haringey
clinical strategy as a result of the increased acute activity at the trust which has seen the trust care for
an increasingly aged and more acutely unwell patient population. Whilst 2014/15 saw the monthly falls
rate increase, the injury rate for falls that resulted in a moderate or severe injury reduced. Therefore whilst
some important progress has been made at reducing the harm from patient falls, there remains work to
be done that can further reduce the risk of patient harm from falling. Furthermore, the CQC inspection
report identified how the risk of patient falls in accident and emergency could be reduced by introducing a
departmental falls risk assessment tool. Therefore the trust has continued to commit to reducing harm from
patient falls as a quality priority for 2015/16.
28
Quality Account
Section 2
What are we trying to improve?
What will success look like?
In order to reduce the harm caused by patient falls,
the trust will improve the falls risk assessment
process so that all patients undergo suitably
comprehensive falls risk assessments, and
where these identify a patient as being at risk of
falling, suitable falls prevention interventions are
implemented. Achieving this will reduce the number
of unobserved falls and increase the number of
falls that are assisted by staff for example, where a
patient is lowered to the floor, bed or chair. Where
patients do suffer a fall, it is important that they are
suitably reviewed and where a patient’s condition
deteriorates, they are escalated appropriately. The
trust therefore will improve compliance with the post
falls protocol for patients who suffer a fall.
• Sustained reduction in the monthly falls rate
•Sustained reduction in the falls injury rate for falls
that result in moderate or severe harm
•Increased percentage of falls where a falls risk
assessment had been completed prior to the fall
•Increased percentage of falls where the patient
was subsequently managed in accordance with
the post falls protocol
•Increased percentage of falls where the
risk assessment is reviewed and amended
following a fall in order to reduce the number
of repeat fallers.
How will we monitor progress?
Reducing patient harm from falls has been included in the 2015/16 safety improvement plan. The safety
improvement plan is monitored at the patient safety group which is chaired by the medical director. The
falls improvement project will continue to be led by the falls working group, a multidisciplinary team which
reports to the patient safety group.
Measure
Domain
Source
Frequency
Consistent
Proportion of falls
incidents resulting
Past harm
Falls report
Monthly
in harm
Rate of falls per 1,000
bed days
Aim/Target
reduction in
proportion of falls
resulting in harm
Past harm,
sensitivity to
Sustained
Falls report
Monthly
operations
Percentage of falls
Past harm,
reported where falls risk
reliability,
assessment had been
sensitivity to
completed prior to fall
operations
reduction in falls
per 1,000 bed days
Baseline data
17.72% of falls
resulted in an injury
in March 2015
3.001 falls per 1,000
bed days
Falls report
Monthly
>98%
87.89%
Falls report
Monthly
>98%
83.42%
Percentage of falls
reported where
Past harm,
patient was
reliability,
subsequently managed
sensitivity to
in accordance with the
operations
post falls protocol
29
Why have we chosen this as a priority?
What will success look like?
This priority has been selected because the trust
has made continued progress with reducing the
number of hospital-acquired pressure ulcers. The
trust is committed to continuing this reduction in
hospital-acquired pressure ulcers and aspires to
eliminate avoidable or preventable hospital-acquired
grade 3 or grade 4 pressure ulcers. Furthermore, we
have included this priority in our safety improvement
plan and this year’s Quality Account because
reducing the risk of pressure ulcers for patients in
accident and emergency was also highlighted by
the CQC in their inspection report.
•Reduction in the number of hospital-acquired
grade 3 and grade 4 pressure ulcers
What are we trying to improve?
Quality Account
Section 2
Priority 3: To continue to reduce harm from pressure ulcers and aspire to eliminate avoidable
hospital-acquired grade 3 and grade 4 pressure ulcers
•Reduction in the number of avoidable hospitalacquired pressure ulcers
•Reduction in the number of patients who have
developed new pressure ulcers and number with
existing pressure ulcers as measured by the
“safety thermometer”
•Reduction in the comparative proportion of
hospital-acquired pressure ulcers in comparison
to community-acquired pressure ulcers.
The aim of this project is to reduce patient harm
caused by pressure ulcers by reducing the number
and severity of hospital-acquired pressure ulcers.
This will be delivered through the early recognition
of patients at risk of developing hospital-acquired
pressure ulcers, implementation of effective care to
prevent skin deterioration and the configuration and
provision of infrastructure to support patients with
pressure ulcers.
The trust has recently expanded its tissue viability
service and will:
•Continue and improve the robust use of the
SSKIN bundle
•Expanded training in pressure ulcer prevention
and management
•Improve access to pressure relieving equipment
and effective barrier products
•Work with commissioners and community
services to assist in the management of pressure
ulcers in the community to aid the reduction of
patients being admitted with pressure ulcers.
30
Quality Account
Section 2
How will we monitor progress?
The safety improvement plan is monitored at the patient safety group which is chaired by the medical
director. In addition, each hospital-acquired grade 3 or grade 4 pressure ulcer is reported to our
commissioners as a serious incident and subject to a root cause analysis investigation. The findings of
these investigations and remedial action plans are reported to the trust’s risk and quality committee which
is chaired by a non-executive director. Furthermore, the NHS “safety thermometer” provides the trust with
national comparative data which enables the trust to benchmark its performance in reducing the number of
patients who have developed new pressure ulcers and the number of patients with existing pressure ulcers.
ulcers in the community to aid the reduction of patients being admitted with pressure ulcers.
Measure
Domain
Number of hospitalacquired, 3 and 4
Safety
pressure ulcers
Source
TVN report to patient
safety group
Frequency
Aim/Target
Baseline data
Monthly
Fewer than 10
10 during 2014/15
Reduction in the
Prevalence of all PUs = 4.66%
Number of patients
surveyed who have
developed new pressure
ulcers, and number with
Safety
Safety thermometer
report
Monthly
prevalence of new
pressure ulcers
Prevalence of new PUs = 1.17%
existing pressure ulcers
Details of the full range of safety interventions and improvements that will take place across the trust can be
accessed via the 2015/16 safety improvement plan which can be found via the trust’s website.
31
Quality Account
Section 2
Patient experience priorities
for delivery in 2015/16
Priority 1: To improve patient satisfaction as measured by national surveys and the Friends and
Family test
Why have we chosen this as a priority?
It is well established that a positive experience of care aids and expedites our patients’ recovery. In order
to ensure our patients enjoy a positive and improving experience, we need to listen to them and respond
to their feedback, concerns and complaints. Delivering improved patient satisfaction demonstrates that
our services are caring, and well-led by clinicians and managers who are responsive to the needs of
our patients.
What are we trying to improve?
Our aim is to improve overall patient satisfaction as measured by the national inpatient, outpatient and
cancer surveys conducted and published by the CQC. We want to provide our patients with an ever
improving experience that results in continually improving patient ratings of the overall experience of care
in the national patient experience surveys. In addition to the rating of overall experience, the trust will target
interventions where it performs worse than expected in any of the national patient experience surveys. In
addition to this, the trust seeks to improve the experience of inpatients, patients in accident and emergency,
and expectant mothers who use our maternity services so that they increasingly would recommend North
Middlesex University Hospital to their friends and family.
What will success look like?
National patient surveys
Friends and Family test
Each year the CQC conducts the national inpatient
survey. The results of this survey are benchmarked
alongside the performance of all other NHS trusts
and foundation trusts. As such, they enable us
to accurately compare how satisfied our patients
are with their care at North Middlesex University
Hospital, in comparison to other local trusts. Our
aspiration is to achieve continuous improvement
on the question which asks patients to rate their
experience from zero to 10, with 10 representing
a ‘very good’ experience.
In addition to the national patient surveys, the trust
also asks inpatients, patients who use our accident
and emergency department, and expectant mothers
who use our maternity service, whether they would
recommend us to their friends and family. Our
aim is to increase the percentage of patients who
respond to the Friends and Family test stating they
would be ‘very likely’ to recommend the trust to
their friends and family. We want to see continuous
improvement in our friends and family test scores
for inpatients, accident and emergency patients and
maternity users so that 90% of our patients would
recommend us to their friends and family.
We will also target those aspects of the patient
experience which, according to the national
surveys, we perform worse than expected.
Therefore, success will see the number of questions
in which the trust perform as worse than expected
being continuously reduced.
32
Quality Account
Section 2
How will we monitor progress?
The trust uses a patient experience tracker to survey patient experience and provide real time feedback
throughout the year. Patient experience tracker results are used at ward and department level so that ward
managers and heads of department can monitor and respond to patient experience concerns in a timely
manner. In addition to the patient experience tracker, the friends and family test is also monitored at ward
level, including maternity and accident and emergency. These scores are aggregated and feed into the
trust’s overarching performance management framework so that patient experience is seen as a vital key
performance indicator. This data also feeds into the trust board integrated performance report so that there
is a clear line of sight on patient experience performance from the ward to the trust board. Additionally,
this information will also be used by the patient experience group which works closely with our patient
representative forum and tracks progress and monitors improvements in patient experience across the trust.
Measure
Domain
Source
Frequency
Aim/Target
Baseline data
To improve overall patient
Patient
Patient
satisfaction
experience
National patient
experience survey
reports
satisfaction and to reduce
Published by the
the number of areas
CQC annually
where the trust performs
worse than expected in
To be reported in 2014/15 national
patient survey results to be published
in May 2015
national patient surveys
Friends and Family test
Patient
Patient
(FFT) for Inpatients,
satisfaction
experience
A&E patients and
maternity service users
Monthly
The trust will improve the
via trust’s
percentage of patients
performance
who respond to the FFT
management
question with a response
framework
of ‘very likely’
Inpatients FFT baseline – 73.3%
A&E FFT baseline – 37.3%
Maternity users baseline – 30%
To improve the turnaround
time for formal patient
Patient
Patient
Trust’s performance
complaints
experience
reports
Monthly
complaints so that 80%
of patients receive an
appropriate response
During 2014/15, the trust responded
to 40.6% of formal complaints within
target deadlines
within target deadlines
Priority 2: Continued improvement to end-of-life care so that North Middlesex University Hospital
becomes an exemplar provider
Why have we chosen this as a priority?
Delivering compassionate, high quality care to patients at the end of their life is important to our patients
and their loved ones. Providing such high quality care is also important to our staff, however some may
find it difficult to initiate conversations with patients about their treatment preferences and their preferred
location to receive their care. For example, some patients may wish to be cared for at home surrounded by
their family, rather than in hospital. By having these conversations about treatment choices and making sure
that all members of a patient’s multidisciplinary team know the patient’s care plan, we will provide good
quality care that responds to the individual needs of our patients. Furthermore, we have chosen this as a
priority because end-of-life care was an area that the CQC identified as requiring improvement when they
inspected the trust in June 2014.
33
How will we monitor progress?
We want to expand our end-of-life service so that
it is accessible seven days a week. In addition,
we want to improve end-of-life care pathways
with providers in the local community, so that
patients approaching the end-of-life can experience
a seamless transition between the trust and
community providers so that an increased number
of patients are able to die in their preferred location.
We also want to expand end-of-life training to all
relevant wards and specialties so that our staff
are equipped with the knowledge and have the
skills and confidence to provide patients with
compassionate care that is tailored to each end-oflife patient’s needs.
An end-of-life group is chaired by the director of
nursing and will monitor these improvements to the
end-of-life service.
Quality Account
Section 2
What are we trying to improve?
What will success look like?
• Increased referrals to the end-of-life care team
• Increased number of referrals seen on the same
or following day
• Expanded service provision to seven days a week
• Increased percentage of patients who are able to
die in their location of choice
• L
aunch four tier end-of-life care training
programme for delivery to providers across North
Central and East London.
Measure
Domain
Source
Patient
End-of-life care service
experience
activity report
Frequency
Increased
access to
dedicated
end-of-life care
Monthly
end-of-life care
of patients who are
2014/15 – 545 end-of-life
referred to the end-of-life
care referrals
care team
Increase the number
Increased
dedicated
Baseline data
Increase the number
service
access to
Aim/Target
Patient
End-of-life care service
experience
activity report
of patients who are seen
Monthly
on the same or following
day by the end-of-life
care team
service
2014/15 – 97% (528 out of 545)
end-of-life care referrals were seen
on the same or following day by the
end-of-life care team
Increase the percentage
Patient deaths
in preferred
locations
Patient
experience
of patients who are
Bereavement survey
Annual
enabled to die in their
preferred location
To be calculated during Q1 of
2015/16
of choice
34
Quality Account
Section 2
Priority 3: Improving care for patients with dementia
Why have we chosen this as a priority?
Patients suffering from dementia often have complex care needs and, particularly in the later stages of the
disease, high levels of dependency and increased risk of morbidity and mortality. High quality dementia
care recognises and promotes the human value of patients with dementia and those who care for them by
recognising and preserving the patient’s individuality and taking action to promote and protect their safety
and well-being. Patients with dementia can often challenge the skills of carers and the capacity of service
so it is essential that staff are equipped with the requisite expertise to care for patients with dementia.
Furthermore, we have chosen this priority because the CQC identified our medical services, including care
of the elderly, as one of the areas that required improvement. The quality of our dementia care was one of
the aspects that contributed to this.
What are we trying to improve?
How will we monitor progress?
We want to enhance and expand the knowledge
and skills of staff to ensure they can care for
patients with dementia across the trust. We will,
however, target this training on the most relevant
clinical areas, which are the care of the elderly
wards, accident and emergency department and the
acute medical unit. We will increase the number of
staff who have undergone dementia training in these
high risk clinical areas.
The trust has a dementia care steering group which
will monitor the implementation of these quality
improvement initiatives aimed at improving the
quality of dementia care that we provide. The trust
is also participating in the UCL Partners (UCLP)
dementia programme and the performance of the
trust in terms of providing dementia training is
reported through to UCLP.
What will success look like?
Increased percentage of staff in accident and emergency, the care of the elderly wards and the acute
medical unit who have received dementia training. Increased use of the carer’s passport scheme to support
carers of patients with dementia.
Increased capture of MTS and diagnoses of dementia on electronic discharge summaries as a percentage
of patients aged over seven years.
Measure
Domain
Source
Frequency
Aim/Target
Baseline data
Increased percentage of staff in
Dementia
Patient
training
experience
Performance
management
framework
Reported
monthly
accident and emergency, the care
of the elderly wards and the acute
To be calculated during Q1
medical unit who have received
dementia training
Carer’s passport
Patient
Audit of carer’s
experience
passport usage
Increased use of the carer's
Annual
passport scheme to support carers
To be calculated during Q1
of patients with dementia
Increased capture of MTS and
Dementia
diagnosis and
capture of MTS
Patient
Audit of electronic
experience
discharge summaries
diagnoses of dementia on
Annual
electronic discharge summaries as
a percentage of patients aged over
seven years
35
To be calculated during Q1
QA Section 2
Quality Account
Section 2
Clinical effectiveness priorities
for delivery in 2015/16
Priority 1: Improved patient participation in the patient reported outcome measures
(PROMs) questionnaires
Why have we chosen this as a priority?
In last year’s Quality Account we identified the need to increase patient completion of the PROMs
questionnaires in response to data received from the national centre which indicated we had a low level
of patient participation. In response to this, we set an ambitious stretch target of giving 95% of eligible
patients the opportunity to participate in PROMs. Performance against this target during 2014/15 was
mixed. We succeeded in getting 96% of patients who underwent total hip replacements to participate
in PROMs. However we failed to deliver 95% participation for knee replacement patients, of whom
participation increased to 86%, and groin hernia patients, of whom only 34% of patients opted to
participate. This indicates a need to continue the concentration on PROMs in order to maintain the current
good performance regarding knee replacement patients and to improve performance for hip replacement
and groin hernia patients to the requisite level. The trust also failed to instigate a system for capturing the
details of patients who decline to participate in PROMs questionnaires.
What are we trying to improve?
How will we monitor progress?
•We want to maintain the current level of good
performance for hip replacement patients
The nursing sister for pre-assessment will
maintain a log of the number of patients who have
participated in the PROMs surveys for each different
type of procedure. These will be cross-referenced to
the number of applicable patients who underwent
that procedure during the month. This performance
figure will be reported internally via the CBU4
clinical quality dashboard which is discussed at the
bi-monthly clinical effectiveness group, which is
chaired by the medical director.
•We want to improve participation for knee
replacement and groin hernia patients to 95%
•The trust does not perform varicose vein surgery
so we are not measured on this outcome.
36
Quality Account
Section 2
What will success look like?
•95% of patients who are eligible to take part in the PROMs survey will have been given the opportunity to
complete the questionnaire and their information sent to the national team for analysis.
• Where a patient chooses not to participate, this will be recorded.
Measure
Domain
Source
Frequency
Aim/Target
Baseline data
Groin hernia PROMs
participation rate = 34%
PROMs
Clinical
effectiveness
Proms audit
Six monthly
95% of eligible patients to
participate in PROMs surveys
Total hip replacement
PROMs participation rate
= 96%
Knee replacement PROMs
participation rate = 86%
PROMs
Clinical
effectiveness
Implement a system to record
Proms audit
Six monthly
patients who decline to participate
in PROMs
No process currently
in place
Priority 2: Improved performance against the specialty specific clinical outcome measures
Why have we chosen this as a priority?
We identified the specialty specific clinical outcome measures in last year’s Quality Account as a key
barometer to enable us to be assured the trust continued to provide high quality care during the period
of transition and expansion as a result of the implementation of the Barnet, Enfield and Haringey clinical
strategy. Having successfully implemented these measures across the organisation, this year the trust will
enhance the value of this work by using these measures as KPIs to drive forwards improvements in clinical
outcomes for patients across the trust.
37
What are we trying to improve?
How will we monitor progress?
The achievement of this priority will result
in the trust providing increasingly effective
clinical services to our patients. Each specialty
will review their identified specialty specific
clinical outcome measure(s) to stretching targets
for improvement. SMART action plans will be
agreed and implemented to bring about the
desired improvements in each of the clinical
outcome measures.
Performance against the specialty specific outcome
measures will be routinely monitored via the
clinical business unit clinical dashboard that will be
reviewed at the bi-monthly clinical effectiveness
group which is chaired by the medical director.
What will success look like?
Improved performance against each specialty’s
clinical outcome measures across each of the
clinical business units by the end of 2015/16.
Domain
Source
Frequency
Aim/Target
CBU clinical
Clinical outcome
Clinical
measures
effectiveness
measures/CBU
Baseline data
Trustwide clinical outcome
cffectiveness group
clinical outcome
Quality Account
Section 2
Measure
Bi-monthly
Improved performance against each
measure dashboard
clinical outcome measure
populated with 2014/15
dashboard
baseline data to be devised
Priority 3: Design and implement an anaesthetics service improvement plan
Why have we chosen this as a priority?
Feedback from our trainees suggested that our anaesthetics service could be reorganised and modernised
to improve the quality of services provided to patients. The trust has reviewed the configuration of its
anaesthetics service provision which has resulted in a remodelling of the service and an expansion in the
number of consultant anaesthetists at the trust. At present the trust is using locum consultants pending
the successful recruitment of substantive consultants. The appointment of these additional substantive
consultants will present the trust with a unique opportunity to review, innovatively reshape and improve its
anaesthetics and pain service provision. Furthermore, we have also chosen to concentrate on this priority
because the CQC inspection report identified the need for the trust to review the provision of specialist pain
nurse support across the trust.
What are we trying to improve?
The trust has created a new interim post of clinical director for anaesthetics who will devise and lead the
implementation of a service improvement plan to reorganise the department to enable better quality service
provision, seven days a week. This will also enhance the standing and reputation of the anaesthetics
department at North Middlesex University Hospital.
This will be accompanied by an expansion of the critical care outreach team to enable 24 hour, seven days
a week service provision across the trust. The specialist pain nurse provision will also be expanded so as to
enable access to specialist pain nurses seven days a week.
How will we monitor progress?
The trust has an anaesthetics service quality dashboard in place to monitor the quality of the service and
this is reported internally and shared with commissioners at the clinical quality review group. Once finalised,
the service improvement plan will be reviewed and agreed by the trust executive who will monitor the
implementation of the plan and the achievement of key project milestones.
38
Quality Account
Section 2
What will success look like?
Agreement and achievement of service
improvement plan which will include
a commitment to:
• S
ubstantive recruitment to all
anaesthetic vacancies
• P
rovision of 24/7 critical care
outreach team
• Invite a Royal College of Anaesthetists
anaesthesia review team (ART) to
undertake a review
• P
rovision of 7/7 specialist pain
nursing service.
• A
chieve anaesthesia clinical services
accreditation (ACSA) from the Royal
College of Anaesthetists
• D
eveloping the care of high dependency
patients both within the critical care
complex and out on our wards
• C
ommission TIVA equipment
in anaesthetics.
Measure
Domain
Source
Frequency
Clinical
Anaesthetics quality
Monthly monitoring at CBU
effectiveness
improvement plan
performance meeting
care outreach
Clinical
Anaesthetics quality
Monthly monitoring at CBU
CCOT service to 24
team to 24/7
effectiveness
improvement plan
performance meeting
hours a day, seven days
Recruit to
anaesthetics
vacancies
Aim/Target
Substantively recruit to
all current anaesthetic
vacancies
Expand provision of
Expand critical
a week
service
Current vacancy rate –
40%
Current service provision
is 08:00-20:00 seven days
a week
Expand provision of
Expand
specialist pain
Clinical
Anaesthetics quality
Monthly monitoring at CBU
specialist pain service to
Current service provision is
service to 7/7
effectiveness
improvement plan
performance meeting
give patients access 7
in hours
days a week
service
Finalise and
implement
anaesthetics
Clinical
Anaesthetics quality
quality
effectiveness
improvement plan
improvement
plan
39
Baseline data
Monthly monitoring at CBU
To be finalised and
performance meeting and
agreed during Q1 of
clinical quality review group
2015/16
Quality Account
Section 2
Statements of assurance from the board
1. During 2014/15 the North Middlesex University Hospital NHS Trust provided 34 relevant health services.
1.1 The North Middlesex University Hospital NHS Trust has reviewed all the data available to them on the
quality of care in 34 of these relevant health services.
1.2 The income generated by the relevant health services reviewed in 2014/15 represents 92.7% of the total
income generated from the provision of relevant health services by the North Middlesex University Hospital
NHS Trust for 2014/15.
2. During 2014/15 48 national clinical audits and four national confidential enquiries covered relevant health
services that North Middlesex University Hospital NHS Trust provides.
2.1 During 2014/15 North Middlesex University Hospital NHS Trust participated in 78% national clinical
audits and 100% national confidential enquiries which it was eligible to participate in.
2.2 The national clinical audits and national confidential enquiries that North Middlesex University Hospital
NHS Trust was eligible to participate in are as follows:
• National clinical audits – see table 1 following
• National confidential enquiries – see table 2 following.
2.3 The national clinical audits and national confidential enquiries that North Middlesex University Hospital
NHS Trust participated in during 2014/15 are as follows:
• National clinical audits – see table 1
• National confidential enquiries – see table 2.
2.4 The national clinical audits and national confidential enquiries that North Middlesex University Hospital
NHS Trust participated in, and for which data collection was completed during 2014/15, are listed below
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.
40
Quality Account
Section 2
Table 1: National clinical audit participation 2014/15
Audit
Applicable
overall
Data collection: Yes/No 14/15
2014/2015 status
Yes
Participating
No and % of cases
submitted in 2014/15
Cancer
Information not available
Bowel cancer (NBOCAP)
Applicable
at the time of submission
of report
Head and neck cancer
(DAHNO)
Oesophagus-gastric cancer
(NAOGC)
National lung cancer (NLCA)
N/A (via Barnet and Chase
Applicable
Yes
Participating
Applicable
Yes
Participating
30 – 60%
Applicable
Yes
Participating
104
Farm Hospital MDT)
The trust submitted 214
number of patient. The trust
was not able to submit as
many as they would have
Prostate cancer
Applicable
Yes
Participating
liked to. However, urology
and oncology team are
working on developing a
clearer pathway to submit
information to this audit
in 15/16
Children and women’s health
National neonatal audit (NNAP)
Applicable
Yes
Epilepsy 12
Applicable
Yes
N/A
Yes
N/A
N/A
Applicable
Yes
Participating
100%
Applicable
Yes
Participating
47
Paediatric intensive care
(PICANet)
Maternal, infant and newborn
programme (MBRRACE)
Fitting child (care in
emergency department)
41
Participating
Not required to submit
any data
533
N/A
Applicable
overall
Quality Account
Section 2
Audit
Data
collection:
2014/2015 status
No and % of cases submitted in 2014/15
Participating
115
Yes/No 14/15
Heart
Myocardial infarction (MINAP)
Applicable
Yes
There was no catheter laboratory service
between April and November 2014. Since the
Cardiac rhythm management
(CRM)
Applicable
Yes
Participating
cath. lab has been reinstated, there have been
32 cases to include on the CRM, however
these will be uploaded on the national
database in 15/16
Heart failure
National cardiac arrest audit
(NCAA)
National pulmonary
hypertension audit
Adult cardiac surgery
Congenital heart disease
(including paediatric surgery)
Coronary angioplasty audit (also
known as PCIs)
Applicable
Yes
Participating
109 (70%)
Applicable
Yes
Participating
100%
N/A
Yes
N/A
N/A – as refer patients to RFH
N/A
Yes
N/A
N/A
N/A
Yes
N/A
N/A
N/A
Yes
N/A
N/A
N/A
Yes
N/A
N/A
Applicable
Yes
Did not participate
Applicable
Yes
Did not participate
Applicable
Yes
Participating
Applicable
Yes
Did not participate
National vascular registry
(including CIA, peripheral
vascular surgery, VSGBI)
National diabetes audit – adult
(Diabetes UK)-outpatients
Inflammatory bowel
disease (IBD)
National paediatric diabetes
audit (NPDA)
The national pregnancy in
diabetes (NPID) – part of
Did not submit data, due to resource issue,
placed on trust risk register
Did not submit data, due to resource issue,
placed on trust risk register
120
Did not submitted data, due to resource issue.
NAIDIA
However, actions are taken to ensure further
data submission is timely
National chronic obstructive
pulmonary disease (COPD)
Applicable
Yes
Participating
60
N/A
Yes
N/A
N/A
N/A
Yes
N/A
N/A
Applicable
Yes
Did not participate
audit programme
Renal replacement therapy
(renal registry)
Renal transplantation
Rheumatoid and early
inflammatory arthritis
Due to staff shortage, there are no
resources to participate, this is placed
on CBU risk register
42
Quality Account
Section 2
Audit
Applicable
overall
Data collection: Yes/No 14/15
2014/2015 status
No and % of cases
submitted in 2014/15
Heart (continued)
Information is collected
locally, however there is
National diabetes foot care
audit (part of NDIA)
Applicable
Yes
Participating
a delay in uploading the
data to the national database
and this will be placed on
risk register
Chronic kidney disease in
primary care
N/A
Yes
N/A
Applicable
Yes
Participating
N/A
Older people
The sentinel stroke national
audit programme (SSNAP)
Older people (care in
emergency department)
Information not available at
the time of submission of
this report
Applicable
Yes
Participating
50
Applicable
Yes
Participating
266 (100%)
Applicable
Yes
Participating
Falls and fragility fractures
audit programme (FFFAP)
includes hip fracture
database audit (NHFD)
Blood and transplant
National comparative audit of
blood transfusion
Part 1 – 55 (96%)
Part 2 – 13 (15%)
Acute
Case mix programme
intensive care national audit
research centre – adults /
Applicable
Yes
Participating
Applicable
Yes
Participating
100% (till Nov 2014)
adult critical care
National joint registry
Filled NJR 76%, submitted
NJR 67%
TARN has a specific criteria
for uploading, owing to not
Severe trauma (trauma audit
and research network, TARN)
getting sent the ICD10 codes
Applicable
Yes
Participating
for the last 6 months codes
we are currently running 6/12
behind. Submitted 35 cases
so far
63 cases admitted
National emergency laparotomy
audit (NELA)
Applicable
Yes
Participating
54 locked
9 cases unlocked
43
Pleural procedure
National complicated
diverticulitis audit (CAD)
Applicable
No and % of cases
Data collection: Yes/No 14/15
2014/2015 status
Applicable
Yes
Did not participate
Due to lack of resources
Applicable
Yes
Did not participate
Did not submit any data
overall
Quality Account
Section 2
Audit
submitted in 2014/15
Due to lack of resources
Adult communityacquired pneumonia
Applicable
Yes
Did not participate
– however, many aspects
of this audit overlaps with
sepsis audit
PROMs
Elective surgery (national
PROMs programme)
(Jan 14 – Dec 14)
Applicable
Yes
Participating
Q1 participation rate 95%
Q2 Response rate 56%
Other for QA
National audit of
intermediate care
N/A
Yes
N/A
N/A
N/A
Yes
N/A
N/A
Applicable
Yes
Participating
41
N/A
Yes
N/A
N/A
N/A
Yes
N/A
N/A
Adherence to British Society
for Clinical Neurophysiology
(BSCN) and Association of
Neurophysiological Scientists
(ANS) standards for ulnar
neuropathy at elbow
(UNE) testing
Mental health
Mental health (care in
emergency department)
Mental health clinical outcome
review programme: national
confidential inquiry into suicide
and homicide for people with
mental illness (NCISH)
Prescribing observatory for
mental health (POMH)
44
Quality Account
Section 2
In addition, the trust participated in all four national confidential enquires into patient outcome and deaths
and these are listed below:
Table 2: National confidential enquiry participation 2014/15
National confidential enquiry into
patient outcome and death
NMUH applicability
NMUH participation
NMUH participation rate
100% organisational questionnaire
Sepsis
Applicable
Participated
100% clinical questionnaire
100% patient notes
100% organisational questionnaire
Gastrointestinal haemorrhage
Applicable
Participated
100% clinical questionnaire
100% patient notes
Tracheostomy care
Applicable
Participated
100% organisational questionnaire
100% organisational questionnaire
Lower limb amputation
Applicable
Participated
100% clinical questionnaire
100% patient notes
2.5 The reports of 32 national clinical audits were reviewed by the provider in 2014/15 and North
Middlesex University Hospital NHS Trust intends to take the following actions to improve the quality
of healthcare provided:
Trust intends to take necessary actions, where improvement required, eg national COPD audit. The
specialty will focus on following recommendations:
Improve time to second blood gas
Improve recording of FiO2
Continue to improve time to application of NIV
Improve documentation of ceiling of care
Improve patient involvement in decision about ceiling of care
Increase the number of patients admitted to a respiratory ward
Increase the respiratory bed base
Increase the number of patients under the care of the respiratory team
Increase the number of patients discharge under the care of respiratory consultant
Increase the number of patients referred to early/assisted discharge schemes
Increase the number of patients assessed and referred for pulmonary rehabilitation.
45
Quality Account
Section 2
Possible solutions for this:
AMU in-reach to enable early r/v and diagnosis of COPD and other chest patients
Provision of additional respiratory CNS (currently 0.5 WTE) could help too, eg early referral to community /
assisted discharge teams
Better bed management to facilitate moving of COPD patients and other specialty patients to T5, ie chest
drains, TB, pneumonia
Provision of at least two NIV beds on tower 5 ward to improve acute NIV care
National joint registry (NJR):
The trust conducted an internal audit to improve compliance with submission of data to NJR.
Trust compliance for 2013/14 was 68%, which was below national trend, where 77% NHS providers were
95% compliant.
The first cycle of data collection was completed in Dec 2014, recommendations were made to:
1.Improve awareness – NJR theatre poster
2.Designated place to keep forms
3.Meeting with person entering data every month
4.Dedicated session for data entering staff?
5.Liaise with PAC staff for BMI
6.Liaise with regional co-ordinator for advise.
These changes were re-audited and showed improvement for 2014/15 with 100% in all aspects of data
completeness (except BMI that still require further improvement) and an overall improved compliance of
77% in NJR submissions.
46
Quality Account
Section 2
The reports of 138 local clinical audits were reviewed by the provider in 2014/15 and North
Middlesex University Hospital NHS Trust intends to take the following actions to improve the quality
of healthcare provided:
Audit title
Specialty
Recommendations / Outcomes
Improve accessibility by creating a guideline folder on desktop of all
A&E medical staff satisfaction with current A&E
guidelines – service evaluation
A&E computers
A&E
Review guidelines by clinical and educational leads
Improve A&E guidelines introduction on induction
Conclusion:
Positives:
Marked improvement in triage observations allowing more accurate
early stratification.
Improved documentation and history.
Significant improvement in post treatment care including repeat peak
flows, inhaler check, discharge coordination
Static: Door to nebuliser time mildly longer although no drastic delay.
Asthma – emergency department management of
acute asthma re-audit
Similarly seen with door to steroid time.
A&E
Affected by recent increase in service provision due to closure of Chase
Farm Hospital A&E.
Areas for improvement:
Continue to improve on clinical history and documentation – important to
help stratify and rapidly assess patients.
Still need to work harder on checking patient education regarding
inhaler technique.
Need to practice repeat peak flows always on every patient before AND
after treatment – can help guide future admissions.
Recommendations:
Reinstitute the use of long acting opioids for neuraxial block in LSCS.
An audit of post Caesarean section outcomes
Anaesthetics
Revisit post-op analgesia regime.
Minimise changes to post-op analgesia prescription in the first 24 hrs by
non-anaesthetists.
Liaise with pharmacy to confirm.
Identify whether elderly patients nutritional needs are
assessed and monitored
47
Majority of patients have food charts and nursing staff need reminding of
COE
the importance of accurate monitoring, as many medical decisions are
based on whether the patient is eating and drinking
Specialty
Endoscopy staff satisfaction survey
Gastroenterology
Quality Account
Section 2
Audit title
Recommendations / Outcomes
Continue offering patient choice of appointment date / time making
this clear especially for target referrals.
Repeat in six months.
Morbidity and mortality following an endoscopy
Gastroenterology
Improve monitoring of post procedure readmissions / complications
(new ERS)
Continue offering patient choice of appointment date / time making
Patient satisfaction following and endoscopy
Gastroenterology
this clear especially for target referrals when waiting for procedures,
patients to be kept up to date regarding their appointment times.
Nursing staff / admin team to update patients / signature
First round completed in Aug 2013, improvement in second round
Evaluation of post take ward round
General surgery
in September 2013. Second round completed and report submitted
– improvement in results. Third cycle completed in Dec 2013,
improvement shown
As guided by the IUAC, it is important to use the TNM classification
Preoperative MRI TNM staging for cancer rectum
General surgery
in MRI reporting, which is not the case for the majority of MRI
reports at North Middlesex University Hospital NHS Trust. We
recommend the use of TNM classification in the reporting of MRI
To improve compliance with severity stratification, we suggest
Pancreatitis audit
General surgery
adding a checklist / pro-forma to be completed and signed on
admission and 48 hours post admission. This will include all the
values needed for a full Glasgow score and it will be a mandatory
Recommendations:
Clarifications to the current surgical patient’s pathway were agreed
on as follows:
Hand-back patients must be seen by the on-call consultant
routinely on post-take ward round prior to being handed back to the
previously known team.
Time to consultant review and seniority of admitting
doctors in emergency surgical admissions
General surgery
Clinic patients should be reviewed by the admitting consultant in
clinic; patients admitted from nurse-led clinics should be admitted
through A&E in the normal manner.
Evening consultant ward rounds should occur. Once a new
emergency surgical consultant has been appointed (winter 2014)
evening ward rounds will be the responsibility of the on-call
emergency consultant of the day.
Organise group and save blood tests within appropriate time scale,
Compliance with patient consent for operation and
group and save blood tests
General surgery
when required, in the outpatients (OP) department.
Obtain informed consent in the OP clinic
48
Quality Account
Section 2
Audit title
Specialty
Recommendations / Outcomes
Recommendations:
The two guidelines should be amalgamated and updated so that
they reflect the department’s accepted referral criteria.
When referring to a consultant clinic the reason should be stated
clearly in the antenatal plan page by the referring midwife. When
discharging back to the community, the doctor should also use this
page to clearly write their plan and if requesting a midwife to see
outside of the NICE guidance the reason for this should be
clearly stated.
Triage service audit
Obstetrics and
gynaecology
Midwives can use the gynaecology “hotline” for queries that are not
covered in the guidance when they are unsure of the appropriate
follow up and would like to book a woman’s follow up before
they leave.
Consultant teams to be appropriated to respective midwifery teams
to facilitate easy communication and structure. A lead consultant
and midwife for each team.
Where referrals are felt to be unnecessary or outside NICE guidance
this should be fed back to the individual through the lead consultant
or midwife as appropriate with a copy of the notes.
Recommendations:
Suggestions to reduce the number of cancellations of HSG on the
day have been proposed:
Keep a record in room 9 of HSG cancellations – where the HSG
allocated doctor can document the patient details, reason for
Hysterosalpingogram (HSG) cancellation audit
Obstetrics and
cancellation and action taken, eg rescheduled for following month
gynaecology
and preparatory advice given.
Ensure the results of this audit are presented to the
radiology department and all those involved in scheduling
and undertaking HSGs.
Training for doctors performing HSG to limit the number of
“repeat” HSGs.
We must document in all ante-natal notes of patients with
hypertension a target BP.
Aspirin for all high risk women and those with more than one
Hypertension in pregnancy audit
Obstetrics and
moderate risk factor.
gynaecology
We must improve follow-up and ongoing post-natal care of women
with pre-eclampsia.
Consider implementing discharge checklist sticker in
post-natal notes.
49
Diagnosis and management of multiple
Obstetrics and
pregnancies – QS 46
gynaecology
To develop a leaflet
Audit of intra-ocular lens (IOL) selection and
documentation prior to cataract surgery
An audit of the recently introduced protocol for
requesting liver blood tests
Specialty
Quality Account
Section 2
Audit title
Recommendations / Outcomes
IOL selection adhered on most occasions (43/47).
Ophthalmology
WHO checklist – issues with completion and filing.
Pathology
Preliminary findings show that there has been a reduction in the
more specialised and costly send away liver function
A total of 20 blood transfused records selected for the period
1–31March 2013 were handled by 11 porters and 28 clinical staff.
100% of the porters who collected blood/blood products had
documented evidence of training.
36% of clinical staff who administered the blood/blood products did
not have documented evidence of training.
Blood and blood product safety training
Pathology
4% of clinical staff who administered blood/blood products could
not be identified.
Department to feedback the findings to the LeAD team and hospital
transfusion committee by 31 January 2014.
Transfusion practitioner to immediately ensure that transfused
records where clinical staff who administered blood/blood products
cannot be identified is reported to the transfusion practitioner.
Patients were admitted under different specialities, most
commonly care of elderly and general medicine. Presenting
complaints were diverse. Hyponatraemia was more commonly
documented in patient notes than on discharge summaries. Fluid
Retrospective audit of the investigation of
hyponatraemia in adult hospital inpatients
balance assessments and cognitive and neurological variably.
Pathology
Documentation of fluid balance examination was also assessed
and did not show an improvement when compared to the previous
audit. The hyponatraemia bundle of additional biochemistry tests as
outlined on the existing guidelines was implemented sporadically.
The cause of the hyponatraemia was explicitly documented for only
half of the patients. Final report awaited
An audit of the views of consultant staff at North
Middlesex University Hospital NHS Trust of the
Overall satisfaction by the consultant staff of the service, both the
Pathology
pathology service
An audit on the safety of paracetamol prescribing for
inpatients at North Middlesex University Hospital
technical and clinical aspects, with most reporting improvements
over the last two years
The results of the audit highlighted the areas for improvement
Pharmacy
relating to paracetamol prescribing. The main areas which need
improvement are the recording of patient weights
The findings of this audit have been positive, with patients only
The prescribing of NSAIDs for post-operative pain in
accordance with local and national guidelines
Pharmacy
being prescribed NSAIDs if it is appropriate to do so. Pharmacists
should ensure that prescribers are aware of the WHO pain ladder,
whereby they prescribe patients with paracetamol as first
Oxygen prescribing audit – NPSA Alert
Pharmacy
A significant improvement from 52% to 68% in oxygen prescription
was noted between the first and the final re-audit
50
Quality Account
Section 2
Audit title
Specialty
Recommendations / Outcomes
Antibiotic ward rounds have resulted in significant interventions to
Antibiotic ward rounds pilot audit
Pharmacy
improve antimicrobial stewardship in the vast majority of patients
Clear contribution to improving patient safety and quality of care
Ensure nurses are trained to label stock insulin pens for patients
To audit compliance with NPSA guidance (NPSA
guidances 2002–2010)
and keep the pen in use in the POD locker
Pharmacy
Ensure high strength opioids are returned to pharmacy in
a timely manner
Recommendations:
We must document in all ante-natal notes of patients with
hypertension a target BP (<150/100 mmHg or if already end organ
damage < 140/90 mmHg.
Aspirin – in order to be beneficial aspirin must be started by 12
weeks gestation. Many women book later than this therefore there
Management of hypertension in accordance with
NICE guidelines
needs to be greater awareness amongst GPs to start high-risk
Renal medicine
women on aspirin as early as possible (all high risk women and
those with more than one moderate risk factor).
We must improve follow-up and ongoing post-natal care of
women with pre-eclampsia. New post-natal clinic has just been
implemented – recommend audit of cases referred and outcome in
six months.
Consider implementing discharge checklist sticker in
post-natal notes.
GP and patient should be made aware of outcome of joint clinic.
Is the joint renal/HIV clinic affecting management
of patients in NMUH, a district general hospital in
Renal medicine
north London
Improved optimisation of blood pressure control and consideration
of ACE-i or ARB in appropriate patients.
All patients requiring limb elevation should have this prescribed in
the drug chart.
Limb elevation on orthopaedic wards
Trauma and
orthopaedics
This should be communicated to all juniors on their departmental
induction in orthopaedics.
Results should be re-audited in 3 months time.
51
Specialty
Quality Account
Section 2
Audit title
Recommendations / Outcomes
Conclusion:
The NOFs population received appropriate treatment for 20
prevention of osteoporosis.Patients with other fragility fractures are
not being commenced on secondary prevention at NMH and no
recommendations are being made to the general practitioners.
To our knowledge there is a fracture liaison services for our Enfield
population but we have been unable to confirm their procedures
and which of our patients they have picked up.
There is no fracture liaison service for our Haringey population.
Compliance with boast nine guidelines for our fragility
Trauma and
fracture population
orthopaedics
There is a need to highlight these patients to fracture liaison
services or to their GPs for appropriate secondary
prevention management.
Recommendations:
A reminder notice in every fracture clinic room regarding
fragility fractures.
To identify all patients over 50 years with potential fragility
fractures and recommend to the GPs that they consider
secondary prevention management or referral to their local
fracture liaison services.
Re-audit the effectiveness of the measures taken in two
months’ time.
Pre-assessment form should be signed by the risk assessor.
Should the VTE RA be done by the surgeon? If not, it should be
reviewed and if necessary amended by the surgeon.
VTE assessment documentation in elective non-THR/
Trauma and
TKR lower limb patients
orthopaedics
Routinely document the need for VTE prophylaxis or otherwise in
the post-op instructions.
According to the VTE RA documentation, almost every patient
should go home with TEDS, at least.
52
Quality Account
Section 2
3. The number of patients receiving relevant health services provided or sub-contracted by North Middlesex
University Hospital NHS Trust in 2014/15 that were recruited during that period to participate in research
approved by a research ethics committee was 510.
4. A proportion of North Middlesex University Hospital NHS Trust’s income in 2014/15 was conditional on
achieving quality improvement and innovation goals agreed between North Middlesex University Hospital
NHS Trust and any person or body they entered into a contract, agreement or arrangement with for the
provision of relevant health services, through the commissioning for quality and innovation (CQUIN)
payment framework. Further details of the agreed goals for 2014/15 and for the following 12 month period
are available electronically at:
The CQUIN framework allows the trust and commissioners to develop and agree quality requirements in
the annual contracts. The trust is financially incentivized for achieving targets within the CQUIN indicators.
The financial incentive is equivalent to 2.5% of the actual contract value and is split between indicators
which are either nationally mandated (0.5%) or locally agreed (2.0%). The locally agreed CQUIN indicators
are developed through clinical discussion and negotiation between primary care (CCG) and secondary care
(acute) clinicians. The CQUIN Indicators are designed to develop innovative and challenging quality targets
that will have a positive clinical impact on the local healthcare population. Although final values for 2014/15
based on the year end position are yet to be agreed in full with local commissioners, a summary of the
CQUIN indicators for 2014/15 is on the next page.
53
CQUINS name
Safety Thermometer
Dementia
Integrated Care
Sub-indicator
Friends and Family 1.1
1.1 – Further implementation of patient FFT and staff FFT
G
Friends and Family 1.2
1.2 – Early implementation of the patients FFT in outpatient and day – case departments, as
specified in the national guidance, by 1 October 2014.
G
Friends and Family 1.3(a)
1.3(a) – A&E – 15% of the funding for increasing and or maintaining response rates in A&E and
inpatient areas
RA
Friends and Family 1.3(b)
1.3(b) – Inpatient – 15% of the funding for increasing and or maintaining response rates in A&E
and inpatient areas
G
Friends and Family 1.4
1.4 – 40% of the funding for further increasing response rates within inpatient services. The
CQUIN payment to be triggered if the provider achieves a response rate of 40% or more for the
month of March 2015
A
Safety Thermometer 2.1
2.1 – Reporting as per National Safety Thermometer
G
Safety Thermometer 2.2
2.2 – Reduction in the prevalence of pressure ulcers – Hospital Acquired
A
Safety Thermometer 2.3
2.3 – Attendance at community pressure ulcer meetings
G
Dementia 3.1(a)
3.1(a) – Dementia – Find and Assess
G
Dementia 3.1(b)
3.1(b) – Dementia – Investigate
G
Dementia 3.1(c)
3.1(c) – Dementia – Refer
G
Dementia 3.2
3.2 – Dementia – Clinical Leadership
A
Dementia 3.3
3.3 – Dementia – Supporting Carers of People with Dementia
RA
Integrated Care 4.1
4.1 – Provider will participate in not less than 4 case conferences per month and will complete
95% of actions at case conferences. This will be verified by the MDT coordinator
G
Integrated Care 4.2
4.2 – (X)% increase in the percentage of contacts to ambulatory care against a baseline in Q3
14-15 from A&E and UCC (to be agreed via CQRG)
RA
Integrated Care 4.3
4.3 – Q1 establish a baseline for number of admitted patients to be discharged before 10am.
Increasing trajectory in Q2, Q3 and Q4 of at least 2% in each quarter
RA
Prevention Smoking 5.1
5.1 – Smoking status recording and brief advice for all inpatients
RA
Prevention Smoking 5.2
5.2 – Referrals to Community Stop Smoking Service by borough: Enfield and Haringey
RA
Prevention Smoking 5.3
5.3 – Attendance at the Community Stop Smoking Service after referral
G
Quality Account
Section 2
Friends and Family
YTD\
RAG
Ref ID
Prevention Smoking
Prevention Smoking 5.4
5.4 – Staff Smoking Reduction
G
Prevention Alcohol 6.1
6.1 – Screening – Percentage of patients screened for alcohol in A&E, UCC and MAU
R
Prevention Alcohol 6.2
6.2 – Alcohol – brief intervention and advice
R
Prevention Alcohol 6.3
6.3 – Alcohol – communication with GP
R
Prevention Alcohol 6.4
6.4 – Referral to Alcohol Liaison Service
–
Prevention Alcohol 6.5
6.5 – Recording and reporting of alcohol-related violent incidents
A
Prevention Alcohol 6.6
–
R
Domestic Violence 7.1
7.1 – Ensure trained staff ask patients about domestic violence and abuse in A&E.
A
Value Based Commissioning 8.1
8.1 – Clinical and non-clinical managers participate in VBC and Integrated Practice Unit (IPU)
workshops that relate to each of the three work-streams: 1) diabetes 2) elderly people with frailty
3) mental health. A clinical champion is identified who is
G
Value Based Commissioning 8.2
8.2 – North Middlesex University Hospital NHS Trust (NMUH) will work with other trusts to
identify a means of measuring the specific cohort of patients in each work-stream so that
outcomes can be monitored and activity measured.
G
Value Based Commissioning 8.3
8.3 – Development of sharing agreements with other providers within North Central London.
Identification of a means of sharing information about a specific cohort of patients across
all Trusts.
G
Value Based Commissioning 8.4
8.4 – Value based commissioning (VBC) – Re-design
G
0.1% For ODNS
0.1% for ODNS 9.1
9.1 – 0.1% for ODNS
RA
NHS Dashboard –
Haemoglobinopathy,
Paediatric Oncology
NHS Dashboard –
Haemoglobinopathy, Paediatric
Oncology 10.1
HIV – Patient self
management and novel IT
based pathway for stable
HIV patients
HIV – Patient self management
and novel IT based pathway for
stable HIV patients 11.1
Neonatal Intensive Care –
improved access to breast
milk in preterm infants
Neonatal Intensive Care –
Improved access to breast milk in
preterm infants 12.1
12.1 – Neonatal Intensive Care – Improved access to breast milk in preterm infants
A
Smoking Cessation
Smoking Cessation 13.1
13.1 – Services are expected to ask the relevant questions from the patients and offer
intervention at a minimum of thirty (30) patients a week (Target is the number of patients who
were asked the question and provided with intervention if needed).
A
Increase in Uptake
Increase in Uptake of Diabetic
Eye Screening Service 14.1
14.1 – Provider-led development and implementation of uptake improvement action plan that will
demonstrably improve uptake by at least 6% over 12 months (cumulative).
A
Prevention Alcohol
Domestic Violence
Value Based Commissioning
10.1 – 2013–14 – HIV, NICU, Radiotherapy.
2014–15 – Haemoglobinopathy, Paediatric
Oncology
11.1 – The service will introduce a new clinical pathway for eligible, stable HIV patients that
– reduces the need for face to face consultant appointments and
– encourages patient self management.
RA
A
The pathway will be evaluated in terms of cost-effectiveness
54
Quality Account
Section 2
5. North Middlesex University Hospital NHS Trust is required to register with the Care Quality Commission
and its current registration status is registered with the CQC with no conditions attached to the registration.
The Care Quality Commission has taken enforcement action against North Middlesex University Hospital
NHS Trust during 2014/15.
6. Not applicable
7. North Middlesex University Hospital NHS Trust has not participated in any special reviews or
investigations by the CQC during the reporting period.
North Middlesex University Hospital underwent an announced, scheduled CQC inspection between 4–6
June, 2014. The inspection was undertaken using the new CQC inspection framework which assessed
whether services are:
•safe
•effective
•caring
•responsive
•well-led.
The following services were inspected:
• accident and emergency
• medical wards (including care of the elderly)
•surgery
• critical care
•maternity
•paediatrics
•outpatients
• end-of-life care.
55
Safe
Accident and
Requires
emergency
improvement
Medical care
Requires
improvement
Effective
Caring
Not rated
Good
Good
Good
Resppnsive
Well-led
Overall
Requires
Requires
Requires
improvement
improvement
improvement
Requires
Requires
Requires
improvement
improvement
improvement
Surgery
Good
Good
Good
Good
Good
Good
Crtical care
Good
Good
Good
Good
Good
Good
Maternity and
Requires
family planning
improvement
Good
Good
Good
Good
Good
Good
Good
Good
Good
Good
Good
Requires
Requires
Requires
Requires
Requires
improvement
improvement
improvement
improvement
improvement
Requires
Requires
Requires
improvement
improvement
improvement
Requires
Requires
Requires
improvement
improvement
improvement
Quality Account
Section 2
The chart below depicts the ratings awarded to each service and the trust overall.
Services for
children and
young people
End of life care
Outpatients
Overall
Requires
improvement
Requires
improvement
Good
Not rated
Good
Good
Good
The CQC noted one area of concern, for which it issued a compliance notice regarding Regulation 22 HSCA
2008 (Regulated Activities) Regulations 2010 Staffing. People who use services did not always have their
health and welfare needs met by sufficient numbers of appropriate staff in that mandatory training records
did not accurately reflect training undertaken across the trust and dementia awareness training was not
undertaken across the trust.
A compliance action plan was submitted to the commission by the required deadline and the trust has
achieved the improvements in staff training required by the compliance action.
A copy of the CQC inspection report can be accessed here:
www.cqc.org.uk/sites/default/files/new_reports/AAAA1827.pdf
56
Quality Account
Section 2
8. North Middlesex University Hospital NHS Trust submitted records during 2014/15 to the Secondary Uses
Service for inclusion in the hospital episode statistics which are included in the latest published data.
The percentage of records in the published data
which included the patient’s valid NHS number was:
• 97.6% for admitted patient care
• 99.3% for outpatient care and
• 86.9% for accident and emergency care.
The percentage of records in the published data
which included the patient’s valid general medical
practice code was:
• 99.9% for admitted patient care;
• 99.8% for outpatient care; and
• 98.9% for accident and emergency care.
9. The hospital’s information governance assessment report overall score for 2014/15 was 68% and was
graded “green – satisfactory”.
10. North Middlesex University Hospital NHS Trust was subject to the payment by results clinical coding
audit during the reporting period by Monitor and CHKS and the error rates reported in the latest published
audit for that period for diagnoses and treatment coding (clinical coding) were 3.7%.
11. North Middlesex University Hospital NHS Trust will be taking the following actions to improve
data quality:
The hospital has invested in two additional permanent band 4 data quality staff and three apprentices within
the corporate data quality department. This will enabled the trust to initiate a series of robust processes to
monitor and improve data quality trustwide. These include:
•apprentice development programme with the aim to transfer suitably trained apprentices into
operational departments
• dedicated Band 4 corporate data quality clerk for each clinical business unit (CBU)
• weekly meetings with service managers led by data quality manager
• data quality attendance and agenda item on all CBU management meetings
• development of weekly updated issues tracker which is available electronically to all staff
• development of data quality dash board for all CBUs
• rolling programme of monthly data quality audits
• presentation and training sessions for all administrative staff
• development of a mandatory e-learning data quality package
• development of pre-submission validation checks
• data quality update and monitoring at the weekly director-led business meetings
• monthly report to finance committee.
57
Quality Account
Section 2
Reporting against core indicators
12. (a) The value and banding of the summary hospital-level mortality indicator for the reporting period.
Domain 1 – Preventing people from dying prematurely
Summary hospital-level mortality indicator (SHMI)
The SHMI is a clinical performance indicator which compares the actual number of patient deaths following
admission to hospital against the number of deaths that are expected. From this, the trust is placed in a
banding from 1 to 3, with 3 being the best banding with the lowest mortality rate.
(a) The value and banding of SHMI for the trust for the reporting period.
Publication date
January 2015
October 2014
Reporting period
Measure
NMUH value
National average
National lowest
National highest
Value
0.8736
1.0000
0.5407
1.1982
Banding
3
N/A
N/A
N/A
Value
0.8755
1.0000
0.5392
1.1973
Banding
3
N/A
N/A
N/A
July 2013 – June 2014
April 2013 – March 2014
Key: SHMI Banding 3 = “lower than expected”
The North Middlesex University Hospital NHS Trust considers that this data is as described for the
following reasons:
The data is consistent with the hospital’s own internal monitoring and reporting of performance against this
indicator. The trust’s SHMI rate continues to be banded “lower than expected”. Performance in this area
continues to be significantly better than the average score and we remain in the top 10% nationally.
The North Middlesex University Hospital NHS Trust has taken the following actions to improve this
rate, and so the quality of its services, by:
Ensuring that all deaths that occur in the hospital are closely reviewed as routine to assure that the best
possible care was given to patients in all cases. Any subsequent learning events are shared within the
organisation as appropriate.
58
Quality Account
Section 2
The North Middlesex University Hospital NHS
Trust considers that this data is as described for
the following reasons:
The North Middlesex University NHS Trust has
taken the following actions to improve this rate,
and so the quality of its services by:
The data is consistent with the hospital’s internal
monitoring and reporting of performance against
this indicator. The trust’s performance in this area
continued to be significantly better than the national
average score. Furthermore, through the mortality
workstream of the patient safety group, since April
2011 we have reported and discussed retrospective
case-adjusted mortality data, SHMI, HSMR and Dr
Foster Alerts. We also track a simple monthly crude
mortality calculation of the number of patients who
died in the preceding month divided by the number
of patient admissions.
Ensuring that all deaths that occur at the hospital
are routinely reviewed and reported to specialty
level mortality and morbidity meetings. Specialty
teams routinely review the case notes of all patients
who have died and discuss whether the death was
avoidable, that no care or service delivery issues
were found to have contributed to the death, or
whether on review, any different decision making or
care might have contributed. The trust has instituted
a trustwide mortality and morbidity working group
as part of its safety improvement plan for 2015. This
is chaired by the medical director and ensures that
all specialty-level mortality and morbidity meetings
are taking place across the organisation and that
they rigorously review all deaths that occur at
the hospital.
The trust-wide morbidity and mortality workstream
also conducts thematic reviews that span the
different specialty-level reviews to ensure that
trends are identified and learning occurs across the
organisation. For example, there was an unexpected
increase in the number of patients who died at
the hospital in the months of December 2014 and
January 2015. This triggered a thematic review of
all deaths that occurred in these months by the
associate medical director for patient safety. This
review demonstrated the that increase in deaths
during January was not unique to North Middlesex
University Hospital as the Office for National
Statistics recorded a 32% increase over the average
number of deaths in comparison to the preceding
five Januaries. Deaths of people over the age of 65
were higher than expected for the six week period
from before Christmas 2014 to the end of January
2015 with the low effectiveness of the seasonal
flu vaccine likely contributing to this. The trust
therefore undertook a casenote review of all deaths
during this period to be assured that there was no
significant lapses in care for these patients.
59
Quality Account
Section 2
(b) The percentage of patient deaths with palliative care coded at either diagnosis or specialty level for the
trust for the reporting period.
(ii) Percentage of deaths with palliative care coding.
The percentage of deaths with palliative care coded at either diagnosis or specialty level is included in
the Quality Account to add context to the SHMI indicator. This is because other methods of calculating
mortality rates and the risk of mortality make statistical provision for palliative care, whereas the SHMI
methodology does not take palliative care into account.
Publication date
January 2015
October 2014
Reporting period
July 2013 – June
2014
April 2013 – March
2014
Measure
NMUH value
National average
National lowest
National highest
Treatment rate
0.0
1.8
0.0
18.3
Diagnosis rate
26.7
24.5
0.0
49.0
Combined rate
26.7
24.6
0.0
49.0
Treatment rate
0.0
1.8
0.0
18.2
Diagnosis rate
27.7
23.5
0.0
48.5
Combined rate
27.7
23.5
0.0
48.5
The North Middlesex University Hospital NHS Trust considers that this data is as described for the
following reasons:
The data shows performance which is higher than the national average as it represents a period when the
trust was coding palliative care treatment for all of those deaths where patients were noted as being on
end-of-life care pathways irrespective of whether they had input from the palliative care team. This matter
was picked up by the trust as being a data quality over reporting issue and corrected going forward from
2014. The trust’s performance continues to converge towards the national average.
The North Middlesex University Hopital NHS Trust has taken the following action to improve this
percentage and so the quality of its services, by:
Ensuring that all patients receiving input from the palliative care team have this noted on a sticker which
is put into their medical notes. Patients are now only clinically coded as palliative care when this sticker
is present.
60
Quality Account
Section 2
Domain 2 – Enhancing quality of life for people with long-term conditions
Not applicable to the North Middlesex University Hospital NHS Trust
Domain 3 – Helping people to recover from episodes of ill health or following injury
18. The trust’s patient-reported outcome measure scores for:
i. Groin hernia surgery
PROMS; patient-reported outcome measures
Patient-reported outcome measures (PROMS) are surveys where the NHS questions patients about their
quality of life both before and after a surgical procedure. This helps hospitals understand how these
operations are improving the quality of life for their patients and is a measure of the quality of care provided.
A negative score indicates that patients are not reporting an improvement in their health or quality of life
after surgery, whereas a positive score indicates that patients’ health and quality of life has improved
following surgery.
PROMS surveys comprises two distinct self-report elements:
(i) the EQ-5D profile: this is the patients’ self-reported health on each of the five quality of life dimensions of
the descriptive system (mobility, self-care, usual activities, pain and discomfort, anxiety and depression).
(ii) the EQ-VAS: the patients’ own global ratings of their overall health, on a scale from 0 (worst possible
health) to 100 (best possible health).
(i) Groin hernia surgery
Publication date
February 2015
October 2014
61
Reporting period
Measure
NMUH value
National average
National lowest
National highest
EQ VAS
0.132
-1.053
-5.791
2.864
EQ-5D Index
0.069
0.085
0.008
0.139
EQ VAS
-1.764
-0.995
-7.033
4.449
EQ-5D Index
0.090
0.085
0.014
0.153
April 2013 – March 2014
April 2012 – March 2013
Quality Account
Section 2
The North Middlesex University Hospital NHS Trust considers that this data is as described for the
following reasons:
The data is consistent with the hospital’s own internal monitoring and reporting of performance against this
indicator. The trust’s performance has seen improvement between the reporting periods shown above.
(ii) Varicose vein surgery
Patient-reported outcome measures are surveys where the NHS questions patients about their quality of
life both before and after a surgical procedure. This helps hospitals understand how these operations are
improving the quality of life for their patients and is a measure of the quality of care provided. A negative
score indicates that patients are not reporting an improvement in their health or quality of life after surgery,
whereas a positive score indicates that patients’ health and quality of life has improved following surgery.
PROMS surveys comprise two distinct self-report elements:
(i) the EQ-5D profile: this is the patients’ self-reported health on each of the five quality of life dimensions of
the descriptive system (mobility, self-care, usual activities, pain and discomfort, anxiety and depression).
(ii) the EQ-VAS: the patients’ own global ratings of their overall health, on a scale from 0 (worst possible
health) to 100 (best possible health).
Note: No varicose vein surgery data available for 2014/15. No data previous to 2013/14 available.
Publication date
Reporting period
Measure
NMUH value
National average
National lowest
National highest
-10.226
-8.698
-19.385
-2.721
EQ VAS
-1.429
-0.553
-12.045
19.143
EQ-5D index
0.073
0.093
-0.134
0.468
Aberdeen varicose
vein questionnaire
February 2015
April 2013 – March
2014 (unadjusted)
62
Quality Account
Section 2
The North Middlesex University Hospital NHS Trust considers that this data is as described for the
following reasons:
The data is consistent with the hospital’s own internal monitoring and reporting of performance against
this indicator. The trust’s performance was slightly below the national average for this measure in the
only available data set covering the financial year 2013/14. Please note that the data is not currently
case mix-adjusted.
iii. hip replacement surgery
Patient-reported outcome measures (PROMS) are surveys where the NHS questions patients about their
quality of life both before and after a surgical procedure. This helps hospitals understand how these
operations are improving the quality of life for their patients and is a measure of the quality of care provided.
A negative score indicates that patients are not reporting an improvement in their health or quality of life
after surgery, whereas a positive score indicates that patients’ health and quality of life has improved
following surgery.
PROMS surveys comprises two distinct self-report elements
(i) the EQ-5D profile: this is the patients’ self-reported health on each of the five quality of life dimensions of
the descriptive system (mobility, self-care, usual activities, pain and discomfort, anxiety and depression).
(ii) the EQ-VAS: the patients’ own global ratings of their overall health, on a scale from 0 (worst possible
health) to 100 (best possible health).
Note: No hip replacement surgery data available for 2014/15
Publication date
February 2015
August 2014
63
Reporting period
April 2013 – March
2014 (unadjusted)
April 2012 – March
2013 (unadjusted)
Measure
NMUH value
National average
National lowest
National highest
EQ VAS
9.211
11.487
2.531
27.538
EQ-5D Index
0.448
0.436
0.102
0.588
Oxford hip score
20.458
21.340
14.226
28.571
EQ VAS
8.267
11.634
0.833
33.714
EQ-5D Index
0.417
0.438
0.289
0.621
Oxford hip score
16.711
21.299
15.400
31.167
Quality Account
Section 2
The North Middlesex University Hospital NHS Trust considers that this data is as described for the
following reasons:
The data is consistent with the hospital’s own internal monitoring and reporting of performance against this
indicator. The trust’s performance was slightly below the national average but shows improvement between
the two reporting periods. Please note that the data is not currently case mix-adjusted.
(iv) Knee replacement surgery
Patient-reported outcome measures (PROMS) are surveys where the NHS questions patients about their
quality of life both before and after a surgical procedure. This helps hospitals understand how these
operations are improving the quality of life for their patients and is a measure of the quality of care provided.
A negative score indicates that patients are not reporting an improvement in their health or quality of life
after surgery, whereas a positive score indicates that patients’ health and quality of life has improved
following surgery.
PROMS surveys comprises two distinct self-report elements
(i) the EQ-5D profile: this is the patients’ self-reported health on each of the five quality of life dimensions of
the descriptive system (mobility, self-care, usual activities, pain and discomfort, anxiety and depression).
(ii) the EQ-VAS: the patients’ own global ratings of their overall health, on a scale from 0 (worst possible
health) to 100 (best possible health).
Note: No knee replacement surgery data available for 2014/15
Publication date
February 2015
August 2014
Reporting period
April 2013 – March
2014 (unadjusted)
April 2012 – March
2013
Measure
NMUH value
National average
National lowest
National highest
EQ VAS
1.351
5.640
-1.547
15.401
EQ-5D Index
0.319
0.323
0.215
0.416
Oxford knee score
14.789
16.248
12.049
19.762
EQ VAS
1.888
5.191
-1.912
15.592
EQ-5D Index
0.231
0.318
0.209
0.416
Oxford knee score
12.461
15.996
12.461
20.444
The North Middlesex University Hospital NHS Trust considers that this data is as described for the
following reasons:
The data is consistent with the hospital’s own internal monitoring and reporting of performance against this
indicator. The trust’s performance improved against two of the three measures between reporting periods,
but remains below the national average.
64
Quality Account
Section 2
The North Middlesex University Hospital NHS Trust intends to take the following actions to improve
this rate, and so the quality of its service by:
Refocusing organisational attention on the participation of patients in PROMs surveys to increase
participation to 95% by the end of 2015/16.
19. Patients readmitted to a hospital within 28 days of being discharged.
The trust monitors the rate of emergency readmissions (patients who reattend the trust and are admitted
within 28 days of having previously been discharged from the hospital) as a measure of the quality of care
as it provides an indication of the appropriateness of patient discharges. A lower than average score is
considered evidence of a good quality of care and a reducing score is indicative of improved performance.
(i) aged 0 to 15
Publication date
Reporting period
NMUH value
National average
National lowest
National highest
Dec 2013
2011/12
7.88%
10.01%
3.75%
14.94%
Dec 2013
2010/11
6.27%
10.01%
4.04%
16.05%
The North Middlesex University Hospital NHS Trust considers that this data is as described for the
following reasons:
The data is consistent with the hospital’s own internal monitoring and reporting of performance against
this indicator. The trust’s performance is slightly higher in the most recent reporting period above but both
figures remain significantly better than the national average.
The North Middlesex University Hospital NHS Trust has taken the following actions to improve this
rate, and so the quality of its services, by:
Ensuring that paediatric patients can be fast-tracked to dedicated day care facilities for treatment where
clinically appropriate and help to avoid frequent and regular unplanned admissions to hospital. This helps
children and carers to experience treatment in a less daunting and more comfortable environment.
65
Quality Account
Section 2
(ii) aged 16 and over
Publication date
Reporting period
NMUH value
National average
National lowest
National highest
Dec 2013
2011/12
12.56%
11.45%
4.88%
17.15%
Dec 2013
2010/11
11.30%
11.43%
6.67%
17.10%
The North Middlesex University Hospital NHS Trust considers that this data is as described for the
following reasons:
The data is consistent with the hospital’s own internal monitoring and reporting of performance against
this indicator. The trust’s performance over time has been broadly in line with the national average for this
measure although there is an increase between the data time periods above.
The North Middlesex University Hospital NHS Trust has taken the following actions to improve this
rate, and so the quality of its services, by:
Ensuring that patients groups such as sickle cell patients , for example, are helped in both the community
and day care centres to better understand their signs and symptoms and take quicker action. This enables
patients to experience treatment in a more appropriate and comfortable setting and avoid frequent (and
often lengthy) unplanned admissions to hospital wards. Feedback from patients around this amended care
pathway has been very positive indeed.
Current version of data uploaded is December 2013. The next expected publication of refreshed data is
early 2016.
66
Quality Account
Section 2
Domain 4 – Ensuring people have a positive experience of care
20. The trust’s responsiveness to the personal needs of its patients during the reporting period.
Responsiveness to the personal needs of patients
The NHS has prioritised, through its commissioning strategy, an improvement in hospitals’ responsiveness
to the personal needs of their patients. Information is gathered through patient surveys. A higher score
suggests better performance. Current performance is worse than the national average.
Publication date
Reporting period
NMUH value
National average
National lowest
National highest
May 2014
2013/14
65.5
68.7
54.4
84.2
May 2014
2012/13
66.0
68.1
57.4
84.4
The North Middlesex University Hospital NHS Trust considers that this data is as described for the
following reasons:
The data is consistent with the hospital’s own internal monitoring and reporting of performance against this
indicator. The trust’s performance has historically been below the national average for this measure, but has
generally shown improvement over time. Data for 2013/14 is an exception to this rule – but the change is
only 0.5.
The North Middlesex University Hospital NHS Trust intends to take the following actions to improve
this rate, and so the quality of its service by:
The trust has a revised patient experience action plan for implementation throughout 2015/16. The
implementation of the action plan will be led by the deputy director of nursing and monitored by the patient
experience group.
21. The percentage of staff employed by, or under contract to, the trust during the reporting period who
would recommend the trust as a provider of care to their family or friends.
Staff who would recommend the trust to their family or friends
Each year the NHS surveys its staff and one of the questions looks at whether or not staff would
recommend their hospital as a care provider to family or friends.
This measure enables the trust to compare the experience of its staff with that of staff working at other
trusts across the country.
67
Publication date
Reporting period
NMUH value
National average
National lowest
National highest
February 2015
2014
59%
65%
38%
89%
February 2014
2013
58%
65%
38%
97%
Quality Account
Section 2
The North Middlesex University Hospital NHS Trust considers that this data is as described for the
following reasons:
The data is consistent with the hospital’s own internal monitoring and reporting of performance against this
indicator. The trust’s performance has historically been below the national average for this measure, but has
consistently improved over time.
The North Middlesex University Hospital NHS Trust has taken the following action to improve this
percentage and so the quality of its services, by:
The trust has a staff engagement action plan in place to improve the experience of staff working at the trust.
The implementation of this is overseen by the workforce committee.
22. Patients who would recommend the trust to their family or friends
The trust surveys patients to ask whether they would recommend the hospital as a care provider to family
or friends. This measure enables the trust to compare the experience of its patients with that of patients at
other trusts across the country.
A&E
Publication date
Reporting period
NMUH value
National average
National lowest
National highest
Jan-15
Q3 2014/15
78%
87%
60%
99%
Oct-14
Q2 2014/15
87%
87%
66%
99%
Jul-14
Q1 2014/15
89%
86%
62%
98%
The North Middlesex University Hospital NHS Trust considers that this data is as described for the
following reasons:
The data is consistent with the hospital’s own internal monitoring and reporting of performance against this
indicator. Reporting on this measure within the Quality Account this year is optional. The trust achieved a
performance at or above the national benchmark in the first half the 2014/15 financial year, but performance
dipped in Q3 (in line with other major acute trusts in London).
Inpatients
Publication date
Reporting period
NMUH value
National average
National lowest
National highest
Jan-15
Q3 2014–15
95%
95%
79%
100%
Oct-14
Q2 2014–15
95%
94%
74%
100%
Jul-14
Q1 2014–15
94%
94%
77%
100%
68
Quality Account
Section 2
The North Middlesex University Hospital NHS Trust considers that this data is as described for the
following reasons:
The data is consistent with the hospital’s own internal monitoring and reporting of performance against this
indicator. Reporting on this measure within the Quality Account this year is optional. The trust’s performance
during 2014/15 has been broadly similar and continues to show a positive inpatient experience.
The North Middlesex University Hospital NHS Trust has taken the following action to improve this
percentage and so the quality of its services, by:
Devising a patient experience action plan for implementation throughout 2015/16. This project is led by the
deputy director of nursing and progress is reported to the patient experience group.
69
Quality Account
Section 2
Domain 5 – Treating and caring for people in a safe environment and protecting them from
avoidable harm
23. The percentage of patients who were admitted to hospital and who were risk assessed for venomous
thromboembolism during the reporting period.
Many deaths in hospital result each year from Venous Thromboembolism (VTE). These deaths are
potentially preventable. Venous thromboembolism (VTE), or clotting of the blood, is a significant cause of
mortality, long-term disability and chronic ill health. Therefore in addition to risk assessing patients for VTE,
we also closely analyse every case to discover root cause.
Patients admitted to hospital who were risk assessed for venous thromboembolism
Publication date
Reporting period
NMUH value
National average
National lowest
National highest
April 2015
January 2015
96.2%
95.9%
74.1%
100.0%
March 2015
Q3 2014/15
95.9%
96.0%
81.2%
100.0%
December 2014
Q2 2014/15
95.5%
96.2%
86.4%
100.0%
The North Middlesex University Hospital NHS Trust considers that this data is as described for the
following reasons:
The data is consistent with the hospital’s own internal monitoring and reporting of performance against this
indicator. The trust’s performance has historically been at or above the national average for this measure.
The North Middlesex University Hospital NHS Trust has taken the following action to improve this
percentage and so the quality of its services, by:
Ensuring that the measure continues to be high profile within the trust. This indicator was a nationally
mandated target on the NHS standard contract for 2014/15 with a compliance threshold of 95%. The trust
was fully compliant with the contract requirement this year.
24. The rate per 100,000 bed days of cases of C. difficile infection reported within the trust amongst
patients aged two or over during the reporting period.
Rate of C.difficile infection
C. difficile can cause severe diarrhoea and vomiting and an increased risk of mortality. The infection has
been known to spread within hospitals particularly during the winter months. Reducing the rate of C. difficile
infections is a key government target.
Publication date
Reporting period
NMUH value
National average
National lowest
National highest
July 2014
2013/14
15.2
14.7
0.0
37.1
July 2014
2012/13
18.8
17.4
0.0
31.2
70
Quality Account
Section 2
The North Middlesex University Hospital NHS Trust considers that this data is as described for the
following reasons:
The data is consistent with the hospital’s own internal monitoring and reporting of performance against
this indicator. The trust’s performance against this indicator remained above the average but improved
significantly in 2013/14 – at a faster rate than the national comparator.
The North Middlesex University Hospital NHS Trust has taken the following action to improve this
percentage and so the quality of its services, by:
Ensuring that the trust continues to have zero tolerance in respect of avoidable hospital-acquired infections.
Current actions include route cause analysis being carried out following all incidences and lessons learned
from any avoidable outcomes. Screening programmes are routine throughout the trust and hand hygiene
audits take place on a monthly basis across all patient-facing areas and are measured against a strict
compliance threshold.
25. The number and, where available, rate of patient safety incidents reported within the trust during the
reporting period, and the number and percentage of such patient safety incidents that resulted in severe
harm or death.
Patient safety incidents and the percentage that resulted in severe harm or death.
Publication
Reporting
date
period
Measure
Number of patient safety
incidents
Rate of incidents (per 1,000
April 2014 –
April 2015
bed days)
Number resulting in severe harm
or death
% resulting in severe harm
or death
Number of patient safety incidents
Rate of incidents (per 1,000
2014
October
bed days)
National lowest
National highest
3,498
4,196
35
12,020
43.6
35.3
0.2
75.0
7
20
0
97
0.2%
0.5%
0.0%
3.1%
2,657
3,922
301
12,152
35.6
N/A
5.8
74.9
3
21
0
103
0.1%
0.5%
0.0%
3.8%
2013 –
March 2014
Number resulting in severe harm
or death
% resulting in severe harm or death
71
National average
September
2014
September
NMUH value
Quality Account
Section 2
The North Middlesex University Hospital NHS Trust considers that this data is as described for the
following reasons:
The data is consistent with the hospital’s own internal monitoring and reporting of performance against
this indicator. This data is held centrally and exported to the NRLS which provide organisational feedback
reports every six months. These organisational feedback reports benchmark performance against all other
similar sized acute trusts across the country. These organisational feedback reports demonstrate that the
trust has a strong incident reporting culture.
The North Middlesex University Hospital NHS Trust has taken the following action to improve this
percentage and so the quality of its services, by:
Continuous emphasis on the importance of reporting incidents so that the trust can investigate and learn
from them. The consultant lead for learning from incidents, complaints and claims analyses themes of
learning from incidents reported across the trust and uses this to write a patient safety message of the
week. This message is based on findings from key incident reports and is included in the daily trustwide
communications cascade as well as being emailed directly to relevant clinical groups.
The trust continues to hold a daily incident review meeting that is chaired by the director of nursing. Senior
nursing staff brief the meeting on incidents that have been reported across their clinical areas identifying
actions that have been taken in response to each incident report. The meeting reviews each incident report
and the action taken to decides whether further action or investigation is required. Senior nursing staff then
feedback the learning from these meetings to their clinical areas.
The trust reported one “never event” during 2014/15. This incident occurred in March and involved a patient
who received an incorrect blood transfusion. This was reported to our commissioners, a root cause analysis
investigation was undertaken and has been subject to external review to ensure the trust takes robust
action to effectively learn lessons from this event.
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Quality Account
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Annex 1: Statements from
commissioners, local Healthwatch
organisations and Overview and
Scrutiny Committees
Haringey Clinical Commissioning Group
Commissioners Statement for North Middlesex University Hospital Quality Account 2014/15
NHS Haringey Clinical Commissioning Group is the lead commissioner responsible for the commissioning
of non-specialist health services from North Middlesex University Hospital NHS Trust, on behalf of the
population of Haringey and associate commissioners.
NHS Haringey Clinical Commissioning Group welcomes the opportunity to provide this statement on
North Middlesex University Hospital NHS Trust’s Quality Account. We have reviewed the information
contained within the draft Quality Account and are pleased to see that the feedback provided to the trust
has been incorporated.
We have taken particular account of the identified priorities for improvement for the trust and how this work
will enable real focus on improving the quality and safety of health services for the population they serve:
Patient safety
Priority 1: To reduce harm to patients by reducing and aspiring to eliminating avoidable healthcare
associated bloodstream infections and improving the management of Clostridium difficile and patients
with sepsis.
Priority 2: Reducing the harm from patient falls.
Priority 3: To continue to reduce harm from pressure ulcers and aspire to eliminate avoidable hospitalacquired grade 3 and grade 4 pressure ulcers.
Patient experience
Priority 1: To improve patient satisfaction as measured by national surveys and the Friends and Family test.
Priority 2: Continued improvement to end-of-life care so that North Middlesex University Hospital Trust
becomes an exemplar provider.
Priority 3: Improving care for patients with dementia.
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Clinical effectiveness
Priority 1: Improved patient participation
in the patient-reported outcome measures
(PROMs) questionnaires.
Priority 3: Design and implement an anaesthetics
service improvement plan.
We note improvements made by the trust to the
quality of services provided during 2014/15 and
welcome the priorities for quality improvements in
2015/16. We note the aspiration for achievement or
descriptions of what achievement will look like and
will continue to work with the trust to develop more
effective quality outcomes and challenge the trust to
strive to achieve beyond their set targets.
We have reviewed the content of the Quality
Account and confirm that this complies with the
prescribed information, form and content as set out
by the Department of Health. We believe that the
Quality Account represents a fair, representative
and balanced overview of the quality of care at
North Middlesex University Hospital Trust. We have
discussed the development of the accounts with
the trust during 2014/15 and have been able to
contribute our views on consultation and content.
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Priority 2: Improved performance against the
specialty-specific clinical outcome measures.
Transforming community service and out-of-hospital
care is a priority for Haringey CCG. We are reviewing
the models of care, environment, accident and
emergency attendance and admission. We are also
working with the trust to ensure the right clinical
balance of services, between hospital clinics and
community settings closer to patients’ homes.
Haringey CCG is fully committed to continuing its
close co-operation with the trust over the coming
year on these important issues.
Jennie Williams
Executive nurse and director for quality and
integrated governance
NHS Haringey Clinical Commissioning Group
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Healthwatch Enfield
Quality Account
Section 3
Thank you for providing Healthwatch Enfield with the opportunity to review and comment on earlier drafts
of the Quality Account. We are pleased that our comments and suggestions are reflected in the final
document. We note that North Middlesex University Hospital has made some progress in 2014/15 and we
look forward to further significant progress on quality matters in the current year.
Delivery against quality priorities and objectives for 2014/15
Priority 1 – Patient safety
We share the trust’s disappointment that, despite a number of initiatives, the falls rate has not improved.
Similarly, although there has been progress in relation to sepsis management, compliance is still well below
target. We are pleased that there were no MRSA cases during the year but note the challenge still posed
by C-diff.
Priority 2 – Patient experience
We were encouraged to see the improvements in patient experience around end-of-life care and are
pleased to note that the trust met all the objectives in last year’s Quality Account.
We recognise that progress has been made in improving discharge arrangements and would particularly
mention the better multidisciplinary working and communication resulting from having on-site local authority
social services staff, as well as the establishment of a discharge pharmacist role.
We note the poor performance in relation to patient communication and engagement and specifically
the failure to turnaround complaint response times. However, we note that there has very recently been
a marked improvement in complaints management and very much hope that this will be sustained into
the future.
Staff stability is a crucial, strategic, element in meeting the trust’s objectives. We are very aware of the
challenge the trust faces in relation to staff turnover and the work being done around staff retention, as well
as recruitment. We hope to see marked improvement in this area, which has the potential for great impact
on the quality of services and treatment that patients receive.
Priority 3 – Clinical effectiveness
We welcome the good results for PROMS questionnaire completions for patients undergoing knee / total
hip replacements but note the much lower percentage achieved for groin hernia.
Quality priorities for 2015/16
Patient safety
We are in agreement with the selection of Clostridium difficile, sepsis management, patient falls and
pressure ulcers as priorities for patient safety for the coming year. We hope that the learning from the good
results achieved over the previous two years in relation to MRSA and MSSA will lead to improvements in
these other areas.
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Patient experience
We support the selection of the priorities outlined in the Quality Account. Patients have raised concerns
with us about their poor experience with access, appointments and information as outpatients, so we
would like to see particular attention given to outpatient satisfaction. Understanding and improving patient
experience is fundamental to the work of any hospital. Developing more patient engagement mechanisms is
also important.
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We had initially queried the inclusion of end-of-life care as a priority for the coming year, given the
excellent progress made last year, but we understand and very much support the trust’s aim to become
an exemplar provider.
We fully support the priority around improving care for patients with dementia.
Clinical effectiveness
As noted above we are keen to see the good performance around PROMS for hip and knee replacement
patients achieved for groin hernia patients.
We note the current challenges facing the anaesthetics service and fully support the inclusion of both the
development, and implementation of, an improvement plan for the service.
Regards
Lorna Reith
Chief executive
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Haringey Healthwatch
Quality Account
Section 3
Haringey Healthwatch has had an opportunity to review and comment on earlier
drafts of the Quality Account and our comments and suggestions have been
reflected in this final document. To the best of our knowledge the Quality
Account provides an accurate reflection of the progress made in 2014/15
against the targets and milestones and we are in agreement with the
priorities identified for 2015/16.
Mike Wilson
Director, Haringey Healthwatch
Haringey Overview
and Scrutiny Committee
Thank you for the opportunity to comment on the
draft North Middlesex NHS Trust Quality Account
for 2014/15.
Due to the timing of your request, Haringey’s
Overview and Scrutiny Committee (OSC) has
been unable to meet and discuss the Draft
Quality Account.
Cllr Wright, Chair of OSC, and Cllr Connor, ViceChair of OSC, will discuss the Quality Account
with colleagues and consider how best to use
this information to develop the scrutiny work
programme for 2015/16.
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Annex 2: Statement of directors’
responsibilities for the Quality Account
In preparing the Quality Account, directors are required to take steps themselves that:
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• the Quality Account presents a balanced picture of the trust’s performance over the period covered
• the performance information reported in the Quality Account is reliable and accurate
•there are proper internal controls over the collection and reporting of the measures of performance
included in the Quality Account, and these controls are subject to review to confirm that they are working
effectively in practice
•the data underpinning the measures of performance reported in the Quality Account is robust and
reliable, conforms to specified data quality standards and prescribed definitions, and is subject to
appropriate scrutiny and review
• the Quality Account has been prepared in accordance with Department of Health guidance.
The directors confirm to the best of their knowledge and belief they have complied with the above
requirements in preparing the Quality Account.
By order of the board.
John Carrier
Chairman
Julie Lowe
Chief executive
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Annex 3: External audit
assurance report
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Independent auditor’s limited assurance report to the directors
of North Middlesex University Hospital NHS Trust on the annual
Quality Account.
We are required to perform an independent assurance engagement in respect of North Middlesex University
Hospital NHS Trust’s Quality Account for the year ended 31 March 2015 (“the Quality Account”) and certain
performance indicators contained therein as part of our work. NHS trusts are required by section 8 of the
Health Act 2009 to publish a quality account which must include prescribed information set out in The
National Health Service (Quality Account) Regulations 2010, the National Health Service (Quality Account)
Amendment Regulations 2011 and the National Health Service (Quality Account) Amendment Regulations
2012 (“the Regulations”).
Scope and subject matter
The indicators for the year ended 31 March 2015 subject to limited assurance consist of the
following indicators:
• Percentage of patients risk-assessed for venous thromboembolism (VTE)
• Percentage of patient safety incidents resulting in severe harm or death
We refer to these two indicators collectively as “the indicators”.
Respective responsibilities of directors and auditors
The directors are required under the Health Act 2009 to prepare a Quality Account for each financial year.
The Department of Health has issued guidance on the form and content of annual Quality Accounts (which
incorporates the legal requirements in the Health Act 2009 and the Regulations).
In preparing the Quality Account, the directors are required to take steps to satisfy themselves that:
• the Quality Account presents a balanced picture of the trust’s performance over the period covered;
• the performance information reported in the Quality Account is reliable and accurate;
•there are proper internal controls over the collection and reporting of the measures of performance
included in the Quality Account, and these controls are subject to review to confirm that they are working
effectively in practice;
•the data underpinning the measures of performance reported in the Quality Account is robust and
reliable, conforms to specified data quality standards and prescribed definitions, and is subject to
appropriate scrutiny and review; and
• the Quality Account has been prepared in accordance with Department of Health guidance.
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The directors are required to confirm compliance with these requirements in a statement of directors’
responsibilities within the Quality Account. Our responsibility is to form a conclusion, based on limited
assurance procedures, on whether anything has come to our attention that causes us to believe that:
•the Quality Account is not prepared in all material respects in line with the criteria set out in
the Regulations;
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•the Quality Account is not consistent in all material respects with the sources specified in the NHS
Quality Accounts Auditor Guidance 2014–15 issued by DH in March 2015 (“the Guidance”); and
•the indicators in the Quality Account identified as having been the subject of limited assurance in the
Quality Account are not reasonably stated in all material respects in accordance with the Regulations and
the six dimensions of data quality set out in the Guidance.
We read the Quality Account and conclude whether it is consistent with the requirements of the Regulations
and to consider the implications for our report if we become aware of any material omissions.
We read the other information contained in the Quality Account and consider whether it is materially
inconsistent with:
•Board minutes for the period April 2014 to June 2015;
•papers relating to quality reported to the Board over the period April 2014 to June 2015;
•feedback from the NHS Haringey Clinical Commissioners Group;
•feedback from Haringey and Enfield Healthwatch dated 14 May 2015 and 18 May 2015 respectively;
•the trust’s complaints report published under regulation 18 of the Local Authority, Social Services and
NHS Complaints (England) Regulations 2009, dated 24 April 2015;
•the latest national patient survey dated 21 May 2015;
• the latest national staff survey 2014;
•the head of internal audit’s annual opinion over the trust’s control environment dated 14 May 2015;
•the annual governance statement dated 2 June 2015;
•the Care Quality Commission’s Intelligent Monitoring Reports dated December 2014 and
May 2015 (draft);
•the results of the Payment by Results coding review dated 7 November 2014 (draft).
We did not test the consistency of the Quality Account with feedback from some of the other named
stakeholders involved in the sign off of the Quality Account as the draft Quality Account was sent to them
for comment, in accordance with the timetable specified in the Regulations, but no response has been
received at the time the quality accounts were signed. We have considered the consistency with the
other specified documents and are satisfied that there is no material risk of misstatement arising from
this omission.
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We consider the implications for our report if we
become aware of any apparent misstatements or
material inconsistencies with these documents
(collectively the “documents”). Our responsibilities
do not extend to any other information.
Assurance work performed
This report, including the conclusion, is made
solely to the board of directors of North Middlesex
University Hospital NHS Trust.
•evaluating the design and implementation of the
key processes and controls for managing and
reporting the indicators;
We permit the disclosure of this report to enable the
board of directors to demonstrate that they have
discharged their governance responsibilities by
commissioning an independent assurance report in
connection with the indicators. To the fullest extent
permissible by law, we do not accept or assume
responsibility to anyone other than the board of
directors as a body and North Middlesex University
Hospital NHS Trust for our work or this report save
where terms are expressly agreed and with our prior
consent in writing.
• making enquiries of management;
We conducted this limited assurance engagement
under the terms of the guidance. Our limited
assurance procedures included:
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Section 3
• testing key management controls;
• analytical procedures;
•limited testing, on a selective basis, of the data
used to calculate the indicator back to supporting
documentation;
•comparing the content of the Quality Account to
the requirements of the Regulations; and
• reading the documents.
A limited assurance engagement is narrower in
scope than a reasonable assurance engagement.
The nature, timing and extent of procedures
for gathering sufficient appropriate evidence
are deliberately limited relative to a reasonable
assurance engagement.
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Limitations
Conclusion
Non-financial performance information is subject to
more inherent limitations than financial information,
given the characteristics of the subject matter and
the methods used for determining such information.
Based on the results of our procedures, nothing has
come to our attention that causes us to believe that,
for the year ended 31 March 2015
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The absence of a significant body of established
practice on which to draw allows for the selection
of different but acceptable measurement
techniques which can result in materially different
measurements and can impact comparability. The
precision of different measurement techniques may
also vary. Furthermore, the nature and methods
used to determine such information, as well as the
measurement criteria and the precision thereof, may
change over time. It is important to read the Quality
Account in the context of the criteria set out in
the Regulations.
The nature, form and content required of Quality
Accounts are determined by the Department
of Health. This may result in the omission of
information relevant to other users, for example for
the purpose of comparing the results of different
NHS organisations.
In addition, the scope of our assurance work
has not included governance over quality or nonmandated indicators which have been determined
locally by North Middlesex University Hospital
NHS Trust.
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•the Quality Account is not prepared in all
material respects in line with the criteria set
out in the Regulations;
•the Quality Account is not consistent in all
material respects with the sources specified in
the Guidance; and
•the indicators in the Quality Account subject
to limited assurance have not been reasonably
stated in all material respects in accordance with
the Regulations and the six dimensions of data
quality set out in the Guidance.
Grant Thornton UK LLP
Grant Thornton House
Melton Street
Euston Square
London
NW1 2EP
2 June 2015
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North Middlesex University Hospital Trust
Sterling Way, London N18 1QX
85