Quality Report
For the year 2014 ‐ 2015 1
1
QUALITY REPORT 2014-15
STATEMENT ON QUALITY FROM THE CHIEF EXECUTIVE
Welcome to our Quality account 2014/15 which will provide information about how we have
worked to improve the quality of our services; the progress we have made with our Quality
Strategy during the last year and our quality priorities for the coming year.
I am proud to report that following the Care Quality Commission (CQC) inspection within our
hospitals and Community Services from the 8th to the 12th of December 2014 the Trust was
rated as “good”. They also highlighted patient care as "good" for patients across all areas of
the Trust’s work. The Inspectors highlighted the strong leadership, good team working and
the individualised patient care that they observed. Despite how busy staff were they were
also impressed with the friendliness of everyone they met and the pride that staff take in
caring for their patients. Key strengths identified included our work in Surgery, Outpatients,
Imaging, the Emergency Department and the care of people with Dementia.
However, we know that there are still areas that could be improved and the detailed report
from CQC will help us to focus on these areas and ensure that improvements are made.
This winter has been one of the most demanding with increasing numbers of patient
attendances. Our Emergency Department (ED) has seen the record number of daily
attendances broken four times and overall the number of attendances increased by nearly
7%. Our staff have maintained patient safety and the quality of care and worked with a
dedication and professionalism that has been quite outstanding, and has merited us being
shortlisted with only two other Trusts for a prestigious A & E Department of the Year award.
Our Winter Plan appears to have worked very well, despite the huge pressures experienced
in the early part of the winter. We have had very few elective operations cancelled as a
result of bed pressures, and have managed to achieve our ED targets for the year. The
Winter Plan is currently under review and will utilise feedback from staff to determine what
has worked well and how we can improve next winter.
Having largely achieved the priorities of the previous Quality Strategy a new five year Quality
Strategy has been agreed. The new Strategy builds on our foundation of high quality care
and is based on the Care Quality Commission 5 Domains of Quality: safe, care, effective,
responsive and well led. Our Strategy includes the delivery of a local patient safety campaign
entitled the “Patient Safety 10” which has a strong focus on encouraging, empowering and
supporting patients to ask about their care.
We know that we need to work with external partners to transform our service delivery to
ensure integrated care, particularly for frail and vulnerable people who use our service more
frequently than other members of the population. One aspect of this transformation is the
introduction of the Virtual Ward project. Hospital and community staff bring the services
available in a hospital ward into the patient’s home. This means that selected patients can be
discharged earlier and are supported in their recovery within their home environment. This
initiative also frees up beds which has helped to manage the increased admissions over the
winter period.
Following consultation with staff and the public the Trust title has changed to Derby Teaching
Hospitals NHS Foundation Trust with effect from April 2015. This builds on our good
reputation for teaching and education. Our name change better reflects the work and
research that we do as a National Centre for excellence in Renal Disease, Parkinson's
Disease, Diabetes care and in the world renowned Pulvertaft Hand Unit.
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Finally I am proud that a new television series, which will be screened next year, is being
filmed by ITV at the Royal Derby Hospital and will feature the wide variety of people who
keep our services running day and night, every day of the year, without whom we could not
function. This will provide us with a wonderful opportunity to showcase to the world the
outstanding care, professionalism, and teamwork that is offered by our staff and volunteers
on a 24/7 basis.
This statement summarises Derby Hospitals NHS Foundation Trust’s view of the quality of
the NHS services that it provided or subcontracted during 2014/15. To the best of my
knowledge the information in this document is accurate and the Trust Board has received
and endorsed the details set out in the Quality Account document.
Susan James
Chief Executive
28 May 2015
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SECTION 1 - INTRODUCTION TO DERBY HOSPITALS NHS FOUNDATION TRUST
QUALITY ACCOUNT
Current view of the Trust’s position and status for quality.
This Account covers the financial year of 2014/2015 across Derby Hospitals NHS Foundation
Trust (DHFT).
The first part of the Account details how we performed against last year’s Quality Account,
followed by an overview of organisational quality and patient safety and our performance
against national and local metrics in 2014/2015.
The second section identifies our priorities for improving quality, safety, and patient
experience for the coming year, and where we believe further improvements are required to
enhance patient care.
Our 2013/2014 Quality Account detailed the following quality improvement priorities:
Patient Safety:
Protect patients from C.difficile
Continue to drive down mortality rates
Implement speciality level mortality review groups
Introduce public ward staffing and safety information
Clinical Effectiveness:
Develop a "toolkit" of quality assurance methods, i.e. risk and
quality reviews and safety walks
Embed Trust inter-professional standards
Reduce opportunities for clinical variation
Patient Experience:
Embed “Making Your Moment Matter” as a key caregivers
strategy
Roll out Fundamentals of Care education programme to all
staff groups
Implement year two of the Dementia Strategy continuing to
improve the environment for patients
Enhance opportunities to use real time patient experience
feedback to drive improvements
Ensure our complaints process is responsive and
demonstrates the shift to a learning organisation
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SECTION 2
PROGRESS ON 2014/15 QUALITY IMPROVEMENT PRIORITIES
The Statements of Assurance from the Board in respect of the Quality Report can be found in
Annex 2.
The Trust continues to ensure that the Quality Strategy is embedded throughout the
organisation and that these objectives are achieved. These objectives were developed
through organisational learning, patient feedback, and surveys. Wider engagement was not
undertaken when those objectives were developed.
Monitoring and measurement of progress was undertaken with the appropriate Trust
committees and groups. These were reported into the Quality Review Committee, Quality
Committee, and the Trust Board. The priorities for 2014/15 took into account feedback and
engagement with staff and patients through our:
•
•
•
Dementia workshops
Francis Listening Events
Making Your Moments Matter
Consultation with:
• Quality Committee
• Governors Workshops
2.1 PATIENT SAFETY
INFECTION PREVENTION AND CONTROL
The Trust remains fully committed to, and take very seriously, the responsibility for the
prevention and control of healthcare associated infections (HCAI), including Methicillin
Resistant Staphylococcus aureus (MRSA) and Clostridium difficile (C.diff).
The following section outlines the key objectives of the Trust, with particular focus on those
infections that form part of the national reporting requirements. A key factor of infection
prevention and control is the management of specific infections and their risk.
National MRSA Screening Programme
The Department of Health (DH) introduced mandatory screening of all elective and
emergency admissions from April 2009 and December 2010 respectively with the aim of
reducing the risk to patients of developing a serious MRSA infection e.g. blood stream
infection. The Trust continues to screen all planned and unplanned admission to the Trust for
MRSA in line with Department of Health requirements. Good compliance with MRSA
screening continues to be demonstrated.
Key focus on Reducing the Number of MRSA Bacteraemia
In April 2013, the Department of Health adopted a zero tolerance approach to avoidable
MRSA bacteraemia infections; this is where MRSA is identified in the blood stream, which is
a serious infection. The Trust finished the year end with a total of two MRSA bacteraemia
infections, both of which were classified as avoidable.
All cases of MRSA bacteraemia are reported and investigated as a serious incident. A
detailed investigation involving all healthcare practitioners involved in the patient’s care, is
carried out to consider whether all appropriate actions have been taken and to identify any
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learning points. All MRSA bacteraemia case investigations, learning points and associated
action plans are discussed and monitored at the Trust Infection Control Committee.
The learning and action points from two MRSA bacteraemia cases are:
•
•
The necessity of MRSA screening on admission to identify and treat patients who are
colonised with MRSA at the earliest opportunity to prevent serious infections occurring.
The importance of appropriate antibiotic prescribing when a patient is known to be MRSA
positive.
Learning from these cases is discussed and monitored at the Trust Infection Control
Operational Group and Infection Control Committee and is incorporated in staff training.
Clostridium difficile (C.diff) Infection
Clostridium difficile (C.diff) is a bacterium that is found in the intestine of approximately 3% of
healthy adults. It does not usually cause a problem as it is kept in check by the normal
bacteria in the intestine. C.diff causes disease when the normal bacteria in the intestine are
disadvantaged, usually by someone taking antibiotics. This allows C.diff to grow to unusually
high levels. It also allows the toxin that some strains of C.diff produce to reach levels where it
attacks the intestines and causes mild to severe diarrhoea.
For 2014/15 the national trajectory was calculated as rate per 100,000 bed days. DHFT was
set a rate of no more than 22.6 cases per 100,000 bed days, equating to no more than 69
cases. The Trust ended the year with a total of 61 cases. The national target set for 2013/14
was 42 cases and the Trust ended the year with a total of 67 cases.
Continuous assessment and review is crucial to ensure that the Trust is taking all appropriate
actions to minimise the risk of patients developing the infection. Root Cause Analysis (RCA)
is undertaken by the clinical teams on every Trust acquired C.diff case.
Since April 2014 all Trust acquired cases are discussed at the Healthcare Associated
Infection (HCAI) Review Group. This group is chaired jointly by the Chief Nurse and
Executive Medical Director and includes representatives from the clinical teams, infection
prevention and control, antimicrobial stewardship, Public Health England (PHE) and
Southern Derbyshire Clinical Commissioning Group (CCG), as the Trusts coordinating
commissioner.
Each case is reviewed to determine whether there has been lapse in the quality of care given
to patients, in line with NHS England requirements. The appropriate steps to address the
problems identified along with any additional ‘lessons to be learnt’ are identified and shared
across the organisation and discussed and monitored at the Trust Infection Control
Operational Group (ICOG) and Infection Control Committee (ICC).
The graph below shows the Trust monthly performance against the national trajectory and
whether any cases were identified to have a lapse in care.
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The Trust continues to take the necessary steps to ensure that its antibiotic prescribing is in
line with national best practice, whilst balancing the clinical needs of the patient. The Trust
continues to work closely with PHE with regard to the prevention, diagnosis and the
management of C.diff and they remain assured that the Trust has a comprehensive plan for
the management of C.diff in the organisation.
Monthly Clostridium difficile Comparison Data
This data is produced by PHE and is reported as a rate of 100,000 bed days to allow
comparisons between organisations.
The graph below compares DHFT performance against the rest of the East Midlands. DHFT
is generally below the monthly East Midland average for C.diff cases.
East Midlands C.difficile Cases per 100,000 Bed Days
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Meticillin Sensitive Staphylococcus aureus (MSSA) Bacteraemia
Most strains of Staphylococcus aureus are sensitive to the more commonly used antibiotics
and infections can be effectively treated, these are called Meticillin Sensitive Staphylococcus
aureus or MSSA. Some Staphylococcus aureus bacteria are more resistant to commonly
used antibiotics; these are called Meticillin Resistant Staphylococcus aureus or MRSA.
MSSA is a type of bacteria that lives harmlessly on the skin and in the nose of approximately
one third of the population. People who carry MSSA on their skin or in their nose are said to
be colonised. MSSA colonisation usually causes no problems, but can cause an infection
when it has the opportunity to enter the body, e.g. via a surgical wound or break in the skin
such as a leg ulcer.
MSSA Bacteraemia is where MSSA is identified in the blood stream, which is a serious
infection. It has been mandatory to report all cases of MSSA bacteraemia to PHE since
January 2011. There is no trajectory set against MSSA bacteraemia.
There have been 92 MSSA Bacteraemia cases identified since April 2014, 25 of these were
from samples taken post 48 hours of admission. This is an increase from the same time
frame in the previous year when there were 66 cases identified, 13 of which were identified
post 48 hours of admission.
Root Cause Analysis (RCA) is undertaken by the clinical teams on every Trust acquired
C.diff case. Learning from these cases is discussed and monitored at the Trust Infection
Control Operational Group and Infection Control Committee and is incorporated in staff
training.
There was an increase in MSSA bacteraemia cases in the Trust at the beginning of the year,
but the Trust has been below the East Midlands average from September 2014 onwards.
East Midlands MSSA Bacteraemia Cases per 100,000 Bed Days
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Analysis has not identified any trends or links between the MSSA Bacteraemia cases
attributed to DHFT.
Escherichia coli (E.coli) Bacteraemia
E.coli is a species of bacteria commonly found in the intestines of humans and animals.
There are many different types of E.coli and while some live in the intestine quite harmlessly,
others may cause a variety of infections. Urinary tract infection is the most common E.coli
infection; the bacteria spreads from the intestine to the urinary tract. E.coli can also cause
infection in the intestine, causing diarrhoea. These are usually the result of food poisoning.
Overspill from the primary infection site into the blood stream can cause a blood stream
infection. These are referred to as an E.coli bacteraemia. Mandatory reporting of E.coli
bacteraemia commenced in June 2011. There is no trajectory set against E.coli bacteraemia.
There have been 364 E.coli bacteraemia cases identified since April 2014, 68 of these were
from samples taken post 48 hours of admission. This is an increase from the same time
frame in the previous year when there were 331 cases identified, 61 of which were identified
post 48 hours of admission. Analysis has not identified any links between the cases. Public
Health England have identified a rise nationally in the number of E.coli bacteraemia cases
and will be hosting an event for hospitals to come together to share learning and best
practice of the prevention and control of E.coli bacteraemia. DHFT will be part of this event.
Norovirus
Norovirus is a virus which causes diarrhoea and/or vomiting. Although there is an increase in
winter months, cases do occur throughout the year. In general the symptoms last 24-48
hours. There are no long term affects from Norovirus and a full recovery is usual within 48
hours. Norovirus is extremely infectious, with around 50% of people exposed developing
symptoms. The focus within the Trust is to ensure the spread of the infection is minimised.
The table below demonstrates a reduction in the number of patients affected by Norovirus
2014/15 in comparison to previous years. The increase in the number of staff affected this
year is thought to be related to wards being affected by Norovirus that have not been
affected before, therefore new staff being exposed.
2012/13
2013/14
2014/15
Number of
areas
affected
34
21
19
Number of
full ward
closures
8
5
3
Number of
confirmed
Norovirus
18
16
14
Number of
patients
affected
131
82
75
Number of
staff
affected
38
17
29
Hand Hygiene
Hand hygiene is a key measure in controlling the spread of infections in hospital and remains
a key focus for the Trust. Monthly 20 minute observational hand hygiene audits are
undertaken in all clinical areas, assessing compliance against the Hand Hygiene Policy.
Compliance is monitored on a monthly basis at the Infection Control Operational Group,
along with associated action plans. Areas of concern are escalated to the Infection Control
Committee. In addition all clinical staff are required to undertake a competency assessment
of their hand hygiene technique on a two yearly basis.
The table below demonstrates continued compliance with hand hygiene in all Divisions.
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Month
April 2014
May 2014
June 2014
July 2014
August 2014
September
2014
October 2014
November
2014
December
2014
January 2015
February 2015
March 2015
Unplanned
Care
Planned Care
Integrated
Care
100%
99%
98%
99%
98%
99%
100%
100%
100%
100%
100%
100%
99%
99%
99%
100%
100%
99%
99%
99%
100%
100%
100%
100%
99%
99%
99%
100%
99%
98%
100%
98%
100%
100%
99%
99%
Infection Prevention and Control Accreditation Programme
The Infection Prevention and Control Accreditation programme takes a multifaceted
approach to improving patient safety and reducing healthcare associated infections. It sets
standards for infection prevention and control practice in DHFT and is a package of practices
likely to reduce infection rates when carried out consistently.
The accreditation programme recognises excellence of practice and that the area has
consistently exceeded the high infection prevention and control standards expected by
DHFT. Staff in an accredited area have demonstrated their sustained commitment to patient
care, safety, and infection prevention and control standards.
The following areas have achieved Infection Prevention and Control (IPC) Accreditation:
Medicine and Cancer Division
Integrated Care Division
Diagnostics, Surgery & Anaesthetics Division
Medical Outpatients Department
Sunflower ward
Ward 203
Ward 204
Ward 205
Ward 206
Ward 207
Ward 308
Ward 311
Pulvertaft Hand Outpatients Department
Ophthalmic Outpatients Department
Trauma and Orthopaedic Pre-Operative
Assessment
Ebola Preparation
Ebola is a severe illness caused by Ebola virus. It is highly infectious, rapidly fatal, with a
death rate of up to 90%. It is spread through direct contact with body fluids like blood, saliva,
urine, semen, etc. of an infected person and by contact with contaminated surfaces or
equipment, including linen soiled by body fluids from an infected person. If carefully
implemented, IPC measures will reduce or stop the spread of the virus and protect healthcare workers (HCWs) and others.
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The Trust Viral Haemorrhagic Fever Policy, which includes Ebola, has been updated in line
with national guidance and Trust specific information. In addition a quick reference guide for
the identification and management of patients suspected to have an Ebola infection has been
developed. Both of these documents are available on the Trust intranet site and have been
shared widely across the organisation.
Areas have been identified within admitting areas where patients suspected to have Ebola
will be admitted to and assessed. Personal protective equipment has been identified and
staff in the admitting areas trained on the correct techniques for use.
The Cleaning Service
The new model of ward team cleaning is now embedded across the Royal Derby Hospital on
90% of wards. Integrated Service Solutions (ISS), Trust Facilities Management (FM) and the
Infection prevention control team (IPCT) continue to audit all wards to ensure that cleaning
standards are being sustained.
Trust FM, in partnership with Integrated Service Solutions (ISS), from April are planning to
review the evening cleaning services to investigate the feasibility of implementing team
cleaning in our departments and clinics. The same process will be used across this project.
Patient Led Assessments of the Care Environment (PLACE) inspections take place monthly
on each site conducted by the Trust Facilities Management Contract Monitoring Officer along
with Trust Governor representation. The inclusion of both Derby Healthwatch and Derbyshire
Healthwatch on these inspections has added openness to the reporting process.
In 2014 it was agreed that a seasonal clean would take place on all wards, which would
involve the physical removal of dust, dirt and debris followed by a Hydrogen Peroxide Vapour
(HPV) Fog. The aim was to HPV as many patient bedded areas as possible notwithstanding
access limitations due to clinical need. The seasonal clean has been arranged so the
admission areas were cleaned first, followed by a roll out across the Trust, starting on level 4
and working down. The following wards have received a seasonal clean so far:
Ward 3
Ward 4
Ward 5
Ward 6
203
301
302
303
304
305
306
307
308
309
310
311
312
313
MAU
SAU
401
402
403
404
405
406
407
408
Following last year’s use of enhanced auditing using ultra violet (UV) technology, ISS have
now adopted the concept and are using Encompass which is an external tool to benchmark
cleaning on our wards using a UV pen to measure the effectiveness of cleaning touch points.
Joint training has taken place between Trust FM, IPCT, ISS and the domestic staff on the
agreed wards, and the theory of why we clean and how we clean is covered in detail. This is
then followed by practical ‘getting back to basics’ training. Once the results from audits are
sustained and continued improvements are made, the plan is to role this out in all wards and
clinics.
CONTINUATION TO DRIVE DOWN TRUST MORTALITY
The Trust scrutinises all issues relating to mortality with great care. The Mortality Committee
is chaired by the Divisional Medical Director for Medicine and Cancer, and receives a
monthly analysis of all hospital deaths. The Committee commissions investigations and
reviews of patterns in mortality data in order to improve practice and organisational
knowledge where appropriate. This has further been strengthened with the introduction of
Speciality Lead mortality review groups. Learning from these reviews is escalated to the
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Quality Review Committee and the Trust Board, and is disseminated throughout the Trust by
nominated representatives from Business Units.
There are two established benchmarking measurements for mortality across the country:
The Hospital Standardised Mortality Ratio (HSMR) and the Summary Hospital Mortality
Indicator (SHMI). The HSMR looks at only deaths which occur within hospital, and only at
the diagnostic groups which account for around 80% of those deaths. SHMI examines all
deaths from all diagnostic groups and also includes analysis for those patients who died
within 30 days of having been discharged. For both measures, the national index score is
100, with higher scores in each representing a greater proportion of unexpected deaths.
Overall, the DHFT monthly HSMR score has not been significantly different from the national
average, as shown by figure 1. Over the twelve month period to October 2014, HSMR was
101.6.
Figure 1: HSMR by month with control limit intervals - Derby Hospitals NHS Trust
The HSMR value for the last 12 months to January 2015, HSMR was 100.51 a slight increase from the
previous 12-month period. The monthly figure for January 2015 was 100.8.
HSMR
HSMR
120
70
Month
DHFT’s SHMI latest official published value for the period between July 2013 and June 2014
is 106.7, and is not statistically different from the national value of 100.
More recent data available from Healthcare Evaluation Data (HED) suggests that this has
dropped to a lower figure over the latter part of the year, as shown in Figure 2.
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Figure 2: SHMI by month with control limit intervals - Derby Hospitals NHS Trust
Monthly SHMI has been published by HED up to the month of December 2014. DHFT’s 12-month
position was 103.04, with December’s index being 105.22.
INTRODUCTION OF PUBLIC WARD STAFFING AND SAFETY INFORMATION
As of the end of April 2014 Inpatient Ward areas were required to clearly display information
about the nurses, midwives and other care staff in each inpatient area – this included critical
care.
In the future it is proposed that this will also be rolled out to other care settings including ED,
Outpatients and Theatres.
The information displayed includes:
• An explanation of the planned and actual numbers of staff for each shift (registered and
non - registered)
• Details of who is in charge for the shift
• Description of the role for each team member – i.e. Nurse in charge, discharge coordinator etc.
This information is clearly displayed in the clinical area and accessible to patients, carers and
families.
This is now well embedded across the organisation and compliance monitoring of completion
is undertaken by the Matron or Senior Nurse on a regular basis.
Alongside this information wards also report on the following:
•
•
•
•
Falls that result in harm
Unavoidable Pressure Ulcers
C.diff
MRSA
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These are known as Nurse Sensitive Indicators (NSI) which are quality indicators linked to
nursing care. Evidence in literature links low staffing levels and skill mix ratios to adverse
patient outcomes. NSIs refer to quality indicators that can be linked to nurse staffing issues,
including leadership, establishment levels, skill-mix and training and development of staff.
Monitoring NSIs such as infection rates, pressure ulcers and falls is therefore recommended
to ensure that staffing levels determined in the ways described above, deliver the patient
outcomes that we aim to achieve.
TISSUE VIABILITY – PRESSURE ULCER MANAGEMENT
It is nationally recognised that the incidence of pressure ulcers is a key quality indicator and
that 80-95% of these are deemed preventable or avoidable. Pressure ulcers are painful and
distressing for the patient, and require increased support and input to the patient from a
health care perspective. The Trust continues to participate in national and local initiatives to
reduce the incidence and prevalence of pressure ulcers. The numbers of patients with
pressure ulcers are monitored through the prevalence and incident reporting systems across
both the acute and community settings.
The Trust continues to take a zero tolerance stance to acquired avoidable pressure ulcers,
and has strived to achieve this. There continues to be a significant change in the delivery of
care in relation to key pressure ulcer prevention standards. The culture and positive attitudes
towards prevention has become the norm in most areas and this is evidenced in both our
prevalence and incidence data.
The Patient Safety Thermometer measures prevalence rates in pressure ulcers nationally.
The total pressure ulcers prevalence for DHFT (including all grades of admitted and acquired
pressure ulcers) has an average of 4.65% in 2014 and compares favourably against the
performance range regionally and nationally.
The graph below represents the prevalence of all pressure ulcers (acute and community) and
demonstrates a slow but steady fall in the rate of pressure ulcers overall with a static rate for
newly acquired pressure ulcers. The ambition of eliminating all avoidable pressure ulcers is
particularly difficult in the community setting, especially where District Nursing services may
only be visiting once or twice a week and the care is delegated to family, Social Care
agencies, or to the carers within residential homes. Prevalence in the community is also
dependent on the visit patterns from the care agencies.
Pressure Ulcers – New and old: patients with an old or new pressure ulcer
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Trust acquired pressure ulcers reported as Serious Incidents
The Trust (acute and community) reported (up to 19 February 2015) a total of 173 stage 3
and 4 pressure ulcers on the National Strategic Executive Information System (STEIS) during
2014. The Trust (acute and community) reported 161 stage 3 and 4 pressure ulcers during
2013/14. This is an increase in the total overall numbers reported and is partly due to
improved reporting, of which 78 (45%) were confirmed as unavoidable and 44 incidents
(25%) were found to have had some omissions in care and therefore were deemed
avoidable. The remaining 51 (29%) have yet to be confirmed either avoidable or unavoidable
and are classified as unconfirmed. These figures demonstrate a slight fall in the percentage
of avoidable pressure ulcers.
The implementation of an effective and sustained pressure ulcer prevention strategy, which
is described in brief below, has been instrumental in the on-going determination to reduce
our incident rate to zero avoidable pressure ulcers. The Trust Pressure Ulcer Prevention
Group (PUPG) works in collaboration with other disciplines and all Divisions to influence the
elements of pressure ulcer prevention for patients across primary and secondary care.
•
•
•
Root Cause Analysis (RCA) is carried out for all stage/grade 3 and 4 pressure ulcers.
The overall learning from these reports is reported back to the Serious Incident Group
(SIG) at a Scrutiny meeting. From these SI reports Action Plans are drawn up and the
reports are also submitted to the CCG for review. Additional education or training is put in
place to support and reinforce implementation of standards. Additional audits and spot
checks are carried out by Senior Sisters. Individual staff are supported with further
training.
On-going monitoring of pressure ulcer prevention documentation via the Tissue Viability
Excellence audit identifies areas that have consistent issues with compliance to the
essence of care standards, which are integral to the Trust’s Prevention documentation.
This is fed back at Senior Sisters Meetings and gives an overview of the common
themes, highlighting what could have been done to prevent potential harm from occurring
in the first place, holding staff to account where it is evident that harm could or has
occurred as a result of the omissions.
Improved access to training for Nursing Homes over the last 18 months has forged links
with the private sector, helping to improve understanding of pressure ulcer prevention.
Additional training for Residential Homes is planned for this year and will be led by the
community District Nursing Teams with support from Tissue Viability into Residential
Homes with identified high risk needs.
Pressure Ulcer prevention is an on-going process and continuous reinforcement of the use of
the SSKIN Bundles (Surface, Skin Inspection, Keep moving, Incontinence, Nutrition) within
the prevention care pathways and encouraging staff to discuss and find solutions to the
specific issues in their areas remains a priority. Raising awareness in the wider health care
community and within the home, stressing the need for early detection and escalation is key
to the reduction of grade 2 pressure ulcers. In order to promote this the Trust is part of the
Derbyshire Pressure Ulcer Awareness Campaign that aims to develop patient facing
information to this effect.
NUTRITION AND HYDRATION
The Nutrition and Hydration Steering Group (NHSG) continue to work proactively to ensure
that provision of high quality food and drink remains on the Trust agenda. This work stretches
across the whole health community ensuring that nutrition and hydration are key elements of
the patient pathway.
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Over the last year the Group has achieved the following:
•
•
•
•
•
•
Ward matrons continue to regularly report their nutrition related Ward Assurance scores
to the Group and present action plans for those areas with poor compliance. Monthly
Ward Assurance monitoring of the documented standards of care provides a range of
patient safety, experience and quality information
The Trust Dysphagia Policy has been produced and signed off by the Trust
The “Nil By Mouth” pathway has been implemented across the Trust and is available on
the hospital intranet
The National Descriptors audit has been completed
Patient meals are now served straight onto a plate using new packaging presented by
Anglia Crown
Nutrition related incident reports (IR1s) are routinely reported on at the NHSG
The Nutrition Ambition Plan for 2015/16 will be concentrating on the following areas:
•
•
•
•
•
•
Compliance to the Hospital Food Standards Report
Development of an e-learning package for Parenteral Nutrition
Resurrection of the Nutrition Link Nurse scheme
Multi-agency health promotion events
Monitoring of Total Parenteral Nutrition delivery (in line with NICE guidance)
Roll-out of the Nutrition Improvement project.
FALLS PREVENTION AND MANAGEMENT 2014-2015
The Trust keeps patients safe by having systems to ensure that Fall Care Pathways are in
place, demonstrating learning and change with the aim of reducing falls. The Trust has
robust assurance and monitoring systems in place. These include: Datix, monthly Ward
Assurance audits, and the National Patient Safety Thermometer monthly audit. Once themes
have been identified, initiatives are implemented in an effort to help deliver and sustain
measures to improve patient safety around falls management and reduce avoidable harm to
patients.
A revised Falls Risk Assessment Tool has been implemented in order to reflect the 2013
NICE guidance that everyone over the age of 65 is deemed a high falls risk. Those under 65
who are deemed at risk are also assessed. Our in-patient wards have revised their Risk
Assessment and Care Planning documentation, and this is to be implemented in early
2015/16. Guidance has also been developed and implemented to support in-patient staff in
managing falls risk using ‘increased supervision’.
The Falls Group has begun a programme of work, initially redrafting the Policy relating to the
prevention and management of patient falls and the introduction of separate guidelines for
the use of bedrails and low beds. These two documents will form the base upon which DHFT
staff will ensure the reduction of the falls risk for patients; and timely, clinically astute
management of patients who sustain a fall whilst in our care.
The detail and standards set within the documents described above lead on to further work
during 2015/16 relating to:
•
•
Further revising the documentation used by staff to assess the risk to patients of falling,
followed by relevant training and implementation
Developing the clinical reasoning processes around selection of preventative measures
to produce an individualised patient care plan to minimise the risk of falls; followed by
relevant training and implementation
16
•
•
Development of a ‘Top to Toe’ assessment for staff initially assessing the fallen patient
together with a revision of essential care post fall
DHFT has signed up to take part in the National Audit of In-patient Falls for 2015/16 as
part of the Falls & Fragility Fracture Audit Programme.
LEADING IMPROVEMENTS IN PATIENT SAFETY (LIPS)
Patient safety in England is now supported by a number of initiatives which includes a patient
safety campaign called ‘Sign up to Safety’. This is designed to support the NHS to reduce
avoidable harm by 50% and save 6,000 lives. The Executive Medical Director is the
Executive Lead for the Trust on this programme and the Trust made five pledges and signed
up to safety in August 2014. The five ‘Sign up to Safety’ pledges are:
•
Put patient safety first. Commit to reduce avoidable harm in the NHS by half and make
public the goals and plans developed locally.
We will deliver a local safety campaign called the ‘Patient Safety 10’ campaign. This will
have a strong focus on encouraging, empowering and supporting patients to ask about
their care.
It focuses on 5 key areas of improvement :
- Acute Kidney Injury
-
Electronic Observations
-
Safer Surgery
-
Urinary Catheter Infections
-
Maternity Safety Thermometer
It improves medicines safety by :
- Adopting the Medicines Safety Thermometer
- Focused work on insulin safety
•
Continually learn. We will make our organisation more resilient to risks, by acting on the
feedback from patients and by constantly measuring and monitoring how safe services
are.
We will develop a tool to collect information from patients about their perceptions of
their safety and promise to act on the findings.
We will measure and monitor how safe our services are so that we can learn using a
range of tools:
- Patient Safety Thermometer
- Maternity Safety Thermometer
- Falls and Pressure Ulcers
- Complaint Action Plans
•
Honesty. We will be transparent with people about our progress to tackle patient safety
issues and support staff to be candid with patients and their families if something goes
wrong. We will work with our staff to ensure that we are high reporters of incidents, which
will be demonstrated by the Trust being in the top quartile of Trusts for incident reporting.
We will create a structured process for staff and the provision of supportive patient
focused material will allow timely honest information to patients and families when things
go wrong.
•
Collaborate. We will take a leading role in supporting local collaborative learning, so that
improvements are made across all the local services that patients use.
17
We will collaborate with local General Practitioners (GPs) by strengthening links with the
local Clinical Improvement Groups in order to effect change for patient safety.
We will work with our commissioners to set up a Patient Safety Collaborative.
•
Support. We will help people understand why things go wrong and how to put them right
and give staff the time and support to improve and celebrate progress.
We will:
Maintain our Board to Ward visits and expand them to include additional patient
safety elements
Provide support and encouragement to our staff through patient safety walks from the
Executive Medical Director, Chief Nurse and Head of Patient Safety and progress
Divisional team walks across all areas. The safety walks will collate the learning and
help the staff to develop action plans to improve patient safety
Develop a patient safety link on the Trust website. This will be an area for staff to get
involved and share good practice and learning
Provide staff with an opportunity to feed back on patient safety issues and be able to
demonstrate the changes and actions taken as a result
Collaborate with staff to review the Trust’s Celebrating Success programme to ensure
that it provides the correct level of recognition and reward.
These pledges are part of the Trust’s Quality Strategy and will be delivered over a three year
outcome based Patient Safety Improvement Plan. The plan will make it clear which areas we
want to achieve improvements in. Each improvement topic will have improvements metrics
which will come together to create a suite of patient safety metrics which will form part of the
Trust’s quality assurance data.
EAST MIDLANDS ACADEMIC HEALTH SCIENCE NETWORK PATIENT SAFETY
COLLABORATIVE (EMAHSN)
EMAHSN has established a local Patient Safety Collaborative (EMPSC) whose role is to
offer staff, service users, carers and patients the opportunity to work together to tackle
specific patient safety problems, improve the safety of systems of care, build patient safety
improvement capability and focus on actions that make the biggest difference using evidence
based improvement methodologies.
DHFT is committed to working with the EMPSC and has pledged to contribute to the
emergent safety priories below:
• Discharge, transfers and transitions
• Suicide, delirium and restraint
• The deteriorating patient
• The older person: focusing on what ‘good safety’ looks like in the care home setting.
In addition we pledge to support the core priorities identified below:
• Developing a safety culture/leadership
• Measurement for improvement
• Capability building.
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REDUCING MEDICATION ERRORS
Priorities for Improvement: ‘Right First time’ Reduce Medication Errors
The Trust promotes a positive safety culture and encourages incident reporting, placing the
Trust in the top quartile of acute hospitals reporting to the National Reporting and Learning
System (NRLS). There is widely published evidence of reduced harm in industries and
organisations which have a positive reporting and learning culture.
Medication Errors
Following a downward trend (which mirrored the roll out of electronic prescribing) the number
of medication incidents reported each month appears to have levelled off during 2013/14 and
2014/15 at ~100 per calendar month.
In September 2014, NHSE published the 12th release of Organisation Patient Safety incident
reports from the National Reporting and Learning System (NRLS). It reports on data for the
period October 2013 – March 2014 and compares DHFT with the group of 39 ‘Large acute’
Trusts. The summary showed an increase in the rate of reporting by DHFT, from 6.8 to 8.4
incidents/100 admissions (Median 6.9). Despite this increase the Trust remains firmly in the
middle 50% of reporters.
Medication errors were 8.6% (previously 9.7%) of all incidents reported (national average
10.3%). The vast majority (>97%) of reported incidents caused ‘no’ or ‘low’ harm which
compares favourably with the ‘large acute’ average of 94%.
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Medication Safety
The Trust has 'Signed up to Safety' as part of a new national patient safety campaign and
committed to a three year plan to reduce avoidable harm in the NHS by 50% and save 6,000
lives. As part of that initiative the Trust launched the ‘Patient Safety 10’ campaign in August
with the focus for that month being on ‘appropriate medicine given’. A variety of
communications and events were used to highlight the importance of checks on allergy
status and patients’ own drugs etc.
A Senior Education Pharmacist continues to provide weekly ‘newsletter’ e-mails for all junior
and senior doctors on safe prescribing practice. The newsletters focus on sharing learning
from real prescribing incidents or near misses and have been well received. Topics covered
during the year include safe prescribing of insulin, opiates, anticoagulants,
immunosuppressants and antibiotics.
Medication Safety Officer
A Patient Safety Alert was issued at the start of the year by NHS England (NHSE) and the
MHRA to ‘improve medication error incident reporting and learning’. It establishes the
Medication Safety Officer (MSO) role and all Trusts are required to appoint one. Our MSO is
the Senior Pharmacist for Patient Safety & Clinical Governance supported by the multidisciplinary Medication Safety Group and the Medical Director.
Electronic Prescribing and Medicines Administration (ePMA)
ePMA is now live in all inpatient areas within the Royal Derby Hospital (RDH) and London
Road Community Hospital (LRCH), with the exception of the Labour Ward and Intensive
Therapy Unit (ITU). Paediatric wards successfully went live in September 2014.
Approximately 4000 medicines are prescribed and 15,000 administrations are recorded each
day on ePMA.
Functionality within ePMA has been utilised to reduce the use of handwritten dispensing lists
within pharmacy and hence minimise the risk of transcription errors.
Work on utilising the reporting potential within ePMA has commenced, with daily reports
already being used to support improvements in the prescribing of antibacterials and
anticoagulants. Another key aim is to use the information within ePMA to help identify and
reduce the omission of medicines.
NEVER EVENTS
DHFT had four Never Events in 2014 compared to three Never Events in 2013/14. The
Never Events in 2014/15 were: wrong site surgery, retained guidewire, maladministration of
insulin; and maladministration of potassium containing solution. Root Cause Analyses were
carried out for each case and learning points identified and changes implemented. In
addition, the Business Units carried out risk assessments against every Never Event
category to determine the mitigations that they have in place to minimise occurrence. In view
of the increased number an external review was commissioned by the Medical Director of
Never Events at DHFT in 2013/14. During the year, enhancing the opportunities for shared
learning was an important aspect of the strategy to minimise further incidents and included
the use of screensavers of safety messages on all Trust computer screens; posting executive
summaries of all Never Events on the Trust Intranet website; and the production of a bimonthly patient safety newsletter which provides an opportunity to share learning from
incidents and provides staff with a medium to showcase the work they have done in
improving patient safety.
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FRAIL ELDERLY CARE
Work has been on-going with the sustainability of the Acute Frail Elderly Pathway. The
specially designed Frail Elderly Assessment Team (FEAT) document screening tool
continues to be used in the Emergency Department and Medical Assessment Unit.
The Frail Elderly Assessment Team is fully implemented seven days a week, 8am to 8pm,
providing a Comprehensive Geriatric Assessment (CGA) across the Medical Assessment
Unit and has now extended into the short stay medical ward. The second phase of the
pathway is now in development. A plan has been developed to implement on-going CGA into
all medical wards and the community through a Frailty Dashboard. The pathway internally is
underway with the development of ‘Frailty is everyone’s business’, initial ideas around link
nurses, training and education packages and a further in-reach model across the Trust.
IMPLEMENTATION OF EXPERIENCE BASED DESIGN OF PATIENT PATHWAYS
THROUGH TRANSFORMATION PROGRAMMES
During 2014/15 the Transformation Team have integrated with the Patient Experience Lead
to ensure that all projects have a Quality Impact Assessment carried out at the very start of
the project. This has to be signed off by the Medical Director and Chief Nurse through the
Quality Review Committee. The use of Patient Panels and patient surveys have led to
informed decisions about the changes required to ensure our services are fit for purpose and
are as appropriate for our current healthcare market as possible whilst recognising the needs
of our patients.
GETTING HEALTHY STAYING HEALTHY
Smoking Cessation Services
With one Specialist Stop Smoking Advisor in post and an Honorary Contract in place, the
Trust’s Stop Smoking Service commenced on 5th January 2015. A second advisor has
recently been appointed and it is anticipated this second person will commence in post in the
near future.
The service is focusing initially on Respiratory and Cardiovascular
wards/departments and pre-operative assessment to promote the ‘Stop Before Your
Operation’ initiative.
The ‘Think Again’ campaign launched on Non Smoking Day March 2014 has led to
significant improvements over the last year after the introduction of new measures to deter
people from smoking within the Trust buildings and grounds. New posters designed by local
schoolchildren reinforce the message throughout the Trust. Trust staff also play a part and
have been trained to approach smokers and offer them alternatives such as Nicotine
Replacement Therapy. Letters are also sent to patients coming into hospital reinforcing the
need for them and their family and friends not to smoke. Staff are also handing out reminder
cards reinforcing the message. Records show that twice as many patients have accepted
Nicotine Replacement Therapy in the last year.
Information Hubs at DHFT
The development of Information Hubs at DHFT supports ‘Making Every Contact Count’ and
the aim to improve patient experience. The Hubs are designed to be accessible to all for the
purpose of health promotion/improvement, management of long term conditions, and
supporting people to stay safe and independent. These Hubs will be run in partnership with
many agencies across the county to help promote healthy living and will support patients and
staff to find support networks.
21
IMPROVEMENTS IN TIMELY DISCHARGE AND COMMUNICATION TO OPTIMISE A
PATIENT’S LENGTH OF STAY
Delayed Transfer of Care (DTOC) – Integrated Model
At the start of January 2013 DHFT applied a weekday system to support any patients that
had gone over their Expected Date of Discharge (EDD). Representatives from Derby City
and Derbyshire Adult Social Care support the daily DTOC meeting and provide support with
escalation of blockages. The process is further supported by the fortnightly attendance of
senior CCG and Social Care Managers. This approach has strengthened the understanding
of internal and external delays and is used to inform future strategies to enable people to be
maintained within their own home environment following timely discharge.
Transformation work is expected:
• To improve integration and responsibility with community teams to facilitate safe transfers
and discharge for patients, ensuring all patients are assessed.
• Develop a generic integrated discharge team that supports all adult wards across DHFT
• Develop a toolkit to enable wards to understand and apply simple and complex discharge
planning
Transfer to Assess
The Southern Derbyshire Virtual Ward pilot is a joint pilot between Southern Derbyshire
CCG, DHFT, Derbyshire Community Health Services (DCHS), Derby City and Derbyshire
County Social Care services. The pilot began in November 2014 and has supported 130
patients through the Virtual ward.
It is intended to provide intensive support to a small number of complex patients in their own
home when they might otherwise have had to stay in hospital. The aim is to reduce the
inpatient occupied bed days and ensure patients are safely assessed and managed at home
with an intensive assessment and support service from both health and social care whilst
overseen by a consultant.
The area virtual ward teams provide a Multi Disciplinary Team (MDT) approach to
rehabilitation, with medical support from GPs, the named Consultant and Community
Matrons. A weekly MDT meeting takes place to co-ordinate each patient’s progress and
safely manage their individual needs in the community, aiming to reduce readmissions.
The pilot has been successful and the aim now is to increase the capacity with the virtual
ward, further developing the services that support patients within their own homes.
ELECTRONIC PATIENT FLOW MANAGEMENT SYSTEM: E-WHITEBOARDS
This system gives live bed state information, assisting with daily multi-disciplinary team board
rounds, facilitating in making clinical decisions for referrals, i.e. x-rays, scans, and ensuring
all patients have an Expected Date of Discharge which is kept up-to-date. Since the
operational roll-out of the e-Whiteboards last year work has continued to strengthen the daily
operational usage and the reporting capabilities of the system. In July 2014 the system went
live in planned care and is now in wide use across the Trust, the only exceptions being
Maternity and Paediatrics. Through close working with partners in Social Services and
Community Services the Trust is using the system to improve communication and referrals to
enhance the patient pathway.
Specific developments include:
Phased e-Whiteboard rollout across the wider health and social community including DCHS,
Mental Health, care homes, Social Services (City and County) community services.
22
This will provide:
• A shared health community bed state
• Inter organisational referrals - with configurable referrals and two-way communication
• Auto alerts for teams when specific patients are admitted
• Live team views for Community Support teams showing where their patients are in the
system
• Virtual wards to help community teams manage their care.
DERBY BIRTH CENTRE
The Birth Centre was officially opened on Tuesday 11 March 2014 by Professor Cathy
Warwick, CBE, who is the Chief Executive of the Royal College of Midwives. The opening
was attended by representation from the Maternity Services Liaison Committee, the Southern
Derbyshire Clinical Commissioning Group, the Trust Chairman and Executive Directors, and
included midwifery and support staff from the Maternity service.
The Birth Centre aims to provide a welcoming, relaxed, comfortable, and supportive
environment for women and their families. Women experiencing a straightforward pregnancy
and anticipating a normal birth are cared for by experienced midwives. The Midwives in the
Birth Centre view childbirth as a positive life experience which enhances the long term
physical and emotional wellbeing of women and their families.
The feedback from women and their families has been extremely positive, and the midwifery
team led by the Senior Midwife for Low Risk is working very hard to improve the women’s
experiences of the birth process.
IMPROVING AND SUSTAINING DISCHARGE COMMUNICATIONS WITH GPs AND THE
WIDER HEALTH AND SOCIAL CARE COMMUNITY
We are working with the CCG to address problems involving medication flagged up via their
‘concerns’ process. The main focus is on improving the quality of discharges for patients
prescribed anticoagulants.
2.2 CLINICAL EFFECTIVNESS
As part of ensuring we have a robust system of quality assurance methods during 2014/15
we have continued to report monthly on the following indictors to the Trust Board:
•
•
•
•
•
Ward Assurance
Patient Safety Thermometer Medication Incidences
Staffing Fill Rate
Sickness Rates
Family and Friends
There is a now well established system of Rapid Risk Reviews that are undertaken by the
Divisional Nurse Director, Divisional Medical Director and Clinical Governance Facilitator.
Safety Walks are also undertaken by the Medical Director and Head of Patient Safety.
Embed Trust inter-professional standards
These were included as an objective in the job planning round in 2014/15. Their value was
superseded by the need for speciality related standards and ongoing work around provision
of 7 day services.
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Reduce opportunities for clinical variation
Clear Specific Measurable Achievable Relevant Time-based (SMART) objectives were
implemented in the job planning round in 2014/15. The Trust theatre dashboard was
launched in 2014 to allow consultants of the same speciality with similar casemix to compare
their productivity. Work is ongoing with the business units to ensure the provision of regular
data to all consultants tied into Patient Level Income and Costings (PLICS) information.
2.3 PATIENT EXPERIENCE
In 2014/15 the Trust continued to implement its Patient Experience Framework to shape and
guide the Trust on its priorities to continue to build on its vision to deliver PRIDE in caring and
put the patient at the heart of all that we do.
Patients first
Right first time
Investment
Developing our people
Ensuring value through partnerships
The approach to this Framework looked at all aspects of care. The importance of ensuring
the organisation grows with both the NHS and the people that it serves is vital if we are to
understand the needs of our ever changing Healthcare economy.
During 2014 Derby Hospitals began a campaign called ‘Making Your Moment Matter’ based
on the Patient Experience Framework. This Framework aimed for us to provide ‘Always
Events’ and during the course of the project development and after discussion with patient
groups we decided to Brand this project ‘Making Your Moment Matter’.
We know from the feedback we receive that the small things that we do often make a big
difference to patients, their carers and their families. We want to understand the things that
make the difference to our patients, and to the member of staff caring for them. The aim of
the project was to ensure that we listen to both our patients and staff and that this
consultation exercise fitted alongside our Taking Pride in Caring Trust vision and objectives,
as well as the National Nursing 6 Cs - Developing a Culture of Compassionate Care.
We wanted staff, patients and their families to help us develop a set of statements which are
right for both our organisation and our patients. 23 statements were drawn from some of the
feedback we received from patients, their carers, and their families.
This was a large scale consultation with a target audience of 3,000 people.
The methodology of this consultation ensured we had a wide range of responses that meant
something to both staff and service users which when published could be related to or be
recognised as a direct comment from them.
The following Top 5 ‘Moments’ were recorded from this consultation:
We will treat you as a person, not just a patient, with dignity and respect at all times
We will give you the best possible treatment that is available to you
We will understand your needs by listening, empathising with you, and keeping you informed
We will make the place you are treated in clean, safe and the environment as caring as
possible
We will give you information in a way that you can understand, to help make decisions about
your care.
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The statements set out the Trust’s Pledge to its patients, visitors and carers to ensure that
we deliver the best possible patient experience by not just doing the ‘Big Stuff’, but ensuring
we get the smallest interaction with patients right first time.
This campaign was rolled out across the Trust during 2014/15 and we have begun
embedding this into every aspect of teaching we do including Trust induction and in
conversations during staff appraisals both medical and non-medical, ensuring we touch every
member of staff delivering care in all its forms. We have to date seen some 2,490 staff go
through this awareness programme and the feedback from staff has been very
complimentary. This campaign was designed as a two year program and will continue in
2015/16.
This is a cultural change programme that whilst difficult to measure is monitored through
responses to the Friends and Family Test and the Influential Factors data that is collected at
the same time.
Strategic Projects Team Partnership
The Patient Experience Team has worked with the Strategic Projects Team, a marketleading, national provider of strategic change services to the NHS to look at roll out of FFT to
outpatient Community and Paediatric services. In return the Trust has received training for
some 150 frontline staff. This training focused on the Patient Journey in 10 steps helping staff
understand how it feels for the patient from the moment they step into the Trust to the time of
discharge.
This training evaluated very well and will be extended further in 2015.
The Fundamentals of Care (FC)
The Fundamentals of Care was successfully rolled out and the learning from evaluations has
allowed it to evolve and grow.
There are now multiple formats and opportunities to access the programme.
The full length version is based on two, three hour modules that explore the patient
experience and physical aspects of care in detail. This is aimed at clinical care providers and
there is also a Paediatric version to focus on the unique needs of children. There is also a
two hour version aimed at administrative staff with a focus on customer care. In addition to
this we have a one hour version that is suitable as an introduction to patient experience
themes for other non-clinical staff.
25
Fundamentals of Care is now included in all Trust inductions where we focus on our
organisational commitment to patient experience within a 30 minute session. Since March
2014 2,100 staff have accessed this programme in one of the above formats.
For the year ahead we have increased the capacity and availability of the full length
programme from one to two sessions per month. The content has been updated to
incorporate user feedback and make customer-care outcomes more explicit as well as a
greater focus on compassion and a culture in which we can support each other.
We are also making stronger links to the ‘Making Your Moments Matter’ campaign and the
‘Living Our Values’ tool kit by using the resources from those workstreams within the
sessions.
Dementia Care
The Trust Dementia Care Framework ensures continuous improvement in the delivery of
high quality care for people with dementia in the Trust. The recent CQC report highlighted
that the Trust was providing responsive care for patients with Dementia. In particular, ward
205 was commended in the report for improving the mental wellbeing of elderly patients and
those with dementia through their reminiscence room, pictorial information and advanced
service planning to enhance patient care. It was also noted that a Healthcare Assistant with
qualifications in looking after patients with Dementia is based in the Frail Elderly Team
lounge in the Medical Admissions Unit every day and provides individualised and responsive
care.
The Lead Nurse for dementia has forged strong links with local interest groups and a
member of the Derby Dementia Action forum now sits on the Trust Dementia steering group.
There have been several initiatives completed including the introduction of special crockery
in wards with higher numbers of patients with dementia and introduction of dementia friendly
signage. Some wards have also had refurbishment to make the environment more suitable
for patients with dementia. This includes the Medical Assessment Unit which is very
important because it is often the first ward that many patients experience when admitted to
the Trust as an emergency. The Dementia steering group are continuing to pursue the
improvement of the patient environments in the coming year by extending dementia friendly
signage and creating spaces in wards that extend the reminiscence room and dementia
friendly concept.
There has been significant work undertaken at the London Road Community Hospital wards
to enhance the patient - staff relationship. This includes the implementation of the
‘personalisation project’, whereby patients and staff are encouraged to share information
about each other to assist in promoting positive relationships. This information might include
detail about family members, social likes and dislikes, or why staff enjoy coming to work. We
have found that this exercise has been welcomed by both patients and staff and it optimises
opportunities for the patients and their families to feel relaxed about speaking to staff about
their worries and fears. The staff at London Road have also been to visit other specialist
dementia wards in neighbouring Trusts to learn and bring back further ideas for
improvement. The Dementia steering group are determined to spread this way of working to
other wards and departments in the Trust.
Staff Training on Dementia
We recognise that providing appropriate training on dementia for staff is key in promoting and
enhancing the care of people with dementia within the Trust and in the community,
supporting their carers and families. We have undertaken a review of our training in line with
the Health Education England mandate ‘to Improve the Care of Patients with Dementia’
within a three tier system as outlined below:
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Tier 1: Dementia awareness training for all staff who come into contact with patients
Tier 2: Specialist training for staff working with people with Dementia on a regular basis
Tier 3: The development of expert leaders in Dementia care
At DHFT the training tiers have also been matched further to the specific training outlined
below which is in progress and includes:
Tier 1: Dementia awareness (face to face and/or e-learning module)
Tier 2: Best practice in dementia care (University of Stirling)
Tier 3: Stirling University Facilitators delivering further training with the Trust
The table below shows the numbers of staff trained up to March 2015:
Dementia Training @
27/03/2015
Total Individuals
Trained (All Staff)
e-Learning Training by
month (All Staff)
Face to face sessions
(All Staff)
Total training per
month (All Staff)
Mar14
Apr14
1615 1650
May14
Jun14
Jul14
Aug14
1687 1713 1738
1758
Sep14
Oct14
1774 1789
Nov14
1814
Dec14
Jan15
1834 1870
Feb15
Mar15
1927
2015
35
29
31
27
24
18
14
9
14
10
15
14
19
58
4
5
1
1
1
2
7
3
13
28
124
80
93
33
36
28
25
19
16
16
17
23
43
138
99
23%
23%
23%
23%
23%
23%
33%
Compliance (TA Only)
The Trust is fully committed to continue increasing the numbers of staff who receive this
training in the coming year.
Assessment of patients to improve early detection and treatment of dementia
The Trust is required to carry out assessment and appropriate referral on a minimum of 90%
of patients over 75 years of age who are admitted to hospital as an emergency. In
December 2014 we recognised that the systems we had in place to achieve this were not
effective enough. Therefore, from February 2015, following consultation with staff, we
introduced a new system to undertake the assessment that we feel will be more effective for
patients. We will continue to monitor this and are confident that we will have significant
improvement in 2015/16.
National Surveys
National Adult Inpatient Survey 2014
The results if the 2014 CQC national survey follow the trends of the previous year but show
lower scores in many areas compared to last year.
The areas that declined the most were as follows:
• Hospital ward - Q11: Did you ever share a sleeping area with patients of the opposite
sex?
• Leaving hospital - Q63: Did hospital staff tell you who to contact if you were worried about
your condition or treatment after you leave hospital?
• The Emergency/A&E Department - Q3: While you were in the A&E Department how
much information about your condition or treatment was given?
• The Trust was placed firmly within the ‘about the same as other trusts’ category across
the domains. The Trust did not feature within the ‘worst performing trusts’ for any of the
27
questions asked and the Trust was within the ‘best performing trusts’ section for Q7 ‘was
your admission date changed by the hospital?’ and Q22 ‘were you offered a choice of
food’.
From both the falling scores and the lower scores that have remained static, the
recommendations for areas of focus are as follows:
• Look at progress on eliminating mixed gender rooms, bays and bathrooms and consider
perceptions of service users
• Review the provision of regular and updated information given to patients about their
condition and treatment in A&E
• Ensure that patients are given as much privacy as possible when being examined or
treated in A&E
• Examine why some patients have long waits to get a bed on a ward and take appropriate
action where possible
• Look at food quality temperature and the timing of food arriving
• Examine pain control on wards giving due concern to specialty and locations
• Examine the call bell wait and reasons why patients may have to wait for more than five
minutes for a response
• Examine the type and volume of information about operations and procedures given to
patients, focussing on:
•
•
•
Before
During
After
Anaesthesia and its effects
Examine the wait for medications paying attention to the process for ordering and
delivery.
Review the clarity of information about medications with attention paid to side effects and
possible worries.
Review what information should be provided about danger signs and priority concerns
following a treatment or procedure.
2014 National Children’s Inpatient and Day Case Survey
The results are based on 50 responders across age ranges up to 15 and including parents.
The Trust results in comparison with the national percentages were overwhelmingly higher,
and of 65 questions about the service, 56 were higher than the national percentage.
The higher scores above the national percentage were:
• Did someone from the hospital tell you what to do or who to talk to if you were worried
about anything when you got home?
• Did a member of staff tell you what would happen after you left hospital?
• Were members of staff available when your child needed attention?
• Do you think that there were appropriate things for your child to play with?
The scores that fell the lowest below the national percentage were:
• Did you like the hospital food?
• Do you think hospital staff did everything they could to help your pain?
• Were there enough things for someone of your age to do on the ward?
• Were you given any new medication to take home with you for your child that they had
not had before?
Action plans are being developed and these will be monitored through the Trust Quality
Structure.
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The National A&E Survey 2014
The National A&E Survey 2014 has just been published – there were 298 responses.
Overall, the report on DHFT was positive. There were a number of improvements although
we came out average or better compared to other Trusts on every question. This is in spite of
the major challenges the department has faced over the past year, which demonstrates the
clear commitment and hard work of our staff.
There were several areas where we performed better than other Trusts including:
• Staff not talking amongst themselves as if patients weren’t there
• Clear explanations of condition and treatment
• Not providing conflicting information
• Cleanliness of the department
• Suitable food and drink on hand
• Explaining purpose of new medications
• Providing contact details if patient was worried post-discharge.
Key headlines were as follows:
• 98% felt we treated them with dignity and respect
• All patients reported being seen within the 4 hour target wait (87% were seen within an
hour)
• 95% felt they had enough time to discuss their health problem with a doctor or nurse
• 93% said that staff explained their condition and treatment in a way they could
understand
• 95% felt listened to by doctors and nurses
• 95% had confidence and trust in our doctors and nurses
• 98% felt the A&E department was clean
• 98% felt they had enough privacy when being examined or treated
• 92% felt they were involved in decision making about their care and treatment
• Only 5% felt they’d been given conflicting information by staff (this was a better
performance than most other trusts)
• Of those who had requested pain relief, 5% reported not being given any, whilst 95%
were given pain relief, and for the majority (78%), this was done within 30 minutes
• One negative finding was that 44% felt we had not considered their family or home
situation before discharging them home from A&E (this was only answered by patients
who were not admitted to a ward, which was a total of 71)
• Overall, 85% of patients rated their experience as seven or more out of 10.
Interestingly, the survey also asked patients who had advised them to go to A&E. The results
showed that the largest percentage (33%) were via the ambulance service, but the second
highest highest volume of patients (23%) had decided to go by themselves without
professional advice. 10% were advised to go by their GP, and 8% were advised by a phone
advisor (e.g. NHS 111). This shows that the general public are being more and more
autonomous in deciding to come to A&E, potentially bypassing professional advice
altogether. This mirrors findings from HealthWatch Derby City, who observed that many
patients had come in of their own accord with minor ailments.
National Cancer Patient Experience 2013/14 Survey
The Cancer Patient Experience Survey 2014 (CPES) follows on from the successful
implementation of the 2010, 2012 and 2013 surveys, designed to monitor national progress
on cancer care. The 2014 survey corresponds with the National Operating Framework
(NOF) for the NHS 2014, which defines quality as those indicators of safety, effectiveness
and patient experience that indicate standards are being maintained or improved; with the
NHS England Business Plan 2013-16 and ‘Everyone Counts’, planning for Patients 2013-14.
The CPES provides information that can be used to drive local quality improvements, both by
Trusts and Commissioners and is consistent with the objectives of NHS policy. The Survey
29
will assist the Trust in benchmarking its performance and identifying trends or patterns that
can be used to drive local quality improvements.
153 acute NHS Trusts providing adult cancer services (aged 16 years and over) took part in
the survey. Respondents had a primary diagnosis of cancer and had been admitted into
hospital as an inpatient or as a day case and were discharged between 1st September and
30th November, 2013. The number of trusts has fallen from 160 in 2010 because of
amalgamations and the disbandment of South London Healthcare in 2013 and the
reallocation of cancer activity to Lewisham, Kings, and Dartford and Gravesham. At this
Trust 1,170 surveys were sent to eligible patients, with 760 questionnaires returned
completed; this represents a response rate of 68%. The national response rate was 64%
and this remains the same as in 2013, both locally and nationally. Where numbers of
respondents in a particular tumour group were less than 20, this represents a rare cancer
and data is not available due to low numbers of patients being treated.
The survey has 15 categories which comprises of between 3 and 8 questions (overall 70
questions).
DHFT has seven categories scoring 20% higher than other trusts nationally and five
categories that scored 20% lower than other trusts nationally. The Trust had 16 question
responses that showed an improvement on the 2013 survey. The remaining questions either
showed improved results or remained the same against 2013. It is clear that many specialist
cancer teams have been working hard to improve services for patients over a considerable
period of time and have succeeded in making improvements that have been reported by
patients.
Responses by Tumour Group
Number of respondents
Tumour Group
2013/14
155
107
26
39
5
54
154
44
5
43
34
116
7
Breast
Colorectal/lower Gastrointestinal
lung
prostate
Brain/Central Nervous System
Gynaecological
Haematological
Head and Neck
Sarcoma
Skin
Upper Gastrointestinal
Urology
other
2012/13
143
112
35
42
2
66
103
30
0
36
49
113
12
Themes listed in 20% higher than other Trusts Category
• Patients given a choice of different types of treatment
• Patients given the name of the Clinical Nurse Specialist (CNS) in charge of their care
• Patients had confidence and trust in all doctors treating them
• Patients were always given enough privacy when discussing their condition/treatment
• Doctor shad the correct notes and other documentation with them
• Patients rating of care `excellent`/`very good`
Areas for improvement:
• Patients offered written assessments and care plans
30
• Hospital staff definitely gave patients enough emotional support
• Patients never thought they were given conflicting information
• Hospital staff told patients they could get free prescriptions
• Hospital staff gave information about the impact cancer could have on work/education
Action required
When considering what questions/areas to focus on, simply concentrating on the questions
which were in the upper or lower 20% should not be used in isolation as the benchmark for
improvement. It is good to see where the Trust is in comparison with our peers, but it is also
important to recognise the purpose of the survey is to improve cancer patients’ experience.
Where the Trust has scored below the 70% mark, of which there were 13 questions with two
placing the Trust in the bottom 20%, was examined. These questions fell into the range of
best treatment options and the amount of financial and emotional information offered when
leaving hospital. Also the lack of a written assessment and care plan offered to the patients.
Action planning
•
•
•
•
•
•
•
•
•
Each MDT lead and Clinical Nurse Specialist (CNS) lead to review site specific survey
results and develop an action plan
A detailed action plan will be developed and monitored
Lead Cancer Nurse to discuss with Commissioners and Macmillan GPs a way forward
regarding GP and community involvement
Group debate at MDT lead and CNS/AHP lead meetings to discuss generic themes
To review the process of patients being offered a written assessment and care plan. This
will be reviewed in line with the Holistic Needs Assessment (HNA) implementation
Develop on-going patient satisfaction surveys against the planned improvements, to
continually measure responses over the next 12 months
Share result summaries with key stakeholders
Discussion to take place locally around research, to review and improve process
Cancer Lead Nurse to share the report at Trust Quality Committee and Divisions.
The National Friends and Family Test is now embedded in the inpatient areas, Emergency
Department and Maternity services.
The use of Your Views Matters cards, a web link, text messaging, and tablet computers have
enabled Derby Hospitals to listen to patients and gain useful service user feedback. Clinical
leads have been trained and given access to the data and reporting functions. This allows
detailed reports to be downloaded with a drill-down function to specific wards if required.
Sisters/Charge Nurses can now print their own ward performance posters and display them
in professionally produced display boards.
FFT ratings
Trust wide FFT ratings 2014/2015
100
80
60
40
FFT score
20
31
Mar‐15
Feb‐15
Jan‐15
Dec‐14
Nov‐14
Oct‐14
Sep‐14
Aug‐14
Jul‐14
Jun‐14
May‐14
Apr‐14
0
A new scoring system was introduced in September 2014 by NHS England, so the response
‘Likely’ along with ‘Extremely Likely’ would be included in the figures. This resulted in an uplift
when this change came in to place in September 2014.
Maternity ratings
Maternity ratings 2014/2015
120
Antenatal
appointment
Axis Title
100
80
Labour/Birth
60
40
Postnatal hospital
20
Postnatal
community
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
0
The changes in the scoring system resulted in the same uplift that was discussed above.
Emergency Department ratings
Emergency Department 2014/2015
100
90
80
70
60
50
ED
40
30
20
10
0
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
The changes in the scoring system resulted in the same uplift that was discussed above
32
FFT Inpatient response rates
The inpatient response rate has been variable with a trend that reflects the times that we
have seen higher activity within the Trust.
FFT IP Reponses Rate % Comparison 13/14 ‐ 14/15 60.00%
50.00%
40.00%
Inpatients 1
30.00%
Inpatients 1
20.00%
CQUIN Targ
10.00%
Mar
eb
an
ec
ov
Oct
ep
ug
Jul
un
ay
Apr
0.00%
However, we have seen a year-on-year improvement. This has been achieved through the
following:
•
•
•
Leadership support
Staff engagement
Increased service user understanding and knowledge
Emergency Department FFT response rates
Response rates for ED Comparision 13/14 ‐ 14/15
30%
25%
20%
A&E 13
15%
A&E 14
10%
CQUIN
5%
0%
Emergency Department response rates continue to vary, with a trend that reflects the times
that have seen higher activity in the area, the majority of these responses come via text
messaging.
33
Maternity response rates
Maternity responses are based on four reporting areas that are submitted separately.
For this reason and the complexity of a year on year chart for this data, the there is no 13/1414/15 comparison chart.
The response rate trend for this year remains variable.
Response rates for Maternity Services
70%
50%
30%
10%
Apr‐14
May‐14
Jun‐14
Jul‐14
Aug‐14
Sep‐14
Oct‐14
Nov‐14
Dec‐14
Jan‐15
Feb‐15
Mar‐15
Antenatal
Labour/Birth
FFT Roll Out
As well as the response rate targets, the Trust was challenged to make the FFT question
available to all service users by April 2015 as an implementation CQUIN.
This has been achieved with cards, text messages, posters (with web links) leaflets and
tablet computers. The ‘kiosk’ tablet in ED is now increasing usage so this will be considered
for other areas with rapid throughput.
Paediatrics have their own online version of the questionnaire that is now available in either a
handheld version or one that will is installed as a kiosk style device on a stand. There is an
under and over eight years version to enable the Trust to reach as many service users as
possible.
Under 8 Version
Over 8 Version
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Developing Real Time Patient Feedback
The Trust has been committed to gathering real time patient feedback this year using a
varying array of methods. Listening to the patient on a one to one basis is important. It is
what we then do with the information to effect change that will make the difference to the
care we provide.
The number of NHS Choices reviews continues to climb, and Twitter activity continues to be
relatively high. This is likely to continue to increase, especially as we have now jointly
launched with the Communications Team a new Patient Experience section on our external
Trust website. This will invite yet more patient feedback – available to view at
http://www.derbyhospitals.nhs.uk/patients/tell-us-about-your-experience. The majority of the
online feedback has continued to be positive this year.
The use of technology has figured heavily this year in our real time feedback and the
introduction of both the patient experience section on the Trust website and the ‘Your Views
Matter’ on line survey are just starting to have an impact on the return rates which has been
variable this year.
The fear for the Trust is ‘Survey overload’ and the patient experience team will be very
mindful of this when we launch the Friends and Family Test into outpatient services in April
2015.
Themes from online reviews
The top themes from online reviews this year continue to be related to staff behaviours,
clinical care/procedure quality, timeliness, efficiency, and facilities. Some will state they
weren’t happy with a number of aspects of care, but found staff to be very helpful and
compassionate (in other words staff behaviours and attitude was the one positive element for
them).
The challenge to the Trust in 2015/16 will be to ensure we keep the flow of information from
all of these formats available for the organisation to learn from and adapt to the comments
made about services if appropriate
The ‘Your Views Matter’ campaign was designed to support and enhance the Friends and
Family Test. The campaign was set up to raise awareness of the different ways in which
people could tell us about their experiences. There is also a section for people to leave
comments or suggestions on where we are doing well or where we could improve. We plan
to reduce the number of version of the cards in circulation to enable developments and
translation.
35
As part of the campaign posters on who to speak to on the ward if someone has a concern
are displayed in the inpatient areas. Banners advertising the campaign have been placed
across the Trust and information for staff and patients has been put onto the Intranet and
Internet.
Currently 87% of comments made are positive and these are captured in the database and
are e-mailed back to the wards and departments to the senior nurse for them to display.
COMPLAINTS AND COMPLIMENTS
In 2014/15 the Trust has continued to welcome patient feedback. Following a review of the
Complaints and Concerns Policy there has been a continuing focus to ensure that we
effectively and efficiently answer complaints and concerns in a timely manner, and
continually use this information to improve our services.
2012/13
2013/14
2014/15
Number of Complaints
602
736
819
Number of Informal concerns and enquiries
963
2110
2961
The focus of improvements since April 2014 has been to drive forward change following the
Francis Report and the Clwyd/Hart Report, and to put patients at the centre of everything we
do when handling complaints and concerns. This has been achieved by taking forward the
Patients’ Association Good Practice Standards for NHS Complaint handling. The Trust’s
Complaints Policy has been updated in line with these reports and the Patients Association
Standards supported by the roll out of the complaints management system, DATIX.
The most significant changes have been the introduction of triage within 1-2 hours and
provisional grading of all complaints by senior members of the Complaints team and ensuring
there is a robust Complaints Management Plan. It is also important to note that the
accountability in the Divisions is now much stronger with the teams improving the way they
respond to complaints and concerns. This has been supported by risk training and serious
complaints are now escalated immediately to Risk & Governance and/or Executive Directors
for action. The Complaints Management Plan means that complainants expectations are
better managed from the outset ensuring that complaints are dealt within a timely manner
and the complainant is assured that their concerns are being addressed effectively and within
a reasonable timeframe.
Although we do not wish for more people to be unhappy with the service they receive, the
increase continues to be encouraging as more people are telling us about their experience.
The increase is felt to be due to the heightened awareness amongst the public about the
option to complain. This trend reflects the local and national picture, and our own internal
campaign related to ‘Your Views Matter’. Proportionately, there have been a higher number
of concerns this year and we have made a significant effort to resolve concerns quickly,
reducing the need for them to follow the formal complaints process.
The key areas of focus are:
36
•
•
•
•
•
Ensuring that all key staff are trained to deal effectively and efficiently with complaints
and concerns
Embedding systems and processes to make sure that learning and improvements from
complaints and concerns are part of our core activity and robust action is taken to put
things right when required
Consolidating the use of the electronic information systems to ensure that complaints and
concerns are responded to in a timely manner. We have established a Complaints
Review Group, chaired by the Trust's Head of Complaints/Patient Advice and Liaison
Service (PALS), to carry out monthly reviews of the quality of our complaint responses.
Consisting of Non-Executive, Governors and staff members the group feed back to staff
to ensure that learning takes place. The Trust has also enlisted the support of the
Patients Association in surveying all people who make a complaint about their experience
of the complaints process. Learning from complaints will continue to take place at several
different levels of the Trust, at Board, Divisional, Business Unit and local ward and
department levels
Joint working will take place with the Patient Experience team and the Complaints/PALS
Department to ensure that trends are monitored on complaints and concerns and further
work carried out to embed learning throughout the Trust
A Complaints Improvements Plan focussed on responsiveness and organisational
learning is in place and is monitored through the Patient Experience Committee.
Complaints Received by the Health Service Ombudsman
The Parliamentary and Health Service Ombudsman (PHSO) represents the second and final
stage of the NHS complaints process. The Trust continues to work directly with PHSO to
satisfactorily resolve complaints.
A person may refer to the PHSO if they do not feel that the Trust has responded to all of their
concerns, or they are unhappy with the way in which we have dealt with their complaint. The
PHSO gives the Trust the opportunity to ensure that all local resolution has taken place to try
and resolve the issues and will give an independent view on the complaint.
In 2014/15 there were 12 new referrals received by the PHSO. In 2013/14 there were seven
new referrals.
Compliments
The Trust has widened the ways by which compliments are received, with the comments
from Friends & Family Test and NHS Choices website adding a rich source of information to
the compliments received in writing by the Trust. The high number of compliments received
is very encouraging and are fed back to the department teams to reinforce good practice.
Year
Source of feedback
In writing
Number of
Number of
359
149
2013/14
2014/15
NHS choices
32*
193
Friends &
Family
8838**
11316
* Data collected from September 2013
**Data collected from June 2013
LEARNING DISABILITIES
The Learning Disability Liaison Nurse continues to support the patients, carers and staff in
improving the experience of this patient group. This includes assessing their care needs and
advising on specific requirements, including communication techniques, complex behaviours
37
and advising on reasonable adjustments in care in order to assist the Trust in effectively
meeting the healthcare needs of people with a learning disability.
The Traffic Light Assessment continues to be well received by people with a learning
disability and their carers, and is now readily asked for by staff that come into contact with
this patient group. The Assessment promotes a picture of the whole person by including
information other than illness or health. There are 3 sections including:
•
•
•
Red:
Things you must know
Amber: Things that are important to the patient
Green: Patient likes and dislikes
The document enables staff to have a clearer understanding of the person’s learning
disability, and gives an insight into their communication and specific needs. The Assessment
is given to patients who are asked to share it with staff who will be caring for them.
Person centred care plans have also been introduced along with communication charts
between carers and staff.
The alerts/patient flags continue to be added onto the Lorenzo system, clearly identifying the
person has a learning disability. There is also now a free text box which allows individual
information to be recorded or reasonable adjustment needs to be documented.
Support for surgery continues to increase following the liaison within pre-operative
appointments. Planning admission and support reduces the anxiety for all concerned and
proves to lead to a positive hospital experience.
The short films about this topic which are available on the DHFT website were chosen as
markers of Good Practice by NHS Employers this year. The aim is to increase the number of
films.
ENSURING THAT PATIENTS WHO ARE AT THE END OF LIFE RECEIVE THE MOST
APPROPRIATE CARE
The Trust remains committed to providing high quality individualised care to patients and
those who are important to them when a person is at the end of their life.
In 2014 the Trust responded proactively to the withdrawal of the Liverpool Care Pathway and
the subsequent government report ‘One Chance to Get it Right’, which describes how the
health service should care for those believed to be in the last year of life. DHFT has worked
collaboratively with partners across Derbyshire to develop a county-wide ‘toolkit’, an on-line
repository of information for professionals and patients. We have undertaken a benchmark of
end of life care across all adult wards in the Trust which allows us to plan on going education
for our staff. We have continued to participate in the National Programme ‘Transforming End
of Life Care in Acute Hospitals’. Embedding the five key enablers described by this
programme (discussed below) remains a key focus for the work plan of the End of Life team
within the Department of Specialist Palliative Medicine.
Advance Care Planning and Individualised End of Life Care Plans
‘One Chance to Get it Right’ mandates that those believed to be in the last year of their life
be cared for according to their individual priorities. Advance Care Plans offer patients an
opportunity to record wishes and preferences for End of Life Care. The Gold Record is a
locally designed, patient-held booklet which is given out by a range of community staff
working with patients at the end of life. In 2014-15 it has also been used in the hospital by
specialist Palliative Care teams.
38
When a patient in hospital is recognised to be in the last days of life, staff are encouraged to
communicate openly and frequently with the patient and their family about their priorities, and
plan bespoke care accordingly. Care plans are documented in Medical and nursing notes.
Electronic Palliative Care Co-ordination Systems (EPaCCS)
This is a system enabling key information to be communicated between health care
professionals and improve co-ordination of care so that patients’ wishes can be achieved
wherever possible. The Trust continues to work with Southern Derbyshire CCG to introduce
a common system that can be implemented across all providers involved in the care of
patients at the end of life.
Amber Care Bundle (ACB)
The AMBER Care Bundle encourages clinical teams to identify critically ill hospital patients
whose recovery is uncertain and who are at risk of dying in the next one to two months. This
leads to better involvement of patients and their families in discussions about treatment and
future care. The success the Trust has had with the implementation of this programme to
date has led to the Trust joining the National Design Team as a ‘faculty hospital’. All of the
Medical wards, Cancer wards, London Road Hospital and the Medical Assessment Unit are
now using this approach. As a baseline for 2014/15 55% of patients supported by the tool
should have a documented discussion about their clinical uncertainty that they may die or
recover, this is currently recorded for 84% of patients. Work continues to implement the
AMBER Care Bundle across all other wards in 2015/16.
Working with NHS IQ, we have developed a data collection tool to be used to record an audit
of the use of the AMBER Care Bundle in acute hospitals. This tool has been offered to acute
Trusts across the national network. Robert Smith has been seconded one day a week as a
clinical advisor within the National Design Team, which further strengthens both the
reputation of DHFT and our relationship with teams at national level.
Rapid Discharge Home to Die
Most patients say they would prefer to die at home, yet many die in hospitals. During 2014
work has been undertaken to develop a Rapid Discharge Home to Die Pathway to enable
those patients who may be in the last hours of their life and who express a wish to return
home to die to do so. This has involved close working with a number of key stakeholders
including Primary Care, Ambulance Services, Pharmacy and the Coroner to develop a safe
and robust process to support a patient to die at home if this is their choice. It is anticipated
that this service will commence 1st April 2015.
Further Trust initiatives in End of Life Care
The Bereavement Survey (Voices)
The National End of Life Care Strategy (DoH, 2008) set out a commitment to promote high
quality care for all adults at the End of Life stating that outcomes of End of Life care would be
monitored through surveys of bereaved relatives.
The National Bereavement Survey (VOICES) commissioned by the Department of Health
and administered by the Office for National Statistics (ONS, 2011) used a questionnaire
which was completed by bereaved relatives as a method of evaluating these experiences.
This questionnaire was adapted to provide a mechanism for assessing the quality of care
provided to people at the End of Life within DHFT.
To capture this valuable data this survey is offered to all bereaved relatives, with the
exclusion of where the death has happened in the Emergency Department, those referred to
the Coroner and Paediatric deaths.
39
This project is managed by the Patient Experience Team and a system is in place to contact
bereaved relatives and carers who express any concerns around the care of their loved one.
Carers Diary
The Trust has introduced a Carers Diary for loved ones of patients in the last in the last days
of life. Relatives and carers are encouraged to write down any concerns, comments and
questions regarding processes at the end of life. This information is read by staff and acted
upon as necessary.
The Carers Diary is used across all inpatient areas within the Trust and has recently
extended to Community Services for the care of patients at home at the End of Life. This
initiative was recognised as best practice by the Royal College of Nursing in 2014.
Carers Comfort Packs
A Carers Comfort Pack has been developed to support relatives/carers whose loved one is
in the last days/hours of life. The pack contains information and complimentary vouchers for
facilities i.e. car parking and meal vouchers as well as things to expect as the patient
approaches the end of life and where to seek support and advice. This pack will be given to
those important to the patient at the end of life. These are currently being prepared and are
expected to be launched Trust wide in April 2015.
Enhanced Nursing Home Beds for Palliative Care
The Enhanced Beds initiative was originally a project to support patients approaching the end
of life who face a crisis or deterioration at home and would prefer not to be admitted to the
acute hospital. It offers a short term stay in a dedicated Nursing Home bed as an alternative
to this admission. During the stay the patient and those important to them are offered
symptom control and support to understand the cause of the crisis. Opportunity is given to
plan future care, which may include discharge back to their usual place of residence with an
increased care package, or may provide care in the last days of life within the Nursing Home.
The success of this initial project has led to the project being commissioned as a recurrent
service within Southern Derbyshire. We now look to how this service can continue to develop
in the future.
End of Life Care Curriculum
Underpinning excellence in any care, but particularly at the end of life, is access to training
and education. ‘One Chance to get it Right’ set out standards and guidance and a call to all
agencies to ensure staff have the skills and knowledge to provide care in the last days of life.
Working as part of the Derbyshire Alliance and in close collaboration with the East Midlands
Regional Network we aim to implement an End of Life Care Curriculum later this year.
Underpinned by competency based learning, this curriculum will ensure that staff in all
settings have the skills and confidence to provide care for these patients.
Transformation in Palliative Medicine
This Transformation work is being undertaken with all partners across health and Social Care
and the Commissioners. Palliative Medicine are reviewing their service model and provision
to ensure they continue to provide an excellent service to those patients who require
specialist Palliative Care across Southern Derbyshire. This includes understanding their role
in providing care for those patients with non-malignant, chronic disease and patients with
Dementia or frailty as they reach older age. As well as delivering specialist support, they are
enhancing their role in education to ensure other teams are empowered to deliver high
quality Palliative Care. They are working collaboratively with other specialists to develop
services for these groups to ensure that all patients can access the right level of care in all
settings.
40
DERBY ARTS PROGRAM AIR (Arts In Rehabilitation)
This has been an exciting year for the arts program in Derby, with this year’s work being split
into four categories
Music Performances
Two seasons of weekly live music performances including nationally acclaimed baroque
ensemble. We are currently in talks with Birmingham Conservatoire and Royal Northern
College of Music to create opportunities for students to perform at DHFT as part of their arts
in health training courses.
Visual Arts Exhibitions
Two curated visual arts exhibitions of local artists work over 14 locations has taken place
(MORPHOLOGY and RESILIENCE). The next exhibition ‘Daft as a brush’ is due to launch in
April 2016. LRCH will become part of the exhibition season from 2016.
Poetry booklets
Volume 9 of Poetry in the Waiting Room, was published by Hidden Histories Collection. This
is a project collaboration with Landau Forte College exploring and sharing the Hidden
Histories archive.
Pride In Place
A Century of Care
A centenary celebration at LRCH intended to boost staff morale and engagement. A timeline
was set up and staff were invited to bring along photos, stories and memories to populate the
timeline which has been documented and photographed. A series of participative arts
workshops also took place alongside the timeline to encourage staff to visit it and to donate
items. A permanent exhibition and commemorative calendar will be launched on 25
September 2015.
Engage
Pain Clinic
The visual artist worked in partnership with patients and staff in the pain clinic to devise a 10week creative programme to enhance the current Pain Management Programme. She is
currently working on her second programme and we are developing a longer-term
programme to create an evidence base for the positive effects of creative activities on pain
management. We are also working with the charity ‘away with pain’ to look at rolling this
programme out to other pain clinics in the UK.
The Imaginarium on the Renal Ward
Drama practitioner Jen Sumner developed the ‘Imaginarium’ to take onto the Renal unit. The
Imaginarium is a place that patients and their visitors can physically visit – a room which is
transformed into a magical room full of shadow puppetry, audio and visual cues to elicit
memories and stories which are then transcribed and shared. Jen is now developing a
mobile Imaginarium to take bedside on the wards.
Banishers of Boredom (BOB)
Theatre Practitioner Maison Foo developed the BOBs as characters to visit patients and
visitors to play a specially designed board game aimed at combatting feelings of boredom
and associated negative feelings. They are now working on developing the BOBs into a
training programme for volunteers.
Rhythm and Moves at LRCH
Dance artist Andrea Haley developed a Rhythm and Moves programme for older adults,
specializing in dementia care. Andrea collected memories of dance and music to develop
musical memory boxes to take onto the wards, each one representing a different decade to
evoke memories of dance and music. (1940s –1970s). She is now developing a training
41
programme for LRCH staff to deliver the Rhythm and Moves sessions due to start summer
2015.
National Recognition
The Arts Council England recognised the AIR programme as having national significance
and created a film and case study to share the programme as a flagship project. We have
subsequently been invited to apply for the national lottery awards on recommendation from
Arts Council England.
2.4 PRIORITIES FOR IMPROVEMENT DURING 2015/16
The Trust continues to ensure that the Quality Strategy is embedded throughout the
organisation and that these objectives are achieved through the overarching delivery plan,
with specific objectives and targets being reflected in performance management
arrangements for each Division within the Trust.
The delivery plan will be subject to regular review and scrutiny by the Quality Committee and
Trust Board. Monitoring and measurement of progress against the delivery plan will be
undertaken with the appropriate Trust Committees and Groups. These will report into the
Quality Review Committee, Quality Committee, and the Trust Board. The Statement of
Assurance from the Board in respect of the Quality Account can be found in Annex 2.
The priorities for 2015/16 have taken into account feedback and engagement with staff and
patients through the Quality Strategy development consultation process, which included input
from:
•
•
•
•
•
Service Line Managament (SLM) Quality Strategy Event
Governor's Workshop
Gap Analysis of Francis & Beyond
Quality Committee Workshop
Staff Listening & Engagement Events
The one year delivery plan identifies the key priorities for 2015/16, acknowledging that a five
year plan needs to identify and reflect the required changes in focus, based on internal and
external influencing factors at any one time.
CQC Domain
Making Us Safer
Strategic Aim
We will protect our patients from
avoidable harm.
Priority
Delivery of Safety Improvement Plan – year 1 including sign up to Safety and Patient Safety
10 campaign.
Year 1 priorities: AKI, Sepsis, Medicines
Safety, Escalation of deteriorating patient.
Named consultant / Nurse – name above the
bed.
Use of whiteboards: SHOP principals, Daily
Board Rounds.
Seven Day Service – evidence of impact on
patient safety / delivery of 10 clinical
standards.
Never Events – learning from and act on
themes – identify any contributing Human
Factors.
42
Making Us More Caring
Making Us More Effective
We will ensure that all our staff
adhere to the values and
behaviours of "Making your
Moment Matter".
Roll out of campaign – part of all teaching, all
inductions, and appraisal.
Continuous learning from when
things go wrong.
Every member of staff involved in a complaint
will get a copy of the final response letter –
process to be agreed and embedded.
Continuous learning from when
things go wrong.
Establish Patient Experience Committee to
triangulate emergent themes from incidents /
complaints and ensure they are addressed.
Delivery of Person Centred Care Project.
We will see the person not the
patient in everything we do.
We will ensure we use evidence
based practice to improve
outcomes for our patients.
'My name is….' Campaign implemented.
Develop a robust system for monitoring audit
activity and ensure action plans are developed
and implemented.
Fit for purpose audit database.
Local governance
strengthened.
Making
Us
Responsive
Making Us Well Led
More
arrangements
to
be
We will empower staff to take
action, then and there, when
quality is compromised.
All staff will be able to describe
their role in providing a quality
service.
Support staff to feel enabled to speak up when
things go wrong through appropriate
leadership development and support.
Individual staff sign up to agreed quality
priorities for themselves and their area of
work.
Embed
robust
governance structure.
Ensure staff at all levels understand and can
describe the structure and its purpose.
clinical
Decision-making, assurance, and learning are
aligned to the structure.
2.5 REVIEW OF SERVICES
The Trust provides a wide range of secondary care NHS services and since April 2011 has
continued to provide the Adult Community Services across the City Centre.
During 2014/15 Derby Hospitals NHS Foundation Trust provided and/or sub-contracted 99
relevant health services. The Derby Hospitals NHS Foundation Trust has reviewed all the
data available to them on the quality of care in 99 of these relevant health services.
The income generated by the relevant health services reviewed in 2014/15 represents 100%
per cent of the total income generated from the provision of relevant health services by the
Derby Hospitals NHS Foundation Trust for 2014/15.
2.6 PARTICIPATION IN NATIONAL CLINICAL AUDITS AND NATIONAL CONFIDENTIAL
ENQUIRIES
Clinical audit is recognised as an effective mechanism for improving the quality of care
patients’ receive and is the main way of assessing compliance of clinical care against
evidence-based standards. The clinical audit framework provides a robust mechanism for
assuring the Trust that action is taken promptly when areas of potential risk, concern, or poor
practice are identified. Equally examples of good practice are disseminated throughout the
Trust.
The audit programme reflects the needs of the specialities in the Business Units, balancing
national and local interests, and the need to address specific local risks, strategic interests
43
and concerns. However it has been identified that further work is required to ensure there is
a robust system for monitoring audit activity, at all levels across the Trust, ensuring
appropriate action plans are developed, implemented and reviewed, and re-audits are
undertaken within an appropriate timescale. Work to address this is currently being scoped.
Audit is integral to providing evidence that the Trust is meeting national targets and
demonstrating compliance with the recommendations and guidance from the National
Confidential Enquiries of Patient Outcome and Death (NCEPOD), the National Institute for
Health and Clinical Excellence (NICE) and the Department of Health.
The Trust Audit Group has an important role in assisting Divisions in the prioritisation of
audits and monitoring progress against the Divisional Annual Audit Programmes and Action
Plans when improvements are indicated and checking that re-audits are carried out. The
Trust Audit Strategy and Audit Policy are available for staff on the Trust Intranet.
During 2014/15 32 national clinical audits and four national confidential enquiries covered
relevant health services that Derby Hospitals NHS Foundation Trust provides. The Audits
and Enquiries for which data collection was completed during 2014/15 are shown in the
tables below. This data includes the number of cases submitted to each audit or enquiry as a
percentage of the number of cases required by the terms of that Audit or Enquiry.
During 2014/15 Derby Hospitals NHS Foundation Trust participated in 100% of national
clinical audits and 100% of national confidential enquiries of the national clinical audits and
national confidential enquiries which it was eligible to participate in.
The national clinical audits and national confidential enquiries that Derby Hospitals NHS
Foundation Trust participated in during 2014/15 are as follows:
NATIONAL CONFIDENTIAL ENQUIRIES INTO PATIENT OUTCOME AND DEATH
(NCEPOD) REPORTS
The aim of NCEPOD audits is to maintain and improve standards of patient care in all
specialties by reviewing the care of patients in confidential surveys and making the results
and recommendations available to the Trust and relevant clinicians and departments. The
Trust has an NCEPOD Ambassador who is responsible for the formalised process of review
and management of National Confidential Enquiry reports and recommendations. The
process includes identification of a designated Clinical Lead and a robust reporting structure
via reports to the Mortality Review Group, and the Clinical Audit and Effectiveness
Committee.
The national clinical audits and national confidential enquiries that the Derby Hospitals NHS
Foundation Trust was eligible to participate in during 2014/2015 are as follows:
Title
Participated
During
Completed
2014-15
Publication
Date
Gastro-Intestinal Haemorrhage
Completed
June/July 2015
Sepsis
Completed
Autumn 2015
Rheumatoid & Early Inflammatory
Arthritis
In Progress
Acute Pancreatitis
In Progress
44
The following NCEPOD Reports were received in 2014/15 and reviewed by the appropriate
sub-committee of the Board.
NCEPOD On the Right Trach? July 2014
Nationally 2,546 patients underwent a tracheostomy during the study period.
Key Findings
• 20/217 (9.2%) of hospitals did not have immediate access to a difficult airway trolley in
the critical care unit
• 47/209 (22.5%) of hospitals did not have bronchoscopy/fibre optic laryngoscopy
equipment immediately available within the critical care unit
• 181/212 (85.4% of hospitals delivered training programmes in accordance with clinical
consensus
• 152/175 (86.9%) of hospitals included the re-establishment of a blocked airway in training
• 91/175 (52.0% of hospitals included practice on difficult tube changes in training
• 138/216 (63.9%) hospitals had a protocol to help patients communicate
• 116/215 (54%) of hospitals had a Resuscitation Policy covering patients with a
tracheostomy but whose upper airway may still be patent
• 97/214 (45.3%) had a Resuscitation Policy covering patients who are totally reliant on
breathing through the stoma in the neck
• 77/212 (36.3%) had a protocol for the management of neck breathers in an emergency
• 286/312 (91.7%) Critical Care Units had capnography available, but was used
continuously in only 218/305 (71.5%)
• 135/212 (63.7%) had a stated level of competency for staff
• Only 135/212 (21.2% undertook regular audit of tracheostomy care
• 203/295 (68.8%) had wards where less than 2 patients per month had surgical or
percutaneous tracheostomy.
Principal Recommendations
• Tracheostomy insertion should be recorded and coded as an operative procedure. Data
collection in all locations should be robust to facilitate care planning and national review
and local audit
• The diameter and length of the tube should be appropriate for the size and anatomy of
the patient. An adequate stock of tubes should be available
• Clinicians should be aware of the type of tubes available and recognise that adjustable
flanged tubes are available with inner tubes. Professionals should work with
manufacturers to optimise design and tube size
• All Trusts should have a protocol and mandatory training for tracheostomy care including
humidification, cuff pressure monitoring and cleaning of the inner cannula and
resuscitation
• Tracheostomy clinical practice should be part of local quality improvement initiatives
• Tube data should be recorded more clearly and available for bedside review and
‘passport’ development for each patient
• To facilitate de-cannulation and discharge planning multidisciplinary care needs should
be established as part of the routine pathway for all patients
• Patients should have at least daily review with key other members of the team involved at
an early stage
• Teams should be flexible to meet individual patient needs and provide continuity of care
• Key team members should include Physiotherapy, Speech and Language, Outreach
nurses and Dieticians. Hospitals should provide sufficient staff to ensure this happens in
a routine and timely way
• Staff at the bedside should be competent in recognising and managing common airway
complications including tube obstruction or displacements
45
•
Unplanned and night time critical care discharge is not recommended particularly for
patients recently weaned from respiratory support.
Trust Self-Assessment
Self Assessments were carried out in the Intensive Care Unit (ICU), Step Down Unit (SDU),
the Ear Nose and Throat Service and the Respiratory Service.
Adult Intensive Care was compliant in 16 of the 20 relevant recommendations, not compliant
in one and one was not applicable.
The Step Down Unit was compliant with five of the relevant 20 recommendations and not
compliant with one. There were 14 recommendations which were not applicable to this area.
The Ear Nose and Throat Service was compliant in 10 out of the 25 relevant
recommendations, not compliant with three, one was not applicable and they were partially
compliant in twelve of them.
The Respiratory Service was compliant in 15 recommendations and partially compliant in
one, nine recommendations were not applicable to the Service.
Actions
• ICU have an on-going programme to replace ventilators with in line capnography
• Capnography is not available on the areas outside ITU to confirm tube placement
• ICU have an on-going programme to replace ventilators with in line capnography
• Discussions will be held with clinical skills trainers about how best to deliver training for
the core competencies on wards that receive tracheostomy patients. Currently
Anaesthetic and Outreach support is always available
• Review of the documentation for the process of changing tracheostomy tubes
• Review ICU Speech and Language Service assessment participation for patients who
have dysphagia
• Review of skill mix and night staffing levels in relation to the wards that care for
Tracheostomy patients
• Review of discharge documentation
• Consideration of the most appropriate place for Neurology patients with tracheostomies if
Kings Lodge moves to LRCH
• Updated competency documentation to be distributed.
NCEPOD Lower Limb Amputation: Working Together November 2014
Organisation of Care
Key Findings
• 102/123 (82.9%) of hospitals had written protocols or care pathways for the transfer of
patients between hospitals
• 116/136 (85.3%) submitted date to the National Vascular Directory (NVD) and 68/116
(58%) submitted data to the British Society for Interventional Radiology
• 82/140 had an MDT for lower limb amputation patients
• Pre-operative Review by Rehabilitation, Physiotherapy, Diabetes Nurse Specialist, and
Vascular Nurse Specialist or Amputation Co-ordinator was poor 60/134 (44.8%) had a
Policy or Protocol for this care
Principle Recommendations
• A best practice clinical care pathway, supporting the Vascular Society’s Quality
Improvement Framework for Major Amputation Surgery should be developed and
include protocols for transfer, a dedicated MDT for care planning and access to other
specialists pre and post operatively
46
•
•
•
•
•
•
•
Promotion of vascular lists for surgery
All patients should be reviewed by the Diabetes team
Pre-operative review should not delay the operation
Emergency patients with limb threatening ischaemia, including diabetic foot problems,
should be assessed by a relevant Consultant within 12 hours of decision to admit or
14 hours since arrival, If this is not a Vascular
Surgeon should review the patient within 24hrs
Planning for rehabilitation and discharge should start as soon as amputation identified
Amputations should be done on a planned operating list during normal hours and
within 48 hours or be the subject of a case review.
The Trust was compliant in 17 out of 20 recommendations and partially compliant in 3.
Actions
• Greater liaison with the admitting surgical team and the Diabetology Unit regarding pre
and post operative reviews
• All patients currently have a MUST assessment on admission to hospital. There will be
closer liaison with the Nutrition Team to ensure that patients’ nutritional needs are met
throughout their stay
• All patients have a routine Pain Team review currently and the use of intra-neural
catheters and other pain relieving techniques has been introduced and will be fully
operational at the end of 2015.
MBBRACE: Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries
across the UK.
'MBRRACE-UK' is the collaboration appointed by the Healthcare Quality Improvement
Partnership (HQIP) to continue the national programme of work investigating maternal
deaths, stillbirths and infant deaths, including the Confidential Enquiry into Maternal Deaths
(CEMD). The programme of work is now called the Maternal, Newborn and Infant Clinical
Outcome Review Programme (MNI-CORP).
The aim of the MBRRACE-UK programme is to provide robust information to support the
delivery of safe, equitable, high quality, patient-centred maternal, newborn and infant health
services. The first Triennial report for Maternal deaths was published in December 2014.
Local action: the report is currently being presented and discussed at all key forums.
UKEPSS: (NEW 2014) The UK Early Pregnancy Surveillance Service (UKEPSS) is a
network designed to study uncommon, but serious conditions in early pregnancy.
UKEPSS is a joint initiative of the Association of Early Pregnancy Units (UK), the Early
Pregnancy Clinical Studies Group, the Miscarriage Association, and the Ectopic Pregnancy
Trust, and has been endorsed by the Royal College of Obstetricians and Gynaecologists.
Uncommon conditions in early pregnancy contribute to the morbidity and mortality of mothers
in the UK. Maternal mortality reports recommend improvements in the care of mothers with
problems in early pregnancy such as infection, miscarriage and unusual presentations of
ectopic pregnancy.
Local action: The first UKEPSS study for surveillance is Caesarean Scar Pregnancy, and we
registered with the study in October 2014.
47
UKOSS: To develop a UK-wide Obstetric Surveillance System to describe the epidemiology
of a variety of uncommon disorders of pregnancy.
2014 report available
Current subjects:
• Adrenal Tumours in Pregnancy
• Amniotic Fluid Embolism
• Anaphylaxis in Pregnancy
• Aspiration in Pregnancy
• Epidural Haematoma or Abscess Study
• Gastric Bypass Surgery in Pregnancy
• Pregnancy outcomes in women with artificial heart valves
• Primary ITP (Immune Thrombocytopenia) in Pregnancy
• Vasa Praevia
NATIONAL AUDITS
Participation in National Audits 2014/15
The national clinical audits and national confidential enquiries that DHFT participated in,
2014/15, are as follows.
The national clinical audits and national confidential enquiries that DHFT 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. The chart also identifies
audits for which data collection is continuous.
Title
Acronym
National emergency laparotomy
audit
Heavy Menstrual Bleeding
Children
Childhood Epilepsy
RCPH National Childhood
Epilepsy Audit
Diabetes
RCPH National Paediatric
Diabetes Audit
Maternal, New-born and Infant
Clinical Outcome Review
Programme
Completed
Cases
Submitted
% of
required/
eligible
cases
submitted
NELA
145
90%
RCOG
Starts April
2016
156
100%
145
100%
On-going
48
100%
On-going
1048
100%
43
100%
253
100%
-
-
NAD
National Audit of Dementia
Rheumatoid & Early
Inflammatory Arthritis
Peri-Natal / Neo Natal
Coronary angioplasty
Participated
in
2014/15
PCI
NPDA
MBRRACEUK
Not
commenced
Commenced
Jan 2015
Ends May
2015
BAD-BSPD Paediatric Eczema
National Clinical Audit 2015
Acute Care
Commenced
Dec 2014
Ends May
2015
Adult Community Acquired
Pneumonia
British Thoracic Society
48
Cardiac Arrest
National Cardiac Arrest Audit
Adult Critical Care
ICNARC CMPD
NCAA
93
100%
ICNARC
968
100%
Potential Donor Audit
NHS Blood & Transplant Audit
Response
requested by
03/03/2015
Charmine Buss
On-going
Long-term Conditions
Diabetes
National Diabetes Audit
Commenced
July 2014
Ends July
2015
Commenced
30 April 2015
ANDA
Parkinson's Disease
National Parkinson's Audit
Title
National Chronic Obstructive
Pulmonary Disease Audit
Programme
Renal Disease
Renal Replacement Therapy
Renal Registry
Renal Transplantation
NHSBT UK Transplant Registry
Renal Colic
College of Emergency Medicine
Cancer
Lung Cancer
National Lung Cancer Audit
Bowel Cancer
National Bowel Cancer Audit
Programme
Head & Neck Cancer
DAHNO
Oesopho-gastric Cancer
National OG Cancer Audit
Prostate Cancer
Trauma
Hip Fracture
National Hip Fracture Database
Severe Trauma
Trauma Audit & Research Network
Sentinel Stroke National Audit
Programme
No figures see
link on national
tab of Quality
accounts
Adult Asthma
British Thoracic Society
Elective Procedures
Elective Surgery
National PROMs Programme
Liver Transplantation
NHSBT UK Transplant Registry
Peripheral Vascular Surgery
National Vascular Database
Cardiovascular Disease
Acute Myocardial Infarction &
Other ACS
PROMs
1610
71%
276
100%
Cases
Submitted
% of
required/
eligible
cases
submitted
154
54
74
100%
NLCA
350
100%
NBOCAP
300+
100%
DHANO
100+
100%
NAOGC
180
100%
310
100%
NHFD
538
94%
TARN
42
39
NHSBT
On-going
VSGBI
On-going
MINAP
Acronym
Participated
in
2013/14
Completed
COPD
On-going
On-going
SSNAP
On-going
49
60
National Audit Reports 2014-15
The reports of seven national clinical audits were reviewed by the provider in 2014/2015 and
the DHFT intends to take the following actions to improve the quality of healthcare provided.
1. National Cardiac Arrest Audit (NCAA)
The National Cardiac Arrest Audit (NCAA) is the National Clinical Audit for in-hospital cardiac
arrest. The purpose of NCAA is to promote local performance management through the
provision of timely, validated comparative data to participating hospitals. NCAA is a joint
initiative between the Resuscitation Council (UK) and Intensive Care National Audit &
Research Centre (ICNARC).
NCAA monitors and reports on the incidence of and outcome from, in-hospital cardiac arrests
and aims to identify and foster improvements, where necessary, in the prevention, care
delivery and outcome from cardiac arrest. This Trust collects and enters data according to
the NCAA data collection scope and comprehensive dataset specification. The NCAA
dataset was developed to ensure that all hospitals collect the same standardised data, so
that accurate comparisons can be made.
The NCAA Report provides an overview of the completeness of the data that the DHFT has
reported. This includes analysis of activity and comparisons between this Trust and national
data.
Trust Findings
The Trust entered into the NCAA and commenced submitting data from April 2012. The most
recent report which has been received is the third quarter report for the period April December 2014. The total number of cardiac arrest for this period is 142 and the number of
individuals is 135.
The following graph represents the reported number of cardiac arrests per 1,000 hospital
admissions for adult, acute hospitals in NCAA (for the period that this Report covers).
Comparison Reporting from NCAA Audit for In-hospital Cardiac Arrest
Rate of in-hospital cardiac arrests
50
In the graph above, data for DHFT is presented in red, and data for other hospitals are
presented in blue.
The interpretation of the data is subject to:
• the inclusion of the most recent nine months of validated data for all adult acute hospitals
participating in NCAA
• the inclusion of hospitals with at least five in-hospital cardiac arrests attended by the
team and at last three months data in the given financial year
• an assumption that all hospitals are capturing the numerator and denominator data
accurately; and
• variation across hospitals of type of admissions included in denominator data.
Results
Rate of cardiac arrests attended by the team per 1000 hospital admissions – trended
51
Year
2012/13
2013/14
2014/15
(up to the 3rd Quarter report)
Total Number of Cardiac
Arrests
202
185
142
52
Patient Survival to Discharge
15.7%
22.7%
19.3%
Since the DHFT had been included in the National Cardiac Arrest Audit there has been an
overall reduction cardiac arrests year on year and an increase in patient survival to
discharge. The two main areas of work that has been likely to have reduced the total
number are surrounding patient recognition and escalation of care and the clinical use of the
Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Policy.
Actions
• To continue with the quality of data collection and maintain the speed of data
collection/entry.
• Compare outcomes with the other NCAA participating hospitals and examine what other
factors (e.g. age, etc.) might be causing any variations seen
• Examine survival rates following cardiac arrests and if they fall under the NCAA scope,
review any unexpected patterns in patient outcome
• To continue to identify and review specific resuscitation team calls for unexpected
patterns in patient outcome, escalation or issues surrounding resuscitation status. Action
specific audits / case reviews to further examine of identified issues
• To continue to circulate the NCAA reports to key individuals within the Trust, Executive
Medical Director, Groups and Committees.
2. National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme
The new national COPD audit programme for England and Wales brings together primary
care, secondary care, pulmonary rehabilitation and patient experience. It comprises a
number of ambitious audit workstreams, combined with an extensive partnership approach
and comprehensive multidisciplinary, collaborative working.
Organisational Audit: COPD: Who Cares?
Local Results
The audit results were scored across 6 domains. The Trust scored 39 out of 51 points and
was placed in the upper quartile of participating units.
Red flags were issued if none of the standards were reached within a domain, or if an
essential element of COPD care was not present within the organisation (eg access to noninvasive ventilation). The Trust was not issued with any red flags.
53
Green flags were issued if all elements of a domain were met. The Trust achieved green
flags in domain 3: Non Invasive Ventilation (NIV) and domain 4: managing respiratory failure
and oxygen.
The Trust failed to achieve green flags in other domains due to the following lack of services:
Domain 1: Senior review on admissions ward occurs once daily on weekdays and weekends
(full score required twice daily review). Senior review is available more than once daily on
admissions ward according to requirement.
Domain 2: There is no on call respiratory Specialist Registrar (SpR) service. There are not
sufficient numbers of registrars to provide this. The audit results show numbers of SpRs
available for COPD admission is below the national average (2.9 verses 3.8 whole time
equivalent (wte) per 1000 COPD admissions).
Domain 5: At the time of the audit the pulmonary rehabilitation service was in the process of
reconfiguration and no service existed for referral or fast-track referral within 4 week. The
services are now available.
Domain 6: No dedicated inpatient smoking cessation service was available for COPD
patients. Currently there is a pilot project on site but it is unclear if there is long term funding
available. A fully funded and resourced smoking cessation service is required for the care of
COPD patients and should be a priority for the Trust to meet the key national
recommendations.
National COPD Clinical Audit: COPD: Who Cares Matters
Local Results
141 out of 283 possible cases were audited. The results compared favourably to national
results especially in specialist and timely provision of care. Recording of key clinical
information was good. A higher percentage of patients received key elements of care
including oxygen prescription, smoking cessation advice and assessment for pulmonary
rehabilitation. Integrated and specialist discharge was above the national average.
The Trust fell below the national average in some aspects of managing respiratory failure.
There was a significantly longer time to Non Invasive Ventilation (NIV) and fewer patients
received NIV within 3 hours of admission. This has prompted a further prospective audit of
NIV care which is currently underway and will report into the Respiratory Quality and
Performance meeting.
Actions
• Review of the time to NIV and the percentage of patients receiving this within 3 hours of
admission.
• Monitor the Hospital Stop Smoking Service which commenced in January 2015 in the
respiratory and cardiovascular wards/departments and pre-operative assessment.
3. National Lung Cancer Audit
The aim of this audit was to summarise the key findings for patients diagnosed with lung
cancer who were first seen in secondary care in 2013.
Results
Overall standards of care had been maintained and slightly improved compared to the last
audit However results also showed that there was marked variation between Trusts and
Networks which was not explained by the type of cases presenting.
There were small improvements in:
54
•
•
•
The number of patients having their cancer sub-typed
The proportion of patients with small cell lung cancer having chemotherapy
The proportion of patients who may be seen by a Lung Cancer Nurse specialist.
Recommendations and Actions include:
• Details of co-morbidity should be recorded for at least 85% of patients who do not receive
the first choice treatment as a result: DHFT 75%
• Over 95% of patients should be discussed at an MDT: DHFT 81%
• The Histological Confirmation rate should be at least 75%: DHFT 71%
• Over 80% have a Lung Cancer Nurse Specialist present at diagnosis
• Anti cancer treatment rated below 60% should be reviewed. DHFT 57% Chemotherapy
rates for patients with PS-0-1 with advanced NSCLC 111B/1V DHFT 47% - Further audit
and monitoring is planned.
Actions
• Improvement of data accuracy and monitoring in the next planned audit
• Chemotherapy rates for patients with PS-0-1 with advanced NSCLC 111B/1V to be
reviewed.
• Review of the case mix ratio during the audit period as this may reflect under resourcing
of Oncology during this time.
4. Sentinal Stroke National Audit Programme (SSNAP)
The aim of SSNAP is to improve the quality of stroke care by auditing stroke services in each
Trust against evidence based standards, and local and national benchmarks. It is run by the
Clinical Effectiveness and Evaluation Unit of the Royal College of Physicians (RCP). There
are two separate audit components to SSNAP:
•
SSNAP Organisation Audit:
This looks at the setup of the stroke services in each Trust on a biennial basis. The
stroke services are assessed against six domains (acute care, specialist roles,
interdisciplinary services, neurovascular/TIA clinic, quality improvement/training/
research, and planning/access to specialist support). Each of the domains are rated ‘A’
(best) to ‘E’ (worst), in addition to an overall band. DHFT has been given an overall band
of ‘A’ with a total organisational score of 93.1% (national median 73.5%).
•
SSNAP Clinical Audit:
This is a continuous prospective audit that collects data on every stroke patient admitted
to the department, in order to measure the quality of acute care, rehabilitation and care in
the community. The stroke services are assessed against 10 domains and 44 ‘key
indicators’ of stroke care. The most recent published report covered the July-September
period in 2014 which collected data on 19,232 patients in 202 hospitals across the
country. At a national level there is evidence of continued improvements in stroke care.
DHFT has been given on overall band of ‘C’ which compares favourably with other
hospitals in the region. Areas of strength are timely assessments and input of specialists
such as stroke nurses, consultants, physiotherapists and occupational therapists, as well
as team working and preparation for discharge. Access to Speech and Language therapy
remains a problem, both locally and at a national level. The thrombolysis (clot-busting
drug) rates are above the national average but there is potential for improving door-toneedle times.
A Stroke Improvement event took place in December 2014 to review the patient
pathways throughout the service.
55
•
•
•
•
•
•
•
•
•
Actions
Continue overall improvements in stroke care and review service performance and
improvement by participation in the prospective clinical component of SSNAP
Review of administration services currently undertaken to release patient contact time
Planning for family/patient/friend time to include education and training and a family
meeting prior to discharge
All patients to receive a joint Health and Social Care Plan including contact details
and information about follow up services and support
Daytime open visiting for one or two identified family/friends to benefit mood,
motivation, feeding and rehabilitation
Stroke specific Discharge Co-ordinator trial commenced in February 2015
Increased specialised seating provision for the wards and community
Increase in the number of Nutrition Assistants
Review of the Stroke Pathway documentation.
5. College of Emergency Medicine (CEM) Asthma
This was an audit of the treatment of children over five years of age and under 16 years of
age presenting to Emergency Departments (ED) with moderate or severe asthma against the
CEM standards which include:
•
•
•
Oxygen prescribed on arrival to maintain oxygen saturations above 92%
Vital signs taken as CEM standards
Beta-agonist given for moderate episode or combined with Ipratropium for severe
episodes within 10 minutes of arrival
DHFT Children’s ED performed favourably in all of the measured outcomes with respect to
the recording of vital signs compared to other EDs, placing this Trust between the median
and upper quartiles for each.
This is an excellent outcome and can be explained by the use of the POPS score (Paediatric
Observation Priority Score) and the requirement to undertake 2 sets of observations in each
child who attends the ED.
The standard to be achieved in each measured outcome was 100%. With regards to
measured outcomes including the time of receiving definitive treatment such as inhalers or
nebulisers and steroids, the Trust did not perform as favourably.
Areas identified for improvement include:
• Beta-agonists to be given within ten minutes of arrival
• Intravenous Hydrocortisone or Prednisolone within 1 hour of arrival
Actions
• Education sessions for nursing staff as part of rolling education programme
• Move towards a discussion by triage nurse to a doctor or nurse practitioner to commence
appropriate treatment, particularly if the patient is known to have asthma. Treatment plan
and education package to be developed
• Laminated copies of treatment standards in triage and other clinical areas
• Re-audit in 1 year
• Patients presenting after 8 hours ingestion with a toxic (large or staggered) overdose who
received N-acetylcysteine within 1hour of arrival: all EDs should assess the reasons for
their scores, and take action where necessary - particularly those with a score equal to or
below the median
• Compliance with MHRA guidelines: EDs performing below the median should
investigate their processes, and take steps to improve their performance.
56
All audit leads should look at improving the detail and accuracy of data entered in patient
records. A structured proforma may support this.
.
6. Inflammatory Bowel Disease (IBD) Service Provision
This is the fourth IBD Service Provision Report and hospital-level findings on the quality of
IBD services throughout the United Kingdom. The report findings enable the quality of adult
IBD service provision at a national level to be compared with the national standards outlined
in Standards for the Healthcare of People who have Inflammatory Bowel Disease.
This report provides a comprehensive picture of current provision of IBD services across the
UK. This report can be used by policymakers, commissioners and hospital teams providing
IBD care to assess the quality of their IBD service and plan improvements.
Key Recommendations:
• Provision of specialist IBD nurse support remains a priority. Although some progress has
been made with meetings arranged to draw up a Business Case and funding
procurement, further appointments are needed to enable services to meet the standards
and to be able to offer patients access to a robust and reliable IBD Nurse service. An
interim plan has been to prioritise core areas such as review of seriously ill patients,
provision of Biologics, drug monitoring and manning of the IBD helpline until staff
numbers are increased to expand the service in line with the National IBD Guideline.
• The apparent decline in access for relapsing patients to be seen quickly (within 7 days) is
a concern and it is recommended that services implement local systems to monitor
waiting times for newly diagnosed and relapsing IBD patients. This will enable local
action planning to address any issues identified.
• Despite a strong desire from the IBD community, the slow uptake of IBD databases is
holding back innovation and flexibility in IBD care. Work needs to be done at a national
level to overcome the barriers to the uptake of the IBD Registry and similar databases.
Local champions will also be required to develop business cases for funding and
implementation.
Actions
• The submission of a business case for the provision of potentially two, and at least one
additional IBD Nurse Specialist
• The feasibility of the secondment of a suitably qualified nurse to assist with blood
monitoring to improve the service short term will be explored
• Discussions are in progress with the CCG to formalise future provision of the IBD service
and the expectations of Primary Care
• A patient satisfaction survey to identify key areas in which to focus our efforts to improve
the service is planned
• Plans are in progress for the National IBD Registry for use in the Trust. This will help the
Team meet future audit targets, and will assist with areas such as blood monitoring and
co-ordination of patients requiring colorectal cancer surveillance.
To comply with guidelines we need additional IBD nurses. Meetings have already been
arranged with management colleagues to draw up a business case and case of need to
procure funding for additional full time IBD nurse posts in the Trust. An interim plan has been
to prioritise core areas such as a review of acutely ill patients, provision of Biologics, drug
monitoring and manning of an IBD help line until adequate numbers of staff are available to
expand the service in line with the National IBD guidelines.
57
7. National Care of the Dying Audit for Hospitals, England
Background
DHFT has participated in the National Care of the Dying Audit (NCDAH) since it was first
undertaken in round 1 in 2006/2007. Round 2 followed in 2008/2009 and round 3 in
2011/2012.
The 2013/14 round for audit represents a departure from previous audits which have been
based on the goals of care within the Liverpool Care Pathway for the Dying Patient. This
audit involved a case note review of a sample of patients dying in hospital, regardless of
whether they were supported by a framework of care in the last hours or days of life.
Evidence was obtained from both the Liverpool Care Pathway document and the patient’s
case notes for the DHFT audit sample.
The audit questions were informed by the 44 recommendations of the independent review of
the Liverpool Care Pathway led by Julia Neuberger in 2013.
The audit comprised of the following three sections:
• Organisational audit - key organisational elements that underpin the delivery of care
• Clinical Audit - a consecutive, anonymised case note review of all the patients who died
(excluding sudden unexpected deaths) within participating sites within a timeframe
• An optional local survey of the views of bereaved relatives or friends – DHFT did not
participate in this survey as the VOICES questionnaire for bereaved relatives is used in
the Trust.
Organisational Audit Results
The organisational audit was undertaken by the Trust audit department and sought to gain an
understanding of the size, scope and environment in which care was provided as well as
relevant structures, processes and policies for care of dying patients and their relatives or
friends.
The full organisational results can be found in the final NCDAH Site report May 2014
http://www.rcplondon.ac.uk/resources/national-care-dying-audit-hospitals
DHFT participate in the Transforming End of Life Care in Acute Hospitals programme
supported by the NHS Institute for Innovation and Improvement; therefore this report also
details our performance against other organisations who also participate in the programme to
enable us to benchmark against national figures.
The programme focuses on the five End of Life key enablers shown below.
1
2
3
4
5
Advance Care Planning
Electronic Palliative Care Co-ordination System (EPaCCS)
AMBER Care Bundle
Rapid Discharge Home to Die Pathway
Framework for the last hours or days of life
58
Question
No.
2.e
2.f
National
n = 131 Trusts
Questions
In place
at Derby
Hospitals
Percentage (and number) of participating Trusts who use
the following End of Life Key Enablers
Advance Care Planning
% (n)
55%(72)
Yes
Electronic Palliative Care Co-ordination system (EPaCCS)
AMBER Care Bundle
Rapid Discharge Home to Die Pathway
Framework for the last hours or days of life.
21%(28)
No
19%(25)
Yes
59%(77)
No
99%(130)
Yes
Percentage (and number) of trusts who have a named
member of the Trust Board for care of the dying.
53%
Yes
The results for Derby Hospitals confirm that the Trust is in line with other participating Trusts
in implementing 5 key enablers. The AMBER Care Bundle has now been implemented within
the Trust and is being used across all medical wards.
Clinical Audit Results
The clinical element was based upon a set of case note review questions which were
devised to reflect the best care for the dying patient by consultation with members of the
multidisciplinary audit steering group and informed by the 44 recommendations of the
Independent Review of the Liverpool Care Pathway undertaken by Neuberger and
colleagues in 2013.
DHFT audit sample contained 38 patients who died within a time frame on a variety of wards
within the Trust during the data collection period 01-31 May 2014.
Main questions from each section of the case note review element of the audit were identified
and incorporated into relevant KPIs for that section/domain reflecting accepted national
standards
The DHFT results shown below from the case note review element of the audit are
subdivided into 10 domains representing specific areas of clinical care and are compared
against the national results.
Results
• Recognition of death by an MDT was reported nationally in 59% of cases. DHFT = 100%.
The MDT involved a consultant in 75% of cases reported nationally. DHFT = 82%.
•
Communication regarding health professional’s awareness that the patient is
expected to die in the coming hours or days, with the patient and the nominated relative,
friend or advocate was reported nationally in 74% of cases. DHFT = 100%.
•
Communication regarding the plan of care for the dying phase with the patient and
the nominated relative or friend was reported nationally in 57% of cases. DHFT = 100%. The
median number of hours between the date and time of the first discussion with the relative or
friend regarding the plan of care for the dying phase and the date and time of death was
reported nationally as 31.0 (The Inter Quartile Range Nationally was 10.3 - 76.6) DHFT =
75.
59
• For DHFT 84% of discussions regarding the plan of care was with the patient who
was capable of participating in such discussions. A discussion regarding a plan of care
for symptom control was reported in 100% of cases for all 5 key symptoms.
• Spirituality to enable patients, where possible and deemed appropriate, and
nominated relatives or friends to visit/revisit their spiritual need (i.e. wishes, feelings, faith
and values) was reported nationally in 37% of cases. DHFT = 90%. The median number
of hours between the date and time of the first discussion with the relative or friend
regarding their personal spiritual needs and the date and time of death was reported
nationally as 26.8 (IQR 10.2 -69.4) DHFT = 84.
• Medication prescribed “prn” to support the five key symptoms that may develop in the
last hours or days of life was reported nationally in 50% of all cases. DHFT = 82%.
DHFT prescribing for the 5 key symptoms:
Pain = 87%
Agitation = 92%
Nausea = 89%
Noisy Breathing = 84%
Dyspnoea = 82%
At the time of death a continuous subcutaneous infusion (CSCI) was in place for 34% of
cases.
• A review of interventions during the dying phase was reported nationally in 55% of
cases. DHFT = 95%. The main intervention continued for DHFT patients was the
administration of oxygen. At the time of the patients death a “Do not Attempt
Cardiopulmonary Resuscitation (DNACPR) was in place for 100% of DHFT patients.
• Review of the patient’s nutritional requirements during the dying phase was reported
nationally in 39% of all cases. DHFT = 87%.
• Review of the patient’s hydration requirements was reported nationally in 48% of all
cases. DHFT = 84%.
It is acknowledged that a framework, i.e. the Liverpool Care Pathway does prompt staff
to assess all aspects of the patients care; however without the prompt the assessments
of the patient’s nutritional and hydration needs may not always have been undertaken or
documented.
• The number of 5 or more clinical assessments during the last 24 hours of the patient’s
life was reported nationally in 82% of all cases. DHFT = 76%.
• Care of the patient and the nominated relative/friend immediately after the patient’s
death to ensure dignity and respect was achieved in 56% of all cases nationally. DHFT =
97%.
One of the aims of the national report is to enable organisations to be able to benchmark
against each other, share best practice to contribute to the drive to achieve the highest
standards of end of life care in hospitals across the UK.
The results of the case note review element of the audit across the other East Midlands
hospitals are shown below for comparison in the table below. This enables us to
benchmark our current practice in the delivery of End of Life Care.
60
When evaluating these results it is noted that participating trusts submitted different
numbers of cases dependent on the number of appropriate cases during the data
collection period.
Clinical Key
Performance
Indicators (KPI’s)
DHF
T
Northampto
n
General
Hospital
NHS Trust
Lincoln
County
Hospital
Pilgrim
Hospit
al
Nottingha
m
University
Hospital
NHS Trust
Sherwoo
d Forest
Hospital
NHS FT
University
Hospitals
of
Leicester
NHS Trust
63%
Northern
Lincolnshir
e
and
Goole
Hospitals
Trust
67%
1 Multidisciplinary
decision that the
patient is dying
100%
59%
44%
81%
74%
65%
2 Health
professionals
discussions with
both the patient
and their
relatives/friends
regarding their
recognition that
the patient is
dying
3 Communication
regarding the
patients plan of
care
4 Assessment of
the spiritual needs
of the patient and
their nominated
relatives or
friends
5 Medication
prescribed prn for
the 5 key
symptoms that
may develop
during the dying
phase
6 A review of the
interventions
during the dying
phase
7 A review of the
patients nutritional
requirements
8 A review of the
patients hydration
requirements
9 A review of the
number of
assessments
undertaken in the
patients last
24hours of life
10 A review of the
care after death
100%
72%
68%
72%
68%
76%
90%
51%
100%
59%
33%
71%
47%
68%
78%
46%
90%
49%
3%
49%
28%
77%
86%
33%
82%
16%
37%%
51%
26%
62%
50%
26%
95%
57%
37%
41%
37%
61%
68%
22%
87%
44%
23%
53%
26%
54%
65%
28%
84%
54%
23%
56%
44%
60%
79%
31%
76%
94%
73%
88%
95%
92%
96%
67%
97%
22%
33%
51%
37%
48%
72%
52%
Key Findings
The final statement released by the Leadership Alliance for the Care of Dying People ‘One
Chance to Get it Right’ June 2014 who are committed to ensuring that everyone who is in the
last days and hours of life proposed specific outcomes for the care of dying people alongside
guiding principles for professionals, these have been developed into the five priority areas
shown below:
61
When it is thought that a person may die within the next few days or hours:
•
•
•
•
•
This possibility is recognised and communicated clearly, decisions made and actions
taken in accordance with the person’s needs and wishes, and these are regularly
reviewed and decisions revised accordingly
Sensitive communication takes place between staff and the dying person, and those
identified as important to them
The dying person, and those identified as important to them, are involved in decisions
about treatment and care to the extent that the dying person wants
The needs of families and others identified as important to the dying person are
actively explored, respected and met as far as possible
An individual plan of care, which includes food and drink, symptom control and
psychological, social and spiritual support, is agreed, coordinated and delivered with
compassion.
The DHFT results from the National Care of the Dying Audit 2014 demonstrate that staff
ensure they involve patients, family and carers in discussions and decisions about End of
Life Care. Staff are also shown to engage with patients and their family/carer regarding their
spiritual needs. DHFT were one of only four hospitals in the country to achieve 100% for
communicating with patients and their families.
DHFT achieved slightly above the national average for prescribing for the five key symptoms
that may develop during the dying phase, however since the audit was undertaken the
decreasing use of the Liverpool Care Pathway across the Trust has impacted on anticipatory
prescribing for all five key symptoms.
It is acknowledged that evidence was obtained from both the Liverpool Care Pathway
document and the patient’s case notes for the DHFT audit sample. The prompts within the
Liverpool Care Pathway for the audit questions may possibly have favourably influenced
some of our results.
Following the withdrawal of the Liverpool Care Pathway on 14 July 2014, all people in the
last days of life will receive care according to their individualised care plan tailored to their
needs and wishes. This care will continue to be monitored and measured to ensure DHFT
staff continue to deliver high quality End of Life Care with compassion and confidence.
8. Heavy Menstrual Bleeding (HMB)
The final report of a four-year national audit in July 2014 shows improved treatment for
women with heavy menstrual bleeding, with 90% of women rating their care as good, very
good or excellent.
One in four women aged between 15 and 50 experience heavy menstrual bleeding which
often has a severe impact on their quality of life. Each year approximately 30,000 women
undergo surgical treatment for heavy menstrual bleeding in an NHS hospital in England and
Wales.
This report, commissioned by the Healthcare Quality Improvement Partnership (HQIP) as
part of the National Clinical Audit Programme, published by the Royal College of
Obstetricians and Gynaecologists (RCOG) and was co-led by the London School of Hygiene.
The organisational survey completed by hospitals in the first year of this audit was repeated
in the fourth year of the audit. Over the 4 years, the organisation of clinical services for
women with HMB has remained relatively stable. However, information and communication
has been improved, with an increase in written protocols and more hospitals providing
women with an information leaflet.
62
9. National Maternity Survey
This survey looked at all three stages of the maternity pathway and covered care provided
before birth (antenatal), during labour and birth, and in the first few weeks after birth
(postnatal). The survey asked questions which recent mothers told us were important to them
concerning: access to care, communication, involvement in decision making, and continuity
and quality of care, amongst other key themes.
Action Plan
• Working groups set up to address identified areas to be considered for improvement
• Subsequently the survey was run locally in November 2014 and is currently being
analysed
• The next National audit will be based on February 2015 births.
10. National Comparative Audit of Patient Information and Consent for Blood
Transfusion
Previous limited audit showed that although there are numerous leaflets regarding Consent
for Transfusion, including those developed by the Blood Transfusion Service, many patients
having a blood transfusion in hospital are not given this information. Recommendations by
the Advisory Committee on the Safety of Blood, Tissue and Organs reinforced the need for
valid consent to be documented. Valid consent, though not specifically written consent, does
require patients to be given specific information on the Risks and Benefits of the transfusion
and documentation of this in the patient health record.
The aim of this audit was to obtain a comprehensive overview of current practice and to
make recommendations for change to improve practice. 164 sites took part in the audit and
collated data on 2,784 elective cases.
Derby Hospitals contributed 23 cases.
Recommendation
•
All Trusts must have a policy for patient consent and information for blood transfusion.
At DHFT this is part of the Transfusion Policy.
•
The reason for the transfusion should be documented in the patient health record.
At Derby Hospitals there is a section for this to be completed in the Transfusion
Prescription Record.
•
Written consent is not needed however the patient should be informed of the risks and
benefits of the procedure and be given information.
At DHFT this is part of the Transfusion Prescription Record.
•
Further audit should be carried out in Emergency patients and Paediatrics as this study
focused on Elective patients only.
At DHFT leaflets are available from NHS Blood and Transplant (NHSBT).
•
Practice could be improved by adding valid consent to existing patient pathways.
At DHFT the Blood Transfusion Prescription Record has a section to be completed for
verbal consent.
•
Training for blood transfusion should be reviewed and include valid consent.
At DHFT mandatory Blood Transfusion training covers this.
63
•
Hospitals and professional bodies must ensure that junior doctors are trained in
appropriate prescription and patient safety as they are often the prescribers of blood
transfusion.
At DHFT all junior doctors receive mandatory Blood Transfusion and Theory training
which covers this.
•
There is limited awareness of the Blood Transfusion Consent learning module and this
should be promoted in hospitals as part of Induction and Training.
DHFT Transfusion Team is considering this.
•
Written Patient Information leaflets should be developed and distributed.
At DHFT Patient Information is available in all areas that transfuse patients.
•
Information should be available in other languages and alternatives to written information
should be explored.
At DHFT these recommendations are under consideration by the Transfusion Team.
11. Paracetamol Overdose (Adults)
The purpose of the audit is to identify current performance in Emergency Departments (EDs)
against the College of Emergency Medicine (CEM) clinical standards. This audit has been
conducted by the College of Emergency Medicine (CEM) before but it is the first audit
conducted against the College’s revised standards published in 2013, which were produced
in cooperation with the National Poisons Information Service (NPIS) and Medicines and
Healthcare Products Regulatory Agency (MRHA). This audit includes patients 18 years or
older who presented with a Paracetamol overdose in the Emergency Department.
•
All Emergency Department clinicians should carry out a plasma test if unable to
ascertain overdose size. Having a treatment pathway proforma in place will assist with
this.
•
All Emergency Department clinicians should ensure that capacity to consent is
recorded in every case of declined treatment where possible. Audit leads should review
documentation to ensure that capacity can be simply recorded.
•
Emergency Departments appearing above the upper quartile for plasma level tests
taken earlier than 4 hours after ingestion should review their practice, and delay testing.
Brief guidance notes could be provided as a reminder.
•
All Emergency Departments, particularly those falling below the lower quartile, should
aim to treat patients with N-acetylcysteine within 8 hours of ingestion. A treatment
pathway summary can assist with this.
•
Patients presenting after 8 hours ingestion with a toxic (large or staggered) overdose
who received N-acetylcysteine within 1hour of arrival. All EDs should assess the reasons
for their scores, and take action where necessary, particularly those with a score equal to
or below the median.
•
Compliance with MHRA guidelines: EDs performing below the median should
investigate their processes, and take steps to improve their performance.
•
All audit leads should look at improving the detail and accuracy of data entered in
patient records. A structured proforma may support this
64
Actions
The recommendations are under consideration by the Emergency Department team.
% Abandoned
Audits Against NICE
% Audits Against NICE
1
3
2
5
11
28
1
3
40
Medicine &
Cancer
Cancer
14
29
30
63
4
8
0
0
2
4
6
13
48
Specialist Medicine
18
45
18
45
4
10
0
0
1
6
15
40
Anaesthetics &
Critical Care
30
57
13
25
7
13
3
6
9
17
2
4
53
Diagnostics
Surgery
&
Anaesthetics
Pathology
3
19
11
69
2
13
0
0
3
19
1
6
16
Radiology
13
37
19
54
3
9
0
0
0
0
2
6
35
Surgery
60
69
14
16
2
2
11
13
4
5
16
18
87
Trauma &
Orthopaedics
23
44
20
38
1
2
8
15
1
2
8
15
52
Rehabilitation
& Therapy
4
67
2
33
0
0
0
0
3
50
0
0
6
Maternity &
Gynaecology
42
72
9
16
7
12
0
0
23
40
10
17
58
Integrated
Care
Genito Urinary
Medicine
4
57
3
43
0
0
0
0
3
43
0
0
7
Paediatrics
11
35
16
52
2
6
2
6
6
19
1
3
31
Pharmacy
1
10
4
40
4
40
1
10
1
10
1
10
10
Elderly Medicine
5
45
5
45
0
0
1
9
1
9
1
9
11
Overall
237
48
192
608
37
7
28
6
68
14
55
11
494
National Audit
3
The Clinical Audit Department within the Trust continues to promote and support adherence
to the approved Clinical Audit process to ensure the provision of accurate clinical audit
information for the Trust and external organisations. Clinical audit also identifies
improvements in patient care, good practice and excellence in the services provided by the
Trust.
The Clinical Audit Department works closely with the Post Graduate Medical Education
Centre and Foundation Programme Director to co-ordinate the Foundation House Officer,
year two of training (F2) Audit Programme. This ensures active involvement of the F2 in the
audit process and their ability to select and complete a clinical audit that is of value to patient
care within the trust and add to their professional development.
Each Division develops a local Clinical Audit Forward Programme that is monitored by the
Audit Department as part of the overall Trust Clinical Audit Forward Programme. Topics
include, National Guidelines, NICE Guidance, National Service Frameworks, Clinical Risk
and Clinical Indicators.
65
Total
Abandoned
70
% National Audit
% Continuous
28
% Completed
23
Completed
9
% In Progress
Acute Medicine
In Progress
Continuous
DIVISIONAL AUDIT ACTIVITY
The Clinical Audit Department provides support and resources to facilitate audits throughout
the Trust. All audits are registered and monitored through to completion.
The audit team have recently secured a development of the Formic software (Audit form
production, scanning and data collection tool) that allows the production of electronic audit
forms, available on our intranet, allowing our audit processes to become more ‘paperlite’ and
lean.
The team has also reviewed available systems and commissioned a bespoke database for
the collection of audit information, to allow more streamlined reporting and live information for
the audit leads on projects within their areas. Estimated completion of this system is within
this calendar year.
The reports of 22 local clinical audits were reviewed by the provider in 2014/15 and DHFT
intends to take the following actions to improve the quality of healthcare provided.
Title of Audit
Aim
Key Findings
Actions
Additional
Opioid
Requirements
Following
Hip and Knee Surgery on
the Enhanced Recovery
Pathway
To establish whether
the analgesia regime
was adequate for the
majority of patients
None required
Steroid Prescribing in the
Nightingale MacMillan Unit
To improve the quality
of steroid prescribing for
Palliative Care patients
Acute Kidney Injury(AKI):
Audit
of
Basic
Care
Standards
To assess the current
management of AKI
across the Trust
Although some patients
required
additional
analgesia.
The
audit
confirmed
that
the
analgesia regime was
satisfactory.
85% of patients had
appropriate prescriptions
on admission and 100%
had
prescriptions
reviewed. 70% had a
Proton Pump Inhibitor
(PPI) prescribed
30%
of
non-diabetic
patients had blood sugar
checks
Significant increase in the
documentation of fluid
balance.
Decrease in the number
receiving medical reviews
NICE Guidelines for the
management of Diabetes in
Children
To
assess
the
management of children
with a new diagnosis of
diabetes
Malignant Otitis Externa
Management in the Ear
Nose and Throat (ENT)
Department
Obesity in Pregnancy
To review management
against
the
agreed
protocol
To audit performance
against
Clinical
Negligence Scheme for
Trusts
(CNST)
standards with particular
emphasis
on
Anaesthesia
referral
and
input
during
delivery
66
There
has
been
significant improvement
over the last 4 years.
100% of patients referred
on same day by GP and
added to the Diabetic
Register.
96% screened for Coeliac
and thyroid disease.
All cases were compliant
with the protocol
100% of patients had their
BMI recorded
88% were offered referral
to Anaesthetists.
56% had a documented
Anaesthetic Plan.
Guidelines
to
be
developed
Tutorials
for
junior
doctors
Discussions being held
re
blood
sugar
monitoring
for
nondiabetic patients
Care Bundles for AKI in
junior doctors Induction.
E Learning package
Co-ordination
with
Pharmacy re medical
management.
Proposed new proforma
Continue to support and
educate GPs.
None needed
Obesity in Pregnancy
Pathway
Improved training in the
Maternity IT programme
ANC information in junior
doctors Induction
Improved
communications
with
Anaesthetists
Option for patients to
Unexpected
admissions
after ear Nose and Throat
(ENT) surgery
To establish admission
rates following ENT
surgery
Neonatal Intensive Care
(NICU) Rapid Safety Alerts:
Admissions
Audit
and
Blood Gases
To review observation
rates and blood gases
estimation
Adult
Central
Venous
Catheter (CVC) Insertion
To assess compliance
with Matching Michigan
Guidelines and related
blood stream infections
Management of patients
with Diabetes Mellitus (DM)
on the Step Down Unit
To
compare
management of these
patients
with
local
guidelines
100% of patients with diet
controlled DM had a preoperative assessment.
60% of Insulin Dependant
DM patients admitted on
surgery day and No Step
Down Unit discharges
delayed.
Surgical Management of
Localised Renal Carcinoma
To determine current
practice
in
the
management of Renal
Cell Carcinoma
The mainstay of treatment
is currently Laparoscopic
Renal Nephrology
Operating Waiting Times
for Patients with Mandibular
Fracture and the Influence
on post-operative Outcome
To establish waiting
times
and
postoperative outcomes
Impact of the revised 120
Pathway on the emergency
management of patients
presenting with low risk
chest pain
To
assess
how
successful the change
in Pathway has been
Clinical Effectiveness of
Care
for
Acute
Exacerbation of Chronic
Obstructive
Pulmonary
Disease (COPD)
To audit compliance
with the COPD Care
Bundle
and
NICE
Guidance
Almost all patients had
fast-track
surgical
intervention.
Waiting times had no
direct impact on postoperative outcome.
Reduction in the length of
stay in the Emergency
Department.
Small numbers put on the
Pathway despite high
numbers presenting with
chest pain.
Results
showed
that
patients
had
prompt:
Check X Rays and
Electrocardiographs
(ECG),
Oxygen
prescribing, response to
acidosis,
and
bronchodilator,
steroids
and Respiratory Specialist
review within 24hours
67
Significant increase in
admission rates from
2007 audit.
Inaccurate coding of day
cases.
Most
admissions
for
bleeding or epistaxis and
pain.
Documentation unspecific
for 50% of patients.
100% had observations
recorded within the first
hour.
79% had blood gases
recorded within 4 hours.
Following
awareness
raising
audit
showed
100%
results
for
observations and blood
gases.
No correlation between
BSI and failures with
aseptic technique
BSI more likely during
insertion than pre or post
procedure
choose
anaesthetic
referral date
Raise awareness of the
need
for
accurate
documentation
Coding issue to be
addressed
Promotion of accuracy of
documentation
via
posters
and
a
presentation
for
all
Neonatal Unit staff
Education and retraining
of
Consultants
and
Anaesthetic trainees.
Awareness
raising
amongst staff.
Expand audit to include
follow up data e.g. date
of removal.
Diabetic patients should
be first on the operative
lists.
Hourly recording of blood
sugar with Sliding Scale
Insulin.
High risk patients to be
identified in pre-operative
assessment
and
management planned.
Laparoscopic
Partial
Nephrectomy currently in
development and may
reduce Chronic Kidney
Disease
New trauma proforma to
be developed to improve
documentation.
Audit appropriateness of
patients on the Pathway
and other patients that
could be.
Raise awareness of the
Pathway with the team
Improve awareness of
COPD Care Bundle.
Documentation
of
smoking and referral to
Fresh Start.
Review Guidelines for
antibiotic prescribing in
COPD.
Post-Operative
Effectiveness of
Tunnel Surgery
Carpel
Colles Fracture: Adequate
or Inadequate Plaster
To
evaluate
the
effectiveness of Carpel
Tunnel Surgery after 3
months now there is no
longer a follow up
appointment
To evaluate plastering
of Colles fractures in the
Emergency Department
and Fracture Clinic
Iron Deficiency Anaemia
(Haematological Society)
To
improve
management
of
anaemia in pregnancy
patients
Maternity/Obstetric Early
Warning Score (MOEWS)
To assess Midwives
understanding of the
use of MOEWS
Steroid use in pregnancy
Compliance
guidelines
Caesarean Section(CS)
Recurrent Miscarriage
Lung Cancer, Mortality and
Coding
with
To look at indications
that may be influencing
the local increased CS
rate
Compliance
with
guidelines & assess if
possible
areas
of
improvement
To review all patients
that were discharged or
died with a HES code of
lung cancer (Primary or
secondary)
There was no significant
change in outcome since
the follow up appointment
was discontinued
Development of clear
post-operative
information leaflets.
Develop an algorithm for
GPs to simplify referrals.
Overall of positioning and
plastering were of a
recognised standard.
One patient had remanipulation
due
to
inaccurate plastering.
Insufficient evidence for
further conclusions
More than 70% was
achieved in prescribing,
antenatal checking at
appropriate gestations /
checking
ferritin
in
relevant cases.
Delays in Delays in
checking
haemoglobin levels 2
days following treatment
Good understanding of
MOEWS
principles,
Weaknesses identified in
escalation
85% of mothers receiving
steroids when delivering
between 24+0 & 34+6
weeks
Continue to audit a
minimum of 50 patients
Highest incidence in
Robson groups 2 & 5:
Primiparas at term &
Previous Caesarean
Section women.
Appropriate investigations
undertaken.
Early pregnancy support
offered (70%) Live birth
rate after 3 miscarriages
38%
All relevant co-morbidities
were included in all cases
Coding was accurate in
all cases although this
was a small sample
Develop Guidelines for
Management of iron
deficiency anaemia with
the Maternity Guidelines
Group
Discussions at Midwives
meetings
Discussions at Midwives
meetings
Current working group
looking at this.
Considering improved
counselling provision
particularly around
women suitable for
vaginal birth
Continue with Clinic
Re-audit with larger
cohort
2.7 PARTICIPATION IN CLINICAL RESEARCH AND INNOVATION
The NHS aspires to the highest standards of excellence and professionalism in the provision
of high quality care that is safe, effective and focused on patient experience. This includes
the people it employs, and the support, education, training and development they receive and
in the leadership and management of its organisations. It is also through its commitment to
innovation and to the promotion, conduct and use of research to improve the current and
future health and care of the population.
Respect, dignity, compassion and care should be at the core of how patients and staff are
treated not only because that is the right thing to do but because patient safety, experience
and outcomes are all improved when staff are valued, empowered, and supported.
(Principle 3 of the NHS Constitution, 26 March 2013)
68
The importance of innovation and medical research is underscored by this principle as
integral to driving improvements in healthcare services for patients.
(Handbook to the NHS Constitution, 26 March 2013)
The promotion and conduct of research continues to be a core NHS function and continued
commitment to research is vital if we are to address future challenges. Further action is
needed to embed a culture that encourages and values research throughout the NHS.
(Quality, 2.4, The Operating Framework for the NHS in England 2012-13)
RESEARCH
Derby Hospitals NHS Foundation Trust is a research-active teaching hospital with research
taking place in most disease areas and specialties across the organisation. Activity in clinical
research is a hallmark of high quality service and it places our Trust at the leading edge of
patient care and treatment.
In 2013/14, research studies and clinical trials took place in obstetrics, maternity and
gynaecology, paediatrics, cardiology, dermatology, hepatology, gastroenterology, renal
medicine, cancer and palliative care, lymphoedema, diabetes, stroke, rheumatology and
musculoskeletal disease (including physiotherapy), hand surgery, vascular surgery, breast
surgery, ophthalmology, neurology and Parkinson’s Disease, general surgery, respiratory
medicine, rehabilitation and accident and emergency.
In 2014/2015, for studies listed on the UKCRN Portfolio:
•
•
48 new studies were approved and opened in the Trust, making a total of 112 actively
recruiting studies in this year
The number of patients receiving relevant health services provided or sub-contracted by,
Derby Hospitals NHS Foundation Trust that were recruited during that period to
participate in research approved by a research ethics committee was 2,621 as at 26th
February 2015.
In addition to this, patients were recruited to non-portfolio studies, including commerciallysponsored clinical trials not adopted onto the UKCRN portfolio, local Investigator-led pilot
studies and student studies (e.g. Doctor of Medicine (MD), Doctor of Philosophy (PhD),
Master of Science (MSc) etc.) all of which support the growth and development of research
capacity and capability within DHFT and the wider NHS.
In 2014-15, for studies not listed on the UK Clinical Research Network (UKCRN) Portfolio:
• 53 new studies were approved and opened in the Trust
• making a total of 3,242 actively recruiting studies in this year.
This level of participation in clinical research demonstrates the Trust’s commitment to
improving the quality of care we offer and to making our contribution to wider health
improvement. Our clinicians stay abreast of the latest treatment possibilities and active
participation in research leads to successful patient outcomes. Our engagement with clinical
research also demonstrates the Trust’s commitment to testing and offering the latest medical
treatments and techniques.
Recruitment to a number of studies has been notable. Details of the ‘top ten’ recruiting
studies are shown in the following table.
69
Acronym / Short Title
Main Speciality
The United Kingdom Aneurysm Growth study
Mechanisms underlying physiology and pathophysiology of pregnancy
ARID Main Study
Leg oedema in Multiple Sclerosis (LIMS) version 1.0
Investigating the prevalence of thyroid antibodies
The Parkinson's Pain Study
eGFR-C
Cost efficient service provision in neurorehabilitation
Multifrequency Bioimpedance in the early detection of Lymphoedema
BRAGGSS Study
Surgery
Reproductive health & childbirth
Renal disorders
Neurological disorders
Reproductive health & childbirth
Dementias & neurodegeneration
Renal disorders
Health Services and delivery
research
Cancer
Musculoskeletal disorders
No. of
Participants
796
337
315
240
88
54
51
49
48
46
Here is some further information about three of these ‘top ten’ recruiting studies:
•
Leg oedema in Multiple Sclerosis (MS) – the LIMS Study.
Dr Vaughan Keeley, Consultant in Palliative Medicine, worked closely with colleagues in the
University of Nottingham, Dr Lorraine Pinnington & Professor Christine Moffatt to develop this
study. Their application to the MS Society for funding to conduct this study was successful
and they were awarded £108,000 in 2014/15.
People who have Multiple Sclerosis (MS) sometimes have swollen legs. This leg swelling can
occur for a number of reasons, particularly if it has become difficult for the patient to walk. In
these circumstances, excess water may build up in the tissues and cause the legs to become
swollen. Swollen legs can be painful and uncomfortable, particularly if it is difficult to find
shoes that fit. Some people also find that swollen legs make it more difficult to walk or
transfer, for instance from a wheelchair to a car. When the condition is severe, the skin can
develop sores and infections that may require treatment and admissions to hospital.
The first aim of this study is to estimate the proportion of people with MS who are known to
the neurology and rehabilitation medicine services of the Trust who experience leg swelling.
The second aim is to assess how severe the leg swelling is amongst those who have it,
determine what factors might precipitate swelling and what problems it creates for the
patients in everyday life. The third aim is to assess the extent to which leg swelling is
unrecognised by patients.
Once we know how many people experience leg swelling and what factors precipitate it, it
should be possible to recognise, treat and advise people with MS more effectively. In the
short-term, this information will enable clinicians to develop more accurate information for
those who have MS and leg swelling. It will also allow clinicians and managers to modify
clinical services to ensure that leg swelling does not remain undetected amongst people with
MS and that it is treated more effectively. In the longer term, the information gathered will
also enable the research team to design clinical studies in which the effectiveness of different
treatments for leg swelling in people with MS can be assessed.
The study started promptly and recruitment of patients has gone well and the study is
expected to run for 18 months.
•
GE tomosynthesis versus supplementary mammographic views
Mammography is our current primary method for detecting breast cancer, however it has
limitations. One limitation is that in some cases we are unable to distinguish benign
conditions from cancer and we will, therefore, subject ladies (who are ultimately shown not to
have cancer) to further tests.
70
Tomosynthesis is an advanced form of digital mammography, providing 3-D like images of
the breast tissue. Early clinical research is tending to support the theory that tomosynthesis
should offer increased accuracy compared with standard mammography.
This study aims to assess whether digital breast tomosynthesis can improve upon our current
standard of care for assessment of soft tissue abnormalities picked up on screening
mammograms.
The study involves ladies who have been recalled following an abnormal mammogram as
part of the NHS Breast Screening Programme and is being carried out at Derby Hospitals
NHS Foundation Trust, led by Dr Anne Turnbull, Consultant Radiologist, and at Nottingham
University Hospitals NHS Trust.
Recruitment to this study has gone well this year and it is hoped that the study will be
finalised within 9 months.
•
A prospective, observational study investigating the prevalence of thyroid antibodies in
women of reproductive age
Miscarriage, the loss of pregnancy before 24 weeks gestation, affects 1 in 5 women who
conceive, making it the commonest complication of pregnancy. It substantially impacts on
physical and psychological well-being. In addition, pre-term birth (that is the delivery of the
baby between 24-37 weeks of gestation) occurs in 6-10% of pregnancies. Of those who
survive, approximately 10% suffer long-term disability. Therefore, the personal, social and
financial cost of pre-term birth is enormous.
It has been shown that there is a strong link between the presence of thyroid antibodies and
miscarriage and pre-term birth; the risks are more than doubled. However, the prevalence of
this thyroid antibody in various populations is not known.
Patients of Derby Hospitals NHS Foundation Trust have been actively participating in an ongoing, national trial called TABLET (Thyroid AntiBodies and LevoThyroxine study) led by Mr
Kanna Jayaprakasan, Consultant in Obstetrics & Gynaecology, which has provided the
opportunity to study the prevalence of the thyroid antibody in various population sub-groups.
Knowing the accurate prevalence will help us to understand if there should be routine testing
for these antibodies.
Research Funding
A number of applications have been made by Chief Investigators within the Trust for National
Institute for Health Research (NIHR) and other high quality research funding. Applications
have been made to NIHR Research for Patient Benefit, National Institute for Health Research
Efficacy and Mechanism Evaluation (NIHR EME), NIHR Health Services & Delivery
Research (HS&DR), NIHR Health Technology Assessment (HTA), Wellcome Trust, The
Health Foundation, Ferring Fertility Award, British Foot and Ankle Society (BOFAS), Bowel
Disease Research Foundation, the College of Emergency Medicine, European Society of
Human Reproduction and Embryology, British Elbow & Shoulder Society.
A number of these research funding applications have been successful and this is a further
indication of the high quality research environment within the Trust which supports the
delivery of high quality patient care.
Raising the Profile of Research
Each year, we celebrate International Clinical Trials Day by placing a number of posters and
stands, manned by Research & Department staff, in key locations around the Trust where
they can be seen and visited by patients, staff and visitors to the Trust.
71
The aim of International Clinical Trials Day is to raise awareness of health research and to
highlight how important it is that partnerships develop between patients and health care
providers. Throughout 2014/15, the Trust, in partnership with the National Institute for Health
Research (NIHR), promoted the fact that ‘It’s OK to ask’ about clinical research.
INNOVATION
Derby Hospitals NHS Foundation Trust continues to enhance the quality of its services and
develop new sources of income through its innovative staff and the support provided by the
Research & Development Department. The Trust has an Innovation and Horizon Scanning
Group, which identifies and develops any potential clinical and technological developments
which may impact on clinical services within the Trust and to link these to the Trust Strategy.
The most successful organisations anchor innovation in their strategies and in recent years
there has been an increasing emphasis on innovation as a key contributor to organisational
success.
Innovation is about developing new ideas and ‘inventions’, to generate new products or
services (product innovation) and new ways of working (process innovation).
Collaborating with the Healthcare Industry to bring Innovation to the Bedside
The staff of the Research & Development Department work closely with our clinicians and
with healthcare companies to bring innovative products to the bedside for the benefit of
patients and for improved patient care.
We work collaboratively with a number of Small/Medium-sized enterprises (SMEs) in the
healthcare and social care arenas, to design and deliver high quality studies and trials that
provide the evidence for the efficacy and cost-effectiveness of a number of innovative
products. This evidence is published in peer-reviewed journals, which informs other clinicians
of the efficacy of the products and facilitates the dissemination and wider uptake of
innovations.
Each year, representatives from the Trust attend the Medilink East Midlands Innovation Day
to showcase our services and to stimulate further interactions and collaborations.
72
2.8 GOALS AGREED WITH COMMISSIONERS
CLINICAL QUALITY AND INNOVATIONS MEASURES (CQUIN)
A proportion of DHFT’s income in 2014/15 was conditional on achieving quality improvement
and innovation goals agreed between DHFT 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 payment framework. For 2013/14 the
total income dependent upon achieving quality improvement and innovation goals was
£8,671, of this we received £8.570. For 2014/15 the total income dependent upon achieving
quality improvement and innovation goals was £8,770, of this we received £8,938.
Further details of the agreed goals for 2014/15 and for the following 12 month period are
available online at:
http://www.england.nhs.uk/wp-content/uploads/2015/02/cquin-guidance.pdf
Year
2013/14
2014/15
Tariff Income
Non-Tariff Income
£000's
£280,128
£111,851
Total Income
£391,979
Tariff Income
Non-Tariff Income
£247,355
£71,591
Total Income
£318,946
73
CQUIN
£000's
£8,570
2.18%
£7,537
2.36%
ACUTE SERVICES
Goal Type
National
National
Goal
Number
Indicator
Number
1a
Friends and Family Test –
Implementation of staff FFT
£251,449
1b
Friends and Family Test – Early
implementation
£125,423
1c
Friends and Family Test –
Increased Response Rate
1
2
2
3a
National
3
3b
3c
Local
4
4
5a
Local
5
5b
5c
Local
6
6
Local
7
7
8a
8
8b
Local
Local
Local
9
NHS Safety Thermometer –
Reduction in the prevalence of
pressure ulcers
Dementia – Find, Assess, Investigate
and Refer
Dementia –
Clinical Leadership
Dementia – Supporting Carers of
People with Dementia
Local Dementia – Improve the
management and care of patients
with dementia receiving hospital care
End of Life - Implementation of
Amber Care Bundle
End of Life - Discussions as End of
Life approaches
End of Life - Improve care of patient
and support for family in the last few
days of life
Improve standards of care by
implementing the Chief Nursing
Officer strategy 'Compassion in
Practice'
Patient Experience –
Complaint Management
Acute Kidney Injury –
Risked assessed
Acute Kidney Injury –
Patient information
Year End Result
Achieved
£125,423
On target to
achieve
(confirmed data
available May
2015)
£502,596
Not on target to
achieve
£301,498
(confirmed data
available May
2015)
£50,350
£150,749
£565,308
£188,436
£188,436
On target to
achieve
£188,436
(confirmed data
available May
2015)
£376,872
£565,308
£565,308
£565,307
On target to
partially achieve
Clinical Information –
Improving patient level clinical
information
£565,308
10a
Discharges –
Improving patient flow
£565,308
Not on target to
achieve
10b
Discharges –
Forward planning discharge
£565,307
(confirmed data
available May
2015)
9
10
11
Expected
Financial value
of indicator (£)
Indicator Name
11
Service Specifications
£1,130,616
Sub Total:
£7,537,438
74
(confirmed data
available May
2015)
On target to
achieve
(confirmed data
available May
2015)
COMMUNITY INDICATORS
Goal Type
Goal
Number
Indicator
Number
1a
National
1
1a
National
2
2
3a
Local
3
3b
Local
4
4
5
5
Expected
Financial value
of indicator (£)
Indicator Name
Friends and Family Test –
Implementation of staff FFT
Friends and Family Test – Early
implementation
NHS Safety Thermometer –
Reduction in the prevalence of
pressure ulcers
End of Life – Improve communication
and co-ordination of patient care at
the End of Life
End of Life – Discussions as End of
Life approaches
Care and Compassion – Improve
standards of care by implementing
the Chief Nursing Officer strategy
'Compassion in Practice'
Pressure Ulcers – Improving noncompliance
Sub Total:
75
£26,374
Year End Result
Achieved
£26,374
£52,748
Not on target to
achieve
(confirmed data
available May
2015)
£26,374
£26,374
£52,748
£52,749
£263,741
On target to
achieve
(confirmed data
available May
2015)
NHS England Contract
Goal
Type
Goal
Number
Indicator
Number
1a
1b
National
2
2
3a
National
3
3b
3c
Local
AO6
WC6
TR9 2
Local
Friends and Family Test –
Increased Response Rate
NHS Safety thermometer –
reduction in the prevalence of
pressure ulcers
Dementia – Find, Assess,
Investigate and Refer
Dementia –
Clinical Leadership
Dementia –
Supporting Carers
Specialised Dashboards
National
Local
Friends and Family Test –
Implementation of staff FFT
Friends and Family Test –
Early implementation
£28,756
TR9
TR9 3
Shared haemodialysis care Patient involvement in the
tasks of haemodialysis
Improved access to breast
milk in preterm infants Percentage of preterm babies
born at <34+0 weeks
gestation who are receiving
some of their own mother’s
breast milk at final discharge
home from the neonatal unit.
Inpatient flow improvement Implementation Set-Up for
real time on-going use
Inpatient flow improvement Clinical Utilisation Review
Implementation Rollout
(Training and Live use)
Sub-total
Sub-total value (Acute, Community & NHSE contracts)
Penalty reinvestment value
Total CQUIN value
76
Year End
Result
Achieved
£14,344
1
1c
National
Indicator Name
Expected
Financial
value of
indicator (£)
£14,344
On target to
achieve
(confirmed data
available May
2015)
£57,479
Not on target
to achieve
£34,480
(confirmed data
available May
2015)
£5,758
£17,239
£86,199
£129,299
On target to
achieve
(confirmed data
available May
2015)
£129,299
£344,798
TBC
£861,995
£8,318,376
£2,195,624
£10,858,798
2.9 REGISTRATION WITH THE CARE QUALITY COMMISSION (CQC)
DHFT to register with the Care Quality Commission and its current registration status is
registered without any conditions. The Care Quality Commission has not taken enforcement
action against Derby Hospitals NHS Foundation Trust during 2014/15. Derby Hospitals NHS
Foundation Trust has not participated in any special reviews or investigations by the Care
Quality Commission during the reporting period.
Care Quality Commission Planned Inspection
The Care Quality Commission carried out a planned inspection of the Derby Hospitals and
Community Services between the 8th and 11th of December 2014.
There was also an un-announced inspection of the Emergency Department, Critical Care and
a number of wards at both hospitals on the night of 22nd of December 2014 between 5pm
and midnight.
The Trust was rated as ‘good’ overall and some outstanding practice and innovation was
highlighted. Good care for patients across all areas of the Trust’s work was noted. The
Inspectors also highlighted the strong leadership, good team working and individualised
patient care and were impressed with the friendliness of staff and their obvious pride in the
work they did.
Key Findings
• There were good processes to prevent the spread of infections by the Infection
Prevention and Control. All of the wards in each hospital were clean and staff followed
the Policies for Infection Control which was evidenced by hand-washing between
different patients and the investigation of infections that did occur
• Patients received help to eat and drink and systems such as the Red Tray for patients
that required help, Nutrition assistants to assist them and protected mealtimes. Day
rooms were also used for communal meals and nutrition assessments were completed
and acted on. Food and fluid charts were also completed appropriately
• All areas were adequately staffed except Medicine and End of Life Care on some
occasions
• The high number of vacancies and sickness levels combined with the increasingly
complex patient needs in the Community Nursing Service was a significant problem. The
Nursing workload had increased and doubled for seven of the last eighteen months.
Concerns had been escalated to the Safer Staffing Board
• Following a compliance action by the CQC in July 2013 to improve complaints handling,
the Trust had met the Commissioners quality target for improvement and the compliance
action was met.
Outstanding practice was highlighted in several areas including:
• Responsive care for patients who had dementia and the Frail Elderly Assessment Team
(FEAT) based in the Medical Assessment Unit with a healthcare assistant qualified to
care for dementia patients available there every day providing care that was responsive
to their individual needs
• Ward 205 were commended for their reminiscence room, pictorial information and
advanced care planning for patients with Dementia
• The Medical Admissions Unit had Pharmacists working with the FEAT team optimising
medicines use and were available 12 hours every day
• Respiratory medicine had developed colour coded wristbands identifying individual
patients oxygen needs
• The facilities and within the Nightingale MacMillan Unit were excellent and staff gave
individualised care to patients requiring End of life care.
77
Recommendations for areas that must be improved included:
• DNA CPR forms were not recorded accurately in line with Trust policy. This generated
the risk of delivery of safe patient care
• Ensuring at all times there were sufficient numbers of suitably qualified, skilled and
experienced district nursing staff employed for the purpose of carrying out regulated
activity
• There were not suitable arrangements in place to ensure that all district nursing staff
were able to attend mandatory training and other essential training as required by the
service
• Suitable arrangements were not in place at the London Road Community Hospital and
Royal Derby Hospital in relation to acting in best interests of patients without capacity
(linked to the issues around DNA CPR)
• The provider did not ensure that electronic patient records could be located by staff
visiting patients at home, before providing treatment and care.
Recommendations for the Trust to consider included:
• Review of the Lone Working Policy and processes are in place to maintain midwives
safety and security within the Community
• Having suitable arrangements to ensure the numbers and qualifications of nursing staff to
meet patient needs on the medical wards and in the adult Emergency Ward
• Providing information for patient’s relatives and friends in different formats and different
languages.
• Development of the electronic prescribing system (ePMA) for Intensive Care to ensure a
Trust wide system and improvement of the facilities for patients waiting for prescriptions
from the Pharmacy at DHFT
• Training and support for Puffin ward staff to care for patients needing CAHMS
assessment and maintain the care and welfare of other patients
• Reviewing the design and layout Neurology Outpatient area at London Road Community
Hospital particularly for people with limited mobility
• Consideration of ‘patients’ stories during public Board meetings to promote the positive
and negative experiences of patients
• Reviewing equipment storage to ensure safe access to bathrooms on medical wards
• Review of VTE assessment practice in the Surgical Assessment Unit.
The Trust is currently reviewing the report and recommendations. An action plan is being
developed in line with CQC requirements and will be monitored via the Quality Governance
Structures.
2.7.1 SOUTHERN DERBYSHIRE CLINICAL COMMISSIONING GROUP (CCG) QUALITY
VISITS
These visits are undertaken as part of the CCG's quality assurance process with the aim to
understand how the services are operated and delivered within the Trust, and to gain
assurance that the care given is high quality and evidence based.
There have been five visits.
UROLOGY SERVICE VISIT 24 JULY 2014
The purpose of this visit was to understand how the service was currently operating and the
challenges around capacity and demand. Patient feedback was very positive and most
patients were very happy with the service although there were issues reported with privacy
and dignity in some areas. This has now been addressed along with a clear monitoring and
escalation plan for reporting. Alongside this a review is underway across the organisation in
line with Trust Privacy and Dignity Policy.
78
The department has dedicated outpatient and day case operating facilities offering consultant
and nurse led clinics, a one-stop haematuria service, urinary stone and continence services.
More complex operating is undertaken in the general operating suite, where specific theatres
are designated to the urology service
Recommendations Include:
•
Undertake capacity and demand modelling across the patient pathway from the point
of referral coming into the trust to full discharge from follow up, incorporating on-going
monitoring
•
Review across the pathway of where improvements could be made for the patient
experience e.g. elective admissions lounge
•
Consider a review of the planning process for day-case patients to ensure that all
patients are appropriate; also to include pre-operative assessment capacity issues
•
The purchase of curtains or solid screens to address the privacy and dignity issues
for patients
•
Replacement of two washer/disinfectors immediately
•
Review of the current washing procedure for cystoscopies with regard to the potential
physical problems for staff
•
Consider a review to improve list planning by using the medical secretaries to
undertake this task
•
The CCG to investigate the issues identified with GP’s referrals.
COMMUNITY SERVICES VISIT 15th SEPTEMBER 2014 AND 16th SEPTEMBER 2014
The purpose of this visit was to understand the current working practices within the
Community Services with regard to quality and safety. The visit was carried out over 2 days
due to the complexity of the Services. The general impression was that there is still work to
be done improving and updating the service to meet future demands.
Patient Experience feedback was positive, there are good systems for reporting, sharing and
learning within the teams and there was a lot of good practice observed. The Care Coordinator role was seen as a positive development and the Community Matrons were seen
as energetic and innovative and keen to work with the District Nursing Teams. There is a
great deal of work being undertaken including a Task and Finish group reviewing the Call
Centre and a new Matron post introduced in District Nursing.
Recommendations:
• A review of the service
• Benchmarking and learning from the Keith Hurst Review
• Review referral and communication processes particularly for complex discharges
• Escalate the introduction of the IT services
• Review staffing, training and referral rates
• Raise awareness on patient safety and quality systems. Incident and complaints data
themes and trends should be identified and reported. Also all lessons learned should be
shared with staff.
79
Actions
• District Nursing has taken part in the National benchmarking Audit of Community
Services. They have also shared their working practices and had discussions about how
the findings from the Hurst review can be shared
• A programme of continuous development is on-going. This has seen the introduction of
call handler scripts and a reduction in call answer times to two minutes. A review of all
referrals through the call centre, including the 111 service, is being completed.
Performance and developments are also reported monthly at the Business Unit
Performance Management meeting. The CCG are leading a review of Single Points of
access which will include merging of the District Nurse Call Centre
• A task and finish group has been established to review the referral and information
sharing process to District Nurses for complex discharges. This includes work on the
electronic referral system, information sharing at the Senior Sisters meetings and with
the Education Team that delivers Induction
• The organisational change process is underway to address the issues relating to
handover times for day and evening District Nurses
• Information Technology (IT) solutions are part of the Business Units Plans and includes
the implementation of IT systems in the community that link to the Trust. This has been
discussed at the Management Executive. This includes generic emails to manage
referrals
• Staffing levels have been discussed at the Safe Staffing Board and additional staff have
been recruited. District Nurse leadership has been increased with an additional Matron
and Band 7 Senior nurses which are now at the establishment figure
• Profiling beds have been purchased for Perth House and are now in place
• The Business Unit is reviewing all quality reports to ensure that learning is highlighted
and shared.
STROKE SERVICES VISIT 21 OCTOBER 2014
The Stroke Service visit was undertaken to review and understand the provision of services
and the Patient Pathway. The report showed that staff were welcoming and very informative
regarding the services that were offered. All the staff encountered on the visit demonstrated
enthusiasm and pride in the Stroke Services that are provided. All the areas that were visited
were found to have a calm atmosphere with minimal levels of noise. The areas were noted to
be clean and tidy and appeared well organised.
Recommendations include:
• Evaluate the potential for joint working between the Paediatric Team and the Specialist
Stroke Team if required in the Emergency Department
• In order to resolve high risk patients not being seen within the agreed 24 hour timeframe,
it was suggested that GPs receive feedback notifying them of delayed referrals and the
associated potential risks to patient safety. This could also be supported by SDCCG
through awareness raising and GP education
• Consider changing the location of the Transient Ischaemic Attack (TIA) consultation room
into the Clinical Measurement Department.
• Monitoring data on the numbers of patients seen urgently in Neurological Outpatients to
inform any service re-design, including the feasibility of a patient self-referral process
• Review the process to reduce the waiting time between Early Supported Stroke
Discharge Team (ESSD) and NOTS to ensure continuity of care and minimise the
potential physical and psychological deterioration of patients awaiting therapy
• Improve the patient experience by reviewing Psychology Services to give additional
support to stroke patients.
80
Actions
• The Stroke Team have agreed to work jointly with the Paediatric Service when required
in the in the Childrens Emergency Department
• Late referring practices have been identified and informed of the Stroke Pathway
proforma. This has also been emphasised at Consortia meetings. Delays in Doppler
examination bookings and clinic appointments are being reviewed each month. This will
be a focus for the stroke Operational meeting in May and is part of the Action Plan
• The location of the TIA clinic has been reviewed and the benefits of its current position
outside the ward and the proximity to Therapists and doctors outweigh the benefits of a
move to CMD
• The reduction of waiting times and the number of patients seen urgently in Neurology
Outpatients will feed into the re-design of specialist rehabilitation services
• A course delivered by a Clinical Psychologist on patient moods following a stroke was
attended by Therapists and nurses. This will also be part of service re-design.
External Review of Maternity Services 16 APRIL 2014 and 17 APRIL 2014
During February 2014 the CCG received two external ‘whistleblowing’ letters following
concerns raised regarding the Maternity service including:
•
•
•
•
Staffing levels
Safety
Leadership
Bullying
Southern Derbyshire CCG requested an external review of the service to provide them with
additional assurance against the concerns that were raised. The CCG had undertaken their
own Quality Visit during the summer of 2013 and the Local Midwifery Supervising Authority
had undertaken its annual review of the service later in 2013, neither of these earlier reviews
had highlighted any specific issues.
The external review was undertaken in April 2014 by an independent reviewer commissioned
by the CCG and agreed by the Trust following concerns. The reviewer was an experienced
Head of Midwifery and also a CQC inspector.
Initial feedback to the Trust was extremely positive.
The report has been received positively by the Business Unit and recognises the work and
areas of good practice within the service as well as the challenges the service has faced in
the last 12 months and how it has dealt with those challenges.
Recommendations include:
• A review of the Maternity Dashboard and it’s indicators in line with national best practice
• A review of the workforce model based on rising complexity and demand
• Evaluating the Preceptorship package for new midwives after 12 months
• Utilising principles of the national CQC Maternity Survey into a more frequent local
survey
• Continue service reconfiguration projects to improve pathways for women and their
babies
• Practice changes to meet wider best practice.
The report and recommendations are being reviewed through the Maternity Clinical
Governance Group and the Action Plan will be monitored via the Divisional Governance
meeting and reported through to the Quality Committee.
81
A visit to look at the Discharge Processes including Discharge Lounge and Ward Areas was
undertaken on Tuesday 20th January 2014. To date we have not received a formal report on
the findings.
2.10 DATA QUALITY
Derby Hospitals NHS Foundation 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:
Trust %
For admitted patient care:
For outpatient care: and
For accident and emergency care
-
99.6
99.8
98.7
National %
99.2
99.3
95.2
which included the patient’s valid General Medical Practice Code was:
Trust %
For admitted patient care:
For outpatient care: and
For accident and emergency care
99.5
99.5
98.4
National %
99.9
99.9
99.2
Clinical Coding Audit
Derby Hospitals NHS Foundation Trust has a regular programme of internal clinical coding
audit. These are performed by the Trusts Clinical Coding Manager and her deputy who are
both Health and Social Care Information Centre (HSCIC) approved Clinical Coding Auditors
and accredited Clinical Coders. These audits aim to cover a random sample of the coding in
all specialties. Auditors must conform to the Auditor’s Code of Practice and The Clinical
Coding Audit Methodology version 8.0 must be adhered to for any audits during 2014-2015.
All reports and action plans from audits are submitted by the Clinical Coding Manager to the
relevant Information Governance groups for approval. Where audits have focussed on the
coding of deceased patients these reports are discussed at the Trust’s monthly Mortality
Committee meeting, clinical involvement in these audits is secured wherever relevant.
In addition to the programme of internal audit, Trusts are required to complete an audit of a
random sample of 200 Finished Consultant Episodes each year to support Information
Governance requirement 505. The 2014-15 Information Governance audit were carried out
during March and April 2015. When available, final results will be discussed with the Medical
Director and relevant Information Governance groups.
Derby Hospitals NHS Foundation Trust was subject to the Payment by Results (PbR) clinical
coding audit during the audit period by the Audit Commission and the error rates reported in
the latest published audit for that period for diagnoses and treatment coding (clinical coding)
were 4.5% Primary diagnosis, 3.8% secondary diagnoses, 14.5% primary procedures, 23.5
secondary procedures.
As part of their Payment by Results Assurance programme, the Audit Commission has
carried out Clinical Coding audits at various Trusts. The audit for Derby Hospitals was carried
82
out in November 2014 and focused on 200 Finished Consultant Episodes for 2 areas;
Thoracic Procedures and Disorders and Musculoskeletal Disorders. The results should not
be extrapolated further than the actual sample audited. The audit report acknowledged that
the Trust ensures that:
•
•
•
Novice coder training and mandatory coder refresher training was up to date.
The Trust has good clinician engagement. The Coding management team have close
links with the Trust’s Medical Director. Monthly validation reports are sent out to over 70
of the Trust’s consultants.
The Clinical Coding policy and procedure document is up to date and does not breach
national standards. The document contains guidance for coders as a result of good
clinical engagement.
Depth of Coding
The Royal Derby Hospitals will be taking the following actions to improve data quality:
•
A Task and Finish group was set up to look at ways of improving clinical documentation
of comorbidities (secondary diagnoses) as the coded data can only reflect what is
documented in the clinical notes. Awareness of the need for accurate and comprehensive
documentation was raised and Trust wide initiatives have been implemented.
•
A document has been developed which is incorporated into the Medical Clerking booklet
and has been in use from September 2014. Work is ongoing to develop an electronic
solution.
Monthly reports regarding Depth of Coding are now circulated to each Business Unit,
thus further highlighting their importance. High quality clinical coding ensures that service
performance, commissioning, and payment data is accurate.
•
As a result of this raised awareness and investment in the Clinical Coding team,
improvements in Depth of Coding have been evidenced. Much work has been done within
the Coding department to ensure that coders fully understand the need to record
documented comorbidities. As a result, between January and August 2014 the average
secondary diagnoses per spell had risen from 2.9 to 3.4. Since the introduction of the
document the Trust’s Depth of Coding has risen to 3.7 by December 2014.
INFORMATION GOVERNANCE (IG) TOOLKIT ATTAINMENT LEVELS
The Derby Hospitals NHS Foundation Trust Information Governance Assessment Report
overall score for 2014/2015 was 81% and was graded satisfactory.
2.11 DELIVERY OF NATIONAL TARGETS
The following table reflects the national targets the organisation is required to report as part
of its board reporting:
*All Cancer targets are the latest position (21.04.2015), to be updated once submitted
nationally.
83
Monitor
Target
14/15
Indicator
Incidence of Clostridium difficile - Total
69
(annual)
C.Diff Cases Under Review/No Lapse in Care
C.Diff Cases due to Lapse in Care
Q4
Actual to
March 15
Q4
Status
to
March
15
Actual
YTD to
Mar 15
17
61
12
47
5
14
Referral To Treatment – Admitted
>90%
81.72%
82.31%
Referral To Treatment - Non Admitted
>95%
94.02%
93.46%
Referral To Treatment – Incompletes
>92%
89.80%
90.06%
Total time in A&E (95% seen within 4 Hours)
>95%
95.61%
95.47%
Cancer 2 Week Wait
>93%
94.38%
93.09%
Cancers: 2 Week Wait - Breast Symptoms
>93%
98.72%
96.07%
Cancers: 31 Day Standard
>96%
96.56%
96.66%
Cancer: 31 Day - Subsequent Treatment – Surgery
>94%
97.33%
95.18%
Cancer: 31 Day - Subsequent Treatment – Drugs
>98%
99.23%
99.06%
Cancer: 31 Day - Subsequent Treatment – Radiotherapy
>94%
98.65%
95.60%
Cancer: 62 Day Std - Urgent Referral to Treatment
>85%
79.32%
79.92%
Cancer: 62 Day Screening
>90%
92.98%
94.05%
munity Services Data completeness – Activity
>50%
57.29%
55.34%
Community Services Data completeness – Referrals
>50%
65.34%
63.82%
Community Services Data completeness – RTT
>50%
100.0%
100.0%
Full
YTD
Status
ADDITIONAL INDICATORS
Prescribed info
Related NHS Outcomes
Framework Domain & Who
will report on them
The data made available to the National
Health Service Trust or NHS Foundation
Trust by the Health & Social Care
Information Centre with regard to:
Jul 2013 –
Jun 2014
(a) the value and banding of the summary
hospital-level mortality indicator (SHMI) for
the Trust for the reporting period; and
Apr 2013Mar 2014
Value
Banding
Value
Banding
84
Trust
Value
National
Average
High
Value
Low Value
1.067
2
1
1.198
0.5407
1
1.197
0.539
1.090
2
Apr 2012Mar 2013
(b) the percentage of patient deaths with
palliative care coded at either diagnosis or
specialty level for the Trust for the
reporting period.
Jul 2013Jun 2014
Apr 2012Mar 2013
Apr – Sept
2014
(i)
groin hernia surgery, (the "EQ-5D
Index" has been used: this is a
combination of five key criteria concerning
general health).
Apr 2013Mar 2014
Apr 2012Mar 2013
Apr – Sept
2014
(ii)
varicose vein surgery, (the "EQ-5D
Index’’ has been used: This is a
combination of five key criteria concerning
general health).
(iii) hip replacement surgery, (the "EQ-5D
Index" has been used: this is a
combination of five key criteria concerning
general health).
(iv) knee replacement surgery, (the "EQ5D Index" has been used: this is a
combination of five key criteria concerning
general health).
(i)
0-15; and readmitted to a hospital
which forms part of the Trust within 28
days of being discharged from a hospital
which forms part of the Trust during the
reporting period.
(ii) 16 or over; and readmitted to a
hospital which forms part of the Trust
within 28 days of being discharged from a
hospital which forms part of the Trust
during the reporting period.
The data made available to the National
Health Service Trust or NHS Foundation
Trust by the Health & Social Care
Information Centre with regard to the
Trust's responsiveness to the personal
needs of its patients during the reporting
period.
The data made available to the National
Health Service Trust or NHS Foundation
Trust by the Health & Social Care
Information Centre with regard to the
Value
1
1.1563
0.6259
24.6
10.4
29.2
29.4
29.1
0.09
1.11
1.12
49.0
16.9
43.9
44
0
0
0.1
0.1
Health Gain
0.065
0.081
0.125
0.009
% Improved
41.7%
50.2%
55.9%
25.7%
Health Gain
0.085
0.085
0.139
0.008
% Improved
45.4%
50.6%
66.7%
30.0%
Health Gain
0.055
0.087
0.147
0.002
% Improved
40.2%
51.0%
64.3%
30.0%
0.1
0.142
0.054
53.8%
61.5%
47.1%
0.093
0.15
0.023
51.8%
66.7%
44.3%
0.095
0.167
0.049
Banding
Treatment Rate
Diag Rate
Combined Rate
Treatment Rate
Diag Rate
Combined Rate
50%
Health Gain
% Improved
Apr 2012Mar 2013
2
Health Gain
% Improved
Apr 2013Mar 2014
1.1102
57.1%
Health Gain
% Improved
Health Gain
% Improved
0.418
91.4%
53.6%
0.442
90.6%
70.6%
0.501
93.8%
54.3%
0.35
80.0%
Health Gain
0.401
0.436
0.545
0.342
% Improved
85.4%
89.3%
100%
77.8%
Health Gain
0.412
0.416
0.499
0.306
% Improved
Health Gain
% Improved
86.5%
0.355
85%
87.5%
0.328
82.2%
96.8%
0.394
87.2%
76.9%
0.249
74.0%
Health Gain
0.323
0.323
0.416
0.215
% Improved
81.9%
81.4%
100%
67.5%
Health Gain
0.321
0.319
0.409
0.195
% Improved
80.3%
80.7%
90.2%
69.7%
7.27
10.09
16.38
0
7.91
10.15
25.8
0
Apr 2013- Mar 2014
11.54
11.45
41.65
0
Apr 2012- Mar 2013
12.91
11.42
22.93
0
Apr 2013- Mar 2014
78.5
76.9
87
67.1
Apr 2012- Mar 2013
78.0
76.5
88.2
68
Apr 2014- Dec 2014
95.6%
96.1%
100%
81%
Apr – Sept
2014
Apr 2013Mar 2014
Apr 2012Mar 2013
Apr – Sept
2014
Apr 2013Mar 2014
Apr 2012Mar 2013
Apr 2013- Mar 2014
Apr 2012- Mar 2013
85
percentage of patients who were admitted
to hospital and who were risk assessed for
venous thromboembolism during the
reporting period.
The data made available to the National
Health Service Trust or NHS Foundation
Trust by the Health & Social Care
Information Centre with regard to the rate
per 100,000 bed days of cases of
C.difficile infection reported within the
Trust amongst patients aged 2 or over
during the reporting period.
The data made available to the National
Health Service Trust or NHS Foundation
Trust by the Health & Social Care
Information Centre with regard to 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.
Prescribed info
Friends and Family Test - Question
Number 12d – Staff - ‘If a friend or relative
needed treatment I would be happy with
the standard of care provided by this
organisation'
Friends and Family Test – Patient covering services for inpatients and
patients discharged from Accident and
Emergency (types 1 and 2) Percentage
Recommend
Apr 2013- Mar 2014
93.16%
Apr 2013- Mar 2014
21
14.7
0
Apr 2012- Mar 2013
21.3
17.4
0
95.77%
100%
79%
37.1
31.2
01/04/14 - 30/09/14
- Incidents
- rate per 1000 bed bays.
- severe harm - number
- percentage
- death - number
- percentage
5807
33.93
6
0.1 %
3
0.052%
4196
36
15
1%
5
0%
12020
75
74
74 %
24
9%
35
0
0
0%
0
0%
01/10/12 - 31/03/13
- Incidents
- rate per 100 admissions
- severe harm - number
- percentage
- death - number
- percentage
5735
8.12
3
0.052%
3
0.052%
4428
7.22
25
0.014%
9
0.004%
7835
12.73
101
3.35 %
20
0.42%
1761
3.04
0
0%
0
0%
Related NHS Outcomes
Framework Domain & Who will
report on them
Trust
Value
National
Average
High Value
Low Value
2014 / 2015 Q2
86%
75%
98%
41%
2013 / 2014
69%
64%
94%
40%
Feb 2015
89%
91%
100%
82%
Jan 2015
89%
91%
100%
51%
Mortality Indicator
The Derby Hospitals NHS Foundation Trust considers that this data is as described for the
following reasons:
Given that there is a hospice on site at the Royal Derby Hospital, this has an impact on the
SHMI index for in-hospital deaths.
The Mortality indicators are in line with the expected national average.
Derby Hospitals NHS Foundation Trust has taken the following actions to improve this score
and so the quality of its services, by:
•
•
•
A concerted effort this year to improve the depth of coding of co-morbidities.
Any condition that triggers a mortality alert is subject to a case-note review.
The Trust is in the process of implementing a system whereby every death will be
scrutinised against markers of good quality care.
86
Patient Reported Outcome Measures (PROMS)
The Derby Hospitals NHS Foundation Trust considers that this data is as described for the
following reasons:
The EQ-5D Index is a combination of five key criteria concerning general health. The EQ-5D
INDEX CHANGE is a calculated average for these five criteria (Mobility, Self-Care, Usual
Activities, Pain/Discomfort and Anxiety/Depression)
The EQ VAS is the current state of the patients general health marked on a visual analogue
scale 0 - 100. The EQ-VAS INDEX CHANGE is calculated as Q2 result minus Q1 result.
In addition to the EQ indexes, there are additional Hip/Knee Replacement specific questions
that were asked of the patients and the score is a calculated average of these 12 questions.
The data has been analysed at consultant level for knee replacement as there appeared to
be deterioration in year. There were no themes or issues highlighted following the review and
all the results were shared at the Trust audit and effectiveness committee as well as at
Divisional level.
Derby Hospitals NHS Foundation Trust has taken the following actions to improve this score
and so the quality of its services, by:
•
•
•
In addition to the PROMS, knee replacement patients are telephoned by the
physiotherapist two days post discharge for support related to mobility and rehabilitation.
This may result in a home visit. Patient feedback has resulted in the re-enforcement of
prescribing appropriate analgesia.
In addition to the PROMS, hip replacement patients are telephoned by the senior sister
four days post discharge for general support and guidance. The patient feedback has
resulted in a review of patient information to include coping strategies for patients, for
patients to use due to disturbed sleep patterns which can impact on their health and
wellbeing, and mobility, post operatively.
For both varicose veins and groin hernia, the number of procedures carried out within the
Trust is relatively small; however, additional training sessions for staff have been
organised in year to support an increase in questionnaire response rates.
Readmission Rates
The data made available to Derby Hospitals NHS Foundation Trust by the Health and Social
Care
Information Centre with regard to:
Readmission rates during 2014/15 for the percentage of patients aged:
I. 0-15 was 4.9%
II. 16 or over was 13.2%, readmitted to hospital within 28 days of being discharged from a
hospital that forms part of the Trust during the reporting period.
The Derby Hospitals NHS Foundation Trust considers that this data is as described for the
following
reasons:
•
There has been an increase in the admission rate for both sets of data from 2013/14 to
2014/15, and abdominal pain and infection were the largest readmission diagnoses
across all specialities. The Trust has set up a reducing readmissions group which is
aiming to tackle readmissions rates through an enhanced discharge programme for
patients at risk of readmission, learning from good practice nationally and benchmarking
standard readmission definitions.
87
•
Overall, for the financial year 2013/14 the Derby Hospitals NHS Foundation Trust’s
readmission rate was at 12.0% and increased to 13.1% during 2014/15.
Derby Hospitals NHS Foundation Trust has taken the following actions to improve this score
and so the quality of its services, by:
•
•
•
•
•
•
•
•
Continued to run re-admission group with a focus within medicine, this is currently
being reviewed to align with divisions in order to feed back at specialty level. The
group will target readmissions projects according to areas identified from data
analysis for improvement.
Developed a dashboard containing current data which is accessible by key managers
within the Organisation. This is currently being revised to provide more detail. This will
show readmissions by specialty, but also readmissions which go back to the same
specialty in order to provide an indication of avoidable and unavoidable readmissions.
The dashboard will also show expected vs actual readmissions and will be aligned
with PbR.
Data analysis has been completed for the CQC indicator for elective readmissions
with an overnight stay, this highlighted that improvement is required in Gynaecology.
A Gynaecology audit is currently being completed and results are expected shortly.
Currently using Healthcare Evaluation Data (HED) to benchmark readmissions and
identify improvement areas.
Enhanced discharge project has been rolled out, an evaluation will be complete by
the end of May, this will make recommendations to further inform the roll out,
particularly to ensure that resource is focussed in the right areas.
Monthly audit is carried out for ‘ED top 20 attenders’, GP’s will be written to and
informed of patients who re-attend. Top attenders have been highlighted as patients
with no fixed abode. A patient information leaflet has been developed with the Healthy
Futures Project, this is available for patients in ED, MAU and Short Stay wards. It
includes a referral form for DHFT to refer to housing.
Amber Care Project for End of Life Care.
Work on Frail Elderly Pathway, including an evaluation of the impact of the FEAT
team on future demand of services.
Staff Experience/Engagement
The Derby Hospitals Foundation Trust considers that this data is as described for the
following reasons:
The organisation has been using a staff impressions system which has enabled us to
introduce the national staff friends and family test, as well as provide us with the flexibility to
ask additional locally themed questions to help us better understand current views and
experiences of staff working within the Trust. There is approximately a quarter of our
workforce who completes this survey each quarter.
“if a friend or relative needed treatment would be happy with the standard of care provided by
this organisation“
The data made available to DHFT by the Health and Social care Information Centre with
regard to 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
In 2014 national staff survey there was an improvement in score from 69% to 77 %
88
Derby NHS Foundation Trust is taking the following actions to continue to improve this score
and the quality of its services by:
•
Continuing to build on existing engagement structures alongside the locally themed
questions this includes:
•
Staff forums, Health Care Assistant Conferences, Non-Executive surgeries, and
confidential surgeries as well as active back to the floor programmes.
•
Over the next year, we will be continuing to undertake a variety of activities both internally
and externally to the Trust to promote the benefits of working within the Trust and the
wider NHS as well as the range of NHS careers available.
Venous Thromboembolism
The Derby Hospitals NHS Foundation Trust considers that this data is as described for the
following reasons:
• This data demonstrates the percentage of all adult inpatients that have had a VTE risk
assessment on admission to hospital using the clinical criteria of the national audit tool.
Derby Hospitals NHS Foundation Trust has taken the following actions to improve this score
and so the quality of its services, by
•
Increasing and sustaining the percentage of recorded risk assessments to 95% in line
with National Guidance by:
- Ensuring doctors carry out the risk assessment prior to prescribing – and reviewing
compliance at Business Unit level monthly
- Working with our electronic prescribing system to force a risk assessment being
completed electronically before the prophylaxis is prescribed
- Reviewing current local policies on prescribing of thromboprophylaxis.
Clostridium difficile (C.diff)
Derby Hospitals Foundation Trust considers that this data is as described for the following
reason:
• This data demonstrates the number of patients with a positive test result 72 hours or
more after admission.
The target set for 2014/15 was no more than 69 cases. The Trust ended the year with a total
of 61 cases.
The Trust has taken the following actions to improve this score and so the quality of its
service by:
• Continuous assessment and review to ensure that all actions to minimise the risk of
patients developing the infection have been undertaken.
• Root causes analysis is undertaken for each Trust acquired case of C.diff. The outcomes
of these are shared with the clinical teams and action plans that are put into place.
• The C.diff Review Group reviews all patients with C.diff infection to ensure optimum
treatment and supporting care to patients is given. The group also develops and assists
with the implementation of the C.diff policy.
• Learning points from the C.diff cases are presented at the Trust Infection Control
Committee.
89
Safety Incidents
The data made available to the Trust by the Health and Social Care Information Centre with
regard to –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.
The Derby Hospitals Foundation Trust considers that this data is as described for the
following reasons:
• 6 monthly retrospective reports are published by the NHS Commissioning Board and are
monitored closely
• The Trust supports an effective safety culture via the increased reporting of incidents
• Increase in incident reporting against the same period last year which reflects the Derby
Hospitals NHS Foundation Trust’s position of 13th highest incident reporter out of 38 large
acute organisations listed by the NHS Commissioning Board.
Derby Hospitals NHS Foundation Trust has taken the following actions to improve this score
and so the quality of its services:
•
•
Continue to monitor and review all classification of incidents to ensure correct rating
Ensure Datix is updated appropriately.
Friends & Family Test
The Derby Hospitals NHS Foundation Trust considers that this data is as described for the
following reasons:
•
•
•
Monthly submission of data in line with national reporting requirements which are
published by NHS England and are monitored closely.
Over the last year, compared with 12/13, the Trust has seen a steady rise in its Friends
and Family test score for inpatient Services.
The Trust continues to use new and varied ways of getting real time feedback, which will
be made easier with the introduction of our Electronic Friends and Family Test.
The Derby Hospitals NHS Foundation Trust has taken the following actions to improve this
score and so the quality of its services, by:
-
our ‘Your Views Matter’ cards
text messaging in ED; and
via an electronic portal which we rolled out in March 2014 - this will allow for an on line
portal to be available to all patients, visitors, and carers. This is the sister system to that
currently used by our Human Resources Team so that triangulation between both staff
surveys and patient feedback will be able to be carried out.
ASSURANCE OVER MANDATED INDICATORS
PERCENTAGE OF INCOMPLETE PATHWAYS WITHIN 18 WEEKS FOR PATIENTS ON
INCOMPLETE PATHWAYS AT THE END OF THE REPORTING PERIOD
Detailed descriptor
patients on
The percentage of incomplete pathways within 18 weeks for
incomplete pathways at the end of the period
Numerator
reporting
The number of patients on an incomplete pathway at the end of the
period who have been waiting no more than 18 weeks
90
Denominator
The total number of patients on an incomplete pathway at the end
of the reporting period
Denominator (monthly average number of patients on the waiting list 14/15): 29,228
Numerator (monthly average number of patients waiting 18 weeks+): 2,902
Indicator Percentage: 90.1%
The Trust introduced a new patient access system in 2014, and this disrupted the flow of
information concerning RTT pathways. Consequently, the first four months of the financial
year were submitted to Monitor retrospectively and were therefore not fully accessible to
audit requirements. However, the external auditors will be undertaking further work in
2015/16 to confirm that the 2015/16 process for submitting RTT data is compliant with
regulations.
EMERGENCY READMISSIONS WITHIN 28 DAYS OF DISCHARGE FROM HOSPITAL
Indicator description Emergency re-admissions within 28 days of discharge from hospital
Numerator The number of finished and unfinished continuous inpatient spells that are
emergency admissions within 0 to 27 days (inclusive) of the last, previous discharge from
hospital (see denominator), including those where the patient dies, but excluding the
following: those with a main speciality upon re-admission coded under obstetric; and
those where the re-admitting spell has a diagnosis of cancer (other than benign or in situ)
or chemotherapy for cancer coded anywhere in the spell.
Denominator The number of finished continuous inpatient spells within selected medical
and surgical specialities, with a discharge date up to 31 March within the year of
analysis. Day cases, spells with a discharge coded as death, maternity spells (based on
specialty, episode type, diagnosis), and those with mention of a diagnosis of cancer or
chemotherapy for cancer anywhere in the spell are excluded. Patients with mention of a
diagnosis of cancer or chemotherapy for cancer anywhere in the 365 days prior to
admission are excluded.
Trust readmission rate for FY 13/14
Number of admissions:
Number of readmissions:
* Readmission rate:
Trust readmission rate for FY 14/15
Number of admissions:
Number of readmissions:
Readmission rate:
52257
6251
12.0%
55838
7320
13.1%
* these figures have been restated to exclude non admitted patients in triage wards
FRIENDS AND FAMILY TEST (QUESTION NO. 12d STAFF)
Indicator description: If a friend or relative needed treatment I would be happy with the
standard of care provided by this organisation.
This is a local indicator chosen by the Governors and subsequently looked at by the external
auditors as part of their quality inspection audit. The scores were 77% for 2014 and 69% for
2013.
91
SECTION 3
QUALITY PERFORMANCE GOVERNANCE ARRANGEMENTS
The Trust has a robust structure of groups and committees (see quality governance structure
below) which feed into the Board Quality Committee (QC), along with quality reports from the
Divisions.
The Quality Committee is a committee of the Trust Board and it meets monthly. Each month
the Committee hears a patient story and the subsequent actions taken by staff. Each Division
presents to the Quality Committee in turn, enabling the Committee to triangulate data and
intelligence from a rich number of sources.
This is further enriched by the ability to develop recommendations and action for any issues.
QRC reports through performance and scrutiny management meetings and also to the
Quality Committee. This is being further enhanced through our Divisional Performance
Management Meetings which will include a quality focus on the meeting agenda, a quality
dashboard used by the Business Units, our Management Executive, and Trust Board to
actively monitor quality metrics in line with the five CQC domains of safe, caring, effective,
responsive and well led services.
Internal and external auditors routinely incorporate quality assurance into their annual audit
plans. All internal audit reports are reported to Board committees and to the Board by Audit
committee minutes. The Trust's annual quality report is audited by PricewaterhouseCoopers
(PwC).
Quality Governance Structure
TRUST BOARD
QUALITY COMMITTEE
For assurance
MANAGEMENT EXECUTIVE
Organ Donation
Committee
Ethics
Committee
QUALITY REVIEW COMMITTEE
Health &
Safety
Committee
Health &
Safety
Operational
Group
Mortality
Committee
Clinical Audit
& Effectiveness
Committee
Patient Safety
Committee
Patient
Experience
Committee
Infection
Control
Committee
Safeguarding
Committee
Research Group
Incident Review
Group
Patient Experience
and Engagement
Group
Infection Control
Group
Dementia Group
Horizon Scanning
Group
Critically Ill Patient
Group
Nutrition &
Hydration Group
Facilities
Access to Acute
Group
Drugs &
Therapeutics
Group
Leading
Improvement in
Patient Safety
Health Prom
Hosp Group
Decontamination
Clinical Guidelines
Group
Radiation
Protection Group
Pain Forum
Transfusion &
Thrombosis
Group
Clinical Change
Management
Group
92
End of Life Steering
Group
Engagement Group
Patient Panel
Complaints Review
Group
3.1 BOARD TO WARD PROGRAMME
The Board to Ward programme was launched in November 2011, and between April 2014
and March 2015, 48 visits have been undertaken. An Executive and Non-Executive Board
Member carry out each visit jointly. The focus of the programme is:
•
•
•
•
Relationship Development - the visiting team will have the opportunity to meet with
staff, patients and carers in the clinical area. Two way communication during these visits
means that both teams will be able to share key messages. It is also a time when the
care environment can demonstrate areas of good practice.
Visible Leadership - this programme supports the clear message that the delivery of
high quality care across the organisation is important to the Trust Board. This is the
message that is important internally for patients and staff, and externally for the public
and key stakeholder organisations.
Supporting the embedding of the Quality Strategy - the visits provide the forum to
ensure that there is a wide understanding of the strategy across the organisation. The
Executive/Non-Executive receive an update on the current clinical delivery, and it brings
to the life for the team some of the areas that are being demonstrated in the reports at
Trust Board Meetings.
Seeking further understanding and assurance of Patient Experience – where
appropriate the team explore the experience of the patient through informal discussion
The format of the Board to Ward visit has recently been reviewed and is now in line with the
CQC five Key lines of Enquiry (KLOE). This helps the team to gain an understanding of how
patients and service users feel about the care provided and what gives them confidence. It
helps to identify the key components of high quality care that are important to patients and
carers from their first contact with a care setting.
The five KLOE are
•
Are services safe?
•
Are services effective?
•
Are services caring?
•
Are services responsive?
•
Are services well led?
Themes from the visits include:
•
Overall patients are very happy with treatment and care, giving positive feedback.
•
Visible strong leadership with a clear focus on high quality of patient care.
•
Genuine commitment and engagement from staff for the delivery of high quality services
to patients.
•
Collaborative working of the MDT and rotation of nursing staff in the Trust, introduction of
different roles, i.e. Advanced Nurse Practitioners and the support they give ward areas.
•
Regular MDT meetings and multi-speciality working.
•
Overall a very clean and inviting environment, however there is inconsistent access to
bedside entertainment across all wards.
•
Introduction of focused patient experience activities, i.e. "afternoon tea events".
•
Lack of storage space and large items of equipment stored in bathrooms.
93
Annex 1:
STATEMENTS FROM CLINICAL COMMISSIONING GROUPS, HEALTHWATCH
DERBYSHIRE,
IMPROVEMENT AND SCRUTINY COMMITTEES, AND THE TRUST COUNCIL OF
GOVERNORS
STATEMENT FROM
FOUNDATION TRUST
COUNCIL
OF
GOVERNORS
DERBY
HOSPITALS
NHS
During 2014/15 the Core Regulations Working Group which is a sub-committee of the
Council of Governors has met on a regular basis to discuss the findings of a number of audits
undertaken by members of the group. During the year a total of 13 audits have been carried
out in a variety of settings across the Trust.
The audits have followed the previous format with two members of the group on each
occasion who observe the area, interview the sister or matron and a total of 4 patients. The
interviews are built around the Essential Standards and Outcomes developed by the Care
Quality Commission (CQC) who regulate health and adult social care in England.
Evidence is collected during the audit to assure the governors that the standards are being
met. A verbal report is always given to the matron or sister on the day of the audit and a full
report written. The findings of each report are discussed at the Core Regulations working
group that is attended by the Head of Governance, the report is sent to the area with the key
findings and actions required if necessary. If there have been any concerns these are
highlighted and the area is asked to develop an action plan to resolve issues. The group has
a system in place to monitor any actions required and ensure that problems are resolved.
Members of the group have continued to undertake 15 steps audits with some of the NonExecutive Directors across a range of wards in the Trust. These audits are designed to
capture first impressions when walking into an area, amongst other things observing what
does it look like, how does it sound what is the atmosphere like in the area. All things that are
so important to the patient and their journey.
Towards the end of the year members of the group assisted with the mock inspections
undertaken in preparation for the CQC inspection that took place in December. This was felt
to be a useful exercise and the group has agreed to review its work in light of the CQC report
once it has been published and discussed.
Governors also continue to sit on a range of Trust groups and committees and give regular
feedback to their fellow governors. This enables the Governors to discuss, comment on and,
where necessary, question a broad range of activities many involving the patient experience
but also looking at the annual plans and service developments, finances and facilities
management. In addition Governors support the Trust with the Patient Led Assessments of
the Care Environment (PLACE) visits that are attended by our local Healthwatch
organisations.
Through all of these activities Governors are able to gain a valuable insight into the work of
the Trust. They talk to staff, patients and other members of the general public to gauge how
people feel about the Trust and to enable them to carry out their roles as public governors.
94
STATEMENT FROM SOUTHERN DERBYSHIRE CLINICAL COMMISSIONING GROUP
GENERAL COMMENTS
NHS Southern Derbyshire Clinical Commissioning Group (SDCCG) is the co-ordinating
commissioner for services provided by Derby Teaching Hospitals NHS Foundation Trust
(DTHFT). In this role, SDCCG is responsible for ensuring publication clearance of the Quality
Account produced by DTHFT for 2014/15.
MEASURING AND IMPROVING THE PERFORMANCE
The Quality Account has been subject to a detailed review by the CCG, ensuring that the
data and information reported in the account is consistent with the data submitted to the
CCG.
COMMENTARY
Firstly the CCG would like to thank the Trust for their continued hard work in the production
of this annual Quality Report. The report sets out the priorities for 2014/15 which were
established following engagement with staff and patients. The CCG acknowledges the work
undertaken by the Trust to fully embed their Quality Strategy and the improvement to the
services provided to patients as a consequence.
It is recognised that the content of the Quality Account is dictated nationally however the way
in which that content is worded and presented is at the discretion of the Trust. In places, the
CCG found that the language that was used was very technical, sometimes making it difficult
to interpret, for those not familiar with the terminology. As a consequence the report is
perhaps longer than would be expected. In addition, it would be good to see more
information about the services that were reviewed during 2014/15. The Trust has made a
commitment to review the format of the report next year and engage stakeholders earlier in
the process.
The Quality Account details many quality schemes attracting financial incentives. In the main
these indicators are mandated nationally or locally, having been negotiated by both the CCG
and the Trust. One area which did not enjoy success during 2014/15 was Dementia care.
Whilst not explicitly stated in the report, a number of requirements were not achieved. A
revised approach will be taken during 2015/16 with the CCG and Trust being committed to
working more closely during 2015/16 to recognise non-achievement earlier in the year and
support greater success in this area.
During 2014/15, the Trust was subject to a visit and subsequent report from the CQC.
Overall, the Trust was scored as ‘Good’ for the services they provide. A number of key areas
have been identified for further work and development. These will be monitored using the
Trust CQC Action Plan that has been developed in response to the report.
Amongst the many achievements this year is the work around Infection Prevention and
Control (IPC), in particular the performance against the number of avoidable C.Diff cases.
The Trust was set a target of no more than 69 cases for the year. Through a variety of
initiatives, the Trust achieved 61. The CCG attends the review group that has been
established to identify learning from Healthcare Associated Infections (HCAI) and has been
assured by the scrutiny that has been witnessed at the HCAI Review Group.
The CCG has worked closely with the Trust to implement the ‘Think Kidney’ initiative in order
to quickly identify and treat patients with AKI (Acute Kidney Injury). The Trust has received
significant recognition for the excellent work that has taken place, which has also resulted in
presentations by Trust Consultants at an international level.
An area of good practice highlighted in the report is the initiative to support palliative care
patients through the commissioning and implementation of palliative care beds in local care
95
homes. This project has evaluated very positively and is expected to be developed further
going forward.
It is good to see the Trust visit programme set out in the report. A number of these are
undertaken with the CCG who then monitor and support the Trust to ensure that
recommendations are implemented. Comprehensive reports are produced and, where
appropriate, follow-up visits are carried out.
The CCG are pleased to see the number of safety initiatives that the Trust is implementing
and supporting. Of note is the local initiative ‘Patient Safety 10’ which seeks to empower
patients and also the national campaign ‘Sign up to Safety’ which the report states ‘is
designed to support the NHS to reduce avoidable harm by 50% and save 6,000 lives’.
The CCG notes the further roll-out of the Friends and Family Test (FFT) into maternity and
the mechanism used to do this which is based upon feedback from patients. Overall, the
Trust has made good progress in this area, and has highlighted patient feedback as an area
for further work and development.
The Trust and CCG seek to work in collaboration. 2014/15 saw this implemented for specific
areas of work, e.g. Pressure Ulcer avoidance. There is an expectation that this will continue
and grow during 2015/16 with an increased focus on working more closely with quality teams
to better understand each other’s roles and expectations.
PRIORITIES FOR 2015/16
The Trust Quality Strategy clearly sets out the priorities for 2015/16 with a one year delivery
plan against the 5 CQC domains; ‘Making Us Safer’, ‘Making Us More Caring’, ‘Making Us
More Effective’, ‘Making Us More Responsive’ and ‘Making Us Well Led’. The Quality
Account states that the delivery plan will be subject to scrutiny within the Trust. The CCG will
continue to apply the same rigour to the contractual requirements that are encompassed
within the strategy and looks forward to celebrating the anticipated achievements and
successes.
Andy Layzell
Chief Officer
96
STATEMENT FROM HEALTHWATCH DERBY
On behalf of Healthwatch Derby, I would like to present our formal response to Derby
Teaching Hospitals NHS Foundation Trust's Quality Account 2014/2015. I would like to
congratulate the Trust on a very positive year, and we take note of all your key
achievements.
At Healthwatch Derby we are proud of our partnership work with the Trust, and are delighted
to report we continue to engage and feedback our findings regularly to colleagues within the
Trust.
A few observations about the Quality Account:
1. We note the significant pressures on A&E services during the last winter period. We have
recently completed a report looking at GP services, and made recommendations which we
hope will help reroute patients to correct treatment paths rather than choosing A&E where it
is not necessary. We have spoken to commissioners about the need to promote routes of
treatment other than A&E.
2. The Quality Account refers to the enter and view assessments we have undertaken in
conjunction with the PLACE visits, but does not make any reference to the findings of these
reports. We have done considerable work with enter and views, and also monitoring the
outcomes of these reports. We believe apart from inhouse data, it is important for the Trust to
fully take on board and examine the independent data provided by local Healthwatches.
3. We are pleased to see discharge is going to be prioritised as an area of improvement. In
the period observed, we have been aware of several serious discharge related concerns
reported to us which we fed back to the Trust following established data sharing and
escalation policies. Unfortunately issues with discharge as observed by Healthwatch Derby
have become worse in the last twelve months with an increase in incidents that have
required safeguarding referrals.
4. We note the information about incidents regarding medication. Again this is a key area that
we have highlighted in the feedback provided about discharge experiences.
We look forward to working closely with the Trust as it implements changes to improve
discharge experiences for patients, carers and families.
5. We are unable to comment on complaints and compliments received in the observed
period due to lack of data in the version submitted to us for our response (page 29).
The above are some key observations from the Quality Account, and we are pleased to
advise you that this year we received the full 30 day consultation period to respond at our
request.
We look forward to another year of continued successful partnership, with work already
underway to support our 'Little Voices' project looking at patient experiences of pregnancy,
maternity, and children’s services run by the Trust and other providers.
Samragi Madden
Healthwatch Derby
Quality Assurance & Compliance Officer
97
STATEMENT FROM HEALTHWATCH DERBYSHIRE
Healthwatch Derbyshire collects real people’s experiences of health and social care services,
as told by patients, their families and carers. These experiences, as reported to Healthwatch,
will form the basis of this response.
Healthwatch Derbyshire has passed this patient feedback to the Trust during the reporting
period in the form of comments. Well in excess of 100 comments have been received about
the services provided by the Trust, with a range of positive, negative and mixed sentiments.
These comments are regarding a whole range of Trust services and present a wide variety of
themes.
The Trust has fed back to Healthwatch comprehensive responses which demonstrate actions
and learning within the organisation based on these comments and experiences.
On several occasions, the Trust has provided feedback indicating a specific change in line
with the content of a comment given, which is a useful demonstration of the Trust’s capacity
to listen to and learn from patient feedback. This feedback is also fed back to the specific
individuals who spoke to Healthwatch Derbyshire, and so inspires confidence in Healthwatch
Derbyshire, the Trust, and the value of ‘speaking up’.
Healthwatch Derbyshire looks forward to working with the Trust in 2015-16 along similar
lines.
Helen Hart
Intelligence and Insight Manager
Healthwatch Derbyshire
STATEMENT FROM DERBY CITY COUNCIL'S ADULT AND PUBLIC HEALTH
OVERVIEW AND SCRUTINY BOARD
The Adults and Public Health Overview and Scrutiny Board has a wide remit and therefore
mainly seeks to take strategic approach to scrutiny of health and social care issue. This can
affect amount of time it can devote to some items and the depth of scrutiny it can undertake.
During the 2014/15 the board has looked at the following areas which may be linked to Derby
Teaching Hospitals NHS Trust:
•
•
•
•
Timely hospital discharge
Access to GP services
Re-commissioning Derby Walk-in services
Health Inequalities Gap
The Board has not been alerted to any concerns linked to Derby Teaching Hospitals Trust
and therefore does not have any comments to make.
Submitted by Mahroof Hussain, Scrutiny and Civic Services Manager on 30 April 2015
98
Annex 2:
STATEMENT OF DIRECTORS’ RESPONSIBILITIES IN RESPECT OF THE QUALITY
ACCOUNT
The directors are required under the Health Act 2009 and the National Health Service
(Quality Accounts) Regulations to prepare Quality Accounts for each financial year.
Monitor has issued guidance to NHS foundation trust boards on the form and content of
annual quality accounts (which incorporate the above legal requirements) and on the
arrangements that foundation trust boards should put in place to support the data quality for
the preparation of the quality account.
In preparing the Quality Account, directors are required to take steps to satisfy themselves
that:
•
•
•
•
the content of the Quality Account meets the requirements set out in the NHS Foundation
Trust Annual Reporting Manual 2014/15 and supporting guidance;
the content of the Quality Account is not inconsistent with internal and external sources of
information including: o Board minutes for the period April 2014 to the date of signing this limited
assurance report (the period);
o Papers relating to quality report reported to the Board over the period April 2014
to the date of signing this limited assurance report;
o Feedback from the Commissioners Southern Derbyshire Clinical Commissioning
Group dated 27/05/2015;
o Feedback from Governors dated 19/05/2015;
o Feedback from Healthwatch Derby dated 14/05/2015;
o Feedback from Healthwatch Derbyshire dated 19/05/2015;
o Feedback from the Adults and Public Health Overview and Scrutiny Board at
Derby City Council dated 30/04/2015;
o The Trust’s complaints report published under regulation 18 of the Local Authority
Social Services and NHS Complaints Regulations 2009, Derby Teaching
Hospitals NHS Foundation Trust Complaints and Compliments Annual Report
2014-2015;
o The 2014 Children’s Inpatient and Day Case Survey and Patient survey report
2014 dated 01/04/2015.
o The 2014 National NHS staff survey, Results from Derby Hospitals NHS
Foundation Trust;
o Care Quality Commission Intelligent Monitoring Reports dated 31/03/2014,
31/07/2014, 31/12/2014 and 31/03/2015;
o 360 Assurance Interim Head of Internal Audit Opinion, Derby Teaching Hospitals
NHS Foundation Trust, 13th May 2015;
o Trust Board Update CQC minutes dated 06/10/2014;
o Care Quality Commission, Derby Hospitals NHS Foundation Trust, Royal Derby
Hospital Quality Report December 2014;
o Care Quality Commission, Derby Hospitals NHS Foundation Trust, Quality Report
Inspection, Date of Inspection Visit 8-11 December 2014.
o PbR DAF Clinical Coding Audit from Monitor dated 19/05/2015
the Quality Account presents a balanced picture of the NHS foundation trust's
performance over the period covered;
the performance information reporting in the Quality Account is reliable and accurate
99
•
•
•
there are proper internal controls over the collection and reporting of the measures of
performance included in the quality report, and these controls are subject to review to
confirm that they are working effectively in practice;
the data underpinning the measures of performance reported in the quality report is
robust and reliable, conforms to specified data quality standards and prescribed
definitions, is subject to appropriate scrutiny and review, and
the quality report has been prepared in accordance with Monitor’s annual reporting
guidance (which incorporates the Quality Accounts regulations) (published at
www.monitor.gov.uk/annualreportingmanual) as well as the standards to support data
quality
for
the
preparation
of
the
Quality
Report
(available
at
www.monitor.gov.uk/annualreportingmanual).
The directors confirm to the best of their knowledge and belief they have complied with the
above requirements in preparing the Quality Account.
By order of the Board
28 May 2015
28 May 2015
. . . . . . . . . . . Chairman
. . . . . . . Chief Executive
100
Annex 3:
INDEPENDENT ASSURANCE REPORT
Independent Auditor’s Limited Assurance Report to the Council of Governors of Derby
Hospitals NHS Foundation Trust on the Annual Quality Account
We have been engaged by the Council of Governors of Derby Hospitals NHS Foundation
Trust to perform an independent assurance engagement in respect of Derby Hospitals NHS
Foundation Trust’s Quality Report for the year ended 31 March 2015 (the ‘Quality Report’)
and specified performance indicators contained therein.
Scope and subject matter
The indicators for the year ended 31 March 2015 subject to limited assurance (the “specified
indicators”); marked with the symbol
in the Quality Report, consist of the following
national priority indicators as mandated by Monitor:
Specified Indicators
Specified indicators criteria
Emergency re-admissions within 28 days Page 149
of discharge from hospital.
Percentage of incomplete pathways Page 148
within 18 weeks for patients on
incomplete pathways at the end of the
reporting period.
Respective responsibilities of the Directors and auditors
The Directors are responsible for the content and the preparation of the Quality Report in
accordance with the specified indicators criteria referred to on the pages of the Quality
Report as listed above (the "Criteria"). The Directors are also responsible for the conformity
of their criteria with the assessment criteria set out in the NHS Foundation Trust Annual
Reporting Manual (“FT ARM”) and the “Detailed requirements for quality reports 2014/15”
issued by the Independent Regulator of NHS Foundation Trusts (“Monitor”).
Our responsibility is to form a conclusion, based on limited assurance procedures, on
whether anything has come to our attention that causes us to believe that:
•
The Quality Report does not incorporate the matters required to be reported on as
specified in Annex 2 to Chapter 7 of the FT ARM and Monitor’s “Detailed
requirements for quality reports 2014/15”;
•
The Quality Report is not consistent in all material respects with the sources specified
below; and
•
The specified indicators have not been prepared in all material respects in accordance
with the Criteria and the six dimensions of data quality set out in Monitor’s “2014/15
Detailed guidance for external assurance on quality reports”.
We read the Quality Report and consider whether it addresses the content requirements of
the FT ARM and Monitor’s “Detailed requirements for quality reports 2014/15; and consider
the implications for our report if we become aware of any material omissions.
We read the other information contained in the Quality Report and consider whether it is
101
materially inconsistent with the following documents:
•
•
•
•
•
•
•
•
•
•
•
•
•
Board minutes for the period April 2014 to the date of signing this limited assurance
report (the period);
• Papers relating to quality report reported to the Board over the period April 2014 to
the date of signing this limited assurance report;
• Feedback from the Commissioners Southern Derbyshire Clinical Commissioning
Group dated 27/05/2015;
• Feedback from Governors dated 19/05/2015;
Feedback from Healthwatch Derby dated 14/05/2015;
Feedback from Healthwatch Derbyshire dated 19/05/2015;
Feedback from the Adults and Public Health Overview and Scrutiny Board at Derby City
Council dated 30/04/2015;
The Trust’s complaints report published under regulation 18 of the Local Authority Social
Services and NHS Complaints Regulations 2009, Derby Teaching Hospitals NHS
Foundation Trust Complaints and Compliments Annual Report 2014-2015;
The 2014 Children’s Inpatient and Day Case Survey and Patient survey report 2014 dated
01/04/2015.
The 2014 National NHS staff survey, Results from Derby Hospitals NHS Foundation
Trust;
Care Quality Commission Intelligent Monitoring Reports dated 31/03/2014, 31/07/2014,
31/12/2014 and 31/03/2015;
360 Assurance Interim Head of Internal Audit Opinion, Derby Teaching Hospitals NHS
Foundation Trust, 13th May 2015;
Trust Board Update CQC minutes dated 06/10/2014;
Care Quality Commission, Derby Hospitals NHS Foundation Trust, Royal Derby Hospital
Quality Report December 2014;
Care Quality Commission, Derby Hospitals NHS Foundation Trust, Quality Report
Inspection, Date of Inspection Visit 8-11 December 2014.
PbR DAF Clinical Coding Audit from Monitor dated 19/05/2015
We consider the implications for our report if we become aware of any apparent
misstatements or material inconsistencies with those documents (collectively, the
“documents”). Our responsibilities do not extend to any other information.
We are in compliance with the applicable independence and competency requirements of the
Institute of Chartered Accountants in England and Wales (“ICAEW”) Code of Ethics. Our
team comprised assurance practitioners and relevant subject matter experts.
This report, including the conclusion, has been prepared solely for the Council of Governors
of Derby Hospitals NHS Foundation Trust as a body, to assist the Council of Governors in
reporting Derby Hospitals NHS Foundation Trust’s quality agenda, performance and
activities. We permit the disclosure of this report within the Trust’s Annual Report for the
year ended 31 March 2015, to enable the Council of Governors to demonstrate they have
discharged their governance responsibilities by commissioning an independent assurance
report in connection with the indicators. To the fullest extent permitted by law, we do not
accept or assume responsibility to anyone other than the Council of Governors as a body and
Derby Hospitals NHS Foundation Trust for our work or this report save where terms are
expressly agreed and with our prior consent in writing.
Assurance work performed
We conducted this limited assurance engagement in accordance with International Standard
on Assurance Engagements 3000 ‘Assurance Engagements other than Audits or Reviews of
Historical Financial Information’ issued by the International Auditing and Assurance
102
Standards Board (‘ISAE 3000’). Our limited assurance procedures included:
•
•
•
•
•
•
•
•
Reviewing the content of the Quality Report against the requirements of the FT ARM
and Monitor’s “Detailed requirements for quality reports 2014/15”;
Reviewing the Quality Report for consistency against the documents specified above;
Obtaining an understanding of the design and operation of the controls in place in
relation to the collation and reporting of the specified indicators, including controls
over third party information (if applicable) and performing walkthroughs to confirm
our understanding;
Based on our understanding, assessing the risks that the performance against the
specified indicators may be materially misstated and determining the nature, timing
and extent of further procedures;
Making enquiries of relevant management, personnel and, where relevant, third
parties;
considering significant judgements made by the Trust in preparation of the specified
indicators;
Performing limited testing, on a selective basis of evidence supporting the reported
performance indicators, and assessing the related disclosures; and
Reading the documents.
A limited assurance engagement is less 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.
Limitations
Non-financial performance information is subject to more inherent limitations than financial
information, given the characteristics of the subject matter and the methods used for
determining such information.
The absence of a significant body of established practice on which to draw allows for the
selection of different but acceptable measurement techniques which can result in materially
different measurements and can 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 Report in the context of the
assessment criteria set out in the FT ARM, Monitor’s “Detailed requirements for quality
reports 2014/15 and the criteria referred to above.
The nature, form and content required of Quality Reports are determined by Monitor. This
may result in the omission of information relevant to other users, for example for the purpose
of comparing the results of different NHS Foundation Trusts.
In addition, the scope of our assurance work has not included governance over quality or
non-mandated indicators in the Quality Report, which have been determined locally by
Derby Hospitals NHS Foundation Trust.
Basis for Disclaimer of Conclusion – Percentage of incomplete pathways within
18 weeks for patients on incomplete pathways
The Trust reports monthly to Monitor on the Incomplete 18 Weeks indicator, based on the
waiting time of each patient who has been referred to a consultant but whose treatment is yet
to start. The Trust implemented a new Patient Administration System (Lorenzo) in April
2014. As a result the Trust has been unable to provide detailed reports to support monthly
submissions for the first four months of the year (April 2014 - July 2014). In addition, for the
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remaining months of the year, the Trust was unable to provide final and complete data. As a
result, we have been unable to access accurate and complete data to verify the waiting period
from referral to treatment reported across the year.
Conclusions (including disclaimer of conclusion on the Incomplete Pathways
indicator)
Because the data required to support the indicator is not available, as described in the Basis
for Disclaimer of Conclusion paragraph, we have not been able to form a conclusion on the
Incomplete Pathways indicator.
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ABBREVIATIONS USED:
Abbreviation Used
AHP
AKI
ANTT
BMI
C.diff
CCG
CCOT
CDS
CGA
CLRN
CNS
CPES
CQC
CQUIN
CT
CVC
DHFT
DNACPR
DOH
E.coli
ED
EDD
EMAHSN
EMCSN
EMPSC
EPaCCS
EWS
EPMA
FM
GP
HNA
IBD
ICC
ICOG
ICNARC
IPC
IPCT
ISS
HCAI
HCW
HED
HRS
HSMR
HPA
HPV
In Full
Advanced Health Practitioner
Acute Kidney Injury
Aseptic Non Touch Technique
Body Mass Index
Clostridium difficile
Clinical Commissioning Group
Critical Care Outreach Team
Commissioning Data Set
Comprehensive Geriatric Assessment
Comprehensive Local Research Network
Clinical Nurse Specialist
Cancer Patients Experience Survey
Care Quality Commission
Commissioning for Quality and Innovation
Computerised Tomography
Central Venous Catheter
Derby Hospitals NHS Foundation Trust
Do Not Attempt Cardio Pulmonary Resuscitation
Department of Health
Escherichia coli
Emergency Department
Expected Date of Discharge
East Midlands Academic Health service Network Patient Safety
Collaborative
East Midlands Cardiac and Stroke Network
East Midlands Patient Safety Collaborative
Electronic Palliative Care Co-ordination system
Early Warning Score
Electronic Prescribing and Medicines Administration
Facilities Management
General Practitioner
Holistic Needs Assessment
Inflammatory Bowel Disease
Infection Control Committee
Infection Control Operational Group
Intensive Care National Audit and Research Centre
Infection Prevention & Control
Infection Prevention Control Team
Integrated Service Solutions
Health Care Associated infection
Health Care Workers
Healthcare Evaluation Data
Health Research Sectors
Hospital Standardised Mortality Rate
Health Protection Agency
Hydrogen Peroxide Vapour
105
HTA
ICOG
ITU
KPI
LCP
LGBT
LIPS
MAU
MDT
MHRA
MRC
MRSA
MRSAb
MSO
MSSA
NCEPOD
NHS
NHSG
NICE
NICU
NIHR
NHSE
NMBR
NNAP
NOF
NPSA
NRLS
PALS
PAS
PbR
PDSA
PEAT
PHE
PHSO
PLACE
PROMS
PUPG
QIPP
RCA
RCP
SBAR
SDU
SHMI
SHOP
SIG
SLAM
SLM
STEIS
SUS
UV
VTE
Health Technology Assessment
Infection Control Operational Group
Intensive Therapy Unit
Key Performance Indicator
Liverpool Care Pathway
Lesbian, Gay, Bisexual and Transgender
Leading Improvements in Patient Safety
Medical Admissions Unit
Multi Disciplinary Team
Medical and Healthcare Products Regulatory Agency
Medical Research Council
Methicillin Resistant Staphylococcus Aureus
Methicillin Resistant Staphylococcus Aureus bacteraemia
Medication Safety Officer
Methicillin Sensitive Staphylococcus Aureus
National Confidential Enquiries of Patient Outcomes and Death
National Health Service
Nutrition and Hydration Steering Group
National Institute for Health and Clinical Excellence
Neonatal Intensive Care Unit
National Institute for Health Research
National Health Service Executive
National Mastectomy and Breast Reconstruction
National Neonatal Audit Programme
National Operating Framework
National Patient Safety Agency
National Reporting and Learning System
Patient Advice and Liaison Service
Patient Administration System
Payment by Results
Plan, Do, Study, Act
Patient Experience Assessment Team
Public Health England
Parliamentary and Health service Ombudsman
Patient Led Assessment for the Care Environment
Patient Reported Outcomes Measures
Pressure Ulcer prevention Group
Quality, Innovation, Productivity and Prevention
Root Cause Analysis
Royal College of Physicians
Situation, Background, Assessment , Recommendation
Step Down Unit
Summary Hospital Level Mortality Index
See Home Other Planned
Serious Incident Group
Service Level Activity Monitoring
Service Line Management
Strategic Executive Information System
Secondary User Service
Ultra Violet
Venous Thrombo Embolus
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