Our Passion, Your Care.
Quality Account 2014 / 15
Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
Contents
Part 1 – Statement on quality
Chief Executive’s commentary
Part 2 – Priorities for improvement and statements of assurance
from the Board
2014 / 15 quality improvement priorities
• Priority 1: Managing the deteriorating patient (harm-free care part 1)
• Priority 2: Reduce the numbers of avoidable pressure ulcers developed in
hospital (harm-free care part 2)
• Priority 3: Reduce inpatient falls (harm-free care part 3) • Priority 4: Reduce reliance on bed capacity • Priority 5: Improve clinical outcomes
• Priority 6: Increase in 7-day working
• Priority 7: Staff values and culture
• Operation Red to Green
Our priorities for improvement in 2015 / 16
Provided and sub-contracted services
Participation in clinical audit
Participation in clinical research
Monitoring quality – use of the CQUIN framework
How healthcare is regulated
• Inspections by the Care Quality Commission
Statements relating to the quality of relevant health services provided
• NHS number and General Medical Practice Code validity
• Information Governance Toolkit attainment levels
• Clinical coding
• Data quality
Core Quality Indicators
Part 3 – Other information
Performance against other key national priorities
• Infection prevention and control
• Prevention of pressure ulcers which develop in hospital
• Learning from incidents, SIRIs and Never Events • Prevention of patient falls
• Emergency Care: 4-hour Emergency Department target
Local priorities – caring for our community
• Stroke Services
• Cancer care
Clinical effectiveness
• Summary hospital-level mortality indicator (SHMI)
Improving the patient and carer experience
• Measuring and reporting the patient experience
• Patient and public involvement, community engagement and patient
feedback
• Complaints and compliments
Hospital workforce
• Education and training of staff
Statements from key stakeholders
Statement of assurance from the Board of Directors
Glossary
Appendix A – Independent Auditors’ Limited Assurance Report
How to provide feedback on the Quality Account
Thank you
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Who was involved in
the development of our
Quality Account?
The Trust consulted with the
following in the development
of its Quality Account and the
content within:
• o
ur commissioners, Ipswich
and East Suffolk Clinical
Commissioning Group;
• S uffolk Health Scrutiny
Committee;
• Healthwatch Suffolk; and
• staff, volunteers and carers.
The Ipswich Hospital NHS Trust
would like to thank those who
contributed to the development
and publication of this Quality
Account.
Our front cover shows the
Constable Suite, our new ward
area for medical patients with
dementia and other complex
care needs. The unit is a large
extension of the hospital’s
existing dementia-friendly ward
and has many new design
features.
There are friendly pictorial signs
to help patients find their way,
decluttered bed and public areas
and calming artwork as well as
an old-fashioned mock shop in
the activity room, which we hope
will bring back lots of memories
of good times for people coming
into hospital.
The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
Part 1 – Statement on quality
Chief Executive’s commentary
This is our account to you about the quality of services provided by The Ipswich
Hospital NHS Trust in 2014 / 15. It looks back at our performance over the last
year and gives details of our priorities for improvement in 2015 / 16.
I consider it a privilege to have this
role, and am incredibly proud to work
with so many committed colleagues.
As I walk through and visit different
areas of the hospital early every
morning, there is an overwhelming
sense that people believe they have
made a difference, but also that
Ipswich Hospital is our hospital, which
will care for most of us, our families
and the people we care about, for the
rest of our lives. It is so easy to forget
all the wonderful caring moments that
happen every moment, every hour and
every day at Ipswich Hospital, and the
immense pride that all staff should feel
every day to know that we are doing
our best to improve the lives of our
community.
The Board of Directors remains
committed to providing high quality
care for all patients and seeks to
improve the patient, carer and staff
experience. Everyone can expect:
• a cheerful, friendly welcome;
• kind people who care for them;
• to be fully involved;
• to feel reassured and safe;
• an organised and efficient service;
and
• a skilled team that’s always
improving.
Above all, we want to be a hospital
that staff and patients would be proud
to recommend as a place to be cared
for, that staff would recommend as
a place to work and that those in
training would recommend as a place
to learn.
The Trust was registered without
conditions by the Care Quality
Commission (CQC) from 1 April
2010 when the current system of
regulation became law. The CQC
made one routine announced
visit to the Trust in January 2015
and follow-up unannounced
inspections in January 2015. The
CQC inspected the Trust using Keogh
review methodology consisting of a
large expert team of inspectors over
several days and included listening
events with staff and service users.
The following areas were assessed
during the inspection: Emergency
Department; Surgery; Medicine;
Outpatients Department; Critical Care;
Paediatrics; Maternity; and End of Life
Care. The inspection looked at five key
questions: are services safe, effective,
caring, responsive, and well-led, and
the final judgement was based on a
ratings approach using the following
categories: Outstanding, Good,
Requires Improvement, Inadequate.
The Trust was rated as ‘Good’. More
about our inspection can be found on
pages 25 – 29.
There are clearly areas for
improvement, but the CQC’s report
reinforced my view that patients
generally get good care in this
hospital. We need to make sure that
every patient, every day, in every ward
and every department gets the same,
high quality care.
about how we can go from a good
hospital to a great hospital. Many of
the concerns people raise are more
to do with the process of receiving
care, rather than the care itself. As the
Trust develops its five year strategy
for the hospital and the local health
system, this feedback is invaluable. I
also continue to have listening events
with staff.
I am grateful to our many partners for
their contributions to the hospital. We
could not deliver the high quality care
of which we are rightly proud without
the support of health, social care and
voluntary organisations throughout
the town and county.
To the best of my knowledge and
belief, the information contained
in this Quality Account is accurate.
Nick Hulme
Chief Executive
During the course of the year I have
arranged over 25 meetings with
members of our local community at
listening events where I am taking the
opportunity to hear about people’s
experiences, simply to understand how
we can improve both the process of
providing better access to healthcare
and the overall experience of being
cared for in hospital. I have been
to a village shop, a centre for blind,
visually impaired and disabled people,
met members of the Roma Group,
and many more. I have heard so
many good things about the hospital
but also some really great feedback
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Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
Part 2 – Priorities for improvement and statements of assurance
2014 / 15 quality improvement priorities
Progress against the priorities we set as a Trust
Priority 1: Managing the deteriorating patient (harm-free care part 1)
Why was this a priority?
A priority for the Trust was to
ensure that deteriorating patients
are recognised promptly with timely
escalation and implementation of
appropriate clinical management and
to improve on clinical practice.
Clinical deterioration can occur at
any stage of a patient’s treatment or
illness, although there will be certain
periods during which a patient is
more vulnerable, such as the onset
of illness or during medical, surgical
or dental interventions. Patients who
are at risk of deteriorating may be
identified before a serious adverse
event by monitoring changes in
physiological observations recorded
by healthcare staff. The interpretation
of these changes, and timely
institution of appropriate clinical
management once physiological
deterioration is identified, is of crucial
importance to minimise the likelihood
of serious adverse events, including
cardiac arrest and death.
Lead
The Trust Medical Director.
What was our target and
was it achieved?
This was a CQUIN target. Q1 – Set baseline for targets.
Q2 – 1% reduction.
Q3 – 2.5% reduction.
Q4 – 5% reduction
This priority focussed on:
a) the number of patients whose
avoidable deterioration leads to
cardiac arrest in each quarter of
2014 / 15.
b) the number of patients referred
to a senior clinician following
identification of MEWS score
escalation.
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What did we do to improve
our performance?
How and where was
progress reported?
 The Trust reported and
investigated incidents
involving unrecognised patient
deterioration and serious
incidents which resulted in death
which were, or might have been,
directly related to patient safety. The aim of these investigations
was to learn from these incidents,
reduce the risk of harm and
minimise the likelihood of future
serious adverse events, including
cardiac arrest and death.
Divisional Governance Board, Patient
Safety and Clinical Effectiveness
Group and Healthcare Governance
Committee.
 The Trust recorded MEWS to
recognise clinical deterioration
(ward audit programme).
 Completion of MEWS audits
monthly to monitor the escalation
process.
 This reflected the key
recommendations from
Comprehensive Critical Care
(2000), NICE CG50: Acutely Ill
Patients in Hospital (2007), NPSA:
Recognising and responding
appropriately to early signs of
deterioration in hospitalised
patients (2008), Patient Safety
First Initiative: Reducing Harm
from Deterioration (2009),
NCEPOD: An Acute Problem
(2005), NCEPOD: Emergency
Admissions: (2007), NCEPOD:
Time to Intervene? (2012), RCSE:
The Higher Risk Surgical Patient.
Towards improved care in a
forgotten group (2011), RCP:
Acute medical care. The right
person, in the right setting – first
time (2007).
 100% achievement of MEWS
audit and no incorrect / incomplete
MEWS / escalation.
How did we measure and
monitor our improvement?
Audit of MEWS data.
Our key achievements
 Systems and processes set up for
regular audits.
 Monitoring HDU / CCU cases
throughout the Divisions.
 Acting on MEWS / MEOWS scores
≥4.
 DNACPR compliance continues to
improve.
 Monthly peer audit of vital signs
charts and review of adequate
escalation.
 Stour Ward – Fortnightly meetings
to investigate patients who have
been re-admitted within 30
days of admission, emergency
admissions to HDU / CCU, returns
to theatre and deaths. Trends
monitored in regular audit
meetings and learning feedback
to staff.
 Exploring options of additional
training opportunities.
The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
2014 / 15 quality improvement priorities
Progress against the priorities we set as a Trust
Priority 2: Reduce the numbers of avoidable pressure ulcers developed in
hospital (harm-free care part 2)
Why was this a priority?
The development of a pressure ulcer
is usually the result of a number of
factors including health conditions
that make it difficult to move,
especially for those confined to lying
in a bed or sitting for prolonged
periods of time, sensory impairment,
poor nutrition, dehydration and
incontinence. A patient who has a
pressure ulcer can experience pain
and an extended requirement for
healthcare.
Lead
The Director of Nursing and Quality.
What was our target and
was it achieved?
Our target was to reduce the number
of avoidable pressure ulcers that
develop in hospital. Reduction in avoidable pressure ulcers
forms part of the Trust’s contract with
its commissioners (zero avoidable
pressure ulcers in 2014 / 15), with the
CQUIN requirement broadly being
for closer working with community
providers.
What did we do to improve
our performance?
 Refreshed the education delivered
to staff to ensure they are
equipped with the most up to
date evidence-based education
available.
How did we measure and
monitor our improvement?
Monthly reporting of the number of
developed pressure ulcers per 1,000
bed days, to benchmark the Trust
against other organisations.
Root cause analysis of all Grade 3
and 4 developed pressure ulcers with
sharing of findings across all clinical
areas.
How and where was
progress reported?
Divisional Governance Board, Patient
Safety and Clinical Effectiveness
Group and Healthcare Governance
Committee.
Our key achievements
 Work ongoing to improve
nutritional assessment
compliance.
 Additional scales for wards
ordered.
 Ongoing monitoring of care
rounding.
 Reduction achieved.
 No avoidable pressure ulcers in
Surgery.
 Training requirements
investigated.
Shining Lights
Every single hour of every
single day, colleagues around
the hospital are giving first class
care, much of it unnoticed to
the wider world. To make sure
we do not forget our hospital
heroes, we hand out Shining
Light awards.
Shining Lights is a scheme
to recognise innovative and
dedicated individuals and was
introduced following feedback
made at staff briefings. Both
staff and volunteers can
nominate and be nominated
for an award.
Katie Schubert
Access to Health Records
Officer
Whilst on a visit to her mother
on the wards, another patient
was having trouble eating her
food because she didn’t have
any Fixodent for her dentures.
Katie went to the shops to get
this lady some Fixodent and
also purchased her a magazine
to read. When Katie returned
she helped the lady and also
refused any payment.
 Reinforced the need to use
slide sheets under heels when
repositioning patients to reduce
the likelihood of patients
developing heel pressure ulcers.
 Ensured ‘best practice’ for
pressure ulcer prevention is
consistently in place within all
inpatient areas.
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Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
2014 / 15 quality improvement priorities
Progress against the priorities we set as a Trust
Priority 3: Reduce inpatient falls (harm-free care part 3)
Why was this a priority?
Although we should acknowledge
that preventing falls must be balanced
with patients’ rights to dignity,
privacy, independence, rehabilitation
and their choice about the risks they
are prepared to take, the Trust seeks
to have an overall reduction in the
number of falls occurring within the
Trust. An overall reduction in falls also
aims to reduce complications arising
from falls, for example injury, and will
provide the best quality and safest
care for our patients.
The Trust is committed to reducing
the risk of falls and injury to patients
within the hospital environment. If
a fall does occur we aim to provide
effective care and treatment for those
patients and minimise the risk a fall
occurring again.
Lead
The Director of Nursing and Quality.
What was our target and
was it achieved?
This was a CQUIN target. Proposed trajectory for falls reduction:
Baseline – 149 (based on Q3
2013 / 14 data)
Q1 – 142.
Q2 – 135.
Q3 – 127.
Q4 – 119.
Each ward was set a challenging
trajectory for falls reduction.
What did we do to improve
our performance?
 Refreshed falls prevention
education.
 Refreshed falls prevention
activities and implementation of
falls group workplan.
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 Review by a senior healthcare
professional of patients who fall
more than twice.
How did we measure and
monitor our improvement?
 Increased number of falls mats in
place in high risk areas.
 Achievement of reduction
trajectory.
Monthly review of heatmap metrics
for falls measured as number of falls
and per 1,000 bed days.
How and where was
progress reported?
Divisional Governance Board, Falls
Prevention Group and Healthcare
Governance Committee.
Our key achievements
 Falls maps in place to assess
location of falls within the wards
followed by analysis of falls
locations.
 NICE falls assessment tool being
used.
 Recruitment of additional nurses
on Woodbridge, Sproughton,
Haughley and Grundisburgh
wards.
 Ward sisters are considering
new ways of working at night
following recruitment of
additional nursing staff.
 Purchase of red toilet seats and
funding for painting of bathroom
doors and new desks for each bay
in Woodbridge and Sproughton
wards.
 Piloting of ‘Blue Patrol’ – patients
being accompanied to and from
bathrooms and commodes to
reduce the risk of falls – on
Woodbridge Ward from August
2014.
 Thematic review of falls resulting
in harm undertaken, with learning
being implemented.
Shining Light
Ann Jones
Heart Failure
Nurse Specialist
Ann is held in high esteem by
colleagues and patients alike.
She was towards the end of
her recovery from a broken
arm but even this couldn’t
keep her away from her
patients and she continued
to pop in from sick leave!
“I’m extremely surprised and
touched by the nomination
from a colleague,” Ann
explained though it seems the
surprise is hers alone!
The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
2014 / 15 quality improvement priorities
Progress against the priorities we set as a Trust
Priority 4: Reduce reliance on bed capacity
Why was this a priority?
Hospitals usually experience more
variation in patterns of patient
discharge than in patterns of
admission. The reasons for this
concern the way processes such as
ward rounds, tests, pharmacy etc are
managed. This results in variable and
unpredictable length of stay (LoS),
even among patients admitted with
similar conditions.
Reducing time spent in hospital is
beneficial for all patients. In particular
it:
• stops the deterioration of
function;
• reduces the risk of harm; and
• improves the opportunity to
admit new patients by ensuring
optimum patient flow within the
hospital.
Lead
The Chief Operating Officer.
What was our target and
was it achieved?
Our target was to improve the
number of days a patient needs
to stay in hospital, and reduce the
number of admissions, which might
include some patients who currently
have only a short length of stay.
 Measured and analysed current
patterns of discharge by day of
week, hour of day and speciality.
 Analysed all inpatient stays by LoS
to identify where improvements
in the discharge process will have
the greatest impact.
 Set a planned date for discharge
on the day of admission or at
pre-admission, if possible, using
protocols / pathways for common
conditions.
 Involved patients and their
families or carers in discharge
planning so that they are
prepared and can make their own
arrangements.
 Established regular discharge
making ward rounds at least once
a day.
 Matched the time of discharge
with the time beds are required,
on an hourly basis.
How did we measure and
monitor our improvement?
Following a recent review of length of
stay, inpatient days have been broken
down to ‘red’ and ‘green’ days, green
days being where active treatment
takes place. The aim is to reduce red
days when the patient receives no
active treatment.
Our key achievements
 Use of ‘Operation Red to Green’ –
see more details on pages 11 – 12.
 Red and green day information
has been collected since April,
with ongoing work to reduce
delays.
 Intensive support given to wards
to strengthen shift leadership and
team working.
 Clinical leads identified for each
work strand in LoS project.
 Complex discharge trigger tool
piloted on Brantham Ward.
 Five discharge coordinators in
post across Medical wards.
 Use of 7-day therapy service.
 Extended day working for
physiotherapists in Trauma and
Orthopaedics speciality.
 Admission avoidance strategies
to be developed for Surgical
Assessment Unit alongside
implementation of hot clinics.
 Best practice from outside the
organisation and pathways
developed to underpin
ambulatory models.
What did we do to improve
our performance?
• Monitor red and green days.
 Weekly meetings to discuss
length of stay >7 days, usually
associated with clinical care and
treatment regime.
• Monitor average length of stay.
 Board rounds implemented.
 Mapped the process, identifying
bottlenecks and the main causes
of delay.
• Monitor admissions avoided.
 Mapped the information flows
and responsibility for direct
patient care at all points in the
patient journey.
Divisional Governance Board, Patient
Safety and Clinical Effectiveness
Group and Healthcare Governance
Committee.
How and where was
progress reported?
 Pre-admission multidisciplinary
team meetings have been set up
for any patients who may have
complex discharge.
 Developing relationships with
community services in Essex.
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Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
2014 / 15 quality improvement priorities
Progress against the priorities we set as a Trust
Priority 5: Improve clinical outcomes
Why was this a priority?
Benchmarking is a process of
comparing, sharing and developing
practice in order to achieve and
sustain best practice. It informs
professionals not only of expected
outcomes but also of the structures
and processes that need to be in
place to support the attainment
of such outcomes. Put simply,
benchmarking is an approach to
continuous quality improvement.
Lead
The Trust Medical Director.
What was our target and
was it achieved?
This was a new Trust priority.
Each of the three clinical divisions
chose one area against which to
benchmark their performance.
What did we do to improve
our performance?
 Clinical teams developed
measurable outcomes of clinical
service that were, where possible,
benchmarked against others
and where best practice is the
standard.
 One suggestion for benchmarking
from each Division.
How did we measure and
monitor our improvement?
The stages involved in benchmarking
are broadly:
Stage One – Agree best practice.
Stage Two – Assess clinical area
against best practice.
Stage Three – Produce and implement
action plan aimed at achieving best
practice.
Stage Four – Review achievement
towards best practice.
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Stage Five – Disseminate
improvements and / or review action
plan.
Stage Six / One – Agree best practice.
How and where was
progress reported?
Divisional Governance Board, Patient
Safety and Clinical Effectiveness
Group and Healthcare Governance
Committee.
Our key achievements
 A presentation regarding the
results of a clinical outcome is
given at each bi-monthly Patient
Safety and Clinical Effectiveness
Group meeting.
 Falls maps used to plot where falls
occurring on wards.
 Recruitment of additional nurses
for night shifts.
 The SSNAP (stroke audit)
patient data was interpreted in
conjunction with the National
Organisational Audit. Ipswich
is a front runner in terms of
performance relative to patient
numbers / staff numbers in the
Eastern region. In the given
period there was a below average
discharge rate and 117 cases
were submitted of which 113 had
encounters completed or were
discharged.
 An area that shows room for
improvement is the discharge
process – largely due to there
being no early supported
discharge in the region until
November 2014. Since then
patients have benefited from the implementation of an early
supported discharge process.
 Data and current practice against
national guidance reviewed.
 Surgical Site Infection (SSI) project
group in place.
 Changes to pre-operative
information, antibiotic
administration within an hour of
knife to skin and standardisation
of skin preparation in theatre.
 Audit of antibiotic administration.
 Reviewed NSQIP (surgical site
infection audit) data which
showed a downward trend for
four months.
 Positive patient feedback due to
post-operative / discharge call.
 Systematic targeting of new areas
for improvement, such as ileus and
pneumonia.
 Child Health: door to needle
times – target 100% of
patients receiving antibiotics for
neutropenic sepsis within one hour
of arrival at the hospital (measured
against regional figures).
The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
2014 / 15 quality improvement priorities
Progress against the priorities we set as a Trust
Priority 6: Increase in 7-day working
Why was this a priority?
This priority is inextricably linked to
improved patient care, reduced length
of stay, effectiveness and better
patient experience. The downtime of
equipment is minimised, leading to
smooth running of services.
The arguments for provision of a
7-day health service are becoming
more compelling, especially following
the recent Dr Foster report showing
that mortality rates at weekends
are more likely to be much higher
compared with those during the
working week, and the Keogh review
on 7-day working published in
December 2013.
Lead
The Chief Operating Officer.
What was our target and
was it achieved?
We agreed with the CCG that for
the 7-day CQUIN for Quarter 1 we
will continue with the elements we
delivered last year and agreed a plan
by the end of Month 1 as to which
standards we would be undertaking
as part of this CQUIN.
What did we do to improve
our performance?
 Final Evaluation of the Winter
Initiatives which supported 7-day
working, was reported to the
CCG on 4 April 2015 and we
mapped these to the Professional
Standards. This analysis will
partially support the standards
to be taken forward as part of
the CQUIN. We also reviewed
all the 7-Day Working Standards
that were not included within the
Winter Initiatives.
 By the end of Month 1 we agreed
an implementation plan with the
CCG of the Keogh Standards as
part of this CQUIN.
How did we measure and
monitor our improvement?
Expected achievement is improved
productivity and flow through the
organisation at the weekend and
improved clinical outcomes.
Analysis of Dr Foster weekend
mortality data to clarify the baseline
prior to implementing the 7-day
working.
How and where was
progress reported?
Divisional Governance Board, and
Healthcare Governance Committee.
Our key achievements
 7-day working in Therapies
(Occupational Therapy /
Physiotherapy teams).
 Nurse-led discharge sticker used
across Medicine.
 Reconfigured service to meet ED
activity profile.
 Sunday trauma lists planned.
 Child Health plan to increase
Paediatric Assessment Unit hours
for 7-day working.
Shining Light
Rebecca Tester
Discharge Coordinator,
Kesgrave Ward
On one busy Friday evening,
Rebecca battled against the
odds to get a patient home.
He was medically fit and keen
to leave hospital but several
agencies needed to be involved
in his discharge. Rebecca worked
through them one by one to
make it happen and kept the
family updated and involved in
getting their relative home.
Colleague John Tobin said: “Her
kindness towards the individual
patient was quite remarkable.
This was a challenging task and
many would have given up and
told the patient that it was not
possible to achieve the discharge.
However, she succeeded in the
face of challenges. Rebecca
approaches her work efficiently
and is pleasant and polite at all
times. I have seen and heard her
interacting with patients and their
relatives, and she is courteous,
professional and effective.
 Remodelling of Child Health
emergency pathways.
 Implementation of ‘Operation Red
to Green’ (see pages 11 – 12).
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Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
2014 / 15 quality improvement priorities
Progress against the priorities we set as a Trust
Priority 7: Staff values and culture
Why was this a priority?
Building on the work commenced in
2013 where it was identified as part
of the Patient and Carer Experience
Strategy and supported via the
results from National Patient Surveys
showing the need for improvements
to communication, attitude and
provision of emotional support.
The correlation between patient and
staff experience is also acknowledged
and supported via the results from
the National Staff Survey.
Lead
The Director of Human Resources and
the Director of Nursing and Quality.
What was our target and
was it achieved?
Improved patient and staff experience
demonstrated through patient and
staff surveys.
What did we do to improve
our performance?
 Implemented the ‘Building Pride’
initiative (new name for Future of
Care).
 Supported staff by introducing
more opportunities for reflective
learning eg Schwartz Rounds.
 Made better use of survey data
to close the loop on patient
experience eg ‘You said, we did’.
 Improved complaints
management.
 Developed a cultural barometer.
How did we measure and
monitor our improvement?
We used the Friends and Family
question plus additional survey
questions reflecting the values.
We introduced a staff Friends and
Family question.
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How and where was
progress reported?
Divisional Governance Board, Patient
and Carer Experience Group and
Healthcare Governance Committee.
Our key achievements
 Roll-out to CDGs with discussion
at CDG Boards on values and
behaviours and dissemination
to teams including link to
professional body standards.
 Monthly Schwartz Rounds
commenced February 2015 –
see page 71.
 Staff Survey undertaken August /
September 2014 incorporating
re-worded ‘Friends and Family’
question.
 Ward sister leadership day based
on Trust Values and Behaviours
in September 2014, following
which participants received 360°
feedback.  A number of two-hour workshops
in January / February 2015 held
for all staff up to band 7, to give
further opportunities for staff
to shape how we improve our
services and staff satisfaction and
experience.
 Corporate development day
held on 14 October 2014 to
explore the application of our
values to a number of ambiguous
situations, identifying possible
options and how these may alter
with changing contexts, the
outcome being the development
of tools and approaches for use
throughout the Trust in future.
 Commenced Divisional Leadership
rounds with Diagnostic Imaging
senior team, Therapy staff and
Medicine admin and secretarial
staff.
 Survey Lite undertaken resulting
in a 46% response rate. Detailed
analysis of results undertaken and
monthly newsletters commenced.  Regular listening events with
staff.
 Targeted areas for Occupational
Health and wellbeing
walkarounds.
 Patient feedback boards in place.
The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
Operation Red to Green
‘Operation Red to Green’ week ran from Monday 16 to Sunday 22 March 2015.
Being in hospital limits so many choices that patients have regarding how they
spend their days. Therefore every day not in hospital or suffering is a day we give
them their lives back.
None of us know how many days we
have to enjoy the rest of our lives, but
for many of our patients we know that
they face a limited future. To them,
perhaps more than to us, every day is
precious.
• Directors and managers supported
ward and clinical area staff every
day.
Today, tomorrow, next week and next
month, staff will be involved in the vital
work to give people their lives back, to
add days and weeks to life. Not only
by the fantastic clinical work, but also
the often hidden work by so many that
gives patients and their families more
time together at home.
• Enabled delivery of optimum
patient experience by improving
timely and safe discharge.
The aim of the week was to remove
the blocks and barriers which stand in
the way of the hospital providing the
best patient care. We aimed to improve
patient flow throughout the hospital
and reduce the number of escalation
beds open.
We already use the terms ‘red
days’ and ‘green days’ for patients
being cared for in our wards (see
priority 4 of the 2014 / 15 quality
improvement priorities on page 7
for more information). A ‘red day’
describes a day where there is no
clinical intervention or diagnostic test
carried out (ie delay) and a ‘green day’
describes when interventions are made
to progress the patient’s pathway
through to discharge. The ‘Operation
Red to Green’ week provided
system‑wide intensive focus to build
upon the red and green day concept,
with a view to having system-wide
engagement and active participation
to resolve issues raised at the point of
occurrence.
Key points to note
• Non-essential meetings were
cancelled to focus solely on patient
care.
• All clinicians focussed on clinical
activity only during this week.
• Engaged with commissioners and
community providers to get the
best out of the week.
Key successes
 Two escalation wards were closed.
 Multitude of individual patient
pathway improvement stories.
 It gave the Trust an opportunity to
look at how improvements can be
sustained in the future.
 Increased ‘system’ and ‘internal’
communication and support across
primary, secondary and tertiary
care.
 Improved staff empowerment,
knowledge-sharing and learning.
 Improved internal processes and
understanding / adherence to
professional standards.
 Rich vein of information for
improvement opportunities and
schemes going forward.
 Well-rehearsed, proven ‘Operation
Red to Green’ process, capable
of being deployed at very short
notice.
 Substantial financial savings.
 Fantastic example of wide-scale
team building, engagement,
dedication and positivity.
Key learning points to be
taken forward
• The Board rounds and daily huddle
discussions have proved useful
in ensuring all team members
(nurses, junior and senior doctors,
therapists and ward clerks) are
aware of the outstanding list of
jobs for the day and who is doing
them. This encourages a good level
of communication within teams
working together.
In doing these meetings twice a
day, the number of interruptions to
medicine rounds and provision of
nursing care was reduced during
the week.
• Patients needing intravenous
antibiotics for extended periods
may be able to receive this
treatment in their own home
rather than in hospital, as long as it
is medically suitable for them to be
treated at home.
• TTAs (medicines To Take Away on
discharge) should be written the
day before discharge whenever
possible. A new TTA system
ensures the Pharmacy team has
‘real time’ access to the TTAs
requested and each patient’s
earliest date of discharge, thus
allowing them to prioritise
requests in order to meet their TTA
professional standard.
• Feedback from a number of
families that they have had
improved communications
regarding discharge planning
from ward teams, with more
team members actively discussing
discharge arrangements with the
patient and their family.
• We challenged ourselves to
ensure patients referred from ED
are moved within 30 minutes of
acceptance by a ward to enable
a timely transfer, and are not
delayed in ED unless a treatment
needs to be completed prior
to their transfer, (regardless of
breach time). We improved our
performance on this over the week
and will be continuing to work to
this challenge.
11
Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
Operation Red to Green
• We noted an increase in patients
readmitted with pain following
elective surgery during the week;
this is being followed up with the
relevant teams to ensure we are
giving the best post-operative
advice to patients as they leave
hospital.
The majority of these patients were
discharged the next day after pain
control.
• Continuing healthcare and end
of life fast-track care processes
are causing delays in our patient
pathways. This is being followed
up Trust-wide by our Chief
Executive and Director of Nursing,
to help unblock some of the key
issues, working alongside CCG
colleagues.
Operation Red to Green Week
Ward and operational staff focussed on achieving the best possible
operational performance and providing the best standards of care for our
patients during this week.
Operation Red to Green comes from a national programme that aims
to identify where we can work better in order to break the cycle of
bed escalation measures and end disruptions to clinical business (which
disadvantage patients and frustrate clinical staff). Matron Becky May said: “We had a lot of positive feedback from patients
and their relatives about better communication” while Chief Executive Nick
Hulme said the week had gone “even better than expected”.
Some staff got involved by wearing red clothes at the beginning of the week
and green clothes at the end of the week.
Areas requiring further work
• Review of continuing healthcare
process (when residential or
nursing home care is required).
• Review of end of life fast-track
patient pathways including hospice
services and access routes.
• Care homes criteria and
turnaround times for assessment
and acceptance.
• Production of leaflet / tips for
families to assist in what to look for
when choosing care homes.
• To review system daily
teleconference calls or whether
face-to-face meetings would be
preferable.
• Clarification around the equipment
ordering process – who can order,
single point of contact, tracking of
delivery.
Overall, a fantastic week with
multiple examples of dedication,
commitment, teamwork,
knowledge sharing and passion to
succeed, moving Ipswich Hospital
from ‘Good’ to ‘Great’. A truly
inspirational week, with staff
asking when can we do it again!
12
Shining Light
James Pawsey
Information Analyst
James has been with the hospital
for just over a year. Within that
time he has shown himself to
be flexible, willing to support
colleagues from across the hospital
and has supported the Programme
Management Office team with
his sense of humour, ability to
get analytics tasks done to a high
standard quickly and his ability to
explain the complex in simple terms.
James has been instrumental in
developing the ED trigger tool and a
complex discharge trigger tool, both
of which are supporting the
way we work and giving staff
a tool that can predict issues
arising to allow corrective
action to be taken.
The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
Our priorities for improvement in 2015 / 16
Qualitative information from a number of sources including patient surveys, staff
surveys, complaints, compliments and the views of users and user groups has
helped inform the Trust’s priorities for 2015 / 16.
Priority 1 – Reducing harm
from falls
Why is this a priority?
The impact of falls on individuals is
far reaching. The social impact of
reduced independence through fear,
the potential for loss of independence
and self-confidence, and the
increased burden on families can be
significant. While the risk of falls is
well documented for the elderly, falls
can occur in all age groups. Therefore,
strategies to reduce falls and harm
from falls should not be limited to
older people. Policies, procedures and
protocols need to be based on the
available evidence and best practice.
The risk of falls and harm from falls is
higher for people with impaired vision,
poor balance, muscle weakness,
reduced bone density and those taking
some medications. The more risk
factors an individual has, the greater
the risk of falls and harm from falls.
Older people, in particular, are at
increased risk of falls when they enter
health care facilities. The aim of this
priority is to reduce the number, of
patients’ falls and minimise harm from
falls when they occur.
This priority links to the corporate
strategy relating to maintain our focus
on safe care, and links to our work on
‘Sign up to Safety’.
Lead Director
Director of Nursing and Quality.
2014 / 15 performance
See Chart 6 on page 45 for details of
our performance in 2014 / 15.
What is our target?
Proposed trajectory for falls reduction
(based on 2014 / 15 data):
Q1
Q2
Q3
Q4
105
100
95
90
What will we do to improve our
performance?
• Initiate a ‘task and finish’ group
to drive the initiatives required to
significantly reduce falls.
• Work with Suffolk-wide acute and
community falls prevention services
and share learning and initiatives.
• On presentation, during admission
and when clinically indicated,
patients are screened for risk of
falling and the potential to be
harmed from falls with actions
taken to mitigate risks and keep
patients safe.
• Implement the safety improvement
plan developed as a result of our
involvement with ‘Sign up to
Safety’.
How will we measure and monitor
our performance?
Monthly review of heatmap metrics for
falls, measured as the number of falls
and falls per 1,000 bed days.
How and where will progress be
reported?
Divisional Governance Board, Falls
Task and Finish Group, Falls Prevention
Group and Healthcare Governance
Committee.
Priority 2 – Improving the
care of frail elderly patients
Why is this a priority?
Older patients attending hospitals
are often physically, cognitively or
socially frail (prone to significant
deterioration after apparently minor
stressors). Frailty contributes to older
patients having the longest lengths
of stay, highest readmission rates,
highest rate of use of long-term care
after discharge and a greater risk of
harm during admissions. Admission to
hospital also adds the specific hazards
of cross-infection, noise, disorientation
etc. Improving care for frail older
people has the potential to maintain
longer-term, good quality function and
reducing length of stay in hospital.
This priority will specifically look at:
Hydration and Nutrition
Nutritional care and hydration is
fundamental to wellbeing. Effective
and vigilant multidisciplinary team
working is needed to ensure the
individual dietary needs of all patients
are met consistently. Older people
are more likely to be undernourished
when admitted to hospital and remain
so during their hospital stay. Therefore,
the majority of patients depend on
hospital food to improve or maintain
their nutritional state in order to
optimise their recovery from illness.
Medicines Optimisation
Medicines optimisation is about
ensuring that the right patients get
the right choice of medicine, at the
right time. By focusing on patients and
their experiences, the goal is to help
patients to: improve their outcomes;
take their medicines correctly; avoid
taking unnecessary medicines; reduce
wastage of medicines; improve
medicines safety and ensure patients
and carers understand the medication
regimes and side effects.
13
Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
Our priorities for improvement in 2015 / 16
Ultimately medicines optimisation
can help encourage patients to take
ownership of their treatment.
Learning from mortality
The purpose of mortality case‑note
reviews is to improve patient
care by reviewing accuracy of
diagnosis, efficacy of treatments
and the identification of avoidable
harm. Mortality reviews can reveal
underlying themes about care quality,
for example, poor communication
between clinical staff, specific
diagnosis and therapeutic issues, or
situations where dignity and respect
have been compromised.
Review of the circumstances around
death enables clinicians to:
1 clarify the purpose of the reviews;
2 conduct reviews regularly;
3 select cases systematically;
4 seek system issues and common
themes;
5 share learning and feedback to
clinical teams; and
6 feed learning into strategy.
Lead Directors
Director of Nursing and Quality and
Medical Director.
2014 / 15 performance
Hospital Standardised Mortality Ratio
(HSMR) and SHMI measured – please
see pages 50 – 52 for details of SHMI
and HMSR.
What is our target?
To improve patient safety, as measured
by HSMR and SHMI.
What will we do to improve our
performance?
• Introduce systematic review of
cause of death, treatments and
quality of care.
• Highlight avoidable deaths or
harm.
• In-depth reviews as necessary.
• Improve the % of medicines
reconciliations undertaken.
14
How will we measure and monitor
our performance?
• Monthly review of heatmap
metrics for nutrition and hydration.
• Use of the medication safety
thermometer.
• Review causes of mortality at
departmental morbidity and
mortality meetings.
• Benchmark against hospitals with
a similar demographic using Dr
Foster software.
How and where will progress be
reported?
Divisional Governance Board, Patient
Safety and Clinical Effectiveness
Group and Healthcare Governance
Committee.
Priority 3 – Improve the
management of high
dependency care for children
Why is this a priority?
This was a recommendation following
the CQC announced inspection in
January 2015.
The CQC noted that improvement was
needed with regard to the provision
of a service for children with more
complex needs. They found that
although not commissioned to provide
high dependency care for extremely
sick children, there was a local need
for this service. This meant that the
children’s department was providing
this type of care without specific
numbers of trained staff. The critical
care pathway for children was not
well defined, and there was a lack
of consistency in explanations with
regards to roles and responsibilities.
The critical care operational policy
highlights paediatrics as “a very
small part of admissions, but as such
represents significant risks”. Provision
for critically ill children was primarily
stabilisation prior to transfer. Processes
were in place to determine best
practice guidance, which related to the
children and initiatives and auditing
to monitor and measure patient
outcomes. Training in paediatric
intermediate life support (PILS) had
been completed by 90% of the staff
who required it. Children and younger
people’s individual needs were taken
into account, and there was a good
approach to multidisciplinary working
when delivering care and treatment.
Lead Director
Medical Director.
2014 / 15 performance
N / A.
What is our target?
• To review the critical care pathway
for children – review of case notes,
training for staff, environment and
equipment.
• To improve paediatric intermediate
life support training.
The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
Our priorities for improvement in 2015 / 16
What will we do to improve our
performance?
• Clearly define a critical care
pathway for children and
review the provision of services
for children requiring high
dependency care, including
staffing numbers, competency
and provision of registered sick
children’s nurses (RSCN) and
review integration into regional
services for high and intensive care
for children.
• Develop a robust audit
programme.
• Development of robust
governance systems within the
department.
Priority 4 – Safe, effective
discharge planning
Why is this a priority?
• To improve patient and carer
experience of the discharge
process.
• To gain and maintain the
confidence of our external care
providers.
Lead Director
Chief Operating Officer.
2014 / 15 performance
• Number of complaints received
relating to the discharge process
and transfers of care was 66.
• Safe management of increases in
service demand.
• Number of safeguarding issues
raised relating to the discharge
process and transfers of care was
17.
How will we measure and monitor
our performance?
• Establish a working group to
oversee the implementation
of Care Quality Commission
recommendations.
What is our target?
• Reduction in the number of
complaints and safeguarding
issues raised relating to the
discharge process and transfers of
care.
• Re-audit against national standards
during 2015 / 16.
How and where will progress be
reported?
Child Health Clinical Delivery Group
governance meetings, Divisional
Governance Board, Quality Matters
Steering Board and Healthcare
Governance Committee.
What will we do to improve our
performance?
• Set a planned date for discharge
on the day of admission or at
pre-admission, if possible, using
pathways for common conditions.
• Development of a discharge
communication tool to be
completed by staff.
• Follow-up calls to a percentage of
patients post-discharge.
How will we measure and monitor
our performance?
• Reduction in the number of
complaints relating to the
discharge process and transfers of
care.
• Reduction in the number of
safeguarding issues relating to the
discharge process and transfers of
care.
• Adoption of ‘red to green’
principles within the 10.30 am
capacity meeting (data capture
tool being devised).
• Snapshot audits of use of the
Direction of Choice policy.
• Snapshot audits of use of
discharge communication tool.
• National Inpatient Survey
questions on discharge.
• Audit of findings from follow-up
calls to patients post-discharge.
How and where will progress be
reported?
Divisional Boards and Healthcare
Governance Committee.
• Establish twice-daily board rounds
in all clinical areas to provide
real-time information on patient
progress; these can be nurse-led.
• Provision of information for
patients and their carers regarding
finding a residential or nursing
home.
• Effective and consistent
application of the Direction of
Choice policy.
• Further use of ‘Operation Red to
Green’.
• Development of a patient-held
discharge checklist.
15
Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
Our priorities for improvement in 2015 / 16
Priority 5 – Embedding the
values
What is our target?
Why is this a priority?
(i) aligned employee lifecycle
(recruit, induct, appraise, manage
and progress to values);
The Trust aims to create an
organisational culture which is built on
values. This is a phased approach, with
phase one of four being completed
during 2014 / 15. Our values will help
us to:
Phase 2 – To develop capabilities:
(ii) ensure leaders and managers
have the skills and confidence to
role model and manage values /
behaviours; and
• create an underpinning brand,
culture and way of working which
all staff want to be a part of;
(iii) build ‘service’ mindset and skills in
teams.
• make Ipswich Hospital an
employer of choice and encourage
staff to reconnect with why they
came into the NHS in the first
place; • introduction of values-based
recruitment, induction and
appraisal processes;
• promote being proud of the jobs
we do for patients; and
• remove demarcation lines between
caring for patients and caring for
the Trust.
Lead Director
Director of Human Resources.
2014 / 15 performance
Phase 1 – To define the culture:
(i) identification of shared values,
behaviours and expectations
which are defined around patients
and staff; and
(ii) leaders role model a culture of
appreciation and an openness to
feedback.
Actions taken to achieve Phase 1:
• ‘Our Values and Behaviours’
communicated throughout the
organisation;
• development and sign-off of the
Trust’s behavioural framework;
• co-creation of scenarios and
stories through engagement with
colleagues; and
• leadership conferences with a
strong branding / focus on the
Trust values.
16
Actions taken to achieve Phase 2:
• ensuring our current and future
external partners are made aware
of the expectation of behaviours
and practices, in line with our
values;
• leadership conference for middle
managers (‘Leading from the
Middle’); and
• leading the values sessions for
managers and leaders within the
organisation. This is a 2 – 3 year project, with Phase
2 planned for completion during
2015 / 16.
What will we do to improve our
performance?
To help us to achieve this, a staff
experience / engagement strategy
called Building Pride has been
developed which has our values at its
core. This focuses on the following
eight key programmes:
• supporting staff to do the right
thing;
• saying thank you for your efforts;
• keeping each other informed;
• building our future talent and
leaders;
• being valued and supported;
• creating Team Ipswich;
• giving you and your team the
skills to do a great job; and
• looking after staff health and
wellbeing. (ii) listen, measure and act on patient
feedback;
This strategy is closely aligned to
the NHS pledges as outlined in the
NHS constitution to ensure that all
staff feel trusted, actively listened to,
provided with meaningful feedback,
treated with respect at work, have the
tools, training and support to deliver
compassionate care, and are provided
with opportunities to develop and
progress. (iii) ensure a frontline cycle of
improvement; and
How will we measure and monitor
our performance?
Phase 3 – To develop clear
consequences:
(i) build values into performance
management approach and dayto-day conversations;
(iv) create a safe environment for
staff to feel able to speak up.
Phase 4 – Create connections:
(i) connect staff and patient
experience – evidence, strategy,
measurement;
(ii) campaign to embed values
through leadership focus and
communications; and
(iii) staff communication / feedback
loop.
• Review of results of the NHS staff
survey and the Trust’s own regular
staff surveys.
• Review of complaints where staff
attitude is a factor.
How and where will progress be
reported?
Workforce Development and
Education Committee and Healthcare
Governance Committee.
The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
Provided and sub-contracted services
Provided and sub-contracted
services
During 2014 / 15 The Ipswich
Hospital NHS Trust provided and / or
sub-contracted 69 relevant health
services.
The Ipswich Hospital NHS Trust has
reviewed all the data available to
them on the quality of care in 69 of
these relevant health services.
The income generated by the
relevant health services reviewed in
2014 / 15, represents 100% of the
total income generated from the
provision of relevant health services
by The Ipswich Hospital NHS Trust for
2014 / 15.
Shining Light
Shining Light
Gemma Oakes and
Hayley Turner
Assistant Finance Managers
Flea Kaye
Operational Coordinator for
Trauma and Orthopaedics
(T&O) and Rheumatology
Gemma and Hayley were
nominated for redesigning the
way workloads are handled
at the end of each month.
They have done this work
while line managing new team
members, developing existing
members of the department
and juggling their own
new roles. They are always
taking on new tasks and
responsibilities and are keen to
drive change.
The data reviewed covers the three
dimensions of quality: patient
safety, clinical effectiveness and
patient experience. All relevant
data has been reviewed.
Flea’s role includes helping
to manage the waiting list of
patients who need T&O surgery. Flea has tackled waiting list
problems head on. The surgical
team can now forecast patient
numbers and plan ahead and the
team has recently been meeting
the national target to treat
patients within 18 weeks of GP
referral. She said: “It’s been a lot
of work for all of us and credit
must go to the secretaries who do
lots of waiting list work and the
brilliant consultants who have put
on extra lists to help”.
“Flea has a dedication to her
job because she has a constant
realisation that there is a
patient at the end of it. It is this
connection with the patients that
has been an inspiration and a
constant reminder of the reason
why we are all here – to have a
positive impact on the lives of the
3,000 people cared for here every
day.”
”
I work in a place where amazing
things happen everyday, today I
witnessed it first hand @IpswichHosp
great teamwork from all involved.
”
”
Well done @IpswichHosp Stowupland
Ward and South Theatres for your
attention to detail, attentive care and
excellent communication. #MyNameIs
”
17
Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
Participation in clinical audit
During 2014 /15, 32 national clinical
audits and 4 confidential enquiries
covered relevant health services
that The Ipswich Hospital NHS Trust
provides.
The national clinical audits and
national confidential enquiries that
The Ipswich Hospital NHS Trust
was eligible to participate in during
2014 / 15, are as follows:
National Clinical Audits
Heart
1 MINAP
2 Cardiac Arrhythmia
3 Heart Failure
4 Percutaneous Coronary Interventions
5 National Cardiac Arrest Audit
Acute
6 Adult Critical Care – ICNARC 7 National COPD Audit 8 Mental Health in ED (CEM)
9 Cognitive Impairment in Older People (CEM)
10 Initial Management of the Fitting Child (CEM)
11 National Joint Registry 12 National Emergency Laparotomy
13 Severe Trauma – TARN Women’s and Children’s Health
14 Epilepsy 12 – 2nd round
15 National Neonatal Audit Programme – NNAP 16 MBRRACE Older People
17 SSNAP (Sentinel Stroke National Audit)
18 National Hip Fracture Database
Long Term Conditions
19 Inflammatory Bowel Disease – Biologics
20 Paediatric Diabetes 21 National Diabetes Inpatient Audit
22 Renal Replacement Register
23 National Complicated Diverticulitis Audit
24 Rheumatoid and Early Arthritis Audit
Cancer
25 Lung Cancer 26 National Bowel Cancer
27 Head and Neck Cancer (DAHNO)
28 Oesophago-gastric Cancer
29 Prostate Cancer
Haematology
30 2013 Audit of Use of Anti-D 31 2014 Audit of Transfusion in Sickle Cell Disease
Other
32 PROMs for elective surgery
1
2
3
4
18
National Confidential Enquiries
Tracheostomy care
Lower limb amputation
Gastrointestinal haemorrhage
Sepsis
The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
Participation in clinical audit
The national clinical audits and
national confidential enquiries
that The Ipswich Hospital NHS
Trust participated in during
2014 / 15 are as follows:
The national clinical audits and
national confidential enquiries
that The Ipswich Hospital NHS
Trust participated in, and for
which data collection was
completed during 2014 / 15,
are listed here, 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.
During 2014 / 15 The Ipswich
Hospital NHS Trust participated
in 97% (31 out of 32) of
the national clinical audits
and 100% of the national
confidential enquiries of
the national clinical audits
and national confidential
enquiries that it was eligible to
participate in.
National Clinical Audits
Cases
Cases
submitted expected
Heart
1 MINAP 2 Cardiac Arrhythmia 3 Heart Failure
4 Percutaneous Coronary Interventions
5 National Cardiac Arrest Audit
Acute
6 Adult Critical Care – ICNARC 7 National COPD Audit 8 Mental Health in ED (CEM
9 Cognitive Impairment in Older People (CEM)
10 Initial Management of the Fitting Child (CEM)
11 National Joint Registry 12 National Emergency Laparotomy
13 Severe Trauma – TARN %
430
389
244
271
117
430
389
312
271
117
100
100
78
100
100
979
56
46
30
26
676
141
321
979
56
50
100
50
676
–
321
100
100
92
30
52
100
–
100
Women’s and Children’s Health
14 Epilepsy 12 – 2nd round
40
40
100
15 National Neonatal Audit Programme – NNAP 16 MBRRACE Older People
17 SSNAP (Sentinel Stroke National Audit)
18 National Hip Fracture Database
Long Term Conditions
19 Paediatric Diabetes 20 National Diabetes Inpatient Audit
21 Renal Replacement Register
22 National Complicated Diverticulitis Audit
23 Rheumatoid and Early Arthritis Audit
Cancer
24 Lung Cancer 25 National Bowel Cancer
26 Head and Neck Cancer (DAHNO)
722
11
722
11
100
100**
627
463
635
463
99
100
207
15
354
15
145
207
16
354
15
–
100
94
100
100
–
179
209
67
–
220
67
>75
95
100
27 Oesophago-gastric Cancer
136
–
>90
28 Prostate Cancer
287
287
100
29 2013 Audit of Use of Anti-D 35
35
100
30 2014 Audit of Transfusion in Sickle Cell Disease
2
2
100
818
818
100
2
4
3
4
2
7
3
4
100
57*
100
100
Haematology
Other
31 PROMs for elective surgery 1
2
3
4
National Confidential Enquiries
Tracheostomy care
Lower limb amputation
Gastrointestinal haemorrhage
Sepsis
* Still collecting data – deadline not yet expired for 2014 / 15 data entry.
** For a 6-month period Jan – Jun 2014.
19
Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
Participation in clinical audit
The reports of 32 national clinical
audits were reviewed by The Ipswich
Hospital NHS Trust in 2014 / 15 and
The Ipswich Hospital NHS Trust
intends to take the following actions
to improve the quality of healthcare
provided:
Thoracic Society guidance 2010
and a previous audit had been
conducted in 2013. 150 hospitals
contributed data and Ipswich
Hospital submitted details of 15
cases.
• National Clinical Audit of Blood
Transfusion – Use of Blood in Adult
Medical Patients
In 2012, the National Blood and
Transplant Service conducted a
national audit of the use of red
blood cells for adult medical
patients. The national drive to
reduce the overall use of blood
had occurred in surgical cases
but less so in medical patients. The aim was to check that the
good practice standards set
by the British Committee for
Haematology standards were
being followed.
Ipswich Hospital submitted data
on 65 adult medical cases having
transfusions in late 2011. In the
national report, comparing Ipswich
with national average figures,
pre‑transfusion investigation was
close to the national average,
but post‑transfusion investigation
less so. Ipswich was transfusing
more patients for anaemia than
nationally and some were being
transfused for reversible anaemia. The results were discussed at
a medical staff meeting and
it was agreed to improve the
documentation of the reason for
transfusion in notes, implement
consent for medical transfusion
and continue to monitor the use
of blood for medical patients.
20
This national audit seeks to drive
improvements in the quality of
care and services for patients with
respiratory conditions requiring
insertion of a chest drain. The
audit was based on the British
The results were presented at a
multidisciplinary meeting. The
conclusion was that Ipswich
was doing relatively well. There
were still some aspects of
documentation that needed
improvement. A chest drain
proforma has been developed to
prompt completing all aspects
of care and ensuring good
documentation.
• National Heavy Menstrual Bleeding
(HMB) Audit
• British Thoracic Society – Chest
Drain Insertion Audit (2014)
The findings showed improvement
on the previous audit and, in most
aspects, Ipswich results were
better than the national figures.
Heavy menstrual bleeding affects a
quarter of women of reproductive
age. NICE and the Royal College of
Obstetricians and Gynaecologists
published guidance in 2007 and
2008. This national audit was run
from 2010 to 2014. It involved
an organisational questionnaire
sent to Trusts in 2010 and again in
2013 to determine improvements
in service. Also, a prospective audit
of women attending their first
clinic appointment was run from
February 2011 to February 2012
and the women were all sent a
1-year follow-up questionnaire.
56% returned the follow-up
questionnaire.
The organisational audit found
that national use of written
protocols increased from 30% to
50%, small increases in availability
of diagnostic and therapeutic
services were found and provision
of information leaflets increased
from 76% to 84%. From the women’s responses,
1 in 5 did not receive any
treatment, 1 in 3 had surgery and
1 in 3 received oral medication or
intrauterine device.
The results for Ipswich showed
a good ascertainment rate and
slightly below average ratings but
close to the national mean.
The results were discussed in a
multidisciplinary meeting. The
conclusion was that the Ipswich
baseline organisation was
reasonable and since the audit
further developments had taken
place ie dedicated HMB clinic
with written protocols. Currently
discussions are taking place
with the Clinical Commissioning
Group to agree joint pathways
for primary and secondary care
referral and treatment.
The reports of 245 local clinical
audits were reviewed by The Ipswich
Hospital NHS Trust in 2014 / 15 and
The Ipswich Hospital NHS Trust
intends to take the following actions
to improve the quality of healthcare
provided:
• Neutropenic Sepsis Audit – Door
to Needle Time (2014 Update)
NICE published guidance stating
cancer patients with neutropenic
sepsis should receive intravenous
antibiotics within one hour of
arrival at hospital. The Clinical
Commissioning Group set the
target of 100% and requires
regular audit results. Data has
been collected since 2012 and
in 2013 the Cancer Network
recommended use of a prospective
data collection proforma. This
audit examined before and after
introduction of the proforma
with the aim of demonstrating
progress.
In the first time period, prior to
the introduction of the proforma,
40 patients were admitted. In the
second time period, 80 patients
were admitted. 33% were treated
in one hour in the first period,
The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
Participation in clinical audit
compared to 85% in the second
period.
The audit demonstrated
considerable progress, although
efforts continue to improve the
figures further. Actions taken to
address the delays have been: the
development of nurse prescribing
(Patient Group Directive
development), staff training
and patient education with card
issue with telephone helpline
details. The audit continues and
results are regularly provided to
commissioners, regional network
and Trust staff.
• Re-audit: Delirium Screening in
Acute Medical Admissions Unit,
Ipswich Hospital. Are we doing it
right?
NICE published guidance on
the assessment and treatment
of patients admitted with acute
delirium. An initial audit in 2012
showed documentation of
cognitive assessment score (CAMS)
on admission was poor. A change
was made to the layout of the
clerking proforma and a re-audit
conducted in 2014.
The completion of the CAMS
assessment score had improved
from 6% to 59%. The results
were fed back to staff in a
multidisciplinary meeting.
Education was provided at the
meeting and continues to be
included in the junior doctor
training programme. A re-audit is
planned in 2015.
August 2013 and July 2014 were
reviewed.
89% had immunoglobulin levels
checked prior to starting Rituximab
infusion. A few patients had
continued to be treated despite
having low levels. Review of
the cases indicated they were
appropriate.
The conclusion was that checking
of levels had improved. All staff
were encouraged to document
their reasons for continuing
treatment in a letter to the patients.
National audit reports are
discussed by the teams of
clinicians involved. Action plans
are developed to address any
shortfalls in local care compared
to national standards. This has led
to business cases for additional
staffing and equipment and
system changes. Similarly, local
audit projects have led to service
developments, amendments
to protocols, changes to
documentation, study days,
education programmes and
re‑audit.
Audit showcase success
The Clinical Audit Day held on
15 July 2014 was a great success
with 28 posters displayed and four
clinical audits presented. Plenty of
people turned up to look at the
presentations and posters which
showcased the wide range of
audit work performed by clinical
staff to improve care for patients.
Dr Jonathan Douse, chairman of
the Clinical Audit and Effectiveness
Committee said he was pleased
with the enthusiasm for the event.
The first prize was awarded to
Gill Heard, Georgina Price and
Tracy Hitching from the Oncology
Department for their work on
neutropenic sepsis. The runners‑up
were Charley Mukherjee, Sarah
Clark and Dr Julie Brache for their
work on head injury patients
admitted to surgical wards. The
Best Poster prize was awarded to
Rachel Clegg and Elizabeth Tissingh
who described their project on the
introduction of patient information
leaflets to the Fracture Clinic.
• Re-audit of Rituximab in
Rheumatoid Arthritis –
Immunoglobulin Level Monitoring
This topic had been audited in
2013 when the findings showed
need to improve checking the
levels of immunoglobulin before
and after treatment. This re‑audit
aimed to confirm improved
practice. All patients having
Rituximab infusion between
From left to right: Tracy Hitching, Clinical Audit officer; Gill Heard, Oncology matron; and Dr
Jonathan Douse, chairman of the Clinical Audit and Effectiveness Committee.
21
Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
Participation in clinical research
Commitment to research as
a driver for improving the
quality of care and patient
experience.
The number of patients receiving
relevant health services provided
or sub-contracted by The Ipswich
Hospital NHS Trust in 2014 / 15 that
were recruited during that period to
participate in research approved by a
research ethics committee was 1,677.
Participation in clinical research
demonstrates The Ipswich
Hospital NHS Trust’s commitment
to improving the quality of care
we offer and to making our
contribution to wider health
improvement.
The Ipswich Hospital NHS Trust was
involved in conducting 143 clinical
research studies during 2014 / 15,
examples of which include:
target of 90 participants was
achieved, all of whom were
assessed daily for up to 10 days
during hospital admission to
determine whether they developed
delirium, and again at 30 days for
assessment of any evidence of
persistent delirium and assessment
of experience of care.
22
Ipswich Hospital has recently been
involved in this important piece of
research looking into the clinical
and cost effectiveness of the POD
system of care verses standard care
practice, and to gather data to
inform a future larger study.
The POD system of care is a quality
improvement, multi‑component
delirium prevention intervention
which will be delivered by ward
staff and volunteers. Ipswich
Hospital was randomised to the
control group which continues to
deliver care in line with current
practice. Saxmundham and
Kesgrave wards were chosen to
act as study site wards and staff
collaborated with the research
team to conduct this research over
a six‑month period.
All patients admitted to the wards
aged 65 years or older, who did
not have prevalent delirium were
considered for enrolment and
invited to participate. A recruitment
• East Anglian diabetes study
Ipswich Hospital’s Trust Research
Unit is taking part by running three
clinics a week in a multi‑million
pound study carried out by
Norfolk and Norwich University
Hospitals NHS Foundation Trust and
University of East Anglia to tackle
one of the country’s greatest public
health challenges by screening
people in Norfolk and Suffolk at
risk of developing Type 2 diabetes.
The £2.2 million research study,
funded by the National Institute for
Health Research (NIHR), will screen
10,000 people who are at risk of
developing Type 2 diabetes and
then prescribe dedicated lifestyle
education on diet and exercise
that could prevent hundreds of
people developing the condition. In
England it is estimated 2.4 million
people have diabetes. About 80%
of those with diabetes in England
have Type 2 diabetes.
A group of those at risk of
developing Type 2 diabetes will
then be given help to improve diet
and exercise levels in order to see
if preventative changes to their
lifestyle can help reduce their risk.
We anticipate being invited to
participate in the next phase of the
study when it is launched.
• HALT-IT Study
• POD Study – Prevention of Delirium
for Older People in Hospital
The study is scheduled to be
completed in 2018.
The Emergency Department
(ED) team is taking part in an
international study looking at
treatment for upper or lower
GI (gastrointestinal) bleeds with
patients presenting through ED.
HALT-IT is the Haemorrhage
ALeviation with Tranexamic acid
– InTestinal study. The study is an
international randomised controlled
trial of 8,000 patients with
suspected significant bleeding from
the gut (gullet, stomach, bowel)
to see if the drug tranexamic acid
(TXA) decreases mortality, the need
for blood transfusions and the
need for surgery etc. Gut bleeding
causes 75,000 admissions in the
UK per year and around 10 – 15%
of these patients die. We know
that TXA reduces mortality due to
bleeding in trauma and we hope it
will do the same for gut bleeding
but the only way to know for sure
is to do a trial.
When a patient comes into ED with
suspected significant bleeding from
the gut, he or she will be offered
the opportunity to be in the trial.
All the usual treatment for gut
bleeding continues as normal. If
the patient is eligible and consents
to participate, they are randomised
to receive either TXA or a placebo
over 24 hours alongside standard
therapy. Neither the patient nor
the clinician knows which they are
getting (double-blind trial).
These examples demonstrate that
a commitment to clinical research
leads to better treatments for
patients.
There were 125 clinical staff
participating in research approved
by a research ethics committee
at The Ipswich Hospital during
2014 / 15. These staff participated
in research covering 32 medical
specialities. Our clinical staff stay
abreast of the latest treatment
possibilities and active participation
in research leads to successful patient
outcomes.
The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
Monitoring quality
Shining Light
Deborah Wainwright
Head of Design Services
“Deborah has always been
extremely professional
and efficient. She recently
supported a colleague on
a piece of work with a very
tight deadline and, despite
having other pressures on her
time, she remained calm and
patient and she provided an
excellent service. It is clear
that Deborah takes great pride
in her work and she delivers
to a very high standard. I
felt extremely confident in
Deborah’s ability to deliver and
I was constantly reassured on
progress with clear and timely
communication. Deborah
works very much behind the
scenes, but her skills and
expertise touches so much of
what we see or read.”
When we talk about quality care we
mean care that is safe, responsive to
people’s needs and contributes to a
positive patient experience.
We want to deliver great care for
every patient when and where
they need it. Our vision reflects
our position as a provider of
healthcare for both local people
and for a wider population and
we provide care in many ways
and locations. To deliver this
ambition we know that we will
always seek to improve the
healthcare we provide and we
will be flexible and responsive to
future demands so that we can
make sure patients get great care
when and where they need it.
We monitor and regularly report on
a wide range of quality indicators
at all levels within the Trust. This
information is displayed for the public
on noticeboards in ward and clinic
areas, on the website and on the staff
intranet site. Our performance on
quality is discussed at staff meetings
and at each meeting of the Board of
Directors as well as being reported to
a number of groups and committees,
including the Ipswich Hospital User
Group.
Use of the CQUIN payment
framework
The CQUIN payment framework
enables our commissioners to reward
excellence and innovation, by linking
a proportion of the Trust’s income
to the achievement of locally-agreed
quality improvement goals.
A proportion of The Ipswich Hospital
NHS Trust’s income in 2014 / 15
was conditional upon achieving
quality improvement and innovation
goals agreed between The Ipswich
Hospital NHS Trust and any person
or body they entered into a contract,
agreement or arrangement with
for the provision of relevant health
services, through the Commissioning
for Quality and Innovation payment
framework.
Further details of the agreed goals
for 2014 / 15 and for the following 12
month period are available online at
www.england.nhs.uk/wp-content/
uploads/2014/02/sc-cquin-guid.pdf
Table 1, overleaf, demonstrates the
actual performance for the CQUIN
indicators for 2014 / 15.
Quality Metrics
Our approach to Quality Monitoring
in clinical areas links to the Trust
accountability framework providing
a ‘heatmap’ view of quality and
performance at both Trust and clinical
area level. Review of existing, and the
addition of more relevant specialised
quality metrics, took place during
November and December. These will
provide a more sensitive indicator
to assess quality performance in all
clinical areas. Alongside this a new
IT solution to capture and report on
the quality information is also being
progressed.
23
Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
Monitoring quality
Table 1 – Actual performance for the CQUIN indicators for 2014 / 15.
The total payment represents 2% of Actual Outturn Value of Contract.
Goal
Scheme
1b
Friends & Family: Early Implementation
1c
Friends & Family: Response Rate
1d
Friends & Family: Decreasing Negative Responses
2a
Safety Thermometer: Reduction in all falls: Improve Quarterly falls rate
2b ia
Safety Thermometer: System-wide working to reduce Pressure Ulcers (PUs) – Conduct analysis
2b ib
Safety Thermometer: System-wide working to reduce Pressure Ulcers – Continue to record patients
2b ii
Safety Thermometer: System-wide working to reduce Pressure Ulcers – Undertake RCAs on developed PUs
2b iii
Safety Thermometer: System-wide working to reduce Pressure Ulcers – Quarterly dashboard
2b iv
Safety Thermometer: System-wide working to reduce Pressure Ulcers – Attendance / Follow-up PU forum
2b v
Safety Thermometer: System-wide working to reduce Pressure Ulcers – Attendance / Follow-up care home network
3a
Dementia: Find, Assess, Investigate and Refer – Case finding, assess, refer
3b
Dementia: Clinical Leadership – Named lead clinician and training programme
3c
Dementia: Supporting Carers – Monthly Audit of carers of patients with dementia
4a
Psychiatric Liaison Embed & Extend: Reporting and training
4b
Psychiatric Liaison Embed & Extend: Timeliness of A&E referrals
4c
Psychiatric Liaison Embed & Extend: Training and roll out of screening tool for admitted patients
4d
Psychiatric Liaison Embed & Extend: Norfolk and Suffolk NHS Foundation Trust
5a
Elective Transformation: ALL
*
5b i
Elective Transformation: Clinical Forums – ENT / Audiology
*
5b ii
Elective Transformation: Clinical Forums – Urology
*
5b iii
Elective Transformation: Clinical Forums – Gastroenterology
*
5b iv
Elective Transformation: Clinical Forums – Heart Failure
*
5b v
Elective Transformation: Clinical Forums – Gynaecology
*
5b vi
Elective Transformation: Clinical Forums – Respiratory
*
5b vii Elective Transformation: Clinical Forums – Ophthalmology from Q2, General in Q1
5c
Elective Transformation: Clinical Forums – Suspicious Lymph Nodes
5d i
Elective Transformation: Clinical Forums – Surgical Improvements: a) Staff time and participation
5d ii
Elective Transformation: Clinical Forums – Surgical Improvements: b) wound infection, c) UTI, d) pneumonia
5e
Elective Transformation: Clinical Forums – Enhanced Recovery
6a
Deteriorating Patient: Avoidable deterioration leading to cardiac arrest
6b
Deteriorating Patient: Improve MEWS audit trajectory
7a i
Shared Care Drugs: Rheumatology, Gastro and Urology Shared Care specialities
8a
7-day working: MRI, CT and ultrasound < 24 hrs; CTPA < 24 hours; endoscopy 6 days; DVT 6 days
8b
7-day working: EAU / PAU consultant ward rounds; staff grades review; 7-day consultant GI bleed rota;
PT and OT; Critical Care outreach; same day see-and-treat TIA 7 days
8c i
7-day working: Standard 1 – Patient experience
8c ii
7-day working: Standard 2 – Time to first consultant review
8c iii
7-day working: Standard 3 – Multidisciplinary review
8c iv
7-day working: Standard 4 – Shift handovers
8c v
7-day working: Standard 5 – Diagnostics
8c vi
7-day working: Standard 8 – Ongoing review
8c vii
7-day working: Standard 10 – Quality improvement
9a
End of life
10 i
Surgical Liaison Geriatrics
11
Gallstones
Key: Green = standard achieved
Amber = standard partially achieved
Red = standard not achieved
Grey = development, implementation or not deliverable for this quarter
* = data under review and not finalised
24
Q1
Q2
Q3
Q4
*
*
*
The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
How healthcare is regulated
The Ipswich Hospital NHS Trust is
required to register with the Care
Quality Commission (CQC) and its
current registration status is full
registration. The Ipswich Hospital
NHS Trust has the following
conditions on registration – no
conditions.
Acute hospital inspections are
carried out using a large expert
team of inspectors over several days
and includes listening events. The
following areas are assessed during
an inspection:
The Care Quality Commission has not
taken enforcement action against The
Ipswich Hospital NHS Trust during
2014 / 15.
• Medicine;
The Ipswich Hospital NHS Trust has
not participated in any special reviews
or investigations by the Care Quality
Commission during the reporting
period.
CQC monitoring and
inspection process
The CQC‘s surveillance model is built
on a suite of indicators which relate
to the five key questions – are services
safe, effective, caring, responsive,
and well-led?
The indicators are used to raise
questions about the quality of
care but are not used on their
own to make final judgements.
Judgements will always be based on
a combination of what is found at
inspection, national surveillance data
and local information from the Trust
and other organisations.
The judgement is based on a ratings
approach using the following
categories:
Outstanding
Good
Requires Improvement
Inadequate
• Emergency Department;
• Surgery;
• Outpatients;
• Critical Care;
• Paediatrics;
Inspections by the Care
Quality Commission
The CQC regularly inspects Trusts and
continues to re-inspect those services
which fail to meet the Essential
Standards of Quality and Safety, and
inspect any service at any time if there
are concerns raised.
Following an inspection, the CQC will
judge the Trust as either Outstanding,
Good, Requires Improvement or
Inadequate.
• Maternity; and
January 2015
• End of Life Care.
The Care Quality Commission
conducted an announced inspection
of the Trust between 6 and 8 January
2015 and carried out follow-up
unannounced inspections on 12 and
15 January 2015. This inspection was
part of the CQC’s comprehensive
inspection programme. Forty
inspectors observed care, spoke with
staff, patients, carers and relatives,
and reviewed patient notes.
Intelligent Monitoring Score
The CQC model for monitoring a
range of key indicators about NHS
provision. These indicators relate to
the five key questions asked of all
services – are they safe, effective,
caring, responsive, and well-led?
Each hospital has been placed in one
of six bandings based on a scoring
model.
An overall summary band for each
Trust is then created, by reviewing the
proportion of indicators identified as
‘risk’ or ‘elevated risk’ for each trust
out of all the applicable indicators in
the model.
Within the reporting period two
reports were issued by the CQC with
the risk scores shown overleaf.
The reports are available at
www.cqc.org.uk/sites/default/files/
RGQ_103v3_WV.pdf
www.cqc.org.uk/sites/default/files/
RGQ_104v3_WV.pdf
The inspectors found that the Trust
had a relatively new executive team,
who worked effectively together
to highlight issues and address
challenges within the hospital. The
management team was responsive
and acted quickly to address issues
highlighted to them during the
inspection. The Trust was aware
of the issues faced on Sproughton
Ward and this was highlighted to
the CQC prior to the inspection. The
CQC identified challenges on this
ward, and the Trust took immediate
actions to ensure that people received
safe and effective care in this ward.
This ward was visited again during
the announced and unannounced
inspections, and it was found that
improvements made had been
sustained.
The inspection found that
overall, the Trust was rated
as ‘Good’.
25
Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
How healthcare is regulated
Image 1 – Intelligent Monitoring Score July 2014
Image 2 – Intelligent Monitoring Score December 2014
Comments from people who
use the Trust’s services
The experience of patients using the
hospital was in general very good.
The cancer patients’ survey showed
that patients were satisfied with the
care that they received. The Trust
scored higher than the national
average in respect of staff involving
patients, and providing information
and support to patients.
The NHS patient survey showed that
the Trust performed in line with other
trusts surveyed across all areas. The
number of complaints received by the
Trust has continued to fall since 2011.
However, there was a rise in 2013 / 14
on the previous year. The listening
event held on 6 January 2015 was
well attended by approximately 35
people. Mixed accounts of the care
provided at the Trust were heard,
and a number of people flagged
concerns about the care provided
on Sproughton Ward. However,
most people felt that the hospital
was providing good care and was
responsive to the needs of people
attending the hospital.
26
Are services at the Trust safe?
Services at the Trust were rated
as requiring improvement due
to issues found in surgery and
children’s services; these related to
the feedback from incidents, which
were not always received by staff; or
staff were not able to demonstrate
learning from incidents reported.
Medicines in the south theatres were
found not to be stored appropriately,
and equipment was not always
maintained in an efficient manner. On
the children’s ward, the provision of
higher dependency care, whilst not
commissioned, was provided on the
ward without staff having undertaken
the appropriate training. This level
of care was provided in line with the
hospital’s guidance and risk assessed,
but was in response to patient
need rather than as a planned,
commissioned and supported service.
Are services at the Trust
effective?
Overall, the Trust was meeting and in
some cases exceeding expectations
in national audits, and was therefore
rated as good overall. There was
good multidisciplinary working across
teams, and audit and benchmarking
is a high priority at the Trust.
However, improvements are required
to advance the effectiveness of
children’s and young people’s services,
and those for patients at the end
of their life. In children’s and young
people’s services, inspectors could not
be assured that treatment provided
for respiratory conditions was in line
with national guidance. The end of
life care guidance had been rolled
out across the Trust, but was not
supported by formalised education,
and did not encompass all aspects
of care in line with NICE guidance.
However, the effectiveness in the
Emergency Department was rated
as outstanding, as national guidance
was implemented, and staff followed
clear pathways of care.
The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
How healthcare is regulated
Are services at the Trust
caring?
Patients were treated with dignity and
respect at all times. The Friends and
Family Test was above the national
average, despite a poor response
rate from patients at the Trust. Most
patients and relatives who spoke with
the inspectors talked very highly of
how they had been treated and cared
for in the hospital. Where patients
and relatives shared concerns, they
were referred to the most senior
person, who spoke with these
families and took action to address
their concerns. Patients and their
relatives / carers were kept informed
of their treatment plans, and were
given information to support them.
Are services at the Trust
responsive?
In general, the Trust was responsive
to meeting the needs of patients and
their families. This included making
staff available through the outreach
team, to talk with patients and
explain their treatment and illness.
However, in maternity, the team
had not embraced new initiatives or
guidance as proactively as expected.
Whilst this did not significantly impact
on the care provided, the lack of
specialist midwives meant that some
groups of women were not receiving
the most up-to-date care. Referral
to treatment times from the period
before the inspection showed that
the Trust was not always meeting
these; however, inspectors saw that
action had been taken to improve.
Are services at the Trust
well-led?
Although it has a relatively new Trust
Board, the Trust was aware of where
its challenges and successes lay. It
actively managed the challenges, and
had put in place effective systems
for managing the pressures of extra
patients in the winter. The Emergency
Department trigger tool was well
used, to ensure the Trust was
effective and responsive to meeting
the increasing needs of patients in
this department. Trust executives
were well known to staff, and led
them through an open door policy.
Key findings
• Never events that had occurred
were actively and imaginatively
investigated, including using
human factors analysis, and
lessons were learnt.
• Systems in place within the
Emergency Department were
assisting to effectively tackle
the winter pressures during the
inspection.
• Staff were caring and
compassionate, and treated
patients with dignity and respect.
• The hospital was visibly clean and
well maintained.
• Infection control rates in the
hospital were lower when
compared with those of other
hospitals.
• The Trust performed better than
average in a number of national
audits, including the national hip
fracture audit, the national bowel
cancer audit, the national lung
cancer audit data, the Sentinel
stroke national audit, and the
myocardial infarction national
programme.
• Managers and staff responded
quickly and took appropriate
actions to ensure patient safety
where issues were identified.
• There is an ongoing recruitment
and retention programme to
address staffing shortfalls.
• The critical care pathway for
children was not well defined.
Improvement is needed with
regards to the provision of a
children’s high dependency unit.
• Some of the equipment within
Diagnostic Imaging was aged.
There are plans to replace some
items.
The inspectors witnessed the
following areas of outstanding
practice:
 The Emergency Department
trigger tool, which was in place
to ensure that the responsiveness
of the ED is maintained when
the department sees increasing
pressures.
 The Chaplaincy service carries a
trauma bleep in order to provide
emotional support to the relatives
of trauma victims.
 Ipswich Hospital is one of
only two trusts in the UK to
participate in the American
College of Surgeons National
Surgical Quality Improvement
Program (ACS NSQIP), providing
international benchmarking of
patient outcomes.
 There is a comprehensive
outreach service in place,
providing full 24 / 7 cover,
including a ‘patient activated’
referral for the team.
Areas where the CQC highlighted
the Trust could improve upon are
detailed below with the actions
the Trust intends to take.
• Review the end of life care
paperwork to ensure it is more
individualised and provides a
holistic approach in line with
National Institute of Health and
Care Excellence (NICE) guidelines.
• Provide training to staff providing
end of life care, on how to
identify patients approaching the
end of life, and on how to use the
new care plans.
• Ensure that discussions with
patients and families regarding
end of life care, or advanced care
planning decisions, are clearly
recorded in the person’s medical
records.
27
Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
How healthcare is regulated
• Ensure that prior to undertaking
a procedure, or completing an
end of life care order, the person’s
mental capacity is appropriately
assessed in accordance with the
Mental Capacity Act 2005.
• Ensure that all clinical areas
in Outpatients, including the
equipment in rooms, are cleaned
regularly, and the cleaning is
evidenced.
• Ensure that the decontamination
room in ear, nose and throat (ENT)
outpatients is compliant with
guidelines on decontamination
Hospital Technical Memorandum.
• Review medicines management
within the South Theatres, to
ensure medicines are stored
securely.
• Clearly define a critical care
pathway for children and
review the provision of services
for children requiring high
dependency of care, including
staffing numbers, competency
and provision of registered sick
children’s nurses.
The full report can be viewed on
the CQC website: www.cqc.org.uk/
directory/RGQ02
Following receipt of the report, a
Quality Summit was convened to
consider the Trust’s response to the
report. The summit was attended by
senior representatives of the Trust,
the Trust Development Authority
(TDA), Care Quality Commission, NHS
England and Ipswich and East Suffolk
Clinical Commissioning Group to
discuss the findings from the report.
The discussions from this meeting
have been incorporated into a quality
improvement plan.
28
Overall rating for this hospital
Good
Urgent and emergency services
Outst anding
–––
–
Medical care
Good
–––
Surgery
Good
–––
Critical care
Good
–––
Maternity and gynaecology
Good
–––
Requir es impr ovement
–––
End of life care
Good
–––
Outpatients and diagnostic imaging
Good
–––
Services for children and young people
Following the Care Quality
Commission’s announced inspection
in January 2015, The Ipswich Hospital
NHS Trust is taking the following
actions to address the findings of the
CQC’s report.
Actions the Trust MUST take to
improve
1 Review the end of life care
paperwork to ensure that it is
more individualised and providing
a holistic approach in line with
NICE guidelines.
Executive lead: Director of Nursing
and Quality
Actions
• Amend assessment tool
paperwork to allow greater
individual holistic assessment in
line with NICE guidance.
• Seek CQC opinion on
documentation (if able).
• Documentation approved and
implemented.
• Commence audit of effectiveness
of assessment tool.
• Inclusion of amended assessment
tool, reflecting importance of
attitude and holistic approach, in
ongoing education and training.
2 Provide training to staff
providing end of life care, on how
to identify patients approaching
the end of life, and on how to use
the new care plans.
Executive lead: Director of Nursing
and Quality
Actions
• End of Life Care facilitator in post.
• End of Life Care facilitator to
commence coordination of
training.
• Commence review of effectiveness
of training.
• Identified key staff trained in
CQUIN requirement.
• Commence targeted training in
individual ward areas based on
relevant CQUIN outcomes.
• Roll-out of training programme to
all relevant areas.
The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
How healthcare is regulated
3 Ensure that discussions with
patients and families regarding
end of life care, or advanced care
planning decisions, are clearly
recorded in the person’s medical
records.
6 Ensure that the
decontamination room in ear,
nose and throat (ENT) outpatients
is compliant with guidance
on decontamination Hospital
Technical Memorandum.
Executive lead: Medical Director
Executive lead: Director of Nursing
and Quality
Actions
• Continue audit of end of life
medical documentation (including
reference to CQC report findings).
• Outcome of audit to inform
further development.
• Establish benchmark performance
via participation in National End of
Life Care Audit.
• Continue Palliative Care
Consultant training to medical
staff.
4 Ensure that prior to undertaking
a procedure, or completing an
end of life care order, the person’s
mental capacity is appropriately
assessed in accordance with the
Mental Capacity Act 2005.
Executive lead: Director of Nursing
and Quality
Actions
• Mental capacity assessment to
be included in individualised care
plan.
• Commence audit of assessment
process.
5 Ensure that all clinical areas
in outpatients, including the
equipment in rooms, are cleaned
regularly, and the cleaning is
evidenced.
Actions
• Clearly label entry and exit to
decontamination room.
• Infection Control Team to review
decontamination room practices
against CQC recommendations.
• Commence audit of
decontamination room practices to
ensure ongoing compliance with
CQC recommendations.
7 Review medicines management
in the South Theatre areas to
ensure medicines are stored
securely.
Executive lead: Medical Director
Actions
• Review secure access to theatre
storage areas.
• Agree options and funding for
implementation of secure access
to medicine storage areas in
theatre areas.
• Installation of secure access to
medicine storage areas in theatre
areas.
• Ensure ongoing compliance with
correct drug storage procedures
and monitor through Safe and
Secure Storage of Medicines Audit
Programme.
8 Clearly define a critical care
pathway for children and
review the provision of services
for children requiring high
dependency care, including
staffing numbers, competency
and provision of registered sick
children’s nurses (RSCN).
Executive leads: Director of Nursing
and Quality and Medical Director
Actions
• Continue to work with
stakeholders and commissioners
to secure commissioning of high
dependency unit (HDU).
• Review current critical care process
and revise standard operating
procedure to incorporate pathway
once confirmed and amend
training requirements accordingly.
• Implementation of Paediatric
Acuity Tool to ensure optimum
staffing levels.
• Refine Paediatric Acuity Tool with
support and input from Great
Ormond Street Hospital.
• Paediatric training needs analysis
to incorporate HDU and Critical
Care requirements.
Executive lead: Director of Nursing
and Quality
Actions
• Establish equipment cleaning
record in all relevant areas.
• Audit of cleaning contract with
cleaning contractors.
• Hospital Infection Control
Committee to monitor cleaning
within all OPD areas.
29
Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
Statements relating to the quality of relevant health services provided
NHS number and General
Medical Practice Code
validity
The Ipswich Hospital NHS Trust
submitted records during 2014 / 15
to the Secondary Uses Service for
inclusion in the Hospital Episode
Statistics which are included in the
latest published data.
The percentage of records in the
published data which included the
patient’s valid NHS number was:
• 99.35% for admitted patient care;
• 99.73% for outpatient care; and
• 98.58% for accident and
emergency care.
The percentage of records which
included the patient’s valid General
Practitioner Registration Code was:
• 99.28% for admitted patient care;
• 99.42% for outpatient care; and
• 97.75% for accident and
emergency care.
Source: NHS and Social Care Information Centre
data quality dashboards.
Information Governance
Toolkit attainment levels
The Ipswich Hospital NHS Trust
Information Governance Assessment
Report overall score for 2014 / 15 was
84% and was graded satisfactory
(green).
Clinical coding
The Ipswich Hospital NHS Trust
was subject to the Payment by
Results clinical coding audit during
the reporting period by the Audit
Commission and the error rates
reported in the latest published audit
for the period for diagnoses and
treatment coding (clinical coding) were:
• 4.5% of primary diagnoses
incorrect;
• 6% of secondary diagnoses
incorrect;
• 6.2% of primary procedures
incorrect; and
• 27.3% of secondary procedures
incorrect (only 33 episodes of
the 200 sampling featured a
procedure in the second position).
30
Table 2 – Data quality
The Ipswich Hospital NHS Trust will be taking the following actions
to improve data quality and agreed areas for improvement with GP
commissioners:
Data Quality Indicator
Data Quality
Threshold
Method of
Measurement
Milestone
Date
Consequence
The Provider shall publish
median waiting times
for first and follow-up
outpatient appointments
by specialty on their
website and to inform the
Commissioner
100%
Publish data
Q1 – Agree
In accordance
methodology with SC28*
All inpatient and A&E data
sets including the SUS data
set must have timestamp
information. For clarity
this means the Trust must
submit admission and
discharges times for every
record that can be viewed
by the Commissioner
98% of all
A&E and
inpatient
records
must have
admission
and
discharge
times
Monthly SUS report
Month 2
In accordance
with SC28
Referrals CDS** (patient
level) for outpatient
referrals. Complete dataset
to reflect all outpatient
attendances and to
be consistent with the
outpatient CDS
95% of
Link to Outpatients
referrals to
be linkable
to outpatient
appointment
End of Q1
In accordance
with SC28
Reporting A&E Attendances CCG /
and Admission figures Ipswich
Hospital
to work
towards
using A&E
dataset
supplied to
DSCRO† as
reporting
source
Monthly total
End of Q1
new unplanned
attendances, number
of breaches, number
of admissions, length
of admission (by time
bands), quarterly
new unplanned
attendances, quarterly
number of breaches
and quarterly number
of admissions
In accordance
with SC28
Osteoarthritis Knee Service
Reporting
Monthly
reporting
received
Completed monthly
templates
End of Q1
In accordance
with SC28
Early Inflammatory Arthritis
Monthly
reporting
received
Completed monthly
templates
End of Q1
In accordance
with SC28
Cystic Fibrosis Reporting
Monthly
reporting
received
Completed monthly
templates
End of Q1
In accordance
with SC28
The Provider shall work
Monthly
towards supplying specialty reporting
received
information for drugs and
devices either by using a
combination of the drug
and indication, or using
the internal cost centre
which is the consultant /
clinical department who has
requested the drug to be
dispensed Completed monthly
templates
End of Q1
In accordance
with SC28
* S C28 – Service Conditions: compliance with service conditions within the contract relating to
information reporting.
**CDS – Commissioning Data Set.
†
DSCRO – an organisation employed by commissioners to distribute anonymised data.
The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
Core Quality Indicators
The data given within the Core Quality Indicators is taken from the
Health and Social Care Information Centre Indicator Portal (HSCIC),
unless otherwise indicated.
Indicator: Summary Hospital-Level Mortality Indicator (SHMI)
SHMI is a hospital-level indicator which measures whether mortality associated with a stay in hospital was in line with
expectations. SHMI is the ratio of observed deaths in a trust over a period of time, divided by the expected number given
the characteristics of patients treated by the trust. SHMI is not an absolute measure of quality, however, it is a useful
indicator to help trusts understand mortality rates across every service provided during the reporting period.
The data made available to the Trust by the
HSCIC with regard to:
the value and banding of the SHMI indicator for
the Trust for the reporting period
the percentage of patient deaths with palliative
care coded at either diagnosis or speciality level for
the Trust for the reporting period (the palliative care
indicator is a contextual indicator)
Reporting
period
Ipswich National Highest Lowest
Banding
score average score
score
Oct 11 – Sept 12
1.0263
1
1.1235
0.8901
2
Oct 12 – Sept 13
1.0451
1
1.0947
0.9972
2
Oct 13 – Sept 14
1.049
1
1.198
1.541
2
Oct 11 – Sept 12
18.8
19.2
43.3
0.2
--
Oct 12 – Sept 13
30.95*
20.28
44.1
0
--
Oct 13 – Sept 14
22.5
24.6
42.1
0
--
The Ipswich Hospital NHS Trust considers that this data is as described for the following reasons:
• The Trust is banded as a ‘2’ which is ‘as expected’ mortality. This correlates with the information gained from local
morbidity and mortality meetings.
The Ipswich Hospital NHS Trust has taken the following actions to improve this score, and so the quality of its
services, by:
• implementing NerveCentre – use of patient observation electronic hand-held devices to help coordinate requests
from wards, achieving significant benefits in both efficiency and safety. Doctors receive and acknowledge requests
on their mobile devices without the need to interrupt their current patient activity. Doctors can use mobile devices
to review and update handover notes, work with patient lists and review outstanding tasks, improving the handover
process and making handover notes available to doctors and specialists anywhere in the hospital. NerveCentre
improves patient care by replacing the bleep pager with technology to reduce internal delays, and provides
governance around out of hours activity.
• increasing the profile of the work of the Deteriorating Patient Group;
• raising the profile of departmental morbidity and mortality meetings and sharing lessons across the Trust;
• continually focusing on reducing mortality in a variety of forums; and
• reducing mortality by reviewing care by identifying core issues.
* The apparent large change in the figure in this period is due to an improvement in coding depth. The coding now better reflects the clinical situation.
These patients were clearly known to be in receipt of end of life care.
Indicator: Responsiveness to the personal needs of patients during the reporting period
The data made available to the Trust by the
HSCIC with regard to:
the Trust’s responsiveness to the personal needs of
patients during the reporting period
Reporting
period
Ipswich
score
National
average
Highest
score
Lowest
score
2012 / 13
64.5
68.1
84.4
57.4
2013 / 14
69.4
68.7
83.0
54.4
2014 / 15
No data available.
The Ipswich Hospital NHS Trust considers that this data is as described for the following reason:
• care rounding is used in all appropriate clinical areas. It is regularly audited to ensure practice is embedded.
The Ipswich Hospital NHS Trust has taken the following actions to improve this score, and so the quality of its
services, by:
• increasing ward establishment to improve staffing in clinical areas;
• ensuring all trainee HCAs receive nine classroom days plus a maximum of ten supernumerary days of training; and
• launching a new code of conduct for all healthcare support workers, which is being used as a blueprint for other
hospitals.
31
Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
Core Quality Indicators
Indicator: Patient Reported Outcome Measures (PROMs) scores
PROMs measures a patient’s health-related quality of life from the patient’s perspective using a questionnaire completed
by patients before and after four particular surgical procedures. These questionnaires are important as they capture the
extent of the patient’s improvement following surgery.
The data made available to the Trust by the
HSCIC with regard to:
the Trust’s patient reported outcome measures
scores for groin hernia surgery
the Trust’s patient reported outcome measures
scores for varicose vein surgery
the Trust’s patient reported outcome measures
scores for hip replacement surgery
the Trust’s patient reported outcome measures
scores for knee replacement surgery
Reporting
period
Ipswich
score
National
average
Highest
score
Lowest
score
2012 / 13
2013 / 14
2014 / 15
2012 / 13
2013 / 14
2014 / 15
2012 / 13
2013 / 14
2014 / 15
2012 / 13
2013 / 14
2014 / 15
0.086
0.079
0.06
0.137
0.073
0.109
0.455
0.465
0.453
0.353
0.352
0.085
0.086
0.084
0.093
0.101
0.102
0.438
0.439
0.449
0.318
0.330
0.319
0.109
0.111
0.144
0.141
0.149
0.158
0.466
0.481
0.548
0.346
0.391
0.414
0.061
0.060
0.026
0.045
0.053
0.009
0.410
0.396
0.335
0.291
0.270
0.226
No data available
The Ipswich Hospital NHS Trust considers that this data is as described for the following reasons:
• the data reflects that patients have excellent outcomes from joint arthroplasty. There are high levels of consultant
input, alongside a dedicated team of nurse specialists, theatre and ward staff, physiotherapists and administrative
staff. Detailed pathways have been developed to ensure the efficient, safe and effective delivery of care.
The Ipswich Hospital NHS Trust has taken the following actions to improve this score, and so the quality of its
services, by:
• continuing to monitor the scores. The Trust was pleased to note its good Orthopaedic performance.
Indicator: Re-admission rates
The percentage of patients 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 Trust by the
HSCIC with regard to:
percentage of patients aged 0 – 15 years
readmitted within 28 days
percentage of patients aged 16 years and over
readmitted within 28 days
Reporting
period
Ipswich
score
National
average
Highest
score
Lowest
score
2012 / 13
1.216
1
1.144
1.291
2013 / 14
2014 / 15
2012 / 13
2013 / 14
2014 / 15
No data available, publication due in 2016.
0.914
1
0.914
0.888
No data available, publication due in 2016.
The Ipswich Hospital NHS Trust considers that this data is as described for the following reasons:
• readmission data forms part of the Service Level Agreement with our commissioners and therefore undergoes
multiple levels of scrutiny and validation to ensure accuracy.
The Ipswich Hospital NHS Trust has taken the following actions to improve this score, and so the quality of its
services, by:
• gaining partnership funding for two years from Suffolk Family Carers who have been funded via Suffolk County
Council to support family carers before and after discharge. The service has ensured fewer problems and worries to
face once patients are home. Two support workers are based at the hospital, one liaises with family carers prior to
a patient being discharged, whilst the second support worker follows up in the community to check everything is in
place and working after going home. The service has been extended across all wards; and
• improving information given to patients about medication prior to discharge has received positive feedback from patients.
32
The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
Core Quality Indicators
Indicator: Staff recommendation (Friends and Family Test) Taken from Question 12d of the NHS staff survey
The data made available to the Trust by the
HSCIC with regard to:
Reporting
period
Ipswich
score
National
average
Highest
score
Lowest
score
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
for their family or friends.
2012 / 13
54%
63%
86%
35%
2013 / 14
61%
66%
76%
58%
2014 / 15
65%
66%
89%
38%
The Ipswich Hospital NHS Trust considers that this data is as described for the following reasons:
• responses to the NHS Staff Survey are independently reviewed.
The Ipswich Hospital NHS Trust has taken the following actions to improve this score, and so the quality of its
services, by:
• further development of the Trust’s staff experience and engagement strategy ‘Building Pride’;
• divisional roll-out of the national Staff FFT which has been combined with a local staff satisfaction survey and, as a
result of the responses, ‘Your Views Count’ newsletters adopted within each Division (‘You Said, We Did’ approach)
and divisional teams plotting local progress against the ‘Building Pride’ engagement barometer.
Indicator: Friends and Family Test – Patient
The data made available to the Trust by the
HSCIC with regard to:
the percentage of patients, covering services for
inpatients and patients discharged from Accident &
Emergency (types 1 and 2)
Reporting
period
2012 / 13
2013 / 14
2014 / 15
Ipswich
score
National
average
Highest
score
Lowest
score
The National Friends and Family Test did not commence until April 2013.
17.9%
18.3%
79.4%
4.2%
The National Friends and Family Test data is no longer collected.
The Ipswich Hospital NHS Trust considers that this data is as described for the following reasons:
• results are monitored by the Information Department and Patient and Carer Experience Group; and
• any outlying scores would trigger a review.
The Ipswich Hospital NHS Trust has taken the following actions to improve this score, and so the quality of its
services, by:
• reviewing results within relevant Clinical Delivery Groups and at the Patient and Carer Experience Group meetings,
and any actions required to improve responses are taken;
• emphasising the importance of submission of good returns and the satisfactory outcome scores achieved in
multidisciplinary team meetings; and
• using the Patient and Carer Experience and Involvement Strategy to plan future improvements.
Shining Light
Jonathan Douse
Consultant Respiratory Physician
Jonathan was nominated for the award by matron Kate Taylor for being a ‘motivational
leader’ and for keeping staff informed and supported to do their jobs at a time when
he too was busy caring for patients. Kate said: “Dr Douse conducts himself in a
professional manner at all times. He deserves to be recognised for his leadership skills
and for motivating the consultants at a time when they are relentlessly busy”.
33
Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
Core Quality Indicators
Indicator: Risk assessment for venous thromboembolism (VTE)
The data made available to the Trust by the
HSCIC with regard to:
the percentage of patients who were admitted to
hospital and who were risk assessed for VTE during
the reporting period
Reporting
period
Ipswich
score
National
average
Highest
score
Lowest
score
Q4 2012 / 13
Q4 2013 / 14
Q3 2014 / 15*
97.9%
98%
97%
94.2%
96%
96%
100%
100%
100%
87.9%
75%
81%
The Ipswich Hospital NHS Trust considers that this data is as described for the following reasons:
• VTE data collectors check that all admitted patients have been risk assessed and inform nursing staff if assessments
have not been completed; and
• clinical staff receive update training on the importance of VTE risk assessment and the prescription of appropriate
thromboprophylaxis.
The Ipswich Hospital NHS Trust has taken the following actions to improve this score, and so the quality of its
services, by:
• risk assessing patients for VTE using the mandatory assessment on NerveCentre;
• the forthcoming launch of e-whiteboards, where the absence of a completed VTE assessment will be flagged as
requiring action;
• launching a VTE e-learning programme for all clinical staff to complete as part of their mandatory training
requirement; and
• improving the pathway for acute DVT or PE management.
* The most recent data available at time of publishing.
Indicator: Clostridium difficile infection rate (Please see criteria on page 79.)
The data made available to the Trust by the
HSCIC with regard to:
the rate for 100,000 bed days of cases of Clostridium
difficile infection reported within the Trust amongst
patients aged two or over during the reporting period
Reporting
period
Ipswich
score
National
average
Highest
score
Lowest
score
2012 / 13
14.9
17.3
30.8
0
2013 / 14
12.0
14.7
37.1
0
2014 / 15
12.5
A
Data available July 2015.
The Ipswich Hospital NHS Trust considers that this data is as described for the following reasons:
• the accuracy of the data is checked thoroughly before submission; and
• the data is cross-checked with laboratory data and is subject to external assurance.
The Ipswich Hospital NHS Trust has taken the following actions to improve this infection rate and so the
quality of its services, by:
• reinstating infection control onto the mandatory training update day for all registered nurses;
• making speciality-specific training for clinicians available on request;
• making annual staff grade training for infection control mandatory;
• subjecting all cases of Clostridium difficile to rigorous Root Cause Analysis involving the multidisciplinary team with
follow-up and dissemination of lessons learned;
• subjecting all cases of Clostridium difficile to post-infection review;
• ribotyping of all positive Clostridium difficile samples to identify genetic trends / similarities;
• regularly reviewing the optimal use of antibiotics in conjunction with the Antibiotic Review Group;
• adding an alert to patient administration system if a patient has previously had Clostridium difficile to pre-warn
prescribers of broad spectrum antibiotics of the potential reactivation of Clostridium difficile;
• embedding the SIGHT protocol in all clinical areas allowing accurate Clostridium difficile assessment to take place;
• the Infection Control team visit all wards regularly throughout the week to ensure preventative infection control
systems are adhered to and ensure optimum care for infected patients; and
• making an on-call infection control and microbiological service available to enable staff to have access to expert
advice at all times.
Figure audited by independent auditors. This figure has been calculated by the Trust from its internal data because HSCIC will not be publishing C.diff rates
until July 2015. The Trust has used the number of C.diff cases per the Public Health England Healthcare Associated Infections system, which is the system
it reports these figures to and is ultimately where HSCIC obtains its information once figures are available. The Trust has used its own reporting system to
calculate bed days.
A
34
The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
Core Quality Indicators
Indicator: Patient safety incident rate (Please see criteria on page 79.)
The data made available to the
Trust by the HSCIC with regard to:
the number and rate of patient safety
incidents reported within the Trust
during the reporting period
Reporting
period
Ipswich score
National
average
Highest score Lowest score
Number
Rate
Number
Rate
Number
Rate
Number
Rate
Apr 12 – Sept 12
3,885
9.06
2,603
6.87
4,552
14.44
843
3.11
Oct 12 – Mar 13
4,070
9.50
2,870
7.55
5,272
16.7
631
1.7
Apr 13 – Sept 13
2,855
6.66
2,896
7.44
4,888
14.49
1,535
3.54
Oct 13 – Mar 14
2,497
5.83
Apr 14 – Sept 14
Datix figures
2,644
3,083
8.02
5,495
14.76
1,048
2.41
4,257
26.38
12,020
74.96
35
0.24
29.1
NRLS figures
2,348A
Oct 14 – Mar 15
25.88A
Datix figures
2,871
Data not available at time of publishing.
27.4
NRLS provisional figures
2,660A
Apr 12 – Sep 12
the number and percentage of such
patient safety incidents that resulted
in severe harm or death during the
reporting period
25.4A
Number
%
Number
%
Number
%
Number
%
13
0.4
19.4
0.8
95
3.6
0
0.1
Oct 12 – Mar 13
8
0.2
18
0.6
64
4.8
1
0
Apr 13 – Sept 13
11
0.4
19.4
0.7
106
3.1
0
0
Oct 13 – Mar 14
12
0.5
Apr 14 – Sept 14
Datix figures
26
20.1
0.7
72
2.3
1
0
4.88
1.48
27
3.05
0
0
0.98
NRLS published figures
15A
Oct 14 – Mar 15
0.6A
Datix figures
15
Data not available at time of publishing.
0.52
NRLS provisional figures
12A
0.5A
The Ipswich Hospital NHS Trust considers that this data is as described for the following reason:
Performance this year on peer benchmark fell. This is due to changes in the National Reporting & Learning System (NRLS) reporting
cohorts. In previous years the peer group consisted of 46 ‘medium acute’ hospitals. Since April 2014 this group now consists of 140
‘non-specialist acute’ hospitals, some of which are multi-hospital organisations and / or host out of hospital services. Hence the high
levels of reporting at the top end of the peer group.
The Quality Account indicator is based on the NRLS published figures, as detailed within the criteria detailed on page 79. Figures are
published on a six-monthly basis – those relating to the period October 2014 to March 2015 are not yet publically available. However, a
provisional NRLS submission has been shown for this period.
Based on the NRLS published and provisional information, the number and percentage of patient safety incidents resulting in severe
harm and death is:
• April – September 2014: 0.6%;
• October 2014 – March 2015: 0.5%.
Figure audited by independent auditors.
A
continued overleaf Ô
35
Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
Core Quality Indicators
Indicator: Patient safety incident rate (Please see criteria on page 79.)
continued from page 35:
However, due to errors in the submissions made by the Trust, the correct percentage of patient safety incidents resulting in severe harm
and death is that calculated by using the Trust’s internal figures (Datix figures):
• April – September 2014: 0.98% – a difference of 0.38% to that actually reported by NRLS; and
• October 2014 – March 2015: 0.52% – a difference of 0.02% to that provisionally reported by NRLS.
In reconciling the numbers included within the above calculations, the Trust has identified the following:
i) differences within the reconciliation of total patient safety incidents:
Datix figures (Trust’s internal reporting system)
Total patient safety incidents
1 April 2014 – 31 March 2015
NRLS published / provisional figures
5,515
5,008
The Trust has identified a difference of 507 patient safety incidents which had been reported on Datix (5,515 incidents) but which had
not been submitted to NRLS (5,008 incidents). This being due to the following reasons:
•
•
•
ii)
518 incidents were reported late to NRLS after the cut-off date for NRLS published reports, and therefore are not included in the NRLS
published / provisional figures;
4 incidents were submitted by the Trust to NRLS but failed to upload on the NRLS system, and therefore are not included in the NRLS
published / provisional figures.
15 incidents were reported to NRLS but following further investigation have been removed from Datix figures as these are not patient
safety incidents. This amendment was not later reported to NRLS within the cut-off deadlines, and therefore those incidents are still
incorrectly reflected in the NRLS published / provisional figures.
differences within the total number of ‘severe harm’ and ‘death’ incidents:
Datix figures
(Trust’s internal reporting system)
NRLS published / provisional figures
April 2014 – September 2014
26
15
October 2014 – March 2015
15
12
Total
41
27
Number of ‘severe harm’ and ‘death’ incidents
The Trust has identified a difference of 14 ‘severe harm’ or death patient safety incidents between those reported on Datix (41 incidents)
and submitted to NRLS (27 incidents). This is due to the following reasons.
•
•
Within the NRLS published figures, there are 6 pressure ulcer incidents which had been incorrectly classified as ‘severe harm’
but which have been now reclassified as ‘moderate harm’. As a result, the NRLS published / provisional figure of 27 incidents is
overstated by those 6 pressure ulcer incidents.
The remaining differences relate to:
13 incidents were reported late to NRLS (i.e. after the cut-off date for NRLS published reports);
o 3 incidents claimed as ‘moderate harm’ submitted to NRLS but which following investigation concluded that should have been
classified as ‘severe harm’. These classification amendments were not reported to NRLS by the publication cut-off deadline;
o 4 incidents between the number of ‘severe harm’ and ‘death’ incidents submitted and the number of incidents reported
publically / provisionally by NRLS. The Trust does not have insight into the NRLS data and cannot explain the reasons for this
difference.
o
The external audit of this indicator highlighted the above matters and identified errors in the upload of the internal data relating to the
generation of the Patient Safety Incident Rate to the NRLS database. While errors have been identified, reports on the Datix figures have been
made to the Board and Healthcare Governance Committee, who have also been sighted on all pressure ulcer incidents grade 3 and 4 during
the year. The rate of high level incident was incorrect due to inconsistency of assigning the rate of harm to some pressure ulcer incidents.
As a result of the audit work, our auditors have issued a limited ‘except for’ modified conclusion on the Quality Account. The Ipswich Hospital
NHS Trust acknowledges the differences and errors noted above, and has reviewed the process by which incidents are uploaded to NRLS. As a
consequence of the differences and errors noted above, figures for 2013/14 uploaded to NRLS are also understated.
The Ipswich Hospital NHS Trust has taken the following action to improve this rate and so the quality of its
services by:
The Trust has taken immediate action to ensure that all incidents have been uploaded to the NRLS in line with national guidance. The Trust
has also taken steps to correct the process and strengthen internal validation procedures to prevent this issue recurring and will undertake a
validation exercise for the previous year’s submissions.
36
The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
Part 3 – Other information
Performance against other key national priorities
Infection prevention and control
MRSA bacteraemia
What is MRSA bacteraemia?
Unfortunately a MRSA bacteraemia infection was reported in
January 2015, the previous bacteraemia being in April 2013. Chart
1 shows the Trust’s performance in rates of MRSA bacteraemia
compared with the other hospitals in the East of England. The
rates are calculated using the total number of cases from 1 April
2014 to 31 March 2015, the average daily number of available
and occupied beds and expressed as rates per 10,000 bed days.
MRSA stands for meticillin resistant
Staphylococcus aureus. It is a highly contagious
strain of the Staphylococcus aureus family of
bacteria, which cause a number of infections,
some of which are serious. The reason that MRSA
is such a problem for hospitals – and why it
has become known as a superbug – is that it is
resistant to common antibiotics.
Bacteraemia is when MRSA is in the blood
stream. MRSA can enter the normally sterile
bloodstream either from a local site of infection
(wound, ulcer, abscess) or for example via
an intravenous catheter (placed there for the
patient’s medical care).
Screening of patients for
MRSA – key principles
• All elective (planned) patients
will be screened prior to or on
admission and decolonisation
regimen offered if screen is
positive.
• All patients identified as colonised
with MRSA will be offered
decolonisation treatment.
• All patients previously identified
as colonised with MRSA
will be isolated and offered
decolonisation if identified
positive on current admission or
within the last three months.
• All patients currently colonised
with MRSA will be cared for in an
isolation room or cohort.
• All patients admitted as
emergencies will be screened
on admission or as soon as
practicable but ideally within 24
hours.
Year
Number of cases of MRSA
bacteraemia attributed to
Ipswich Hospital
Target
2012 / 13
2
No more than
one case
2013 / 14
1
Zero cases
2014 / 15
1
Zero cases
Chart 1 – The performance of Ipswich Hospital in rates of
MRSA bacteraemia, compared with the other
hospitals in the East of England region for 2014 / 15
9
8
7
6
5
4
3
2
1
0
rd
fo
d
Be
m
Ca
s
h
a
h ich rts
r
h
lk
d
ck
ex
et
ke
rt
on
ich et
rt
te
dr ug
e
ro
en ffo ag Lut Ess He
es roo wo orw t H psw zab
an oro
P
ur
th Su
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I
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i
h
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rb
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E& & T
So es ame
Co hin
n
s A ete
k
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P
nc
ol
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r
H
Q
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No
Pr
a
B
ge
id
br
lch
The Trust consistently achieves 99.5%
compliance with screening for MRSA.
37
Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
Performance against other key national priorities
Infection prevention and control
Year
Number of cases of C.difficile
attributed to Ipswich Hospital
2012 / 13
27
No more than
27 cases
2013 / 14
23
No more than
21 cases
2014 / 15
26
No more than
23 cases
What is C.difficile?
Target
Chart 2 – Our performance over the last three
years: C.difficile cases
10
2012/13
Number of cases
9
C.difficile is an abbreviation of Clostridium difficile
and it is the major cause of antibiotic-associated
diarrhoea and colitis, an infection of the intestines.
It is part of the Clostridium family of bacteria,
which also includes the bacteria that cause tetanus,
botulism and gas gangrene. It is an anaerobic
bacterium (it does not grow in the presence of
oxygen) and produces spores that can survive for
a long time in the environment. It most commonly
affects elderly patients with other underlying
diseases.
2013/14
2014/15
8
7
6
5
4
3
2
1
0
April
May
June
Chart 3 shows the performance
of the Ipswich Hospital in levels of
C.difficile compared with the other
hospitals in the East of England
region. The rates are calculated as for
MRSA bacteraemia. In order to give
more information, the total number
of cases apportioned to each hospital
for 2014 / 15 is included in brackets
after the hospital name, eg Ipswich
(26).
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
March
Chart 3 – The performance of Ipswich Hospital in levels of
C.difficile compared with the other hospitals in the
East of England region for 2014 / 15
3.00
2.50
2.00
1.50
1.00
0.50
0.00
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The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
Performance against other key national priorities
Infection prevention and control
Norovirus
Key achievements
Future challenges
Norovirus is measured in number of
outbreaks rather than the number
of cases. This is because of its
significance to affect the optimal
management of a hospital (outbreaks
cause ward / hospital closures).
 High levels of MRSA screening for
elective and non-elective patients.
• Ensuring the proposed MRSA
screening system is monitored
effectively so as not to reduce
screening rates.
A maximum number of three samples
will be sent from an affected area
if Norovirus is suspected, so there
may be a large number of patients
affected in an outbreak but only three
will be tested to enable us to identify
the causative organism.
There were two outbreaks of
Norovirus during 2014 / 15. An
outbreak of diarrhoea and vomiting
occurred on Saxmundham Ward on
28 September 2014, with 19 patients
and six staff being affected. The
ward was closed and the outbreak
managed according to Trust policy,
with the ward fully re-opening on
13 October 2014. Norovirus was
confirmed by the reference laboratory
at Cambridge as the causative
organism and the index case was
identified following review.
A second outbreak of Norovirus
was identified on Kesgrave Ward in
January 2015 with 12 patients, two
staff and three visitors being affected.
The ward was closed and the
outbreak managed according to Trust
policy, with the ward fully re-opening
on 13 January 2015. This compares
with three outbreaks in 2012 / 13 and
zero outbreaks in 2013 / 14.
 Full implementation of a safe
needle system.
 Early identification and treatment
of the majority of patients
identified with C.difficile
optimising patient outcome.
 Significantly improved training
figures.
 Effective planning and
implementation of new
Pseudomosas.auriginosa
assurance system.
 Planning and implementation of
Ebola management.
 Outbreaks controlled quickly and
effectively with little disruption to
patient flow.
 Introduction of CarbapenemaseProducing Enterobacteriaceae
(CPE) guidelines and monitoring
systems.
 Setting up effective environmental
microbiological monitoring
system.
• Achieve a consistent 100%
compliance to MRSA
decolonisation.
• Streamline C.difficile infection
identification and reporting.
• Enhance the training system
to increase understanding of
infection control.
• Restart the link nurse system.
• Produce a clear monitoring and
reporting system for water safety
in augmented care units and
ventilation in theatres.
• Increased theatre testing and
monitoring.
• Plan and maintain a SSI (surgical
site infection) review of Caesarean
section infections.
• Interrogate the NSQIP data system
for accurate SSI data, or build a
wound surveillance system.
• Create an infection control
training film and practical
infection control assessment.
• More infection control time on
the wards and in the clinical
areas.
• Increased operating theatre
monitoring.
Shining Light
Clinical Investigations Unit Team
The CIU Team’s award nomination said: “They do their job in a
professional manner with a positive and caring attitude.”
CIU is a day unit for medical patients with a range of illnesses
including blood and muscular disorders and some cancers.
Patients have procedures such as blood and platelet transfusions,
lumbar punctures, chest drains and biopsies and go home on
the same day. On behalf of the team, senior nurse Gemma
Moughton said: “We are a small team but we are good at
supporting each other as well as working together.”
39
Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
Performance against other key national priorities
Prevention of pressure ulcers which develop in hospital
What is a pressure ulcer?
A pressure ulcer is damage that occurs on the skin and
underlying tissue.
Pressure ulcers are caused by three main things:
• pressure – the weight of the body pressing down on
the skin;
• shear – the layers of the skin are forced to slide over one
another or over deeper tissues, for example when you
slide down, or are pulled up, a bed or chair or when
transferring to and from a wheelchair; and
• friction – rubbing the skin.
The development of a pressure ulcer
is usually the result of a number of
factors including health conditions
that make it difficult to move,
especially for those confined to lying
in a bed or sitting for prolonged
periods of time, sensory impairment,
poor nutrition, dehydration and
incontinence.
We have a clinical specialist team
whose main remit is to:
• encourage standard practice
across the Trust to reduce the
incidence of pressure ulcers;
• develop policies and pathways in
line with national guidance;
• provide education and training to
multidisciplinary staff; and
• recommend use of correct
equipment for individual needs.
Our key achievements
 Reduced the number of pressure
ulcers that have developed in
hospital.
 Pressure ulcer education day held
for community colleagues on 20
November 2014.
 Participation in clinical teaching
sessions for practice nurses.
 Launch of new policy to reflect
the NICE guidelines related to
pressure ulcer care.
40
How do you recognise a pressure
ulcer?
The first sign that a pressure ulcer may be forming is
usually discoloured skin, which may get progressively
worse and eventually lead to an open wound.
Where do you get a pressure ulcer?
The most common places for pressure ulcers to occur are
over bony prominences (bones close to the skin) like the
bottom, heel, hip, elbow, ankle, shoulder, back and the
back of the head.
 Refresh of monthly staff tissue
viability training sessions.
 Regular audits of patient risk
assessments to ensure standards
of patient safety are maintained.
 Equipment audits to ensure
patients receive the most
appropriate equipment for their
needs.
What are we doing to make
improvements?
• Purchase of additional equipment.
• Membership of county-wide
Tissue Integrity and Appliance
Group for patient safety across
Suffolk.
• Continue to undertake root cause
analysis on all Grade 3 and Grade
4 developed pressure ulcers.
Pressure ulcer and wound
care education for staff
• Outcomes from root cause
analyses are shared with staff
and students for education and
training purposes.
• Refresh and delivery of a number
of pressure ulcer and wound care
education opportunities.
How pressure ulcers are
graded
European Pressure Advisory Panel
(EPUAP) Classifications
Grade 1
Non-blanchable erythema of
intact skin. Discolouration of
the skin, warmth, oedema,
induration or hardness may
also be used as indicators,
particularly on individuals with
darker skin.
Grade 2
Partial thickness skin loss
involving epidermis, dermis, or
both. The ulcer is superficial and
presents clinically as an abrasion
or blister.
Grade 3
Full thickness of skin involving
damage to, or necrosis of,
subcutaneous tissue that
may extend down to but not
underlying fascia – the skin may
be unbroken.
Grade 4
Extensive damage, tissue
necrosis or damage to muscle,
bone or supporting structures
with or without full thickness
skin loss.
The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
Performance against other key national priorities
Prevention of pressure ulcers which develop in hospital
Incidence of avoidable pressure ulcers
per 1,000 bed days
Chart 4 – Our performance over the last three years:
Avoidable pressure ulcers per 1,000 bed days
1.4
2012/13
2013/14
2014/15
1.2
1
0.8
0.6
0.4
0.2
0
April
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
March
Shining Light
Tim Brammar
Consultant Orthopaedic
Surgeon
Tim had finished a busy
day of on-call and was due
a well-deserved rest. But
despite finishing his duties, he
returned to theatres in his own
time to treat an ill patient. The
knee operation could have
waited until the following day,
but he was keen to see the patient
treated as soon as possible. He liaised
with the evening emergency team
and asked them to notify him when
a theatre slot became available. He
then telephoned the relatives to
explain what he found and how the
patient was feeling. He really did go
over and above the call of duty to put
his patient first.
”
The A&E team assessed me for back pain and sciatic pain in July this year. Not only
was I assessed very quickly when I arrived I was treated very well, given an area
to relax as I could not sit due to the pain, was informed throughout the whole
process of what was going on, and why. All the staff introduced themselves and
were very informative and accommodating overall I came out of a very uncertain
situation feeling very well looked after and cared for. Well done Ipswich Hospital
for a good team effort and excellent service.
Visited in July 2014.
”
41
Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
Performance against other key national priorities
Learning from incidents, SIRIs and Never Events
Learning from incidents
All reported incidents are investigated
and any lessons that can be learnt
are shared within the clinical area at
Divisional Board meetings, and via the
intranet for hospital areas outside the
scope of the Division involved in the
incident.
It is important that when serious
incidents occur, they are reported and
investigated, not only to ensure that
the correct action can be taken, but
also to ensure the Trust learns from the
incident to help prevent recurrence.
The more serious incidents are
categorised as Serious Incidents
Requiring Investigation (SIRIs) and
are reported to the Ipswich and East
Suffolk Clinical Commissioning Group,
CQC and the National Reporting and
Learning System. These incidents are
investigated, a report written and
actions implemented.
In some cases, the involvement of an
external investigator is preferential. This ensures those with appropriate
experience investigate these cases
and demonstrates openness and
transparency.
The percentage of patient safety
incidents resulting in severe harm or
death is subject to external assurance.
The detailed definition for this
performance indicator is presented on
page 79.
Duty of Candour
Following the recommendations
from the Francis Inquiry into Mid
Staffordshire NHS Foundation Trust,
all incidents deemed to be medium
or high severity or resulting in the
death of the patient are reportable
to our commissioners. Regulation
20 of the Health and Social Care
Act 2008 (Regulated Activities)
Regulations 2014 sets out some
specific requirements that providers
must follow when things go wrong
with care and treatment, including
42
informing people about the incident,
providing reasonable support,
providing truthful information and an
apology when things go wrong. As
part of the Trust’s incident reporting
process, patients or their relatives are
informed of any such incidents.
Failure to meet this contracted
standard results in a financial penalty.
To date, the Trust has not been
subject to any penalties relating to
Duty of Candour.
What are we doing to make
improvements?
 An external Human Factors
expert trained 28 staff to become
investigating officers to investigate
all serious incidents.
 Targeted work around never
events and safer surgery.
 Introduction of After Action
Reviews.
After Action Reviews (AARs)
An AAR is a short structured meeting
held immediately after a short term
activity such as a clinical incident. A facilitated ‘debrief’, all the team
members who were involved in the
‘action’ should participate in the AAR.
• Although some issues appear to
be negative, the fact that they are
being discussed openly and learnt
from is enormously positive.
What was supposed to
happen?
What actually happened?
(What went well, could
have been better?)
Why was there a
difference? (What caused
the results?)
What can we learn from
this? (What actions can
be taken to improve or
sustain what went well?)
Examples of key changes to
practice and lessons learnt
following the investigation
of SIRIs in 2014 / 15
• Implementation of NerveCentre
in March 2015 to support timely
escalation of the deteriorating
patient.
• Radiologist review of fractured
neck of femur cases.
• Professional standards launched
for patients requiring admission
to Critical Care Unit.
• An AAR is a short debrief, held
immediately after an event has
taken place (be it a successful
or unsuccessful endeavour) that
enables those involved to learn
from what happened and change
their behaviour for the future. • Ensure senior review of chest
X-rays for placement of
naso‑gastric tubes is undertaken
and implement methods for
improving junior doctors’
competence of chest X-ray
interpretation.
• The AAR comprises a structured
set of questions, and a mindset
of openness and thoughtfulness
that is challenging but not
confrontational.
• Revised policy to include a section
stating that if the chest X-ray is
rotated, the naso-gastric feed is
not to be started until review by a
senior doctor or radiologist.
• After each AAR, the participants
are encouraged to write up their
discussion and store it on the
Trust’s intranet.
• Reinforce the guidance for
anticipation of neonatal problems
by having the correct personnel
present at delivery.
• This database of AARs will build
into a very valuable collection of
learning outcomes. The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
Performance against other key national priorities
Learning from incidents, SIRIs and Never Events
Never Events
Table 3 – Incidents reported
For the year 2014 / 15, there have been the following incidents reported on
the Datix risk management computer system:
Type of incident
No of
Incidents
Access, appointment, admission, transfer, discharge
Abusive, violent, disruptive or self-harming behaviour
Accident that may result in personal injury
Anaesthesia
Clinical assessment (investigations, images and lab tests)
Consent, confidentiality or communication
Diagnosis, failed or delayed
Patient information (records, documents, test results, scans)
Infrastructure or resources (staffing, facilities, environment)
Labour or delivery
Medical device / equipment
Medication
Implementation of care or ongoing monitoring / review
Other
Security
Treatment, procedure
Total
647
46
1,681
10
202
154
18
241
163
311
195
749
782
131
1
184
5,515
Of these, 80 were reported as Serious Incidents Requiring Investigation (SIRIs):
Table 4 – SIRIs reported
Type of incident
No of SIRIs
Information Governance breach
Management of the deteriorating patient
Baby born in poor condition
Developed pressure ulcer grade 3 or 4
Wrong site surgery
Fall causing significant harm
Unexpected death
Possible mismanagement of care (delayed diagnosis)
Unplanned surgery
Complication of treatment
Possible mismanagement of care (misdiagnosis)
Stillbirth
Infection control outbreak
Allegation against staff
Possible mismanagement of care (delayed treatment)
Patient accident
Total
3
7
4
27
2
13
7
1
1
3
1
1
2
5
2
1
80
Never Events are serious, largely
preventable patient safety
incidents that should not occur
if the available preventative
measures have been implemented.
The list of Never Events from the
Department of Health was updated
and slightly amended for 2014 / 15:
1 Wrong site surgery
2 Wrong implant / prosthesis
3 Retained foreign object
post‑operation
4 Wrongly prepared high-risk
injectable medication
5 Maladministration of a
potassium‑containing solution
6 Wrong route administration of
chemotherapy
7 Wrong route administration of
oral / enteral treatment
8 Intravenous administration of
epidural medication
9 Maladministration of insulin
10 Overdose of midazolam during
conscious sedation
11 Opioid overdose of an opioid-naïve
patient
12 Inappropriate administration of
daily oral methotrexate
13 Suicide using non-collapsible rails
14 Escape of a transferred prisoner
15 Falls from unrestricted windows
16 Entrapment in bed rails
17 Transfusion of ABO-incompatible
blood components
18 Transplantation of
ABO‑incompatible organs as a
result of error
19 Misplaced naso- or oro-gastric
tubes
20 Wrong gas administered
21 Failure to monitor and respond to
oxygen saturation
22 Air embolism
23 Misidentification of patients
24 Severe scalding of patients
25 Maternal death due to
post‑partum haemorrhage after
elective Caesarean section
There are exclusions to each Never
Event.
43
Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
Performance against other key national priorities
Learning from incidents, SIRIs and Never Events
Never Events at The Ipswich
Hospital NHS Trust
2012 / 13
2013 / 14
2014 / 15
1
3
3
Regrettably, three Never Events
occurred in 2014 / 15.
• Wrong site injection in
Ophthalmology. This patient was
on the Lucentis pathway and the
wrong eye was injected. No harm
to patient as both eyes required
treatment, she therefore had both
eyes injected that day. • Wrong side spinal root block. The
patient suffered no harm and has
recovered well.
• Misplaced naso-gastric tube. The
patient was X-rayed following
insertion of the naso-gastric tube,
but the X-ray was very difficult to
interpret. The patient has recovered
well.
Serious case review
The healthcare of two patients is being
reviewed as part of a system-wide
serious case review. Ipswich Hospital
is contributing to this review. These
cases will be ultimately peer reviewed
in relation to recommendations and
learning.
Harm-free care
The ‘Harm-free care’ programme has
been implemented nationally to help
NHS organisations in their aim to
eliminate harm in patients from four
common conditions, affecting over
200,000 people each year in England
alone, leading to avoidable suffering
and additional treatment for patients:
• pressure ulcers;
• falls;
• urinary tract infections in patients
with a catheter; and
• new venous thromboembolism.
The ‘harm-free care’ programme
supports the NHS to eliminate
these four harms through one plan,
enabling organisations to consider
complications from the patient’s
perspective, with the aim of every
patient being ‘harm- free’ as they
move through the system.
Safety Thermometer
The NHS Safety Thermometer is
a national improvement tool for
measuring, monitoring and analysing
patient harms and ‘harm-free’ care,
which was introduced in April 2012. The safety thermometer survey provides
a snap shot of ‘harm-free care’ on a
single day each month when every
current inpatient is assessed for the
presence of any of four harms within
the previous 72 hours. These harms and
the results are recorded on a national
database which allows us to monitor
the prevalence of these harms and to
assess our performance in providing
harm-free care.
Chart 5 – Our performance over the last three years: Percentage of harm-free care per month
2012/13
2013/14
2014/15
Target = 95%
100%
% of harm free care per month
95%
90%
85%
80%
75%
70%
65%
60%
55%
50%
44
April
May
June
July
August
Sept
Oct
Nov
Dec
Jan
Feb
March
The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
Performance against other key national priorities
Prevention of patient falls
What are patient slips, trips and falls?
There will always be a risk of falls in hospital given the nature of the patients that are admitted, and the injuries that
may be sustained are not trivial. However, there is much that can be done to reduce the risk of falls and minimise
harm, whilst at the same time properly allowing patients freedom, mobilisation and rehabilitation during their stay in
hospital.
What can contribute to the cause of patient slips, trips and falls?
• badly fitting footwear;
• cluttered areas;
• not being able to call for help;
• not using the correct walking aids where they may be needed;
• dehydration;
• cognitive impairment.
Prevention of patient falls
Our key achievements
We have to acknowledge that
preventing falls must be balanced
with patients’ rights to dignity, privacy,
independence, rehabilitation and
their choice about the risks they are
prepared to take. A ward where no
patient falls is likely to be a ward
where no patient can regain their
independence and return home.
This does not stop the Trust from
wanting to provide the best quality and
safest care for our patients.
 The new multifactorial assessment
process commenced in April 2014
in line with NICE guidance.
 Division of Medicine mapped
location of falls on wards and took
actions to modify the environment.
 Achieved CQUIN target for falls,
which set a ceiling number of falls
for the Trust.
 Conducted an analysis of all falls
resulting in high level harm and
identified themes.
Incidence of patient falls, per 1,000 bed days
Chart 6 – Our performance over the last three years:
Falls per 1,000 bed days
12
2012/13
11
2013/14
What are we doing to make
improvements?
• Themes from the analysis have
formed the work plan for 2015 / 16.
• Review of falls data on a weekly
basis to track performance against
improvement targets.
• Setting new improvement
targets for the Trust for 2015 / 16,
continuing weekly monitoring of
falls data.
• Working with our commissioners
and other care providers in Ipswich
and East Suffolk to improve quality
of care across the area to identify
patients at high risk of falling
repeatedly.
• Participate in system-wide care
planning to improve quality of care
for patients at high risk of falling
repeatedly.
• Participating in National Falls Audit.
2014/15
10
9
8
7
6
5
4
3
2
1
0
April
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
March
45
Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
Performance against other key national priorities
Emergency Care: 4-hour Emergency Department target
Despite many years of various
media campaigns, there is little
evidence that any of these alone
has been successful in changing
attendance numbers. So until the
public believe that their needs can
be met outside of the hospital,
they will continue to present to the
Emergency Department. The number
of attendances to the Emergency
Department and Medical Assessment
Unit (MAU) continues to rise each
year.
NHS England collects weekly data
on the total number of attendances
in the week for all Emergency
Departments, and of these, the
number discharged, admitted or
transferred within four hours of
arrival. Also included are the number
of emergency admissions, and any
delays of over 30 minutes to receive
handover of a patient arriving by
ambulance.
In order to achieve the 4-hour
measurement, the entire hospital has
to be functioning well: wards have
to be safe, well-run and efficient.
46
2012/13
100
2013/14
2014/15
Target = 95%
95
% of patients discharged within 4 hours
There are only three ways people
present to the Emergency
Department. They either self-present,
are sent by their GP or another
primary care service or are brought
in by ambulance. Much is said and
written about so-called inappropriate
Emergency Department attendance
– when patients present who don’t
have need for urgent medical
attention. However, we acknowledge
that what is deemed appropriate
is often driven by the patient’s
perception that they have an urgent
need and their belief that there is
no appropriate alternative service to
respond to their needs.
Chart 7 – Our performance over the last three years:
Emergency Department 4-hour to discharge 95%
target
90
85
80
75
70
65
60
55
50
April
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
March
Feb
March
Chart 8 – Our performance over the last three years:
Emergency Department activity
8000
2012/13
2013/14
2014/15
7000
Number of attendances
Waiting for treatment for a long
time can potentially impact on
clinical outcomes and certainly
does not result in a good patient
experience.
6000
5000
4000
3000
2000
1000
0
April
May
June
July
Aug
The same can be said for diagnostics.
The bed management system needs
to be effective and responsive. The
relationship between managers and
clinicians needs to be respectful even
though at times there can be areas of
conflict. The people who have led and
planned the systems and processes
that underpin the success from the
Sept
Oct
Nov
Dec
Jan
trigger tool to the establishment
of professional standards have also
made an immense contribution. It
goes without saying that ED itself
needs to be safe, effective, of a high
quality and well-run.
The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
Performance against other key national priorities
Emergency Care: 4-hour Emergency Department target
Our key achievements
 Ipswich is one of the topperforming Emergency
Departments in the country.
 We have delivered 95% in six
consecutive quarters, and have
regularly been in the top ten
trusts delivering in excess of 95%
over the past 12 months.
 Our Emergency Therapy Team
now provides extended services
around the Trust. The team can
quickly assess patients who do
not require hospital admission.
Services are provided seven
days a week to the Emergency
Department, the Fracture Clinic
and Brantham Assessment Unit.
 Our service is rated by the
CQC overall as ‘Outstanding’
with specific commendation
of ‘Responsive’ and ‘Well-led’
domains.
 Successful introduction of
advanced nurse practitioner (ANP)
role and training / development
programme.
 We were the first department
in the country to introduce an
emergency care practitioner (ECP)
role through the training and
development of a highly skilled
radiographer.
 Ambulance handover times are
amongst the best in the country.
What does this mean for
patients?
 Having a well-functioning
emergency care service across
both the Emergency Department
and the Medical Assessment
Unit (MAU) is not only the result
of improvements in this service
but a consequence of the Trustwide approach to maintaining
a determined focus on patient
experience and quality of care for
emergency and elective patients.
 The focus of the organisation to
manage patient pathways has
enabled a huge reduction in the
incidence of overcrowding in ED
and improved the functioning
of MAU, both of which mean
reduced journey times and delays
for emergency patients and
ensure patients get to the right
place at the right time.
A first for our
Emergency Department
An international conference
showcased the work of our
Emergency Department in
developing the role of the
radiographer in the emergency
department. The team was
delighted that their paper called
‘Seeing Beyond the Image:
Developing the Role of the
Radiographer in the Emergency
Department’ was selected for
the first global conference on
Emergency Nursing and Trauma
Care which was held in Ireland
in September.
 Innovations with new roles
in staffing have enabled an
unwavering focus on quality and
safety despite the challenges of
increasing and changing demand,
this being reflected in the recent
CQC inspection report.
 Close collaboration with partners
such as the Ambulance Service
has delivered significant benefits
to patient experience whilst at
the same time providing a vast
reduction in financial penalties
and nationally levied fines.
 The enhancement of support
services such as the Emergency
Therapy team has shown to
deliver substantial advances for
improved assessment of frail or
elderly patients whilst avoiding
unnecessary admissions and
supporting discharge.
47
Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
Our Stroke Services have
been applauded for being
among the best in the
country.
Stroke patients need fast access to
treatment to give them the best
possible chance of making a good
recovery. Here at Ipswich Hospital
we have a hyper-acute stroke unit
where intensive nursing, medical
and therapy care is given to treat the
stroke, reduce brain damage and
establish the cause.
Figures looking at how many patients
are admitted to our stroke unit within
a four-hour target show us achieving
83.3% – bettered nationally only by
the London Borough of Hillingdon.
Stroke consultant Dr Rahman
Chowdury said: “Improvements have
been made by close multidisciplinary
working with our hospital, and
support and flexibility for patients
accessing stroke services through
GPs, paramedics and our fantastic
Emergency Department.”
Our hospital now has seven-day
stroke ward rounds using a mixture
Photo: Ipswich Star
Local priorities – caring for our community
Stroke Services
of stroke specialist consultants,
geriatricians with stroke and
neurology experience, stroke specialist
nurses and stroke middle grade
doctors.
The team aims to give patients quick
access to a brain scan, quick transfer
to a dedicated stroke unit and access
to clot-busting thrombolysis treatment
where appropriate. They also
support patients with recovery and
rehabilitation. Recent results put our
hospital’s overall stroke care in the top
30% of hospitals across the country.
The Ipswich team goes on to provide
follow-up clinics after six months
which are a beacon of good practice
nationally. They also collaborate with
local community services to help get
patients home as soon as possible.
Dr Chowdhury said: “The work goes
on to raise standards and deliver
quality care against a very tough
economic back drop for the NHS.”
Chart 9 – Our performance over the last three years: Stroke access targets
100%
90%
% admitted to Stroke Unit
< 4 hours 2012/13
80%
% admitted to Stroke Unit
< 4 hours 2013/14
70%
% admitted to Stroke Unit
< 4 hours 2014/15
60%
% people treated on a Stroke Unit
for > 90% of the time 2012/13
50%
40%
% people treated on a Stroke Unit
for > 90% of the time 2013/14
30%
% people treated on a Stroke Unit
for > 90% of the time 2014/15
20%
Target: 90% admitted < 4 hours
10%
Target: 80% of patients treated on
Stroke Unit for > 90% of the time
0%
Q1
48
Q2
Q3
Q4
The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
Local priorities – caring for our community
Cancer care
Ten years at the Centre
Patients and colleagues got together for a birthday bash for the
John Le Vay Cancer Information Centre, which has been open
for ten years.
Clinical nurse specialists at the centre provide emotional
support, advice and information on all types of cancer and
its management. The centre also provides quiet rooms,
refreshments, complementary therapies and support groups.
Raising the roof on
drug manufacturing unit
Building work is in full swing for a cancer drugs
preparation unit at our hospital. The £2.5million
unit will be used to prepare chemotherapy
drugs for cancer patients.
These photographs show what the building
looks like so far. All the steelwork is now up and
brick work and concrete pouring has begun.
The new unit is next to the Woolverstone Wing
where our cancer patients are treated.
Linac lined up for cancer patients
A new £2million cancer treatment
machine is being installed in our
Radiotherapy department. The linac
X-ray machine produces highenergy radiation for treating cancer.
during the course of treatment.
This results in even more accurate
treatment of tumours, and spares
normal tissue.
The bed on the new linac has a
six-degree tilt so the patient can
be tilted and the accuracy of the
radiation further improved.
The hospital has three linacs which
are replaced when they reach 10
years old to ensure the hospital
keeps up to date with the most
state-of-the-art technology.
The machines have image-guided
technology and take 3D-images
of the patient every time they
attend for treatment. The therapy
radiographers adjust the treatment
delivery by adjusting the patient’s
position to take account of dayto-day changes and to allow for
weight-loss and tumour shrinkage
Head of Radiotherapy Physics Hayley James and Radiotherapy manager Suzanne Isherwood
with the new scientific equipment being installed.
49
Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
Clinical effectiveness
Summary Hospital-level Mortality Indicator (SHMI)
What is SHMI?
The Summary Hospital-level Mortality Indicator is a ratio of the observed number of deaths to the expected number of
deaths for a trust. The SHMI differs from some other measures of mortality by including both in-hospital deaths and
deaths of patients occurring within 30 days of discharge from hospital.
Why is SHMI important?
We need to know what our ratio of actual deaths against expected deaths is, in order to assess and measure how
good the care and treatment is.
What is HSMR?
The Hospital Standardised Mortality Ratio is the ratio of observed deaths to expected deaths for a basket of 56
diagnosis groups, which represent approximately 80% of in-hospital deaths. It is a subset of all and represents about
35% of admitted patient activity.
How does SHMI work?
SHMI, like the HSMR, is a ratio of the observed number of deaths to the expected number of deaths. The calculation
is the total number of patient admissions to hospital which result in a death either in hospital or within 30 days of
discharge. Like all mortality indicators, the SHMI shows whether the number of deaths linked to a particular hospital is
more or less than expected, and whether that difference is statistically significant.
Chart 10 – Mortality: SHMI Trend June 2010 – June 2014
SHMI
140
England
Crude Mortality Rate
5
4.5
120
4
100
3.5
3
80
2.5
60
2
1.5
40
1
20
0.5
0
50
1
15
Q
4
FY
20
14
/
14
Q
3
FY
20
13
/
14
Q
2
FY
20
13
/
14
Q
1
FY
20
13
/
14
Q
4
FY
20
13
/
13
Q
3
FY
20
12
/
13
Q
2
FY
20
12
/
13
Q
1
FY
20
12
/
13
Q
4
12
/
20
FY
FY
20
11
/
12
Q
3
Q
2
12
FY
20
11
/
12
Q
1
FY
20
11
/
12
Q
4
11
/
20
FY
10
/
11
Q
3
Q
11
20
FY
10
/
20
FY
FY
20
10
/
11
Q
2
0
The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
Clinical effectiveness
Summary Hospital-level Mortality Indicator (SHMI)
The Trust is planning to implement
the use of a screening tool to enable
all deaths to be reviewed, particularly
focussing on the quality of care
received and the cause of death.
Table 5 – Results summary for
January 2014 – December 2014
This will enable the Trust to collect more
robust and relevant mortality data.
Once the screening tool is fully
implemented, it is planned that 10% of
all deaths will be reviewed by a second
consultant and any themes discussed at
the Mortality Review Group meetings.
For more information about our
performance with regard to SHMI,
please see page 31.
In-hospital mortality, for all in-patient admissions to The Ipswich Hospital
NHS Trust for the period January to December 2014 has been reviewed.
The SHMI is updated and rebased quarterly.
Metric
Result
Hospital Standardised
Mortality Ratio (HSMR)
(rolling 12-month period).
94.40 – within ‘expected’ range.
Position vs east of England
peers.
One of nine (of 17) trusts who sit within
the ‘as expected’ range for HSMR.
HSMR diagnosis groups
attracting higher than
expected deaths. There are no diagnosis groups which have
attracted statistically significant higher
deaths than expected, but three have a
lower confidence interval above 80:
HSMR analysis: Rolling 12
months (January – December
2014)
• pneumonia (207 deaths vs 205
expected);
• COPD (34 deaths vs 28 expected); and
The Trust’s HSMR is 94.40 and within
‘expected’ range. There are no
diagnosis groups which have attracted
statistically significantly higher than
expected deaths. Three groups have
a lower confidence interval above
80 however, which could become
significant in coming months or
following the benchmark update:
HSMR Emergency weekday /
weekend.
• pneumonia (207 deaths vs 205
expected);
Patient safety indicators and
mortality metrics.
• chronic ulcer of skin (6 deaths vs 3
expected).
There is no disparity between weekday and
weekend admissions, both being within the
‘as expected’ range:
• weekend: 95.09 (‘as expected’);
• weekday: 96.14 (‘as expected’).
Deaths in low risk diagnosis groups – ‘as
expected’.
Deaths after surgery – ‘as expected’.
• COPD (34 deaths vs 28 expected);
and
• chronic ulcer of skin (6 deaths vs 3
expected).
SHMI (data period July 2013
to June 2014)
104.86 – ‘within expected’ range
(published SHMI).
Relative risk
Chart 11 – Mortality: HSMR Monthly Trend January 2014 – December 2014
135
130
125
120
115
110
105
100
95
90
85
80
75
70
65
60
55
Jan 14
High relative risk
Low relative risk
Expected range
Undefined
National benchmark
Confidence intervals
Feb 14
Mar 14
Apr 14
May 14
Jun 14
Jul 14
Aug 14
Sep 14
Oct 14
Nov 14
Dec 14
51
Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
Clinical effectiveness
Summary Hospital-level Mortality Indicator (SHMI)
Table
6 – HSMR
Peer
Comparison
Fig. 2.0
—
HSMR
Peer
Comparison
Given the potential differences
between the weekday and weekend
day of admission emergency HSMR,
further analysis was completed for
the weekend admissions which shows
the key diagnoses for each. There is
no disparity between weekday and
weekend admissions, both are within
the ‘as expected’ range:
• weekend: 95.09 (‘as expected’);
• weekday: 96.14 (‘as expected’).
SHMI for east of England
region: Peers for all
· Dr Foster
support@drfoster.com
7
admissions
July· 2013
to June
2014
Chart 12 – SHMI for east of England region: Peers for all
admissions July 2013 to June 2014
160
140
120
Relative risk
HSMR: 7-day emergency
admissions ‘All Diagnosis’
Analysis
100
80
60
40
20
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Copyright © 2015, Re-used with the permission of The Health and Social Care Information Centre. All rights reserved.
The Ipswich Hospital NHS Trust is
amongst six trusts within the east of
England group of seventeen with a
significantly high SHMI value (using
95% confidence intervals).
The published SHMI is 104.86 and
‘within expected’ range.
52
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The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
Patient experience
Improving the patient and carer experience
Our key achievements
 Improvements to the environment
on Saxmundham Ward and
Constable Suite.
prevent messages being played
where others can hear;
• full review of patient letters to
enhance first impressions; and
 Enabled free-of-charge Wi-Fi access
across the hospital.
 Improvements for carers – new
Carers’ Cabin open in partnership
with Suffolk Family Carers and
the East of England Co-operative
Society.
 Significant improvements to
hospital website developed in
partnership with patient / user
representatives.
 Raising awareness of dementia.
 User involvement recognised – NHS
England study.
What are we doing to make
improvements?
 Encourage a customer care culture
through implementation of explicit
behaviour and attitude standards
such as ‘Hello, my name is...’
campaign.
 Patient surveys have been updated
to reflect the Trust’s values.
 The Chaplaincy service is reviewing
the best way to provide streamlined
services to meet the emotional,
psychological and spiritual needs of
patients, carers and staff.  Continuation of dementia support
worker role supporting activities
and social dining on the Constable
Suite.
 Launch of patient app.
 Feedback stations to encourage
greater number of comments
and compliments, rolled out
across each ward, outpatients and
reception areas alongside targeted
information for carers.
 Undertaking a range of
improvements to redesign
processes in Outpatient clinic areas:
• additional volunteers recruited
to support wayfinding in
outpatients;
• changed answer phones in
outpatient reception areas to
• development of outpatient clinic
professional standards.
 Signatory of the Suffolk Older
People’s Charter, which sets out
how older people should be
treated with recognition and
respect, given information and
clear communication, have choice,
control and independence and be
involved participants in their lives.
Learning Disabilities
As part of a regional network project,
a DVD has been produced to raise
awareness of five agreed core
reasonable adjustments for patients
with learning disabilities with the
acronym ‘HELPS’ – it is an excellent and
informative package which includes
awareness raising cards and a DVD.
(Endorsed by Chief Nursing Officer,
Jane Cummings)
• Hospital Communication Book
• Electronic alerts
• Learning disabilities liaison nurse or
equivalent
• Patient passport
• Support for family carers
Our key achievements
 Launch of easy-read versions of
complaints leaflet and patient
discharge information.
Care of patients with
dementia
Care for patients with dementia
has been given a dramatic boost
thanks to major development,
made possible thanks to a
Department of Health Dementia
Friendly Environment award and
funding from the hospital’s Capital
Investment Programme.
The Constable Suite has been
created complete with a bright,
contemporary environment
using latest best practice design,
in partnership with patient
representatives, Age UK, the
Alzheimer’s Society and Suffolk
Family Carers. “We have built
an old‑fashioned shop window
containing items from the 1960s in
the activity room, which we hope
will bring back lots of memories for
people coming into hospital and
being cared for in the Constable
Suite,” explained Julie Sadler, lead
nurse for dementia care.
The ‘memory walk’ corridor
leading to Saxmundham Ward
now has a series of photographs
of Ipswich and surrounding areas
from the 1930s onwards using
pictures taken from the Kindred
Spirit books by kind permission of
the author David Kindred.
Crys Rapley, a patient
representative who has worked
in dementia care, formally
opened the Constable Suite. Julie
Brache, consultant physician for
Older People, cut the ribbon to
celebrate the transformation of
Saxmundham Ward.
 Introduction of an Autism Passport.
 Autism awareness training and
information leaflet.
 Development and launch of
easy‑read Radiotherapy leaflet.
 Reasonable Adjustment Audit,
patient profiles including reasons
53
Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
Patient experience
Improving the patient and carer experience
Tommy on Tour – One man’s campaign to raise the awareness of dementia
Tommy Whitelaw cared for his
mother Joan for more than five
years while she had dementia. They both spent much of that
time feeling lonely and scared.
Joan died in 2012 and Tommy
now tirelessly campaigns to
improve dementia care.
In December 2014 he gave
a powerful speech in our
Postgraduate Centre. He said:
“I found my mum writing her
name on her arm to remind
her who she was and I found
for admission, readmissions,
lengths of stay, emergency
attendances, monitoring
feedback, complaints, incidents
and mortality data.
 Development of both website and
intranet resource pages.
Caring for Carers
Family Carer Support Service
A new Carers’ Cabin providing
support, information, respite and
free refreshments for the family
carers of our patients was formally
opened during National Carers Week. The Carers’ Cabin is a partnership
between the hospital, Suffolk Family
Carers, who provide the training and
54
scraps of paper under her pillow
with my name on to remind her
who the other person in her house
was. “I didn’t want to walk away
from my mum the first time she
asked me for help. So I became
her carer.” Tommy left pledge
cards for our colleagues to ask
them to make a pledge to make
a difference for people like his
mum. He said: “All it will take is for
people like you and I to care about
the people we meet every day.”
support to volunteers, and the East
of England Co-op which provides
refreshments. The Co-op also kindly
funded the new comfy seating and
other furnishings.
Nick Hulme, Chief Executive, said:
“The importance of family carers
cannot ever be recognised enough.
The work they do every day is
astonishing. We are delighted that
we were able to secure national
funding from the Department of
Health to help the hospital to become
more dementia friendly. As well as
improving wards the funding has also
enabled us to improve the facilities
we offer to family carers through an
upgrade of our first Carers’ Kitchen to
a larger, more fit-for-purpose Cabin.”
Sarah Higson, Patient Experience lead,
said; “We recognise the amazing
support family carers give to our
patients and we wanted to give
something back. We are delighted
that we can now offer enhanced
comfort with a kitchen area and
comfy seating where family carers can
An Evening with
Dementia
An inspirational play, fresh
from the Edinburgh Fringe,
was warmly received by an
audience of over a hundred
in the lecture theatre in
September 2014. An Evening
with Dementia, which was
funded by the Norfolk and
Suffolk Dementia Alliance in
partnership with the East of
England Co-op, portrayed
an ageing actor living with
dementia in a care home who
‘accepts’ rather than ‘suffers’
from dementia. Sarah Higson,
our Patient Experience lead,
said “This was a thoughtprovoking, uplifting as well as
poignant production.”
The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
Patient experience
Improving the patient and carer experience – Care of frail elderly patients
drop in for information, a listening
ear and guidance to services that
can help them with practical and
emotional issues.
The new Cabin also provides
additional space for a quiet area so
carers can have more confidential
chats with our fully trained
volunteers.” “It can be stressful and
tiring when the person you care for
(spouse, partner, parent, child, friend)
is taken ill and, for some, the shock
of suddenly becoming a ‘family carer’
through stroke or similar conditions
means additional help is needed. This
is where the Carers’ Cabin can really
make a difference through providing
space and time just for the carer,”
Sarah added.
Family carers can drop in to the
Carers’ Cabin Monday to Friday
between 2 pm and 5 pm with a
special dementia drop-in provided by
the Alzheimer’s Society every first and
third Wednesday of the month.
One carer who used the cabin said:
“I was very stressed following my
loved one’s operation. [The cabin]
helped to lift my spirits.”
Forget-Me-Nots want to connect and communicate
A Suffolk art group ran a
special project working with
our dementia patients, thanks
to funding from the Big Lottery.
The Forget-Me-Nots from Suffolk
Art Link paid regular visits to the
Constable Suite to encourage
and connect with the patients.
Dressed as their characters,
Filomena Cristalino, Vicki Weitz
and Chris Draude interacted
with the patients as part of the
ten week pilot project which
has already proved a success
in Scotland. Although their
costumes are colourful, Chris said
“It’s not about entertaining, it’s
about having a holistic approach
with patients”. They hope that
through their interaction the
group helped patients have self
expression and brought some
happiness to them.
“The theme of the forget-menot programme is ‘connection’
and finding ways to connect
with people who are not able to
communicate or have difficulty
in communicating. We want to
provide inventive ways for people
to express themselves and at the
same time bring some joy that
will make the often difficult and
frightening experience of being in
an acute hospital less stressful.” The
group are already well known in
the hospital for their work as clown
doctors with the children’s ward.
Welcoming the project Julie
Sadler, Dementia Care and Adult
Safeguarding senior nurse, said
Herbs for happy memories
Elderly patients will benefit
at our hospital after a kindhearted carpentry firm from
Felixstowe added some zest to the
Constable Suite gardens outside
Grundisburgh and
Haughley wards. Turners
Carpentry have been
working with the Trust
for around a year and
when Julie Sadler, senior
nurse for dementia care,
began looking to buy
some planters for a herb
garden, Murray Turner
the firm’s owner, offered
to supply and install the
planters at no cost.
“Incredibly generous support like this
from Murray enables us to provide
our elderly patients, many of whom
struggle with memory through
dementia, with something that can
help to stimulate them and bring
reminders of times past,” said Julie.
“We always remember that inside
every patient, regardless of their
ability to communicate, there’s a
person with years of experiences
and memories. Getting out of the
ward and into the tranquillity of
the garden, watering the plants
and smelling the herbs offers
them a vital connection with their
surroundings and their history.”
Murray and his colleague David
Carey built and painted three
planters and supplied the compost
and herbs.
55
Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
Patient experience
Measuring and reporting the patient experience
Friends and Family Test (FFT)
The Trust has implemented the
nationally mandated Friends and
Family Test (FFT) question. By asking
the question ‘How likely are you
to recommend our ward to family
and friends if they needed similar
treatment?’, respondents indicate this
likelihood from ‘extremely likely’ to
‘not at all likely’.
Net Promoter Score
The net promoter score is based on
the fundamental perspective that
every organisation’s customers /
patients can be divided into three
categories: promoters, passives
and detractors. It is calculated by
subtracting the ‘detractors’ from the
‘promoters’ after removing those
who are ‘passives’ (those who choose
‘likely’ or ‘don’t know’).
The scoring changed nationally in
October 2014 to include the ‘likelies’
and facilitate a score for those who
would ‘recommend’ the service. The
Trust will report using the new format
from April 2015.
A national CQUIN applies to
inpatients and Emergency
Department patients with targets for
percentage return rates. These targets
were met.
Care Quality Commission
National Surveys
Patients are asked to answer
questions about different aspects
of their care and treatment. Based
on their responses, each NHS trust
is given a score out of 10 for each
question (the higher the score the
better). The question scores presented
here have been rounded up or down
to a whole number. Each trust also received a rating of
‘Above’, ‘Average’ or ‘Below’.
• Above (Better): the trust is better
for that particular question than
most other trusts that took part in
the survey.
• Average (About the same): the
trust is performing about the
same for that particular question
as most other trusts that took
part in the survey.
• Below (Worse): the trust did not
perform as well for that particular
question as most other trusts that
took part in the survey.
Where there is no section score
(‘overall score unavailable’), this is
because one or more questions are
missing from that section (‘score
unavailable’). This means that no
section score can be given.
Table 7 – Friends and Family Test: Net Promoter Score results for 2014 / 15
Q1
Q2
Q3
Q4
April
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Trust inpatient NPS
76.5
76.2
73.44
72.7
68.2
67.9
68.4
64.8
63.9 67.2
68.8
68.4
Trust-wide inpatient
response rate
20.3%
19.4%
28.6%
26.6%
29.1%
38.7%
36.5%
33.6%
35.8%
33.7%
43.1%
44.6
Trust ED NPS
66.9
58.0
60.2
61.2
70.9
59.6
68.5
69.6
71.7
71.6
64.8
68.3
Trust-wide ED
response rate
16.9%
22.1%
17.7%
21.4%
20.1%
24.4%
14.2%
24.4%
21.2%
21.8%
25%
25.4%
Trust outpatient NPS
73.6
73.6
73.7
79.6
66.6
63.2
71.6
67.8
66.2
66.7
67.6
71.3
Trust-wide outpatient
response rate
6.7%
5.6%
11.28%
5.6%
7.4%
18.8%
5.10%
15.4%
12.1%
15.4%
10.9%
9.9%
58.2
74.5
74.7
74.5
77.7
66.7
62.2
64.2
97.3
74.1
71.6
55.7
26.8%
27.6%
28.1%
45.1%
27.6%
27.4%
29.9%
38.1%
34.2%
34.5%
27.8%
24.1
77.9
81.6
68.6
76.4
83.6
72.7
73.1
88.7
95.7
80.3
75.8
82.3
Trust-wide birth
response rate
22.8%
27.7%
17.6%
22.4%
17.1%
18%
34.1%
33.8%
24.0%
24.4%
33.7%
29.4
Postnatal ward
67.6
72.5
75.4
69.8
77.8
80.8
72.1
76.7
70.3
79.7
75.3
71.3
22.8%
25.5%
19.7%
19.6%
16.8%
17%
32.8%
31.4%
22.3%
22.8%
31.6%
25.8
66.7
82
82
83.6
76.2
82.2
84.5
83.5
80.5
75.7
83.3
75
12.8%
33%
33%
23.8%
7.1%
26.4%
31.8%
32.2%
27.0%
26.8
16.6
26.2
Trust Maternity NPS
Antenatal
Trust-wide antenatal
response rate
Birth
Trust-wide postnatal ward
response rate
Postnatal community
Trust-wide postnatal
community response rate
56
The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
Patient experience
Measuring and reporting the patient experience
Questions have been omitted where
the number of answers we received
was too low.
There is no single overall rating
for each NHS trust. This would be
misleading as the survey assesses
a number of different aspects
of people’s experiences (such as
care received from doctors and
nurses, tests, views on the hospital
environment eg cleanliness) and
performance varies across these
different aspects.
The structure of the questionnaire
also means that there are a different
number of questions in each section.
This means that it is not possible to
compare trusts overall.
Full report can be found at
www.cqc.org.uk/provider/RGQ/surveys
Care Quality Commission
National Inpatient Survey
Results of the National Inpatient
Survey were published in May 2015. To improve the quality of services
the NHS delivers, it is important to
understand what people think about
their care and treatment. One way of
doing this is by asking people who
have recently used health services to
tell us about their experiences. The
national survey of adult inpatients
involved 154 acute and specialist
NHS trusts and over 59,000 people. People were eligible for the survey if
they were aged 16 years or older, had
spent at least one night in hospital
and were not admitted to maternity
or psychiatric units. The survey took
place for one month in summer 2014
sampling 850 consecutive discharges. Of the 850 patients surveyed, 420
responded. The response rate for
Ipswich Hospital was 51% (national
response rate was 47%).
Table 8 – Based on patients´ responses to the National
Inpatient Survey, this is how Ipswich Hospital
compares with other Trusts
8.4 / 10
8.9 / 10
The Emergency / A&E Department
WORSE
ABOUT
THE
SAME
BETTER
Waiting lists and planned admissions
WORSE
ABOUT
THE
SAME
BETTER
(answered by emergency patients only)
(answered by patients referred to hospital)
7.9 / 10
Waiting to get a bed on a ward
WORSE
ABOUT
THE
SAME
BETTER
8.0 / 10
The hospital and ward
WORSE
ABOUT
THE
SAME
BETTER
8.4 / 10
Doctors
WORSE
ABOUT
THE
SAME
BETTER
8.3 / 10
Nurses
WORSE
ABOUT
THE
SAME
BETTER
7.6 / 10
Care and treatment
WORSE
ABOUT
THE
SAME
BETTER
8.5 / 10
(answered by patients who had an operation or
procedure)
WORSE
ABOUT
THE
SAME
BETTER
7.3 / 10
Leaving hospital
WORSE
ABOUT
THE
SAME
BETTER
5.3 / 10
Overall views of care and services
WORSE
ABOUT
THE
SAME
BETTER
8.0 / 10
Overall experience
WORSE
ABOUT
THE
SAME
BETTER
Operations and procedures
The hospital received a score out
of 10 for each of the 65 questions
asked. Ipswich Hospital was ‘about
the same’ as all other trusts for most
responses and all sections. 57
Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
Patient experience
Measuring and reporting the patient experience
Ipswich Hospital was in the top
20% for one question – Question
08: Specialist had been given all the
necessary information about the
patient’s condition (6% higher than
in 2013).
Ipswich Hospital was in the bottom
20% for one question – Question 14: Patients did not share a bathroom /
shower with patients of the opposite
sex (down 2% on 2013).
Ipswich Hospital’s top five best
ranking scores, which compare most
favourably with other acute trusts in
England were:
Table 9 – Based on patients´ responses to the National
Emergency Department (ED) Survey, this is how
Ipswich Hospital compares with other Trusts
8.2 / 10
Arrival at A&E (ED)
WORSE
ABOUT
THE
SAME
BETTER
5.8 / 10
Waiting times
WORSE
ABOUT
THE
SAME
BETTER
WORSE
ABOUT
THE
SAME
BETTER
WORSE
ABOUT
THE
SAME
BETTER
WORSE
ABOUT
THE
SAME
BETTER
WORSE
ABOUT
THE
SAME
BETTER
8.5 / 10
8.0 / 10
Doctors and nurses
(answered by all those who saw a doctor or nurse)
Care and treatment
• Q08: Specialist had been given all
the necessary information about
patient’s condition; 8.7 / 10
• Q07: Admission date not changed
or changed by the hospital only
once;
8.7 / 10
Hospital environment and facilities
• Q19: Patients did not feel
threatened by other patients or
visitors during their stay;
6.7 / 10
WORSE
ABOUT
THE
SAME
BETTER
• Q45: Before the operation staff
gave understandable answers to
patient questions; and
(answered by those who were not admitted to
hospital or to a nursing home only)
8.6 / 10
Experience overall
WORSE
ABOUT
THE
SAME
BETTER
• Q55: Hospital staff discussed with
patients whether any additional
equipment or adaptations were
required at the patient’s home.
Ipswich Hospital’s five lowest
ranking scores, which compare least
favourably with other acute trusts in
England were:
• Q14: Patients did not share a
bathroom / shower with patients
of the opposite sex;
• Q69: Patients were asked to give
their views on the quality of care
during their stay in hospital;
• Q29: Nurses did not talk in front
of patients as if they were not
there;
• Q21: Patients rated hospital food
good or very good; and
• Q20: Hand wash gels were
available for patients and visitors
to use.
58
Tests
(answered by those who had tests only)
Leaving A&E (ED)
The full report can be found at
www.cqc.org.uk/provider/RGQ/
survey/3
Next steps
Ipswich Hospital will be taking the
following immediate actions to
improve the patient experience for
inpatients, with regular progress
reports being presented to the Trust
Executive Directors:
• the results have been presented
to and discussed at Nursing and
Midwifery Board, Trust Executive,
Quality Matters Steering Board
(QMSB) and Patient and Carer
Experience Group (PCEG);
• an action plan focussing on the
bottom 10 performing questions
has been developed and will be
overseen by PCEG and QMSB;
and
• the Patient Experience Strategy
is due for review and will be
revisited to support a step change
in patient experience ensuring a
move from good to great.
Care Quality Commission
National Emergency
Department (ED) Survey
Results of the national Emergency
Department survey were published
in December 2014. The survey was
sent to almost 40,000 patients
nationally who had attended a major
Emergency Department between
January and March 2014. Of the
850 patients aged 16 years or over
who received the questionnaire
following at attendance at Ipswich
Hospital, 303 responded. Patients
were not included in the survey if
they had attended a minor injuries
The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
Patient experience
Measuring and reporting the patient experience
unit or walk-in centre, visited ED to
obtain contraception or who suffered
a miscarriage or another form of
abortive pregnancy, and patients with
a concealed pregnancy.
The hospital received a score out of
10 for each of the 43 questions asked
and areas where the hospital received
nine out of ten or more were:
• not having to wait long with
the ambulance crew before care
was handed to the ED;
• doctors and nurses not talking
in front of them, as if they
weren’t there;
• being given enough privacy
during examinations and
treatment;
• feeling staff explained their
test results in a way they could
understand, where these were
given before they left the ED;
• describing the ED as clean;
• not feeling threatened by other
patients or visitors;
• having the purpose of new
medications explained before
they left the ED; and
• being treated with respect and
dignity.
The hospital scored 8.5 for involving
patients as much as they wanted to
be in decisions about their care and
this is the highest score in the
country. A score of 9.9 for staff
explaining take home medications in
a way patients could understand was
another top score.
The lowest scores, scoring less than
six out of ten in the survey were:
• being told how long they would
wait to be examined;
• not having a long wait to receive
pain relief if requested;
• being told about possible side
effects of medication, for those
prescribed new medication while
in the ED;
• having had staff explain when
they could resume their usual
activities; and
• feeling staff considered their
family and home situation
before they left the ED.
Following the last survey in 2012, we
have made a number of changes,
including triaging patients quicker,
reviewing our workforce and rotas so
they better match busy times of the
day and employing emergency nurse
practitioners. It is good to hear our
patients are generally very satisfied
with their care and treatment, but
what is even more important is that
we are listening to what they are
saying and using it to shape the
future of services.
The full report can be found at
www.cqc.org.uk/provider/RGQ/
survey/4
The survey also highlights areas
where the hospital can improve. For
example, telling patients how long
they will have to wait before being
examined. As a result, the department
has a new television screen in the
waiting room to display the message
‘The current waiting time is ...’.
59
Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
Patient experience
Patient and public involvement,
community engagement and patient feedback
Patient and public involvement
is a valued and integral part of
service planning and delivery
and the hospital has continued
to involve patients and carers via
the comprehensive user group
network and Ipswich Hospital
User Group (IHUG).
Two hundred people contribute on
a regular basis via the user groups in
the review and planning of services. IHUG remains integral to ensuring
the voices of patients and carers
are heard at Executive and NonExecutive level via its six-weekly cycle
of meetings and monitoring of the
IHUG Action Log. Members continue
to be heavily involved in Trust-wide
strategic, development, educational
and monitoring groups to support
the design and development of
hospital services; for example Trust
Board attendance, Patient and Carer
Experience Group, transformation
workstreams, cost improvement
programmes, CQC mock inspections
and Patient-Led Assessment of Care
Environment (PLACE) audits. • A ‘shared promises’ document
was produced and is displayed
on wards and other public areas
reflecting Trust promises to
patients and carers and a set of
behaviours to be encouraged in
patients / carers.
• IHUG has commenced planning
development sessions for the role
of ‘patient leader’ alongside ‘staff
leaders’ with The King’s Fund.
• Twenty user representatives and
Healthwatch volunteers joined
Trust staff to undertake the
annual PLACE assessment during
May.
• Standard operating procedures
for Outpatients and outpatient
services professional standards
have been drawn up and
reviewed by IHUG.
60
• The Trust has subscribed to
Patient Opinion to gather further
feedback.
IHUG has continued to highlight issues
in relation to outpatients, in particular:
patient letters, signage, website
information and accessibility of X-ray
appointments. Members are involved
in the Transformation workstream
addressing these issues and are
proactively involved in the redesign
of letters, the website and the
environment of outpatients, including
the roll-out of self check-in kiosks.
The Trust’s approach to involvement
and engagement, specifically IHUG, has
been the subject of an NHS England
review of good practice examples,
results to be published in 2015.
Working with the wider
community
The Trust has continued to reach out
to the community to enable us to
listen to the wider patient and public
agenda. This has included:
• taking a stall at the MELA in
the summer and the One Big
MultiCultural Event in August.
wellbeing day focussing on
emotional health and wellbeing;
and
• community listening events.
The Chief Executive has attended over
25 meetings with members of the
local community at listening events,
taking the opportunity to hear about
people’s experiences, to understand
how we can improve both the
process of providing better access to
healthcare and the overall experience
of being cared for in hospital. Events
have taken place in a village shop, a
centre for blind, visually impaired and
disabled people, and he has also met
with members of the Roma Group. HealthWatch
We continue to build upon the solid
relationship with HealthWatch Suffolk
with regular meetings between the
two organisations. HealthWatch is
represented on IHUG and the Patient
and Carer Experience Group and
joined us to review our complaints
process.
• support for the African History
Month activities in Ipswich,
especially the delivery of a
Conversations with the generations
Nick Hulme, our Chief Executive, is pictured here with local resident Emily and
baby Scout at Coddenham Food Store for the first of our ‘Conversations with
Nick’, a series of engagement events for staff, patients and carers.
Those attending ranged
from eight months to those
in their eighties! The events
will allow people within
our communities to directly
inform our patient-centred
developments over coming
months.
The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
Patient experience
Complaints and compliments
What are complaints, concerns and compliments?
Complaints and concerns can be written or verbal communications from patients and/or relatives who are unhappy
regarding an aspect of their interaction with Ipswich Hospital. These are a valuable tool to identify trends which enable
us to improve the service where it may be necessary.
Compliments are always welcome and they are passed on to the staff in the areas involved. They are an equally
important method of identifying trends which enable good practice to be shared widely, as well as a morale boost for
staff.
The Ipswich Hospital NHS Trust
is committed to providing a
complaints service that is fair,
effective and accessible to all.
Complaints and compliments are a
valuable source of feedback about
our services.
Complaints Service
Complaints are treated seriously as
they highlight the times we let our
patients and their families down.
Each complaint is treated as an
opportunity to learn and improve
the service we provide. The hospital
listens and responds to all concerns
and complaints which are treated
confidentially, kept separately from
your medical records and will not
harm or prejudice the care provided
to you.
Learning from complaints
Whilst information drawn from
surveys and other forms of patient
feedback is important, every
complaint received indicates that that
person or their family, did not receive
the high quality care they rightly
expected. Complaints and informal
concerns raised through the PALS
service are an important method by
which the Trust assesses the quality of
the service it provides and can make
the changes necessary to improve the
service.
How complaints are
managed within the hospital
We aim to respond to complaints
within 28 working days from
receiving the complaint. This year
75% of complaints received were
responded to in 28 working days,
or a revised timescale agreed with
the complainant, against a Trust
target of 100%. All complaints are
assigned to a complaints coordinator
who will liaise with the complainant
and ensure that the department
responsible for investigating and
responding to a complaint does so
within the time limits set out above.
Once received, each response is
checked to ensure all issues raised
have been answered, before being
passed to the Chief Executive to
review and sign the letter of response.
Re-opened complaints
During the year 2014 / 15, 76 (11%)
of the complaints received were
re-opened. One of the main reasons
for re-opened complaints has been
identified as being related to poor or
inaccurate investigation. To address
this, the Trust has developed a
more robust process for ensuring all
matters raised within a complaint
are adequately addressed. The Trust
has recently implemented a process
whereby each re-opened complaint
is reviewed and, where necessary, a
Non-executive Director is involved in
the subsequent investigation.
Complaints to the
Parliamentary and Health
Service Ombudsman (PHSO)
During the year 2014 / 15 of the
678 complaints received, 14 were
referred to the Ombudsman by the
complainant as they were unhappy
with the response received from
the Trust. Of these, following
independent investigation by
the Ombudsman, two were not
upheld, two were upheld with
recommendations for compensation
with 10 cases still under review.
What are we doing to make
improvements to complaints
handling?
 All complainants receive a
telephone call from a senior
manager within one working day
to clarify the issues raised and
establish the most appropriate
method of response.
 Emphasis is placed on divisional
accountability of complaints
to ensure lessons learnt are
harnessed and used to improve
care and services.
 Each member of the corporate
Complaints team has a
responsibility for managing, in
partnership with designated
divisional staff, the complaints
relating to a specific division.
 Further training will be delivered
with particular emphasis on
letter writing to ensure all
correspondence is of a high,
consistent standard.
 An easy-read version of the ‘how
to make a complaint’ patient
leaflet developed with the expert
patient group is now available on
wards and on the Trust website.
 Significant improvements
have been made following
the implementation of the
recommendations made by the
Task and Finish group; these
61
Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
Patient experience
Complaints and compliments
Chart 13 – Our performance over the last three years: Complaints received (high and medium level*)
2012/13
Number of complaints
70
2013/14
2014/15
60
50
40
30
20
10
0
April
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
March
* Medium level complaint numbers include coordinated complaints. Coordinated complaints are those that are shared between The Ipswich Hospital NHS
Trust and an external service provider, for example, the patient’s GP or the East of England Ambulance Service.
Top three subjects of complaints:
2012 / 13
2013 / 14
2014 / 15
Any aspect of clinical treatment
All aspects of clinical treatment
Aspects of care
Attitude of staff
Attitude of staff
Elements of treatment
Communication and information
Communication / Information to
patients (written and oral)
Communication and information
improvements include a dramatic
reduction in the number of
complaints going overdue.
 Complaints regarding a staff
member’s attitude now require
evidence of a conversation with
that person to be provided to
the Chief Executive before sign
off and is kept as a file note to
aid the staff member in their
development.
 New complaints policy has
been implemented to further
strengthen the complaints process
to ensure a more timely and
robust investigation and response.
62
Patient Advice and Liaison
Service (PALS)
The PALS team handle queries and
concerns in a practical way, resolving
and addressing issues at source to
prevent matters escalating. This is
seen as a really positive step towards
taking more responsibility for issues
as they arise.
PALS contacts are graded as either
PALS1 or PALS2. PALS1 are contacts
that require straightforward
information or signposting. PALS2 are
contacts that relate to a matter that
needs to be resolved or addressed.
The most common causes for
patients contacting PALS are poor
communication and delays in
obtaining clinic appointments.
Test results and surgery dates also
account for a high proportion of PALS
contacts.
Wards record their compliments
(usually cards) directly onto the
Quality Management System
(QMS); the PALS team processes
those compliments that come in
via the Chief Executive’s office or
are collected from the feedback
stations. The numbers are combined
to inform the monthly Accountability
Framework reporting and are shared
with the Communications team who
publish them on the Trust’s intranet.
PALS offers patients, carers and visitors:
• advice and signposting – helping
to navigate the hospital and its
services;
The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
Patient experience
Complaints and compliments
• compliments and comments –
PALS can pass on compliments
and ideas to improve services; and
Examples of actions taken following complaints
We take patient complaints very seriously and have responded to them in
various ways to improve the quality of care we provide, as the following
examples show:
• can address a non-complex issue
informally, often preventing a
formal complaint being raised.
Complaint
Action taken
Typical matters raised with PALS
include:
Long wait in clinic.
Electronic clinic timetable changed to
avoid unnecessary delays.
• patients being unable to contact
clinics by telephone or messages
left not being returned;
Lack of information about a particular
orthopaedic procedure.
An information leaflet was created to
explain the removal of ‘K’ wires.
Delay in having gall bladder surgery.
A new ‘hot gall bladder’ pathway is
now in place.
• patients chasing appointments;
• cancelled appointments; and
• families or carers raising concerns
regarding elements of inpatient
care.
Complaints are recorded in three ways, depending on severity:
High
level
Multiple issues relating to a longer period of care including an
event resulting in serious harm.
Several issues relating to a short period of care including, for
Medium
example, failure to meet care needs, medical errors, incorrect
level
treatment or attitude of staff or communication.
Low
Simple, non-complex issues including, for example, delayed or
level cancelled appointments, lack of cleanliness, transport problems.
Feedback received through
NHS Choices and Patient
Opinion
Feedback left on the NHS Choices
and Patient Opinion websites is
monitored and responded to, with
actions taken where necessary.
the form of chocolates, biscuits
and flowers directly to staff on the
wards and in the clinics. When
letters of compliment are sent to the
Chief Executive, these are always
responded to with a letter of thanks.
Compliments
Patients, their families and carers
pay their compliments to the Trust
in a variety of ways, very often in
All compliments are shared with the
staff concerned. Over the course
of a year there are usually 10 times
more compliments received than the
number of formal complaints.
Chart 14 – Our performance over the last three years: Compliments received
Number of compliments received
900
2012/13
2013/14
2014/15
800
700
600
500
400
300
200
100
0
April
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
March
63
Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
Hospital workforce
The Trust continues to work towards the achievement of NHS pledges as
outlined in the NHS constitution to ensure that all staff feel trusted, actively
listened to, provided with meaningful feedback, treated with respect at work,
have the tools, training and support to deliver compassionate care, and are
provided with opportunities to develop and progress.
As part of our cultural change we have
an ambition that our staff will highly
recommend Ipswich Hospital as:
• a place to receive treatment and
be cared for;
• a place to work; and
• a place to be trained.
To help us to achieve this, a staff
experience / engagement strategy
called Building Pride has been
developed which has our values at its
core. This focuses on the following
eight key programmes:
• supporting staff to do the right
thing;
• saying thank you for your efforts;
• keeping each other informed;
• building our future talent and
leaders;
• being valued and supported;
• creating Team Ipswich;
• giving you and your team the skills
to do a great job; and
• looking after your health and
wellbeing.
This strategy is closely aligned to
the NHS pledges as outlined in the
NHS Constitution to ensure that all
staff feel trusted, actively listened to,
provided with meaningful feedback,
treated with respect at work, have the
64
tools, training and support to deliver
compassionate care, and are provided
with opportunities to develop and
progress.
National NHS Staff Survey
The 2014 National NHS staff survey,
which involved 287 NHS organisations
in England, took place during Quarter
3. A survey was sent to a random
selection of 850 staff at Ipswich
Hospital and a total of 419 colleagues
responded. This resulted in a local
response rate of 51% which was
in the highest 20% of acute trusts
in England (compared to a national
response rate of 42%).
Key Findings
Overall, the questions that form the
national Staff Friends and Family Test
– recommendation as a place to work
or receive treatment – showed an
improvement from the 2013 survey,
increasing by 4.6% from 3.52 to 3.68
(1 being poorly engaged staff to 5
being highly engaged staff). Responses
to all four component questions within
the FFT test increased significantly:
• ‘Care of patients / service users
is my organisation’s top priority’
increased by 12%;
• ‘My organisation acts on concerns
raised by patients / service users’
increased by 7%;
• ‘I would recommend my
organisation as a place to work’
increased by 10%; and
• ‘If a friend or relative needed
treatment, I would be happy with
the standard of care provided by
this organisation’ increased by
4%.
The overall indicator of staff
engagement increased from 3.68 to
3.75, which is in line with the national
average.
The results are very encouraging and
show that of the 29 key findings in
the survey performance, the Trust
improved in 16 areas and remained
neutral in four. In 18 key findings,
Ipswich was better or equal to the
national 2014 average for acute trusts.
In 2014, four key findings were in the
worst 20% for acute trusts – this was
a significant improvement from 2013
when 11 key findings were in this
category.
The full report is available at
www.nhsstaffsurveys.com/Caches/
Files/NHS_staff_survey_2014_RGQ_
full.pdf
The summary report is available at
www.nhsstaffsurveys.com/Caches/
Files/NHS_staff_survey_2014_RGQ_
sum.pdf
The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
Hospital workforce
The NHS Constitution
outlines the principles and
values of the NHS in England
including four pledges that
set out what staff should
expect from NHS employers.
The pledges are part of the
commitment of the NHS to
provide high-quality working
environments for staff.
What are we doing to provide
all staff with clear roles and
responsibilities and rewarding
jobs for teams and individuals
that make a difference to patients,
their families and carers, and to
communities?
Securing the commitment of all of
our staff to our Trust values and
behaviours has remained a key focus
for us. We have started to apply these
throughout our ‘people processes’
as this will result in a tangible shift
in our culture and a positive impact
on achieving our objectives. Almost
100 frontline and support staff were
involved in four workshops to identify
the content for a range tools and
approaches that can be used to help
staff make judgements and have
conversations about what values-led
care looks like in different situations.
What are we doing to provide all
staff with personal development,
access to appropriate education
and training for their jobs,
and line management support
to enable them to fulfil their
potential?
A review of corporate learning and
development commenced in the
autumn of 2014 and has focussed
on making improvements in three
specific areas: corporate induction,
mandatory and statutory training and
refresher training for clinical staff.
Two leadership conferences were
held in 2014 / 15, attended by
approximately 100 senior leaders in
the organisation at each event. We
were delighted that we had a number
of colleagues successfully completing
one of the NHS Leadership Academy’s
national leadership programmes.
Following the launch of Medical
Revalidation in 2012 the Trust has
been committed to strengthening
processes and ensuring that
all doctors with a prescribed
connection are in the system of an
annual appraisal and revalidation.
Revalidation is the process by which a
doctor’s licence to practise is renewed
and is based on local organisational
systems of appraisal and clinical
governance. Licenced doctors have
a formal link, known as a prescribed
connection with a single organisation,
known as the designated body, which
will provide support with appraisal
and revalidation. To date the Trust has
revalidated 125 doctors with a further
89 doctors due for revalidation in
2015.
The Trust is required to provide
assurance to the Board, our
regulators and commissioners that
there are effective systems in place to
ensure nationally agreed standards
for appraisal and revalidation are
met. The Annual Organisational
Audit Report is a tool used to
achieve a robust, consistent system
of revalidation compliant with the
Responsible Officer Regulations. The
mandatory audit contained within the
report provides a process by which
every responsible officer, on behalf of
their designated bodies, provides a
standardised return to the higher-level
responsible officer.
The collated audits will then form
the basis of a report to Ministers
and ultimately the public, on the
overall status of implementation of
revalidation across England.
Wellbeing Roadshow
In May 2014, the Trust held a
Wellbeing Roadshow which was
very well supported and attended
by over 200 staff and volunteers.
Staff enjoyed the fun range of
interactive stalls including a cake
tasting challenge, our dietitians’
healthy picnic quiz, BMI checks,
Suffolk Wellbeing Service, Cycle
to Work Scheme and mini golf.
65
Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
Hospital workforce
Providing support and
opportunities for staff to maintain
their health, wellbeing and safety.
via Discover magazine, receive daily
updates and be welcomed at open
staff sessions.
The hospital continues to lead
the way in supporting health and
wellbeing initiatives, with our
flagship Looking After Me training
programme for staff.
There are strong working
relationships with our trade union
representatives and they play an
active part in hospital life. There are
a number of debates taking place
throughout the year and colleagues
also take active roles on a number
of committees. Representatives form
part of our quality assurance panel
for programmes of work, which will
introduce change and transformation
programmes and include membership
of the Equality and Diversity Group.
A new Health and Wellbeing Steering
Group was established to provide
enhanced direction and oversight
for our wellbeing activities which
are underpinned by our wellbeing
strategy and priorities.
The hospital offers and maintains
a number of wellbeing schemes,
policies and benefits, including a
running club, an on-site walking
route, yoga, breathing spaces,
smoking cessation, an on-site
Occupational Health service, an
independent and confidential
listening service, support and pastoral
care from a number of multi-faith
chaplains and a physiotherapy service
for musculo-skeletal problems.
Members of staff completed the
Ipswich Half Marathon in September
2014 and the Healthy Ambitions
Suffolk ‘One Million Steps’ pedometer
challenge in October 2014.
Engaging staff in decisions that
affect them and the services they
provide, individually, through
representative organisations and
through local partnership working
arrangements. All staff will be
empowered to put forward ways
to deliver better and safer services
for patients and their families.
Staff engagement and involvement
is vital to the success of the hospital.
The Trust values the opinions of
our employees, and has a number
of practices in place to promote
excellent communication and
involvement. Staff can expect to
read a weekly blog from the Chief
Executive at the beginning of the
week, hear about the ‘Loud and
Proud’ stories at the end of each
week, be updated in more detail
66
Speak out Safely
The Ipswich Hospital NHS Trust is
proud to support the Nursing Times
‘Speak Out Safely’ campaign. We
would like any staff member who
has a concern to raise this within
the organisation at the earliest
opportunity.
Providing high quality, safe,
compassionate care to patients is our
foremost priority. Our staff are often
best placed to identify where care
may be falling below the standard
our patients deserve and should
expect. We want every member of
our staff to feel able to raise concerns
with their manager, or any member
of the leadership team. Everyone
in the organisation should feel able
to highlight wrongdoing or poor
practice when they see it and be
confident that their concerns will be
addressed in a supportive way.
We pledge that where staff identify
a concern, they will not be treated
with prejudice and they will not suffer
any set back to their career. We will
fully support staff with a thorough
investigation and, if appropriate, act
on their concern. We will also give
staff feedback about how we have
responded to the issue they have
raised, as soon as possible.
Shining Light
Beverley Rudland
Complaints Manager
Her nomination told of her
quiet determination ensuring
the voices of those most in
distress are listened to.
She retained her well‑known
serenity amidst the excitement
of winning and deflected
the appreciation by saying:
“If I shine, it’s because
I’m surrounded by stars.”
#teamipswich at its best!
The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
Hospital workforce
Shining Light
Gill Milbourne
Elective Surgery
Bed Coordinator
There are reasons why operations
can need to be cancelled –
because of a high number of
unexpected emergency patients
needing beds, the need for
specialist care to be available
afterwards and the patient
themselves not being fit enough
for surgery or anaesthetic, to
name a few. Gill liaises with
colleagues across the hospital
on all these issues to make sure
operation dates are stuck to as
much as possible.
Patient Flow and Discharge lead
Viv Barker said: “Gill is calm in
her manner, quietly working hard
to ensure we meet our patients’
needs.”
Staff sickness
We have good attendance levels
from staff, with the Trust’s rolling
12-month sickness rate at 3.80%.
The most recent published data for
acute medium trusts (December
2014) lists the sickness percentage
as 4.52% which is higher than that
recorded for The Ipswich Hospital
NHS Trust (3.83%). The Trust’s
most recently recorded sickness
rate is 4.07% (February 2015). This
compares to 3.99% in February 2014.
Volunteers
Our first conference for volunteers
took place on 2 June 2014, during
National Volunteers Week, which
celebrates the contribution made by
millions of people across the UK who
freely give up their time.
Around 500 volunteers of all ages
work at the hospital in a variety of
roles from being an outpatient buddy;
working in Pharmacy, Radiotherapy,
Rheumatology, Emergency
Department, Outpatients, Diabetic
Foot Clinic and the Eye Clinic; to
being a mealtime buddy; ward
walking for Hospital Radio Ipswich;
being a volunteer visitor or part of the
welcoming service.
The first conference for volunteers
was entitled ‘Making Volunteering
Count: a time to say thank you
and plan for the future’. The event
included a welcome address from
Clare Edmondson, HR Director, an
address from Chief Executive Nick
Hulme and discussions and feedback
on how volunteering can develop
both for the volunteers and the
hospital.
There were a number of keynote
speakers who talked about
volunteering from a different
perspective, including BBC Radio
Suffolk’s Mark Murphy who began
his career as a Hospital Radio Ipswich
volunteer.
Ipswich Hospital Trust Chair Ann Tate
said: “We would be lost without
the fantastic contribution volunteers
make on the wards, in the clinics,
behind the scenes in departments,
and welcoming people to the
hospital. Volunteers undertake a
wide range of tasks in the hospital,
anything from greeting an anxious
patient when they first come in to the
hospital and helping them find the
right clinic, to maintaining a garden
loved and enjoyed by the hospital
community.”
67
Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
Hospital workforce
Education and training of staff
The Trust is committed to
providing a multifaceted learning
environment for all staff and
trainees to ensure it has a high
quality workforce which is
committed, engaged, trained and
supported to deliver safe effective,
dignified and respectful care.
One of the Trust’s three key aims is
for people in training to recommend
us as a place to train. We took
a significant step forward with
the opening of the East Anglian
Simulation and Training (EAST)
Centre in April. Sir Bruce Keogh,
Medical Director of NHS England
was our distinguished guest who
formally opened the £250,000 suite.
The hospital invested £125,000
into the project and The Dinwoodie
Settlement generously match-funded.
Since opening, a wide variety of
staff (doctors, nurses, midwives,
chaplains etc) have been able to use
this facility to practice new skills and
review clinical incidents in a safe
environment.
Medical Education Postgraduate Medical Education is
quality managed by Health Education
East of England (HEEoE). Continuous
quality improvement is fundamental
to meeting the requirements and
standards established by the General
Medical Council and outlined within
the Trust’s Learning and Development
Agreement.
The report following a Trust-wide
Quality Performance Review Visit
by HEEoE in January 2015 included
positive feedback from both trainees
and educational supervisors. • All trainees interviewed would
recommend their posts and
placements to friends and
colleagues.
• The new Senior Management
Team and the Associate Medical
Director / Director for Medical
68
Education have forged good
relationships and engagement
with medical trainees through a
wide variety of initiatives such as
the Junior Doctors’ Committee
and Junior Doctors’ Forum. The Trust has appointed two
active senior residents and has
harnessed the ‘trainee voice’ to
develop the new e-handover
system.
• Following the introduction of
new governance arrangements
within the Trust with regard to
education and training, there
is clear evidence of Board level
engagement in this area. This has
resulted in the development of
a clear educational ethos within
the Trust and growing evidence
of excellent engagement between
the senior team and Trust
educators.
• Strong educational leadership
and the development of
multiprofessional education is
evident within postgraduate
medical education. It is
supplemented by high quality
library and knowledge services
and the opening of the EAST
Centre which were praised for
their positive impact on the
clinical learning environment. Also, the Clinical Audit
Department provides high quality
support to enhance this aspect of
education and training.
• Identified areas for improvement
included departmental induction
and further development of e-handover.
The three-yearly Quality Monitoring
School / Specialty Visits to Ipswich
Hospital undertaken during
2014 / 2015 include General Surgery,
General Medicine, Anaesthetics,
General Practice and Foundation. The
aim of the school visits is to facilitate
improvements and disseminate
good practice for all of the training
programmes. The outcomes and
recommendations of the school visits
are also a fundamental part of the
overarching Quality Performance
Review.
Pre-registration nursing
There are currently 212 adult and
18 child health nursing students
undertaking clinical placements at
Ipswich Hospital in partnership with
University Campus Suffolk (UCS).
All nursing students have a formal
induction which includes preparation
for practice in order to balance
perceptions and reality, focussing
on compassion, dignity, respect
and skills in infection prevention,
documentation and patient care.
Students play an active role in the
organisation. Their voices are heard at
the Student Forum and at Trust-wide
and division meetings where their
opinions are sought about patient
Doctors of the future
How to stitch a wound and how
to insert a cannula into a vein
were just two of the experiences
that got Year 11 students excited
about wanting to be a doctor. Forty
pupils from schools in the Ipswich
Hospital catchment area came in
for ‘So You Think You Want To
Be A Doctor?’ day. They were all
specially nominated by their schools.
Organised by Martin Mansfield,
Kay Wilson and Justin Brown, it
was greeted with great enthusiasm
by the youngsters. Judging by
the feedback, the students are
now more determined than ever
to become doctors after their
experience and the chance to talk
to doctors and medical students.
The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
Hospital workforce
Education and training of staff
care and the education environment.
They also have a key role to play in
improving services where the students
work with our ward staff on projects
that will benefit both the patients and
the students’ academic studies.
Preceptorship for newly
qualified registered nurses
All nurses and healthcare
assistants in training at Ipswich
Hospital are being guaranteed a
job by the Trust.
Chief Executive Nick Hulme explained,
“We have trained these student
nurses and healthcare assistants and
it seems absolutely the right thing to
do to guarantee them a job when
they pass their professional exams
and show that they believe in our
values.
The three things I want this hospital
to be renowned for are to be a place
you would recommend for care, you
would recommend to work at and
a place you would recommend to
train or learn. If people have chosen
to train and learn here we should
recognise this. I stopped to talk to
a group of student nurses in the
hospital and they were anxious about
jobs. It started me thinking that we
should guarantee all of our nurses
and healthcare assistants in training
a role with us when they qualify,” he
explained. “We will also give nurses
and healthcare assistants a promise
that if they are not placed in the ward
of their choice, we will make sure
that as soon as there is a vacancy,
they will be able to move there.
Where there are roles which have
many applicants, we will guarantee
nurses in training a priority interview.
We have a great partnership with
the School of Nursing at University
Campus Suffolk and I wanted
to deepen and extend this. Our
values, or promises to patients and
colleagues, set out what anyone in
the hospital can expect including
a cheerful, friendly welcome, kind
people who care about you, to be
fully involved, to feel reassured and
safe and that we deliver an organised
and efficient service in skilled teams
which are always improving,” he
explained.
The hospital has increased the
numbers of nursing and healthcare
assistants throughout the hospital
following a careful review of the
numbers of staff and the dependency
of patients on each ward. Lynne
Wigens, Director of Nursing and
Quality explained: “We have had
much success in recruiting newly
qualified staff to work in the hospital,
our research shows that the support
we put in place, such as ‘buddies’
or mentors, really help new nurses
and healthcare assistants as they
take up their first roles. I am pleased
that we are able to make this
commitment of a guaranteed job to
nurses and healthcare assistants in
training. Some of our most senior
nurses in the hospital began their
careers as healthcare assistants and
were encouraged to do their nurse
training and progress. Every year we
encourage all staff to think about
their own progression and how we
can support that.”
Healthcare assistant training
On commencing with the Trust as
healthcare sssistants (HCAs) they
undertake the Ipswich Hospital
HCA Competency Framework
where they receive nine days’
classroom study plus a maximum
of 10 days’ supernumerary in their
clinical environment. They are then
supported by a practice facilitator to
gain competency in all key clinical
skills and competencies required by
the Trust. This provides assurance for
patients that our healthcare assistants
have been trained to a set of
standards and have been assessed for
the skills, knowledge and behaviours
to ensure they provide compassionate
and high quality care and support.
In March this year the Trust mapped
the skills and knowledge provided
by the Ipswich Hospital HCA
Competency Framework across to
meet the new national HCA training
programme enabling all new HCAs
to gain the new national Care
Certificate.
The hospital works closely with the
Royal College of Nursing and other
professional and trade union bodies
to support on-going development
for nurses and healthcare staff.
Clare Edmondson, Director of
Human Resources said: “ What our
nurses and healthcare assistants in
training tell us about their experience
of working in the hospital on
placements has helped us develop a
new approach to their first weeks and
months with us, when they join us as
newly qualified staff.”
69
Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
Hospital workforce
Education and training of staff
Education of clinical staff
A new life-size and lifelike
mannequin is helping
radiography students get hands
on experience.
The £15,000 piece of kit, known
as a phantom, very closely
replicates the human body.
Mandi Syrett, clinical lecturer for
Diagnostic Radiography, said:
“This means our students can
have real hands-on practice after
learning the theory but before
working with patients. Our
first year students will use the
phantom to work on the X-ray
machine, and our third years can
use it to practice work with more
complex trauma patients.
Trauma patients who come
in through the Emergency
Department can need more
difficult X-rays and often
the students don’t have the
confidence, so a fully qualified
radiographer steps in. Now
they can practice and have the
confidence to carry on.” The
phantom was funded by money
given to the hospital to benefit
student education. It will largely
be used by students but also for
other staff training.
Education of non-clinical
staff
The corporate induction programme
has been reviewed to ensure that it
inspires and engages new starters,
trainees and volunteers alike to
belong to and have a sense of pride
in Team Ipswich. The review has also
incorporated a complete overview of
statutory, mandatory and refresher
training which will ensure that
we create a positive and inspiring
learning experience for existing staff,
enabling them to possess the required
knowledge and skills to provide safe,
effective and high quality care to our
patients.
The changes made to the corporate
induction have been measured over the
last few months, and there has been
a significant jump in attendees rating
induction as either ‘good’ or ‘great’.
Here are a couple of thoughts from
new starters who recently attended
their induction programme:
“I thought the emphasis on the Trust’s
values worked well and gives you a
sense of pride working here.”
“The first three talks have given me
confidence to tackle a problem I
encountered with patient care, on a
ward, in my first week.”
The Trust has been delighted to join
the NHS Online Mentoring Project
this year, with colleagues trained
to provide mentoring support
to students and young people
aged 18 to 24 who are not in
education, employment or training.
Our involvement in this work was
recognised through an article which
appeared in a national newspaper.
We are strongly committed to
developing our leaders. A new
leadership development and talent
management framework is being
developed to ensure that we attract,
assess and manage our leaders and
offer appropriate opportunities
through both local and national
leadership programmes.
A talent management ‘lite’ pilot was
undertaken during 2014 / 15, based
on the Healthcare Leadership Model.
It was recognised that this would be
valuable for a number of reasons:
• to enable successful delivery of
the organisational strategy;
• to identify latent and emerging
talent;
• to improve succession planning
through a more proactive and risk
based approach; and
• to inform development and
training needs.
Students Kristian Keen and Grace Parsons
with the new training equipment in
Radiography.
Jo Wood, Head of Organisational Development,
who is coordinating the project.
70
Leadership opportunities
One colleague is now accredited and
registered as a Healthcare Leadership
Model 360° feedback facilitator with
the Leadership Academy. This 360°
tool supports leaders and managers
to understand their own awareness
The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
Hospital workforce
Education and training of staff
of how their performance is viewed
by their colleagues and how it
compares with their own view of their
performance.
Approximately 40 – 50 colleagues
have successfully completed, or are
currently participating in, the NHS
Leadership Academy programmes,
including the popular Mary Seacole,
Elizabeth Garrett Anderson and Nye
Bevan courses.
Ipswich Hospital recognises the vital
role that first line managers play in
the organisation and has continued
to support first line managers by
providing opportunities in-house
Two awards for top
student radiographer
Superstar Ipswich radiographer
Jo Graça has scooped two
national awards! He took
first prize in the Society
of Radiographers student
competition and has also
won the Society’s Diagnostic
Radiography student of the year
award which was presented to
Jo at the House of Commons in
November.
Dr Steven Garber, clinical lead
for Diagnostic Imaging said
“Everyone in the department
is extremely proud and
pleased with Jo’s outstanding
achievement. It is much
deserved.”
through the delivery of ‘Leading an
Empowered Organisation’ and the
‘First Line Managers’ courses.
We have continued to support
individual colleagues and teams
through tailored leadership
development courses during
2014 / 15.
Two very successful leadership
conferences were held during
2014 / 15. This was a great
opportunity for the top 100 clinical
and non-clinical senior leaders to
come together and focus on the key
organisational priorities.
Weekly leadership briefings are also
held every Tuesday morning with
executive colleagues.
Schwartz rounds
Hospital colleagues are sharing
some of their most difficult patient
experience stories with each other at
monthly Schwartz rounds. Schwartz
rounds are confidential meetings
among professionals where stories
which reveal their feelings and
emotions are shared. They are well
established in America and are now
being introduced to hospitals across
the UK.
Geriatrician Dr Ali Alsawaf is the
clinical lead for Schwartz rounds.
He said: “The purpose is not to
solve problems, but to explore the
human aspects of delivering care
and the challenges that staff face.”
The premise is that the compassion
shown by staff can make all the
difference to a patient’s experience
of care, but to provide care with
compassion, staff must themselves
feel supported. At each meeting,
three or four staff members
present a story about a particular
patient which leads to a discussion
with the wider group. For example,
our first Schwartz round, attended
by more than 100 members of
staff, saw a junior doctor, a senior
nurse and our Chief Executive talk
about ‘A Patient I’ll Never Forget’.
Nick Hulme said: “The ability of our
staff to not only support patients
and their families when they need
help, but also to keep doing it day
after day is truly extraordinary. It
is a resilience I don’t possess and I
have to remind myself sometimes
that some of the stresses and
challenges I face on a daily basis
pale into insignificance compared
with the pressure that staff face
every day.”
Pictured are Jo Wood, Head of Organisational Development, Dr Ali Alsawaf and
Sarah Higson, Patient Experience Lead.
71
Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
Statements from key stakeholders
Having reviewed the 2014/2015 ‘Our Passion, Your Care’ Quality Account
published by Ipswich Hospital NHS Trust and the patient and carer feedback
provided to Healthwatch Suffolk it is evident that Ipswich Hospital is generally
providing good care.
The CQC have rated the hospital as ‘good’, overall and ‘outstanding’ for urgent and emergency services. The
Emergency Department’s ‘outstanding’ rating is applauded. However improvements are required in children’s services
and end of life care. The critical care pathway for children needs improvements in relation to the high dependency
care, which whilst not specifically commissioned is provided. Comments indicate that children with epilepsy may
frequently fall between the gaps in services and that handover to specialist centres is poor. The Hospital is well aware
that improvements are needed. The new carer’s cabin is welcomed by carers.
75% of complaints are responded to within 28 days, it is important that complaints are dealt with speedily to alleviate
distress and stress, however some complaints are complex and do require more time to investigate and reply.
Feedback received by Healthwatch Suffolk is good with some specific issues that have been raised directly with the
Trust. We recognise that most comments were submitted anonymously and often lack sufficient detail for a formal
investigation. We encourage the hospital to learn from these incidents. Mental health does not appear to be given the
parity of esteem it deserves, with some patients commenting to us about attitudes of staff towards patients who selfharm, are anxious or suicidal.
The comments made to us are rarely about the clinical treatment being provided, they are almost always about staff
attitudes and behaviours, with some concerning waiting times. Common themes relate to first impressions of staff
and, in particular, some cases where patients have experienced a perceived lack of compassion for their needs. Some
consider that staff are focused on Tasks rather than patients. Some are about staff welfare, with comments such as
‘they are overworked’, ‘there is not enough of them’. Many patients sought to excuse staff behaviour on this basis.
We are pleased that Ipswich Hospital will now maintain a record and retain it where concerns are raised about staff
attitude. Such comments will be used in formal interviews and provide an opportunity for staff to reflect on their
practices. Formal reviews will enable the highlighting and other issues which affect staff performance. If the Trust is
to build and maintain its reputation as a caring and responsive hospital that is well led then it needs to ensure that all
staff portray a positive image by offering a warm and respectful welcome, introducing themselves, explaining what
they are doing, assessing capacity, respecting patients choice and dignity, involving carers, ensuring information is
appropriately given and that patients are discharged safely and receive the follow-up care required.
Discharge from hospital has been an issue for some patients but not all. We have received comments where patients
have felt ready to leave the hospital and have been involved in detailed discussions about their ongoing care. However,
some people have shared stories where it appears the patient was not ready to leave the care of the hospital and had
been discharged home without an assessment of support and equipment at home.
Comments suggest that the hospital is generally clean and well presented with some positive initiatives such as the
memory walk. For those with learning disabilities some carers feel there is a lack of understanding. It is encouraging to
hear that an Autism passport is to be used and that an educational package is being used to raise awareness.
There is a commitment to learning and development. 125 staff have engaged in clinical research. The Trust is
committed to employing staff that it trains, especially students attending Suffolk University Campus.
The Stroke Services are clearly providing an excellent service in Suffolk and working at a level which places them as
one of the best in the country. They share that good practice across the country. This multidisciplinary approach with a
structured response and pathway for all patients is invariably saving lives and reducing potential harm.
There are many examples of good practice highlighted through the Shining Light awards. There are many dedicated
staff at all levels in the organisation, often these inspirational and committed staff do not get the recognition and
praise they deserve. We congratulate the Trust on the outcome of its latest CQC inspection.
Dr Anthony L Rollo
Chair of Healthwatch Suffolk
72
The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
Statements from key stakeholders
Ipswich and East Suffolk Clinical Commissioning Group, as the commissioning
organisation for The Ipswich Hospital NHS Trust, confirm that the Trust has consulted
and invited comment regarding the Quality Account for 2014 / 2015. This has occurred
within the agreed timeframe and the CCG is satisfied that the Quality Account
incorporates all the mandated elements required.
The CCG has reviewed the Quality Account data to assess reliability and validity and to
the best of our knowledge consider that the data is accurate. The information contained within the Quality Account is
reflective of both the challenges and achievements within the Trust over the previous 12 month period. The priorities
identified within the account for the year ahead reflect and support local priorities.
Ipswich and East Suffolk Clinical Commissioning Group is currently working with clinicians and managers from the
Trust and with local service users to continue to improve services to ensure quality, safety, clinical effectiveness and
good patient / carer experience is delivered across the organisation.
This Quality Account demonstrates the commitment of the Trust to improve services. The Clinical Commissioning
Group endorses the publication of this account.
Barbara McLean
Chief Nursing Officer
Suffolk Health Scrutiny Committee
The Suffolk Health Scrutiny Committee does not intend to comment individually on
the NHS Quality Accounts for 2015. This should in no way be taken as a negative
response. The Committee has, in the main, been content with the engagement of local
healthcare providers in its work over the past year. The Committee has taken the view that it would be appropriate for
Healthwatch Suffolk to consider the content of the Quality Accounts in light of views and comments received from
patients and local residents, and comment accordingly. County Councillor Michael Ladd
on behalf of the Suffolk Health Scrutiny Committee
Response to stakeholder statements
The Ipswich Hospital NHS Trust thanks its stakeholders
for their comments on the 2014 / 15 Quality Account.
The Trust is proud of its performance around quality during the
period covered by this Account, but acknowledges there remain areas
requiring improvement to ensure consistent high quality care for all patients and their families / carers.
This Quality Account aims not only to provide the regulated requirements, but to share our achievements, and we have
strived to give a transparent and honest account of our services.
The Trust has developed a quality improvement plan to address the requirements indicated within the Care Quality
Commission’s report following the announced inspection in January 2015, and progress against the improvements will
be reported regularly to the Quality Matters Steering Board, Healthcare Governance Committee and Trust Board, and
will be documented in the Quality Account to be published in June 2016.
Since the stakeholder comments have been received, typographical errors have been corrected, and where data was
unavailable at the time of issuing the draft Quality Account to stakeholders, this has now been added.
73
The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
Glossary
Bed days The measurement of a day that
a patient occupies a hospital bed as part
of their treatment.
Care Quality Commission The
regulatory body for all health and social
care organisations in England. The CQC
regulates care provided by the NHS, local
authorities, private companies, voluntary
organisations and aims to make sure
better care is provided for everyone in
hospitals, care homes and people’s own
homes.
CCU Critical Care Unit.
Clinical Coding The translation of
medical terminology as written in a
patient’s medical records to describe
a problem, diagnosis, treatment of a
medical problem, into a coded format.
Clinical Commissioning Group (CCG)
CCGs are responsible for commissioning
(planning, designing and paying for) all
NHS services.
Clinical Delivery Group (CDG) CDGs
are sub-groups of one of the Trust’s three
clinical divisions. Each CDG is accountable
to its Divisional Governance Board for all
aspects of performance, including patient
safety, patient and carer experience,
operational standards, financial
performance and staff engagement.
Clostridium difficile or C.diff A sporeforming bacterium present as one of the
normal bacteria in the gut. Clostridium
difficile diarrhoea occurs when the normal
gut flora is altered, allowing Clostridium
difficile bacteria to flourish and produce a
toxin that causes watery diarrhoea.
Colonisation The presence of bacteria on
a body surface (such as the skin, mouth,
intestines or airway) without causing
disease in the person.
CQUIN The CQUIN (Commissioning
for Quality and Innovation) framework
enables commissioners to reward
excellence by linking a proportion of the
Trust’s income to the achievement of local
quality improvement goals.
Datix A Trust-wide computer system used
to record and aid analysis of all incidents,
claims, complaints and PALS enquiries.
Dementia A set of symptoms which
include loss of memory, mood changes,
and problems with communication and
reasoning.
Division The hospital is divided into three
distinct clinical divisions: Medicine and
Therapies; Surgery and Gastroenterology;
and Cancer, Pathology, Women and
Children. There is an additional division
which manages the corporate functions
such as Quality, Education, Operations,
Human Resources, Finance, Performance,
and Information. Each Divisional Board
is chaired by a consultant (Divisional
Director) together with nursing.
and operational leads. The Head of
Nursing / Midwifery and Clinical Services
provides senior nursing and quality of care
expertise, with the Head of Operations
providing expert operational advice to the
Divisional Boards.
DNACPR Do not attempt
cardiopulmonary resuscitation. A formal
decision made when it is not in the best
interests of the patient to be resuscitated
in certain circumstances.
Dr Foster Provider of comparative
information on health and social care
issues.
ED Emergency Department, also known
as A&E, Accident and Emergency
Department or Casualty.
Harm-free care National patient safety
initiative targeted at high impact areas
such as pressure ulcers, catheter care, VTE
and falls.
HDU High Dependency Unit.
Healthcare Governance Committee
The Trust Board sub-committee
responsible for overseeing quality within
the Trust.
HealthWatch Champions the views of
local people to achieve excellent health
and social care services in Suffolk.
HSMR Hospital Standardised Mortality
Rate. An indicator of healthcare quality
that measures whether a hospital’s death
rate is higher or lower than expected.
Ipswich and East Suffolk Clinical
Commissioning Group The main
commissioner of services provided by The
Ipswich Hospital NHS Trust.
Morbidity and Mortality (M&M)
meetings Morbidity and mortality
meetings are held in each Clinical Delivery
Group. The goal of the morbidity and
mortality meeting is to derive knowledge
and insight from surgical error adverse
events. M&M meetings look at: What
happened? Why did it occur? How could
the issue have been prevented or better
managed? What are the key learning
points?
Meticillin Resistant Staphylococcus
Aureus (MRSA) MRSA is an antibioticresistant form of the common bacterium
Staphylococcus Aureus, which grows
harmlessly on the skin in the nose of
around one in three people in the UK.
MRSA bacteraemia is the presence of
Meticillin Resistant Staphylococcus Aureus
in the blood.
MEWS Modified Early Warning Score.
A system of recording vital signs
observations which gives early warning of
a deteriorating patient.
MEOWS Modified Early Obstetric
Warning Score. A system of recording
vital signs observations which gives early
warning of a deteriorating obstetric
patient.
NCEPOD National Confidential Enquiry
into Patient Outcome and Death.
NerveCentre A wireless patient
observation, escalation and task
management system.
Never Events Serious, largely
preventable patient safety incidents
that should not occur if the available
preventative measures have been
implemented.
NPSA National Patient Safety Agency.
PALS Patient Advice and Liaison Service.
For all enquiries to the hospital such as
cost of parking, ward visiting times, how
to change an appointment etc.
PSCEG Patient Safety and Clinical
Effectiveness Group.
Q1 or Quarter 1 April – June 2014
Q2 or Quarter 2 July – September 2014
Q3 or Quarter 3 October – December
2014
Q4 or Quarter 4 January – March 2015
RCA Root Cause Analysis. A structured
investigation of an incident to ensure
effective learning to prevent a similar
event from happening.
RCP Royal College of Physicians.
RCSE Royal College of Surgeons of
England.
SHMI Summary Hospital-Level Mortality
Indicator. An indicator for mortality. The
indicator covers all deaths of patients
admitted to hospital and those that die up
to 30 days after discharge from hospital.
SIRI Serious Incidents Requiring
Investigation.
SLA Service Level Agreement.
A contract to provide or purchase named
services.
Suffolk Family Carers A registered
charity working with unpaid family carers
across Suffolk, supporting family carers
with information, advice and guidance.
SUS Secondary Uses Service. Provides
anonymous patient-based information
for purposes other than direct clinical
care such as healthcare planning,
commissioning, public health, clinical
audit and governance, benchmarking,
performance improvement, medical
research and national policy development.
The King’s Fund A charity that seeks
to understand how the health system in
England can be improved and helps to
shape policy, transform services and bring
about behaviour change.
UCS University Campus Suffolk.
VTE Venous Thrombo-embolism.
Also known as a blood clot, a VTE is a
complication of immobility and surgery.
75
Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
Appendix A
Independent Auditors’ Limited Assurance Report to the Directors
of The Ipswich Hospital NHS Trust on the Annual Quality Account
We have been engaged by the Board of Directors of
Ipswich Hospital NHS Trust to perform an independent
assurance engagement in respect of Ipswich Hospital
NHS Trust’s Quality Account for the year ended 31 March
2015 (“the Quality Account”) and specified performance
indicators contained therein.
In accordance with section 8 of the Health Act 2009 (“the
Health Act”) and the National Health Service (Quality
Accounts) Regulations 2010 and subsequent amendments
thereto (the “Regulations”), the Trust is required to prepare
a Quality Account annually.
NHS Quality Accounts Auditor Guidance 2014 / 15 (the
“Auditor Guidance”), published in March 2015 by
NHS England, sets out the requirements for our limited
assurance work, including the choice of indicators.
Scope and subject matter
The indicators for the year ended 31 March 2015 subject
to limited assurance (the “specified indicators”); marked
with the symbol A in the Quality Account, consist of the
following indicators as mandated by NHS England:
Specified indicators
Specified indicators criteria
Rate of Clostridium
difficile infections
Indicator performance: page 34
Indicator criteria: page 79
Percentage of reported
patient safety incidents
resulting in severe harm
or death
Indicator performance: page 35-36
Indicator criteria: page 79
Respective responsibilities of Directors and
auditors
The Directors are required under the Health Act 2009
to prepare a Quality Account for each financial year.
The Department of Health has issued guidance on the
form and content of annual Quality Accounts (which
incorporates the legal requirements in the Health Act 2009
and the Regulations).
In preparing the Quality Account, the Directors are required
to take steps to satisfy themselves that:
to review to confirm that they are working effectively
in practice;
• the data underpinning the measures of performance
reported in the Quality Account is robust and reliable,
conforms to specified data quality standards and
prescribed definitions, and is subject to appropriate
scrutiny and review; and
• the Quality Account has been prepared in accordance
with Department of Health guidance.
The Directors are required to confirm compliance
with these requirements in a statement of directors’
responsibilities within the Quality Account.
Our responsibility is to form a conclusion, based on limited
assurance procedures, on whether anything has come to
our attention that causes us to believe that:
• the Quality Account has not been prepared in line with
the requirements set out in the Regulations;
• the Quality Account is not consistent in all material
respects with the sources specified in Auditor
Guidance, issued by NHS England on March 2015 and
specified below; and
• the specified indicators in the Quality Account
identified as having been the subject of limited
assurance in the Quality Account have not been
prepared in all material respects in accordance with the
Regulations and the six dimensions of data quality set
out in the Auditor Guidance.
We read the Quality Account and conclude whether it is
consistent with the requirements of the Regulations and
to consider the implications for our report if we become
aware of any material omissions.
We read the other information contained in the Quality
Account and consider whether it is materially inconsistent
with:
• Board minutes for the financial year, April 2014 and up
to the date of signing this limited assurance report;
• Papers relating to the Quality Account reported to the
Board over the period April 2014 to the date of signing
this limited assurance report;
• Feedback from Ipswich and East Suffolk Clinical
Commissioning Group received 12 / 05 / 2015;
• the Quality Account presents a balanced picture of the
Trust’s performance over the period covered;
• Feedback from Suffolk Health Scrutiny Committee
dated 14 / 05 / 2015;
• the performance information reported in the Quality
Account is reliable and accurate;
• Feedback from Suffolk Healthwatch dated
05 / 06 / 2015;
• there are proper internal controls over the collection
and reporting of the measures of performance included
in the Quality Account, and these controls are subject
• The Trust’s 2014 / 15 Korner report on complaints
(form KO41a “Hospital and Community Services
Complaints”);
76
The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
Appendix A
Independent Auditors’ Limited Assurance Report to the Directors
of The Ipswich Hospital NHS Trust on the Annual Quality Account
• The 2014 national patient survey: “CQC Survey of
Inpatients 2014 – Ipswich Hospital NHS Trust”; and
“CQC Survey of Accident and Emergency 2014 –
Ipswich Hospital NHS Trust”;
• The national staff survey “2014 National NHS Staff
Survey – The Ipswich Hospital NHS Trust”;
• The Head of Internal Audit’s annual opinion over the
Trust’s control environment dated May 2015;
• The annual governance statement dated 03 / 06 / 2015;
• Payment and Tariff Assurance Framework: end of
clinical coding audit report dated April 2015;
• Care Quality Commission Intelligent Monitoring
Reports dated July 2014 and December 2014; and
• Care Quality Commission Quality Reported dated
10 / 04 / 15.
We consider the implications for our report if we become
aware of any apparent misstatements or material
inconsistencies with these documents (collectively the
“documents”). Our responsibilities do not extend to any
other information.
This report, including the conclusion, is made solely to
the Board of Directors of Ipswich Hospital NHS Trust. We
permit the disclosure of this report to enable the Board
of Directors to demonstrate that they have discharged
their governance responsibilities by commissioning an
independent assurance report in connection with the
indicators. To the fullest extent permissible by law, we do
not accept or assume responsibility to anyone other than
the Board of Directors as a body and Ipswich Hospital NHS
Trust for our work or this report save where terms are
expressly agreed and with our prior consent in writing.
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.
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 Standards
Board (‘ISAE 3000’) and the Auditor Guidance. Our limited
assurance procedures included: • reviewing the content of the Quality Account against
the requirements of the Regulations;
• reviewing the Quality Account 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
management 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 narrower in scope
than a reasonable assurance engagement. The nature,
timing and extent of procedures for gathering sufficient
appropriate evidence are deliberately limited relative to a
reasonable assurance engagement.
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
Account in the context of the criteria set out in the
Regulations.
The nature, form and content required of Quality Accounts
are determined by the Department of Health. This may
result in the omission of information relevant to other
users, for example for the purpose of comparing the results
of different NHS organisations.
77
Quality Account 2014 / 15 – The Ipswich Hospital NHS Trust
Appendix A
Independent Auditors’ Limited Assurance Report to the Directors
of The Ipswich Hospital NHS Trust on the Annual Quality Account
In addition, the scope of our assurance work has not
included governance over quality or non-mandated
indicators which have been determined locally by Ipswich
Hospital NHS Trust.
Basis for qualified conclusion
In respect of the specified indicator ‘Percentage of reported
patient safety incidents resulting in severe harm or death’
(the specified indicator), the NHS Quality Accounts Auditor
Guidance 2014 / 15 states that the Trust is required to
report the percentage of reported patient safety incidents
resulting in severe harm or death during the reporting
period in line with the following definitions:
• Numerator: Number of reported patient safety
incidents resulting in severe harm or death at a Trust
reported through the National Reporting and Learning
Service (NRLS) during the reporting period.
Conclusion
Based on the results of our procedures, except for the
matters described in the basis for qualified conclusion
paragraph above, nothing has come to our attention that
causes us to believe that, for the year ended 31 March
2015:
• the Quality Account is not prepared in all material
respects in line with the criteria set out in the
Regulations;
• the Quality Account is not consistent in all material
respects with the sources specified above; and
• the indicators in the Quality Account subject to limited
assurance have not been prepared in all material
respects in accordance with the Regulations and the
six dimensions of data quality set out in the Auditor
Guidance.
• Denominator: Number of reported patient safety
incidents at a Trust reported through the NRLS during
the reporting period.
During reconciliation of patient safety incident data
between the Trust’s internal reporting system Datix and the
data reported nationally on NRLS, we identified that the
Trust had under-reported to NRLS on severe harm or death
incidents and under-reported total patient safety incidents
during the year ended 31 March 2015. The overall impact
on total incidents reported and on the indicator reported is
as follows:
• Total number of patient safety incidents between
April 2014 and March 2015 was understated by 507
incidents.
• Number and percentage of patient safety
incidents resulting in severe harm or death (April
2014 – September 2014) was 26 (0.98% of reported
patient safety incidents) compared with NRLS of 15
(0.6% of reported patient safety incidents); and
• Number and percentage of patient safety incidents
resulting in severe harm or death (October
2014 – March 2015) was 15 (0.52% of reported patient
safety incidents) compared with provisional NRLS of 12
(0.5% of reported patient safety incidents).
The discrepancies have been disclosed by the Trust in the
Quality Report on page 35 and 36.
78
PricewaterhouseCoopers LLP
3 St James Court, Whitefriars, Norwich, NR3 1RJ
Date: 08 July 2015
Note: The maintenance and integrity of the Ipswich Hospital
NHS Trust’s website is the responsibility of the directors; the
work carried out by the assurance providers does not involve
consideration of these matters and, accordingly, the assurance
providers accept no responsibility for any changes that may have
occurred to the reported performance indicators or criteria since
they were initially presented on the website.
The Ipswich Hospital NHS Trust – Quality Account 2014 / 15
Definitions for performance indicators subject to external assurance
Rate of C.difficile infections
Detailed descriptor
Rate of Clostridium difficile infections
(CDIs) per 100,000 bed days for patients
aged two or more on the date the
specimen was taken during the reporting
period.
Data definition
Numerator: The number of CDIs
identified within a trust during the
reporting period.
Denominator: The number of bed days
(divided by 100,000) reported by a trust
during the reporting period.
Details of the indicator
The scope of the indicator includes all
cases where the patient shows clinical
symptoms of Clostridium difficile
infection, and has a positive laboratory
test result for CDI recognised as a case
according to the trust’s diagnostic
algorithm. A CDI episode lasts for 28
days, with day one being the date the
first positive specimen was collected. A second positive result for the same
patient, if collected more than 28
days after the first positive specimen,
should be reported as a separate case,
irrespective of the number of specimens
taken in the intervening period, or where
they were taken. Specimens taken from
deceased patients are to be included.
The following cases are excluded from
the indicator:
• people under the age of two at the
date the sample of taken; and
• where the sample was taken before
the third day of an admission to the
trust (where the day of admission is
day one).
Timeframe
Thirteen month data on the number
of CDI cases per trust is produced on a
monthly basis.
Annual reporting on the number and
rates of CDI cases per trust for the
financial year.
Percentage of patient safety incidents
resulting in severe harm or death
Detailed descriptor
Percentage of reported patient safety incidents
resulting in severe harm or death during the
reporting period.
Data definition
Numerator: Number of reported patient safety
incidents resulting in severe harm or death at a
trust reported through the National Reporting
and Learning Service (NRLS) during the reporting
period.
Denominator: Number of reported patient safety
incidents at a trust reported through the NRLS
during the reporting period.
How to provide feedback
on this Quality Account
If you would like to provide
feedback on this account or would
like to make suggestions for
content for future accounts, please
email
press.office@ipswichhospital.nhs.uk
or write to:
Clinical Directorate
(Quality Account) [C365],
The Ipswich Hospital NHS Trust,
Heath Road,
Ipswich IP4 5PD
Details of the indicator
The scope of the indicator includes all patient
safety incidents reported through the NRLS. This
includes reports made by the trust, staff, patients
and the public. From April 2010 it became
mandatory for trusts in England to report all
serious patient safety incidents to the Care Quality
Commission. Trusts do this by reporting incidents
on the NRLS.
A case of severe harm is defined in ‘Seven steps
to patient safety: a full reference guide’, published
by the National Patient Safety Agency in 2004,
as “(a)ny patient safety incident that appears to
have resulted in permanent harm to one or more
persons receiving NHS-funded care”, “Permanent
harm directly related to the incident and not
related to the natural course of the patient’s illness
or underlying condition is defined as permanent
lessening of bodily functions, sensory, motor,
physiologic or intellectual, including removal of
the wrong limb or organ, or brain damage.”
This indicator does not capture any information
about incidents that remain unreported. Incidents
with a degree of harm of ‘severe’ and ‘death’
are now a mandatory reporting requirement by
the CQC, via the NRLS, but the quality statement
states that underreporting is still likely to occur.
Timeframe
Six-monthly data produced for April to September
and October to March of each financial year.
Detailed guidance
More detail about CDIs, including the
latest published 13 month data for
CDI cases for each trust and the latest
published annual data for the number
and rate of CDI cases, can be found on
the Public Health England website.
Source: Public Health England
Detailed guidance
More detail about this indicator and the data can
be found on the Patient Safety section of the NHS
England website and on the HSCIC website in
NHS Outcomes Framework > Domain 5 Treating
and Caring for People in a Safe Environment
and Protecting Them From Avoidable Harm >
Overarching indicators > 5b Severity of harm.
Source: NHS England
Data relating to the rate of
Clostridium difficile infections can be
found on page 38.
Data relating to the percentage of patient
safety incidents resulting in severe harm or
death can be found on page 42.
Thank you
We would like to take this
opportunity to thank all those
involved with The Ipswich Hospital
NHS Trust: our fantastic staff and
volunteers, all of our patients and
visitors, our valuable fundraisers,
local media organisations, our
local Members of Parliament and
health colleagues across the East
of England
Thank you for all that you do
to make this a hospital we can
all be proud to be part of.
79
Find out more about the hospital by visiting
our website at www.ipswichhospital.nhs.uk
The Ipswich Hospital NHS Trust
Heath Road, Ipswich, Suffolk IP4 5PD
Tel: 01473 712233
This report is available online in this format and as an
easy-read document at
www.ipswichhospital.nhs.uk/aboutourhospital/
our-documents-and-policies.htm
DPS ref: 00900-15 © The Ipswich Hospital NHS Trust, 2015. All rights reserved. Not to be reproduced in whole, or in part, without the permission of the copyright owner.