Annual
Quality
Account
2009/10
Statement from the Chief Executive and Medical Director
1
Executive summary
2
Introduction and current view
of the Trust’s position on quality
3
Patient safety 5
Patient experience
9
Staff experience
17
Other clinical governance activity
19
Clinical and cost effectiveness
21
Conclusion and priorities
24
Annual Quality Account 2009/10: Statement from the Chief Executive and Medical Director
Statement from the Chief Executive
and Medical Director
W
e have great pleasure in presenting the Quality Report for Yeovil District Hospital
NHS Foundation Trust for 2009/10. We hope this report shows the progress we
have made in respect of improving the quality of care and patient safety across the Trust.
Improving the quality of care for patients has been a key focus for the NHS and has
been further reinforced by the publication of the Darzi report, ‘High Quality Care for All’.
During 2009/10 the Trust made explicit in its Quality Strategy for Achieving Excellence in
Clinical Care its vision for exceeding national targets and delivering healthcare that
guarantees the best possible clinical care across the whole range of its services.
We want all of our patients to receive care of the highest standard and although this
has been a challenging year we are pleased with our achievements and continued
improvements this year. However, we recognise the importance of listening to our
patients and relatives and learning from patient feedback, clinical audit, incidents and
untoward events of any kind.
To the best of our knowledge the information in this document is accurate.
Gavin Boyle
Chief Executive
1
Steve Gore
Medical Director
Annual Quality Account 2009/10: Executive summary
The Trust received an
NHS South West Health and
Social Care Award for our
work on iCARE.
Executive summary
Y
eovil District Hospital NHS Foundation
Trust aims to provide patient care of
the highest standard and this is assured
through effective clinical governance.
2009/10 has been a busy year in terms of
activity, compounded in the last quarter
by winter pressures and a norovirus
outbreak. Progress with regard to quality
remained continuous.
The Trust continued to make progress
with our iCARE philosophy which aims to
promote an ethos of treating our patients
and staff as individuals, focusing on good,
clear communication, a positive attitude,
respect and an environment which is
clean and welcoming. The Trust received
an NHS South West Health and Social
Care Award for our work on iCARE.
Some of the key achievements during the year:
A total of three healthcare associated MRSA
bacteraemia cases (below the performance
target of six)
A total of 37 healthcare associated Clostridium
difficile cases (below the target of 42)
Being in the top 20% performing trusts in 22
questions out of 40 in the national outpatient
survey results
Being in the top 20% performing trusts in 13
questions out of 64 in the national inpatient
survey results
Achieving a top rating of ‘excellent’ for use of
resources and ‘good’ for quality of services
A reduction in the number of patients who fall
more than once (29% from 36%)
Being the best performing trust in the South
West in respect of the national staff survey
2
Annual Quality Account 2009/10: Introduction and current view of the Trust’s position on quality
Introduction and current view of the
Trust’s position on quality
T
he concern for quality is not new, but there is an increasingly explicit expectation
that patients will receive reliable, high-quality, safe care in all areas of healthcare
provided by the NHS. Trusts have been measured against a range of national targets
for a number of years, and Yeovil District Hospital NHS Foundation Trust has consistently
met those targets, remaining in financial balance and achieving a performance rating
this year of ‘excellent’ for use of resources and ‘good’ for quality of services (source Care
Quality Commission). During 2009/10, the Trust made explicit in its Quality Strategy for
Achieving Excellence in Clinical Care its vision for exceeding those national targets and
delivering healthcare that guarantees excellence in clinical care across the whole range
of its services.
The Quality Strategy for Achieving Excellence in Clinical Care sets out that vision and
complements the Clinical Services Strategy and the Estates Strategy. This Annual Quality
Account outlines the main activities and achievements across Yeovil District Hospital NHS
Foundation Trust between 1 April 2009 and 31 March 2010.
In addition to the work, which is ongoing from the Leading Improvements in Patient
Safety programme, in which the Trust has been involved since 2008, during the year we
have embarked on the NHS South West Quality Improvement and Patient Safety
Programme. This challenging five-year programme of improvement in patient safety
aims to reduce the Hospital Standardised Mortality Ratio (HSMR) by 15% and decrease
adverse events by 30%. There are five workstreams involved in the programme:
Leadership
Critical care
General ward
Peri-operative
Medicines management
The Trust is in the early stages in terms of capturing the baseline data in relation to
the measures that will lead to success. The measures in this programme provide a
benchmark for frontline staff to use when embarking on small steps of change to
improve outcomes.
3
Annual Quality Account 2009/10: Introduction and current view of the Trust’s position on quality
Governance is the responsibility of all staff within the Trust.
They must strive to improve the safety, efficiency and
effectiveness of all systems, and report poor practice so that
corrective action can be taken. We promise to continue to
strengthen clinical governance to ensure that the quality of
care we provide is of the highest standard.
Clinical governance describes the systems and processes by which trusts lead, direct
and control their functions in order to achieve organisational objectives, safety and
quality services. It also describes the way in which we relate to the wider community
and partner organisations. Governance is the responsibility of all staff within the Trust.
They must strive to improve the safety, efficiency and effectiveness of all systems, and
report poor practice so that corrective action can be taken. We promise to continue
to strengthen clinical governance to ensure that the quality of care we provide is of
the highest standard. We hope that you find the information in this report useful and
informative.
We have continued to develop and support our staff in reviewing and revising the clinical
services they provide. We have an active Service Improvement Group, which has agreed
a programme of service efficiencies and improvements. This programme has identified
that some of our systems and processes can be streamlined and simplified, to help us
deliver high-quality healthcare and survive the challenges facing organisations in the
current economic climate.
The Quality Strategy has set out our vision for the future of healthcare across the Trust.
The development process gave staff the opportunity to consider their clinical services,
to review how they know that the care they provide is good, and to agree measures or
key performance indicators that will help to demonstrate the achievement of
high-quality care for all our patients. The Trust already uses a number of indicators on a
regular basis, and a comprehensive dashboard of data is presented to the Board of
Directors on a monthly basis. Service specific data is considered by clinical teams, and
this is formalised in quarterly performance review meetings with the executive directors,
clinical director, general manager and head of nursing for each service area. This
ensures that we regularly review the quality of care provided and the safety of our
patients, and take appropriate action when concerns are identified. The following
section shows progress against some of the key performance indicators measured
during 2009/10.
4
Annual Quality Account 2009/10: Patient safety
Patient safety
Patient falls
R
educing falls is important to patients, relatives and staff. Whilst it is true that
some patients are at high risk of falling, either as a result of their rehabilitation or
condition, it is equally recognised that this causes distress, loss of confidence and in
some cases injury to patients. The length of stay for patients who have fallen whilst in
hospital is often increased as staff attempt to improve their mobility and confidence.
During 2009/10 we set ourselves a target of reducing patient falls by 15% and we are
making progress towards this. We reduced the number of patients who fell on more
than one occasion from 36% of patients who fell to 29%. The following run chart
shows the number of patient falls, the percentage of patients falling more than once
and the rate of falls per 1,000 bed days
Trust-wide
patient falls
2009/10
Trust-wide
15% target
Rate per 1,000 bed days
Percentage of patients falling more than once
120
105
100
89
86
80
78
68
83
77
76
74
76
70
68
60
40
20
7.4
0
9.22
7.91
11.55
9.85
8.49
7.68
8.89
9.08
9.77
8.13
8.02
Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10
This data is also divided by clinical area and is provided to each of the ward sisters and
managers on a monthly basis for review and discussion at the departmental meetings.
The Trust-wide data is submitted to the Risk and Delivery Committee and Board of
Directors every month as part of the clinical governance report.
5
Annual Quality Account 2009/10: Patient safety
The Trust’s VTE Committee has representation
from all directorates and their work plan was
based on the findings of a gap analysis against
national recommendations.
Venous thrombo-embolism (VTE)
There is a national emphasis on the assessment and prevention of venous
thrombo-embolisms. The Trust has established a VTE Committee to take this vital work
forwards across the organisation and during the year a policy and assessment tool have
been developed. NHS South West carried out a peer review visit during 2009 to assess
progress with achieving the national targets and the report highlighted a number of
positive actions underway. The assessment of VTE risk also forms part of the NHS South
West Quality Improvement and Patient Safety Programme, which has raised the profile
further. This assessment helps us to ensure that patients at risk of developing a VTE
receive the right prevention and treatment and we are now beginning to collect data to
confirm that this risk assessment has taken place.
Compliance with the new risk assessment tool has been measured by using snapshot
audits across all ward areas each month, and there has been slow progress with use of
the tool from 5% to 14%. However, the audit has demonstrated that all patients have
received appropriate prophylaxis even if the assessment tool has not been fully
completed. Clearly this is an area of concern and the Trust has been exploring ways to
improve compliance with the assessment tool, with an aim of achieving 90% compliance
during 2010/11. During the year there have been two cases identified where patients
developed a deep vein thrombosis after admission and a full root cause analysis was
completed to identify any lessons to improve the care for future patients.
6
Annual Quality Account 2009/10: Patient safety
Medication incidents
T
he Trust has been working hard to reduce significant medication errors during the
year, and the pharmacy team has also strengthened our systems and processes for
managing medicines to ensure that patients receive the right treatment at the right time.
The recently formed Medication Incident Review Group regularly assesses medication
incidents and identifies ways in which these errors can be avoided. A bulletin
summarising key safety messages as well as listing all recent medication incidents is then
distributed to all doctors and nurses within the Trust. It is hoped that this feedback on
reported incidents will encourage further reporting, and indeed, during 2009/10 there
has been an 18% increase in the overall number of incidents reported at YDH. The Trust
has also introduced a web-based incident reporting system, which helps us to see which
incidents were potentially harmful and those that were minor. Analysis of this data
shows an increase of 2% on those incidents graded as significant or high, with a much
greater increase in near miss reporting. This increased reporting, but with reducing
seriousness of incidents, will remain a focus of our activity during 2010/11. The chart
below shows the number of incidents reported month on month and the rate of
medication incidents per 1,000 bed days, compared with the previous year.
Medication
incidents
2008/09
compared
with 2009/10.
2008/09
No. of incidents per 1,000 bed days 2009/10
2009/10
No. of incidents per 1,000 bed days 2008/09
60
50
40
30
20
10
0
APRIL
MAY
JUNE
JULY
AUG
SEPT
OCT
NOV
DEC
JAN
FEB
Infection prevention and control
The targets for reducing healthcare associated infections were met by the Trust, with a
total of three Methicillin Resistant Staphylococcus Aureus (MRSA) bacteraemia cases
below the performance target of six, and a total of 37 Clostridium difficile cases below
the target of 42. Whilst it is acknowledged that this is a significant achievement, the
aim for 2010/11 is to have no more than 2 cases of healthcare associated MRSA and 31
of Clostridium difficile post 72 hours. These healthcare associated infections are at very
low levels and in the South West league table Yeovil District Hospital is in the top two of
comparable size acute trusts in reducing rates of Clostridium difficile infection and MRSA
bloodstream infection. Future work to maintain such low levels has involved working
together with the health community to drive down infection across the patient pathway;
the actions are no longer simply focused on the hospital.
7
Annual Quality Account 2009/10: Patient safety
In order to learn lessons wherever possible, we have continued to undertake a root
cause analysis (RCA) investigation into all cases of MRSA bacteraemia and Clostridium
difficile, with the results being shared with the ward or department concerned and
action plans being developed where required. The charts below demonstrate the year
on year improvements in cases of healthcare associated Clostridium difficile and MRSA
bacteraemia.
Hospital acquired
Clostridium
difficile cases
year on year.
Total number of cases
160
140
120
100
80
60
40
20
0
2006/07
2007/08
2008/09
2009/10
25
Total MRSA
bacteraemia
cases
20
MRSA
bacteraemia
cases year
on year.
15
10
Hospital
acquired
MRSA
bacteraemia
cases
5
0
2004/05
2005/06
2006/07
2007/08
2008/09
During the year the Trust was subject to an unannounced inspection by the Care
Quality Commission (CQC) against the Health Act 2008 (Hygiene Code). This was a
follow-up visit from the full inspection conducted during 2008/09. The report was
received and the Care Quality Commission noted that the Trust is doing everything it
should to protect patients, workers and others from the risk of acquiring a healthcare
associated infection. They expressed concern about the change in commode cleaning
method, and the understanding of all staff about the new procedure. This was swiftly
dealt with and the CQC were entirely satisfied by the actions taken.
8
Annual Quality Account 2009/10: Patient experience
Patient experience
National patient survey
D
uring the year the Trust participated in the seventh national inpatient survey and
second national outpatient department survey, co-ordinated by the Care Quality
Commission. These are extremely important surveys as they tell us very clearly what our
patients think about our services and provide a valuable opportunity to make changes
for the better.
Although response rates are declining nationally, the Trust continues to maintain above
average returns. Out of a total of 40 questions, the outpatient survey placed the Trust in
the best performing 20% of trusts for 22 questions, intermediate 60% of trusts for 18
questions and the worst performing 20% for no questions. The response to 37
questions out of 40 had improved. The inpatient survey placed YDH in the best
performing 20% of trusts for 13 questions, intermediate 60% for 44 questions and
the worst performing 20% for 7 questions. The table below shows the changes in the
response rate and two of the key over-arching questions asked in the survey.
Trust score (out of 100)
Survey
9
YDH reponse rate
Always treated with
respect and dignity
Overall care rated
as excellent
Inpatient (2006)
71%
89
77
Inpatient (2007)
65%
91
80
Inpatient (2008)
63%
90
79
Inpatient (2009)
61%
91
80
Outpatient department
(2004/05)
49%
95
83
Outpatient department
(2009)
60%
96
85
Annual Quality Account 2009/10: Patient experience
The inpatient survey results reflect continuous
improvement of the patient experience across
the NHS, raising the bar as a result. At Yeovil District
Hospital we welcome the survey as a means to helping us
to continue to improve our service for patients.
The inpatient survey results reflect continuous improvement of the patient experience
across the NHS, raising the bar as a result. At Yeovil District Hospital we welcome the
survey as a means of helping us to continue to improve our service for patients.
There were a number of very positive factors that reflect the overall patient experience
and the Trust’s iCARE philosophy. Patients continue to rate being treated with dignity
and respect highly and for the third year in a row this indicator has scored 91/100 and
benchmarks in the best performing 20% of trusts. Cleanliness of toilets and bathrooms
has improved and ward cleanliness remains consistently good, scoring 90/100 – the
same as last year – and also benchmarks in the best 20% of trusts.
However, the survey clearly identifies where our patients are telling us we do need to
do better and confirms for us the importance of some of the things we are already
working on. Response to call bells is one example that scored poorly, this issue had
already been picked up by observations of care conducted by our Patient and Public
Involvement group and work is underway to address this as part of iCARE and is a high
priority for our matrons. Also, getting better at explaining the risks of medication to
patients is work that is now being taken forward through our involvement in the South
West Quality Improvement and Patient Safety Programme.
Hand hygiene of doctors and nurses had improved, scoring 83/100 for doctors and
86/100 for nurses. This is in the intermediate 60% of trusts. However, it is anticipated
that following intensive training conducted last August and September this has already
improved.
10
Annual Quality Account 2009/10: Patient experience
Internal surveys
The Trust continued to make progress with its iCARE programme during the year. iCARE
is a statement of the Trust’s values and embodies the principle that all patients and staff
members should be treated with courtesy and respect. The ‘i’ reminds us that all of our
patients are individuals and that each staff member has a unique and individual part to
play. ‘C’ represents good, clear communication, ‘A’ is for a positive attitude , ‘R’ is for
respect and the ‘E’ stands for an environment that is clean, safe and welcoming.
The hospital received an NHS South West Health and Social Care Award in 2009 for its
work in developing the iCARE approach.
We have strengthened our internal systems for collecting information about patients’
perception of their care to test our iCARE approach. We have continued to use the
‘Your Care’ questionnaire in every ward area and have introduced a short anonymous
questionnaire that we ask our patients to complete on discharge from the hospital. The
results from these surveys are fed back to the ward sisters every month and the data is
used to inform improvement projects specific to the ward areas.
We set a target of 90% for the percentage of patients rating the overall care as
‘excellent’ and ‘very good’ and achieved 97%. 81% of patients rated the overall
care as ‘excellent’.
We set a target of 90% for the percentage of patients rating staff attitude as
‘excellent’ or ‘very good’ and we achieved 97%. 83% of patients rated staff
attitude as ‘excellent’.
We also measure patients’ opinion about the cleanliness of bathrooms and during
the year 97% rated this as ‘excellent’ or ‘very good’, with 71% rating the
cleanliness of bathrooms as ‘excellent’.
The challenge for the forthcoming year will be:
To develop robust mechanisms to capture information about our patients’ opinion of
the care provided across all services in the Trust
To improve ‘excellent’ ratings for quality of care, staff attitude and the cleanliness of
bathrooms
To develop the Trust’s privacy and dignity work programme, using it as an
opportunity to improve care for patients with dementia, and/or patients with a
learning disability or those who lack capacity to consent
Patient Advice and Liaison Service (PALS)
The Trust has provided a Patient Advice and Liaison Service for the last eight years,
during which time the number of enquiries has increased year on year, with a 42%
increase during 2009/10. A total of 649 enquiries were handled during the year, and
although some of those were simply seeking information, the majority raised concerns
about the service provided by the Trust. The key points to note are as follows:
11
1.
A 64% increase in concerns about access and waiting times
2.
A 150% increase in concerns about co-ordinated care
3.
Only a 3% increase in concerns about building good relationships with patients
4.
A decrease of 18% in concerns relating to information about treatment
5.
A 122% increase in requests for information only
Annual Quality Account 2009/10: Patient experience
The increase in PALS activity also coincides with the relocation of the PALS office to the
main reception area. The new office is easily accessible for patients and relatives to raise
concerns and other queries relating to health services.
Complaints and compliments
Throughout the year the Trust received 268 formal complaints, which was a 6% increase
on the previous year. When taken into consideration with the increased activity across
the Trust this is the equivalent of 0.13% of all patient episodes and is the same as the
previous year’s figures. This represents one written complaint for every 751 patient
attendances (including inpatient, outpatient and Accident and Emergency patients) at
the hospital. 88% of all complaints received a response within the timescale agreed
with the complainant. 84% of all complainants received a full response within the
Trust’s 25 working-day benchmark.
We are aware that not everyone with a concern about care makes a formal complaint,
and as such we are committed to finding other ways to capture patients’ experiences
and ensure that improvements are made and lessons are learned. A total of 1,941
formal letters of commendation were received during the year, compared with 1,921 in
the previous year.
Clinical outcomes
Whilst individual services and clinicians have measured their clinical outcome data for
a number of years, the Trust has previously concentrated on the Hospital Standardised
Mortality Ratio (HSMR). However, in addition to more detailed analysis of the HSMR, the
Trust has also been reviewing data – both Trust-wide and by specialty – for the
percentage of patients who are readmitted to the same specialty within 28 days of
discharge and the percentage of patients who have an unplanned return to theatre
within the same admission.
The figures for unplanned readmission to the same specialty within 28 days of discharge
provide an indication of patients who are either discharged earlier than would be ideal
or who develop late complications of treatment, such as deep vein thrombosis or
infections. This measure helps to identify any trends by procedure or clinical team, and it
is pleasing to note an improvement from 7.7% in 2008/09 to 5.9% during 2009/10.
Whilst it is accepted that some surgical procedures require more than one visit to
theatre, it should not be considered routine. This measure has helped to identify any
trends, by procedure or clinical team, which might need to be addressed.
During the year a total of 47 patients were taken back to theatre within the same
admission as an unplanned procedure. This equates to 0.8% of all theatre activity
during the year. 64% of these were admitted under the care of the general surgeons
and 20% were admitted under the care of the orthopaedic surgeons. This data is
presented to the Clinical Governance Delivery Committee, Risk and Delivery
Committee and Board of Directors every month as part of the performance dashboard
report. The actual numbers are very small so firm conclusions cannot be drawn.
However, the results have been shared with the specialties involved and the data will be
monitored throughout the forthcoming year in conjunction with that available from Dr
Foster Intelligence.
12
Annual Quality Account 2009/10: Patient experience
Hospital Standardised Mortality Ratio (HSMR)
The HSMR for the Trust has been closely monitored throughout the year, and specific
elements have been subject to more detailed review, both for accuracy of coding and
diagnosis. The Trust’s position has improved throughout the year to 98.7 compared with
111.5 for the previous year. However, whilst this is an improvement there is still much
work to be done, and this will remain a high priority for the Trust during the
forthcoming years. The target will be to reduce the HSMR by 2.5% year on year, and
this will be achieved in a number of ways: by working with the NHS South West Quality
Improvement and Patient Safety Programme; integration of the HSMR and outcome
data into directorate rolling governance meetings and quarterly performance review
meetings; working with the coding department and information team to ensure
accurate coding and data collection; and focusing on small steps of change to improve
patient care and clinical outcomes.
Patient Reported Outcome Measures (PROMs)
The Trust has been participating in the national Patient Reported Outcome Measures
(PROMs) programme for three procedures:
Total hip replacement
Total knee replacement
Inguinal hernia repair
The target was for all trusts to submit data for 80% of patients undergoing each of the
above procedures. We have achieved 99% submission for total hip replacement, 95%
for total knee replacements and 77% for hernia repair. The Trust achieved an overall
compliance rate of 88%, which is excellent. The Trust has also commenced data
collection for some local PROMs during the year, and it is anticipated that the reporting
of clinical outcomes will be much more timely than the national programme. The
procedures currently included are: enhanced recovery for laparoscopic colorectal surgery,
the physiotherapy and surgical management of basal thumb arthritis and the
physiotherapy management of shoulder dystocia.
One of the key challenges for 2010/11 will be to improve the time patients with a
fractured neck of femur wait to undergo surgery. The national target states that these
patients should receive surgery within 36 hours of admission – a significant challenge for
most trusts. There is evidence that patients who have an operative intervention early in
their pathway have better clinical outcomes and from 1 April 2010 the Trust has joined
the national hip fracture database, which will improve our data capture in this area.
Clinical audit
The Trust has maintained a strong clinical audit programme built on a combination of
local issues and concerns coupled with national initiatives. The approach has
professional groups working together, with large numbers of clinicians involved in
reviewing the quality of care their patients receive. The Trust has again maintained a
strong clinical audit programme in 2009/10, continuing to combine local issues and
concerns with national drivers. A total of 278 audits have been active during the year
(compared with 225 in 2008/09) and it is encouraging to note a good mix of medical
and nurse-led projects. As at the end of the financial year 88 have had outcomes
reported, been presented, had recommendations made and/or resulted in changes to
improve practice and raise the standard of care. This demonstrates an increased level of
reporting; stronger links have been evident throughout the year, especially with the
Maternity Unit, which is very structured in the approach taken by all grades of staff. It
13
Annual Quality Account 2009/10: Patient experience
has also been another busy year for national audits and the table lists those in which the
Trust participated.
Audit title:
National audit of continence care
British Thoracic Society – adult asthma audit
College of Emergency Medicine – asthma
College of Emergency Medicine – pain in children
College of Emergency Medicine – fractured neck
of femur
National diabetes audit (paediatric)
National neonatal audit programme
4th national audit project (NAP4) major
complications of airway management in the UK
CEMACH obesity in pregnancy audit
The myocardial ischemia national audit project
(MINAP)
NICE management of open abdomen
The national diabetes inpatient audit day
2nd annual BSR audit osteoarthritis
National audit of diagnostic adequacy, accuracy
and complications of image-guided or assisted
liver biopsies
Intensive Care National Audit & Research Centre
(ICNARC)
ABCD nationwide exenatide audit
Audit of the blood collection process
The use of red cells in neonates and children
National health promotion audit
NBOCAP (national bowl cancer audit)
MBR (mastectomy & breast cancer audit)
OG (oesophago-gastric cancer audit)
LUCADA (lung cancer audit)
14
Annual Quality Account 2009/10: Patient experience
Audit subject
Changes made as a result of the audit
Productive ward mealtimes
patient satisfaction snapshot audit
Standard operating procedure begun to aid protected mealtimes
implementation. Re-audit showed improved patient satisfaction.
Are consent forms completed
correctly and are consenting
doctors aware of the risks/benefits
of the procedure/operation?
A link to the website orthopaedicconsent.com was put onto each
of the PCs and training on how to use it was provided to junior
and senior staff. The re-audit showed an improvement in practice.
South West audit of
non-accidental injuries (NAI) to
measure compliance with the
NAI skeletal surveys standards
Copies of the standards have been made more visible around the
radiology department and discussion regarding non-accidental
injuries is now included within the weekly paediatric meeting.
Discharge summary audit
As a result of this audit an improved discharge summary pro forma
is being produced with additional prompts.
Commode audit
Introduction of stickers clearly identifying cleaned commodes
Warfarin audit
As a result of this audit an F1 (Junior Doctor) induction session
was given on the use and prescription of warfarin.
Vaginal birth after caesarean
section
A prompt sheet is being produced to ensure the appropriate
documentation of mothers’ care plans.
A&E nursing documentation audit
Posters have been displayed outlining Nursing & Midwifery
Council (NMC) standards for documentation and a mini staff
survey has been undertaken to raise awareness.
Learning lessons
The Trust realises the importance of learning lessons. Whenever an incident is reported
in the hospital a thorough investigation is carried out and reports made outlining areas
for improvement. In the cases of some of the more significant incidents this information
is anonymised and shared with all grades of clinical staff at a quarterly Trust-wide
meeting. Changes made to services as result of incidents or complaints have included:
Training in administration and management of oxygen therapy
Review of the process for referral of A&E patients to the ophthalmology service
Changes to the access team process for collecting and processing referral letters
Review of communication systems to advise patients of waiting times in orthopaedic
clinic
Review of procedures for surgeons informing the Trust of sickness
Use of voicemail to improve contact in busy periods
Review of signage for the car park pay station
Changes to positioning of signage relating to ward closures (infection control)
Revised links between the A&E computer system and pathology records
Review of process for providing bone density results
Information displayed in pre-assessment clinic providing advice to patients about
withholding certain medications prior to surgery
15
Annual Quality Account 2009/10: Patient experience
Incident reporting
All staff are encouraged to report incidents to ensure an open and fair culture that
promotes learning across the organisation. The Trust has continued to strengthen this
ethos, and has seen a 2% increase in the number of incident forms completed during
the year. This is a much lower increase compared with previous years but the gradual
roll-out of the new web-based incident reporting system has meant that the reports are
submitted in a more timely manner to the clinical governance office. This in turn means
that actions can be taken to reduce the likelihood of a recurrence more quickly, and
lessons are learned and shared widely. The number of incidents and accidents reported
remained similar to the previous year (3,205 in 2009/10 compared with 3,249 in
2008/09).
The Trust has a robust system for reporting, investigating and learning from more
serious untoward events. All are investigated in depth by a senior member of staff
trained in root cause analysis (RCA) techniques. The reports produced are presented to
the Clinical Governance Delivery Committee and then shared, anonymously, at
directorate meetings and through a Trust-wide forum to ensure the widest possible
learning occurs. During the year 45 serious untoward events were investigated under
this system, which is a significant increase (104%) on the 22 conducted in the
previous year. This can be attributed to an increasingly low threshold for undertaking
such a review and a desire to learn lessons from such reviews. Three of these incidents
were reported to NHS Somerset as required by reporting criteria. A number of actions
were taken to improve the care for patients, for example:
Review of the rota for thrombolysis for stroke and the stroke physician joined the
local network to provide better cover for the diagnosis of stroke and the subsequent
administration of thrombolysis
Review of policies and procedures for the management of patients at risk of falls
Review and revision of guidelines for the management of trauma patients
Appointment of a tissue viability nurse
Changes to checking systems in theatre at beginning and end of a procedure
Introduction of high risk handovers on a medical ward
2007/08
1000
900
800
700
600
500
400
300
200
100
0
Clinical Care
Security
Violence &
Agression
2008/09
Equipment
Incidents
Falls
Year on year
comparison
of the types
of patient
incidents
reported.
2009/10
Communication Admission
or Discharge
Concerns
Maternity
Issue
Medication
Issue
16
Annual Quality Account 2009/10: Staff experience
Staff experience
Staff accidents and incidents
W
e actively encourage staff to report all types of incidents. These are shared with
the Trust’s health and safety officer, who works with individuals and managers to
develop systems to reduce the risks to staff. The following chart shows the changes in
the number of staff-related incidents reported over the past three years.
Staff accidents
and incidents.
2007/08
2008/09
2009/10
90
80
70
60
50
40
30
20
10
0
Falls
Manual Handling
Physical Violence
Sharps Incidents
Accidental injury
Verbal Abuse/
Threatening Behaviour
It is very pleasing to note the improvement in the number of falls and manual handling
injuries, but somewhat disappointing that there has been no change in the number of
needlestick injuries. It is of concern that there has been an 8% increase in the number
of incidents of physical abuse or threatening behaviour reported during the year. The
Trust has a clear policy for the management of threats and abuse towards staff, and has
issued ten warning letters to visitors about their unacceptable behaviour during the year.
Staff training
Yeovil District Hospital is committed to providing the appropriate education and training
to ensure that staff are up to date and have the opportunity to develop their
professional skills and broaden their knowledge. This helps them to provide safe, high
quality care for patients. In addition to the commitment to provide undergraduate and
postgraduate training for medical staff as part of the Severn Deanery, and the contracts
for the delivery of skills training to nursing students, Yeovil Academy provides a wide
range of education, training and learning opportunities for all staff, including continuing
professional development (CPD) in-house training, external courses, a Grand Round
multidisciplinary lecture programme and the Trust-wide clinical governance meetings.
17
Annual Quality Account 2009/10: Staff experience
We are currently developing a strategy to improve
management, leadership and service improvement training
across all areas and appropriate staff groups.
During 2009/10 the Academy has seen a year of change as it has joined the Human
Resources Directorate. This will provide a wealth of opportunities to link workforce
planning with workforce development and develop a proactive and structured approach
to planning education and training.
The Academy has a learning and development agreement with the Strategic Health
Authority and has fostered good relationships with a number of external organisations
as we continue with the challenging income generation programme which has been
successful in supporting the Fit for Foundation requirements of Yeovil District Hospital
NHS Foundation Trust to generate additional income to reinvest in the hospital service.
This includes a variety of long-term contracts, for example provision of resuscitation
training to Somerset Partnership Trust, the Navy Divers who are based at Yeovilton, and
extensive use of its conference room facilities, as well as provision of clinical skills
training across the local area.
The feedback on the services delivered by the Academy has been very positive and we
continue to increase the income generation opportunities each year, and were able to
use some of the income gained over and above the target to make direct improvements
to the Academy facilities as a response to evaluations. This included the installation of
electronic room fans and solar film on the windows to aid the comfort of learners in hot
weather.
Re-siting the clinical skills laboratory continues to provide the Academy with a better
opportunity to manage this excellent resource which is used by all staff groups and
enables junior doctors, medical students, student nurses and allied health professional
students to ensure that their technical skills meet the required standards. The South
West Laparoscopic Consortium, led by a consultant surgeon, now has 12 consultants
registered to train in laparoscopic surgery.
A review of mandatory training and policy implementation has continued throughout
2009/10. Ensuring the delivery of a robust and realistic mandatory training programme
is a challenge for every organisation. This has been strengthened with the development
of the new Staff Passport for Mandatory Training, the development of a Trust Training
Needs Analysis matrix, which includes a system for ensuring that staff can demonstrate
competence in the safe use of medical devices.
The Academy has recently held a presentation evening to celebrate the successful
partnership with Yeovil College for vocational training. This increases the
opportunities for staff in the hospital to access training and achieve qualifications under
the skills pledge signed by the Chief Executive. More than 20 staff received their awards
which were presented by the Director of Nursing, and the Principal of Yeovil College.
This joint working approach has enabled both organisations to provide learning
opportunities for staff that as individual organisations would not be possible.
18
Annual Quality Account 2009/10: Other clinical governance activity
PPI member Liz George
listening to a patient’s
feedback
Other clinical governance activity
Patient and Public Involvement
F
or a number of years the Trust has actively sought Patient and Public Involvement
(PPI) and is keen to ensure that services and care are improved in conjunction with
patients, carers, relatives, visitors and other members of the public. 14 people sit on the
PPI Committee and they have been actively involved in a number of workstreams
throughout the year. The key achievements include:
The review of all new and revised patient information leaflets
Observations of care in clinical areas, which are fed back into the ward and
departmental review meetings
Participation in monitoring clinical care through the Peer Review process
Undertaking the ‘Your Care’ questionnaires with patients
Participation in random reviews of Trust services, for example single sex
accommodation audits
Participation in listening events to help inform strategic direction for services
Negligence claims
Between 1 April 2009 and 31 March 2010 the Trust had 85 open clinical negligence
claims and eight employer liability claims at various stages, from request for notes to
settlement of claims or closure of file.
Patient information
All patient information leaflets are co-ordinated by the clinical governance department,
who ensure a consistent approach to style and content. In 2010/11 we are updating our
systems for reviewing and archiving leaflets to make this service more efficient and
accountable. We now have approximately 700 patient leaflets, having produced 55
completely new leaflets in 2009/10.
New leaflets are reviewed by the Patient and Public Involvement (PPI) Group to
ensure that they are fit for purpose. In 2009/10 the PPI Group reviewed important
Trust-wide leaflets such as ‘What to do if you have concerns’ and ‘Same sex
accommodation’.
19
Annual Quality Account 2009/10: Other clinical governance activity
YDH is committed to involving patients and
the public in the planning and delivery of our
services. This is a vital part of ensuring
quality care and ultimately a better
patient experience.
Patients have the option to receive our leaflets in alternative formats such as large print
and we have had some of our information translated into other languages to better
serve the increasingly diverse population. Further leaflets being considered for
translation include Endoscopic procedures, Resuscitation in hospital, Orthopaedic
trauma, Dillington Paediatric Ward information, Fertility and Andrology. The Trust also
hopes to produce some leaflets in an accessible format for patients who also have a
learning disability. There has been a significant increase in producing standardised,
effective patient documentation; this is essential to reduce risks for the Trust. Recent
documentation includes the World Health Organisation’s Surgical Safety Checklist which
has been adapted for use at Yeovil for all general and local anaesthetic surgical
procedures and the revised and much more comprehensive Care of the Dying pathway.
Following the successful modernisation of the patient diaries for cancers, there are
now two booklets (with more planned), using the diary format, for specific orthopaedic
procedures – to keep the patient informed and reassured throughout their journey, from
initial diagnosis to post-operative rehabilitation.
Our patient leaflets are accessible from anywhere in the world via the Trust’s public
website and this is linked directly to the Trust’s internal intranet, enabling staff to locate
latest versions of patient leaflets and download them to print instantly for individual
patients, thereby reducing waste.
Freedom of Information
During 2009/10 the Trust received 204 Freedom of Information requests; an increase of
11% on the previous year. Requests were received from a wide range of individuals and
organisations including commercial organisations, research groups, the media and
politicians. The majority are from individuals closely followed by media and politicians.
20
Annual Quality Account 2009/10: Clinical and cost effectiveness
Clinical and cost effectiveness
Implementing national guidance
W
henever new guidance from the National Institute for Health and Clinical
Excellence (NICE) is issued, the Trust uses its proven system for ensuring our
local arrangements are appropriately reviewed and the recommendations promptly
implemented. A standard assessment template is sent to the relevant clinical staff, the
information is collated by the clinical governance department and a report provided to
the Clinical Governance Committee for assessment and recommendation. A detailed
risk assessment is completed if there is doubt about whether or not to introduce a new
drug or procedure, and the outcome is debated at the Risk and Delivery Committee.
During the year a total of 79 new or revised guidelines have been issued compared with
85 during the previous year. Where NICE recommendations are introduced these are
included in the appropriate patient information leaflet.
The Trust has maintained its structured approach to National Service Frameworks (NSFs),
and ensures effective joint agency working and communication by its continued
involvement in the Local Implementation Teams for each of the NSFs.
The Trust has worked hard to address the challenges it faced in the delivery of the NSF
for Children, Young People and Maternity Services. The results of the Child Health
Mapping data (Children’s Hospital Services Review) that was collected by the Healthcare
Commission for the period 2006/07 were published in December 2008. It was
identified that the Trust was unable to demonstrate improvement or was deteriorating in
a significant number of the categories. During 2009/10 the Trust successfully completed
the main actions identified within the Child Health Mapping Exercise Action Plan which
was submitted to the Healthcare Commission and NHS Somerset in the spring of 2009.
Clinical benchmarking
The Trust works hard to make sure its treatment of diseases follows best practice and
NICE guidance. However, it is also important to see that the result of that treatment is
as successful as it can be. This is where Dr Foster software proves very useful. All
hospitals keep detailed records of patients’ conditions and treatments and this
information is anonymised and sent to the Department of Health. The Dr Foster
software company pays to use this information and it is then turned into a
comprehensive database. Many trusts use this to compare their own performance over
time and also to compare themselves with others. Information on how long patients
stay in hospital, the rate of readmissions and the mortality rate are all available. This
21
Annual Quality Account 2009/10: Clinical and cost effectiveness
Yeovil District Hospital regularly appears at the top
of the national tables for recruitment of
patients into trials and for the quality and timeliness of data
returns. This shows how well the Trust is contributing to
the advance of medical knowledge and how it supports
pioneering work.
data can be broken down by condition, by specialty and even by individual
consultants. During the past year the Trust has continued to use this software to review
its performance and identify any areas that could be of concern. Individual consultants
can look at their own work, clinical directors and general managers for each specialty
can review outcomes and the Clinical Governance Delivery Committee can take an
overview to see if everything is as it should be.
The Hospital Standardised Mortality Ratio (HSMR) for the Trust has been closely
monitored throughout the year, and specific elements have been subject to more
detailed review, both for accuracy of coding and diagnosis. The Trust’s position has
improved throughout the year to 98.7 compared with 111.5 for the previous year.
Research and Development
The Trust continues to be an effective collaborator in 120 multi-centre, externally-funded
national clinical trials, with 381 patients recruited last year. All of these trials have been
approved by a Multi-Centre Research Ethics Committee and managed centrally by the
Trust Research and Development Department. Records of all research projects are
maintained in accordance with the Research Governance Framework for Health and
Social Care and this information is therefore readily available from providers.
Yeovil District Hospital regularly appears at the top of the national tables for recruitment
of patients into trials and for the quality and timeliness of data returns. This shows how
well the Trust is contributing to the advance of medical knowledge and how it supports
pioneering work. The Trust received Research for Patient Benefit grant funding for
research into pain relief following laparoscopic surgery for bowel cancer and this study
has just opened to patient recruitment.
Risk management arrangements
Risk management is an essential part of the Trust’s ability to provide care and services
to patients in a safe environment. The most significant type of risk management will
always be associated with clinical care, but non-clinical risk is managed in the same way.
The two strands are reliant on all staff to be proactive and systematic in the way they
approach risk.
The Trust has built on its existing systems for identifying principal risks against the
strategic objectives identified in the Assurance Framework, with operational risks
managed through the Trust-wide risk register. The Risk and Delivery Committee
assumes responsibility for the operational management of risks across the organisation,
and reviews the Trust’s risk register four times a year. The Board of Directors review both
the risk register and the Assurance Framework at least three times per year. The three
Assurance Committees (Clinical Governance Assurance Committee, Non-Clinical Risk
22
Annual Quality Account 2009/10: Clinical and cost effectiveness
Assurance Committee and Audit Committee) are responsible for providing assurance to
the Board of Directors about how well risk is being managed across the Trust.
Medical devices
The Trust has a comprehensive system for co-ordinating all medical device alerts and
other safety notices. This electronic system provides a clear audit trail of alerts issued
and action taken across the Trust. During the year a total of 130 alerts were issued from
a number of external sources compared with 146 the previous year. This figure includes
medical device alerts, manufacturer letters related to specific products, National Patient
Safety Alerts and Estates and Facilities specific alerts. The appropriate assessment and
action has been taken in respect of each of the notifications and plans have been
developed to ensure that where the Trust is not compliant with the recommendations
this is rectified within the required timescale.
Public health
The Trust develops its broader public health agenda in partnership with NHS Somerset
and the Local Strategic Partnership, South Somerset Together. Population data from the
Primary Care Trust was used to identify health needs for the Clinical Services Strategy,
currently in its third year and about to be refreshed. The Local Strategic Partnership has
identified potential health needs in central Yeovil; the Trust will work with partners to
address areas of deprivation.
The Trust, as one of the largest employers in Yeovil, also has a major public health role
to play through improving the health of its staff; smoking cessation remains well
supported, facilities for cycling and walking to work (eg showers) are increasingly
used, and the occupational health team has been strengthened.
Emergency planning
The Trust has a detailed plan in place to deal with major incidents and the emergency
situations. In April 2009 the Trust undertook a major simulated test of its plans using
the Health Protection Agency’s ‘Emergo Train’ exercise. As part of this event, the
Trust worked with partners across the health community and, from the exercise,
demonstrated the effectiveness of our systems and plans.
The Trust also put in place robust plans in support of the annual Glastonbury Festival and
the major events in the local area. The switchboard call-out system was tested twice
during the year and this has allowed the call-out system to be revised and updated.
A new major incident control room has also been established.
A major focus during 2009/10 has been working with partner organisations to put
robust plans in place to manage the Pandemic Influenza outbreak. The Trust managed
this very well, with high levels of staff uptake of the flu vaccine and the establishment of
an active and participative Pandemic Flu Group, which met weekly during the pandemic
phase. The Trust’s flu plan has been fully updated as a result of the learning gained
during the outbreak. The Trust has also worked closely with NHS Somerset and other
partners during the year and plays an active part in the Local Resilience Forum Health
sub-group.
23
Annual Quality Account 2009/10: Clinical and cost effectiveness
Our tried and tested clinical governance systems identify
where processes are working well, but support staff when
actions are needed to improve the care provided.
Conclusion
T
his Quality Account demonstrates the
Trust’s commitment to providing good
quality care to our patients, our staff, the
public and other users. Our tried and
tested clinical governance systems identify
where processes are working well, but
support staff when actions are needed
to improve the care provided. There are
many examples of good practice and
improving clinical services, and a number
have been included in this report. It is
as important to us that we demonstrate
learning from our patients when we do
not get it right, and there are examples
of this too.
Priorities for 2010/11:
Patients rightly expect to receive timely care that is safe and
of high quality, provided by competent and caring staff in a
clean hospital. Our key priorities for 2010/11 reflect
those expectations and they are listed below:
Continued reduction of healthcare associated infections
Continued roll-out and maintenance of the web-based
incident reporting across all wards and departments
To reduce the number of patient falls across the Trust
To increase the number of clinical audits undertaken
between the Trust and the Primary Care Trust
To agree quality improvement projects that will ensure
improved results in the national patient and staff surveys
To monitor the quality of care provided to our patients
using the agreed key performance indicators as our
benchmarks for improvement
To work with the Strategic Health Authority to deliver
the programme of patient safety improvements across the
South West
To improve compliance with the risk assessment tool for
venous thrombo-embolism across all areas of the Trust
To improve the management of stroke patients across
the Trust
To develop a robust mechanism for identifying patients
with learning disabilities
To improve the care of patients with dementia in the Trust
To strengthen our systems for ensuring patient
involvement to ensure all clinical areas are involved
24
Notes
This report is available online at:
www.yeovilhospital.nhs.uk
This document is also
available in large print:
call 01935 384233
or email
comms@ydh.nhs.uk
Yeovil District Hospital NHS Foundation Trust,
Higher Kingston, Yeovil BA21 4AT;
tel: 01935 475122