A great place to work – NHS staff survey
Quality
Report
2013
NHS Hospital of the year, runner up
Dr Foster Hospital Guide 2012
Frimley Park
Hospital
Foundation
Trust
Final
NHSLA and CNST Level 3: maximum
patient safety standards
A top five trust in MHP Health Mandate
Quality Index
95 (1)
CONTENT
Part 1 – Chairman and Chief Executive Statement
Statement on Quality from the Chairman and the Chief Executive
Summary
4
Part 2 – Priorities for improvement and Statement of Assurance
Quality improvement priorities for 2013/14
Statements of assurance from the Board
11
19
Part 3 – Review of Quality Performance
Quality overview – a review of our performance in 2012/13 against priorities
32
Annex
I
II
III
IV
V
Statements from Commissioners, LINKs and OSC
Statement of Directors responsibilities
Glossary
External Audit Data Quality Standards
L
46
50
51
52
54
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 2 of 55
1
Statement on Quality from the Chairman and the Chief
Executive
Our vision is for Frimley Park Hospital NHS Foundation Trust (the Trust) to be recognised,
locally and nationally, as a leader in quality healthcare, delivering safe, clinically effective
services focused entirely on the needs of the patient, their relatives and carers.
Our staff are committed to providing excellent
care to every patient every time. We know
that staff who enjoy their work have pride in
providing patients with excellent care. We are
therefore pleased that our staff scored the
Trust highly in the 2012 NHS staff survey with
85% of staff saying that “if a friend or relative
needed treatment, they would be happy with
the standard of care provided by us”.
This year we have been working on the
development of our quality improvement
strategy. The strategy starts by recognising
that to be recognised locally and nationally as
a leader in quality healthcare, delivering safe,
clinically effective services focussed entirely
on the needs of the patient, their relatives and
carers, we should focus on three areas:
Patient safety; reducing preventable harm
Clinical outcomes; reducing mortality ratio
by providing appropriate treatments,
interventions at the right time and place
by the right staff
Patient experience; providing individual
care with compassion, continuity and
shared decision making
We are proud that our infection rates have
continued to be amongst the best in the
country. Our Methicillin-Resistant
Staphylococcus Aureus bacteraemia (MRSA)
blood stream infection number fell from two to
one and we maintained an excellent Cdifficile rate of 16. We set out to eliminate all
preventable pressure ulcers and this year we
reported zero grade four pressure ulcers and
overall reduced the prevalence of grade two,
three and four ulcers by 39%. We introduced
the NHS ‘Safety Thermometer’ which allows
us to assess the extent to which our patients
receive harm free care in four defined areas
(venous thromboembolism, falls, pressure
ulcers and urinary catheter infections). Our
average harm free care rate is 93%.
Our work on mortality rates continues to show
significant benefits. Frimley Park Hospital has
consistently reported one of the lowest
mortality rates in the NHS, which means
fewer people die in our hospital than could
reasonably be expected. We are proud of this
and were delighted that this was recognised
when Dr Foster awarded us the runner up for
the ‘hospital of the year’ awards as one of the
safest hospitals nationally.
Feedback from our patients shows us that
Frimley Park Hospital continues to provide a
positive patient experience with 90% of
inpatients saying that they would definitely
recommend the hospital to family and friends.
83% of patients that completed the 2012 NHS
inpatient survey would rate the care provided
with a 7 or above (Picker Institute, 2013) and
95% of inpatients in our local Trust survey
rate their care as very good or excellent.
We will continue to work with patient and staff
groups to develop and implement this
element of our strategy.
In July 2012 we were proud to open the new
emergency department and surgical day unit
at the hospital. This major redevelopment
provides state of the art facilities with
individual cubicles meaning that our patients
are cared for in comfortable and modern
surroundings.
We do recognise that providing health care is
not without risk and we acknowledge that we
do not get it right every time and for every
patient. This quality report outlines our
ambition to reduce preventable harm across
our organisation.
We hope that you will enjoy reading about the
many examples of the improvement work that
teams across the organisation are pursuing
and will see that we strive to provide excellent
care which meets the high standards that our
patients deserve. We want Frimley Park to
continue to be the health care provider that
patients trust to provide those highest
standards of care - and the organisation that
staff have pride in and where they are willing
always to give of their best.
The Trust has mechanisms in place to
identify any guidance issued by the Secretary
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 4 of 55
of State that relates to chapter 2 of the Health
Act 2009 and to act upon it appropriately.
We are pleased to confirm that the Trust
Board has reviewed the 2012/13 Quality
Report and we are satisfied that it is a true
and fair reflection of our performance. We
hope that this quality report provides you with
a clear picture of how important quality
improvement and patient safety are to us at
Frimley Park Hospital.
ADD SIGNATURES
Sir Mike Aaronson
Chairman
Andrew Morris
Chief Executive
23 May 2013
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 5 of 55
Introduction to Frimley Park Hospital and a Summary of
our performance
This section provides a high level summary of the key areas of focus and achievement in
2012/13. It includes a table of quality performance information that gives an overall view of
the quality performance of the Trust in 2012/13.
.
Summary
2012/13 turned out to be a busy and
challenging year for the Trust. We saw our
emergency department activity increase from
103,206 to 104,240 attendees, we admitted
57,643 elective patients and 33,785
emergency admissions, and we saw 377,238
in our outpatient departments compared to
344,768 last year. We also helped deliver
5,564 babies which is 165 more deliveries
than in 2011/12.
In July 2012 we opened our newly built
emergency department which has 25
separate rooms and one of the largest
resuscitation areas in Europe. It also has a
helicopter landing platform and in October we
received our first patient via air ambulance.
Alongside this we also opened our new day
surgery unit, including two new state-of-theart theatres and 19 individual cubicles. In
January 2013 we moved the children’s centre
into the main hospital site to improve
children’s services and we upgraded more of
our wards to four bedded bays incorporating
bathroom facilities.
Quality for our patients
We are determined to be a centre of
excellence and in that regard this year has
seen some significant achievements,
including:
1. Maintaining an unconditional registration
for all of our services with the Care
Quality Commission.
2. Maintaining NHS Litigation Authority
Acute Risk Management Standards and
Maternity Services accreditation at level
three (the highest level of assurance) –
along with only six other trusts.
3. Being awarded runner up trust of the year
in the Doctor Foster awards. Dr Foster
Intelligence produces a hospital guide
annually and it is recognised as one of
the most important independent
assessors of quality and safety in NHS
hospitals.
4. Being rated as one of the five best
hospitals for quality in the country
according to a new index based on what
matters most to patients. MHP Health
Mandate, policy and communications
consultancy, gave every trust an
aggregate weighted score based on
public responses to a set of 10 quality
indicators which were considered most
important to people choosing hospital
services. We scored 7.57, where the
highest was 7.93 and the lowest 2.14.
5. Sustaining high levels of patient
satisfaction; month on month, with over
99% of patients consistently rating their
care as good, very good or excellent and
90% of patients definitely recommending
our hospital to their family and friends.
6. Improving patient safety by undertaking
risk assessments and prescribing
appropriate treatment for those at risk of
venous thromboembolism for over 93% of
our patients.
7. Further reducing hospital acquired
pressure ulcers grade 2 by 42% and
reducing the grade 4 ulcers to zero from
two last year. We unfortunately did not
reduce the number of grade 3 pressure
ulcers as we reported two more
compared to last year’s 13.
8. Remaining in the top 20% of NHS
employers as a place to work.
4 out of 5 staff members would
recommend the Trust as a good place
to work (average 3.6 out of 5 staff
members). The best trust received a
score of 4.1 out of 5.
85% of staff also responded that “if a
friend or relative needed treatment”,
they would be happy with the standard
of care provided by the Trust”
(national average 55%, NHS staff
survey 2012).
9. Further reducing MRSA from two cases in
2011/12 to one in 2012/13; and
maintaining the number of clostridium
difficile cases reported at 16 cases.
10. A further improved low Hospital Mortality
Standardised Ratio at 48 (rolling number
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 7 of 55
Summary continued
as at January 2013, CHKS) and a low
Summary Hospital level Mortality
Indicator at 88.8 (12 month rolling number
as at November 2012, HED).
Quality for our staff
best local and national providers of acute
care”.
We recognise that we could not have made
such significant improvements during
challenging times without the commitment
and dedication of all our staff.
In 2012 we developed our Staff Strategy to:
•
•
•
•
•
•
Determine a core set of trust values in
collaboration with our staff
Increase levels of employee well-being by
actively supporting the health and wellbeing of employees through initiatives
such as staff health days, well-being
audits, and continuing with the subsidised
gym and exercise classes
Grow further a high-performing culture
Continue to provide an extensive
development programme including a
refresh of the leadership development
programme as well as providing an
extensive range of development
opportunities both on and off the job.
Create an employer brand where Frimley
Park Hospital is recognised as a great
place to work.
Implement a bespoke competency based
induction programme for healthcare
assistants;
Some of the indicators that we monitor to look
at employee satisfaction are drawn from the
results of the annual staff survey, which
includes questions on how our staff rate the
Trust as a place to work year on year and the
pride which they take in working here.
Conclusion
This year we have made many improvements
and achieved many of our objectives. We do
however acknowledge that we do not get it
right every time for every patient and
therefore as in previous years we continue to
set ourselves challenging and aspirational
improvement objectives to ensure that we
can justify our claim that “we are one of the
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 8 of 55
Quality Report Performance Summary Table
 Achieved Target
 Target not achieved however
improved performance
 Target not achieved
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 9 of 55
Quality Report Performance Summary Table
 Achieved Target
 Target not achieved however
improved performance
 Target not achieved
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 10 of 55
2
Priorities for Improvement 2013/14 & Statement of
Assurance
This section of our quality report discusses the priorities we have chosen for 2013/14.
These have been agreed after discussion with patients, clinicians, governors and
commissioners and were finalised following a workshop discussion between the Trust
Board and the Council of Governors in January 2013.
2
Building on the Trust’s successful three year
quality strategy (2009 - 2012), where we
achieved a 53% reduction in preventable
harm and a reduction in our hospital mortality
ratio to 53, we are continuing on our journey
to be identified as ‘the’ local and national
leader in quality healthcare. We believe that
focusing on the three key areas of quality
(patient safety, patient experience and clinical
outcomes) as set out by Lord Darzi is the
right approach for the delivery of further
improvements. Therefore we have decided
that our three year quality strategy for 2012 2015 will remain focussed on improving
standards against the three key areas of
quality:
1. Patient Safety; there will be no
preventable harm to patients from the
care they receive from us; this means that
we need to ensure that the environment is
clean and safe at all times.
2. Clinical Outcomes; the most appropriate
treatments, interventions, support and
services will be provided at the right time,
in the right place by the right staff to
everyone who will benefit from treatment,
and wasteful and/or harmful variation will
be eradicated.
3. Patient Experience; we will foster a
mutual beneficial partnership between
patients, their carers and our staff,
respecting individual needs and values
and demonstrating compassion,
continuity, clear communication and
shared decision making.
The performance against the quality
improvement priorities for 2012/13 as
identified in last year’s report is included in
part three of this report (page 25 onwards).
To ensure that we keep enhancing the quality
of our services we have set ourselves
stretching targets for the year ahead under
the three areas of quality as described above.
The performance against these quality
improvement indicators will be included in the
Trust wide quality performance report which
is reviewed by relevant committees on a
regular basis and ultimately by the Board of
Directors.
Priority 1 – Patient Safety
Keeping patients safe is a fundamental and
long standing commitment for us and it is, as
in previous years, the key rationale for the
identified range of patient safety indicators for
2013/14.
In consultation with a wider public of
stakeholders, we have identified that we will
specifically, but not solely, focus on three
trust wide indicators, these being:
Sepsis (continued from 2012)
Catheter Associated Urinary Tract
Infection (continued from 2012)
Acute Kidney Injury (new)
As in previous years we will also remain
focussed on reducing the number of
preventable harms from pressure ulcers, falls,
and medication errors as well as sustaining,
with the aim to reduce further, hospital
acquired infections such as MRSA and
Clostridium Difficile (C.diff).
In line with national requirements and the
continued Commissioning for Quality
(CQUIN) scheme under the acute services
contract, we will continue to focus on
improving the percentage of patients who
have a Venous Thromboembolism (VTE) risk
assessment completed and we will also
continue to complete the NHS Safety
Thermometer (NHS-ST, tool that measures
harm from falls, pressure ulcers, VTE and
catheter associated urine tract infections).
Sepsis
Sepsis is a life-threatening illness caused by
the body overreacting to an infection. The
body’s immune system goes into overdrive,
setting off a series of reactions that can lead
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 12 of 55
2
to widespread inflammation (swelling) and
blood clotting in the body.
in place to drain urine from the body. There is
no national definition available.
In 2012/13 we started collecting baseline data
to establish a baseline for patients with sepsis
who receive antibiotics within one hour.
Nationally there are two standards for the
provision of antibiotics in sepsis. One sets out
that patients who have a neutropenic sepsis
(caused by a condition known as
neutropenia, in which the number of white
blood cells (called neutrophils) in the blood is
low) should receive antibiotics within 60
minutes and the other relates to other sepsis
and requires antibiotics to be provided within
four hours.
The rationale for remaining focused on
CAUTI is linked to the fact that the data
collected identified that 2% of patients with a
urinary catheter had had this inserted
inappropriately and therefore this remains an
area for improvement. We intend to continue
data collection on the number of patients with
a urinary catheter, the number who have the
catheter inserted appropriately, as well as the
number of those patients who have a catheter
associated urinary tract infection. We intend
to collect the data against the last indicator by
also using pathology data to determine the
infection. The data will be collected alongside
the monthly NHS-Safety Thermometer audit
(for further detail on this please see page 27.
The 2012/13 data shows that we achieved an
average compliance percentage for all septic
patients receiving antibiotics within one hour
of 33%. The Trust sepsis group and safety
committee has agreed that the overall aim is
to achieve 50% of patients receiving
antibiotics within 60 minutes. The target for
neutropenic septic patients only is to achieve
this 100% of the time; the target will be 50%
for quarter 1, 75% for quarter 2 and 100% as
of quarter 3.
The rationale for keeping a focus on sepsis is
linked to the performance data presented
above. From this data it is evident that we
have improved our practice; however there is
still room for improvement to enhance clinical
effectiveness by rolling out further and
embedding the pathway (also see page 25).
The steering group will drive the further
implementation and roll out of the pathway as
well as provide training on the identification of
patients that develop a sepsis whilst in
hospital.
Catheter Associated Urinary Tract
Infection
A catheter-associated urinary tract infection
(CAUTI) is an infection that occurs in
someone who has a tube (called a catheter)
Acute Kidney Injury
Acute Kidney Injury (AKI) is a rapid loss of
kidney function.
Extensive internal medical record audits have
been undertaken for patients who passed
away in our care or within 28 days after
discharge. This has highlighted that
improvement can be made in the
management of patients with acute kidney
disease, which is the rationale for the
inclusion of AKI as one of the key focus
areas. We will focus on collecting data by
using the national best practice tool and we
have agreed three specific work streams that
will focus on the:
development of an AKI pathway
development of medical staff training
development of nursing staff training on
the recognition of AKI and appropriate
monitoring
It is intended that the data will be discussed
at the AKI steering group, which is chaired by
the lead consultant for patient safety.
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 13 of 55
2
Other patient safety indicators
Priority 2 – Clinical Outcomes
Alongside the three key areas for
improvement described above, we will also
aim to further reduce preventable harm in the
following areas:
As in previous years, the Trust together with
relevant key stakeholders and the wider
public has decided that the overarching
clinical outcome will be to sustain the Trust’s
low Hospital Standardised Mortality Ratio
(HSMR) and Summary Hospital Mortality
Indicator (SHMI). To do this we will continue
to focus on the four hyper acute pathways as
identified in last year’s report, these being
stroke & transient ischaemic attack, vascular,
cardiology and trauma. We will also include
spinal as the fifth hyper acute pathway of
focus.
HA MRSA
HA C. Difficile
HA pressure ulcer
grade 2
HA pressure ulcer
grade 3
HA pressure ulcer
grade 4
% falls resulting in
significant injury
by overall activity
VTE % risk
assessment
NHSST %harm
free
Target
10/11
11/12
12/13
3
25
2
15
1
16
0
8
243
247
144
131
16
13
15
12
4
2
0
0
0.10%
0.08%
0.03%
0.03%
83%
91%
93%
95%
NA
NA
93%
95%
13/14
Source; Trust data, April 2013
For abbreviation explanation please refer to
glossary Annex III
Specific standards have been identified within
each of the hyper acute pathways against
which performance will be monitored during
the year.
The CQUIN scheme for dementia will be
monitored under the clinical outcome
priorities.
Transient Ischaemic Attack & Stroke
A Transient Ischaemic Attack (TIA) or 'ministroke' is caused by a temporary disruption in
the blood supply to part of the brain. The
disruption in blood supply results in a lack of
oxygen to the brain. This can cause
symptoms similar to those of a stroke, such
as speech and visual disturbance and
numbness or weakness in the arms and legs.
However, unlike a stroke, the effects only last
for a few minutes and are usually fully
resolved within 24 hours.
TIA and stroke have been a key focus and
priority for the Trust since 2009 when both
were included in the three year quality
strategy. Since then vast improvements to
our TIA and stroke services have been made
such as the opening of a dedicated stroke
unit (acute and rehabilitation), a consultant
led service, the introduction of an early
supported discharge team and the
introduction of an emergency stroke call
system.
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 14 of 55
2
In our drive for excellence and with the further
rationale for improving both services we will
continue to focus on achieving the national
targets for stroke and TIA. We will specifically
focus on achieving the national and local
stretch targets for the following standards:
80% of patients receive brain imaging
within one hour of arrival (2011/12 31%
and 2012/13 45%)
90% of patients receive brain imaging
within 12 hours of arrival (new)
60% of eligible patients receive
thrombolysis within one hour of arrival
(2011/12 56% and 2012/13 49%)
90% of patients are admitted directly to
the stroke unit within four hours of arrival
(2012/13 72%)
95% of patients receive a swallow screen
within four hours of admission (2012/13
95%)
80% of patients spend 90% of their
inpatient episode on the stroke unit (new)
40% of stroke patients are discharged
under stroke early supported discharge
(2012/13 36%)
70% of high-risk TIA patients are seen
and treated within 24 hours of their 1st
contact with a healthcare professional
(2011/12 59% and 2012/13 75%)
Vascular (Abdominal Aortic Aneurysm)
An abdominal aortic aneurysm is a bulge in
the largest blood vessel in the body caused
by a weakness in the blood vessel wall. As
blood passes through the weakened blood
vessel, the blood pressure causes it to bulge
outwards like a balloon.
In last year’s report we introduced a focus on
specific standards for Abdominal Aortic
Aneurysm vascular services and for the year
ahead with the rationale to improve our
vascular services further we are looking to
focus on the following key standards:
number of aneurysm repairs undertaken
split between elective and emergency
procedures
number of aneurysm repairs undertaken
as an open or EVAR procedure (2012/13
102)
30 day mortality for all aneurysm repairs
(new)
number of carotid endarterectomy
procedures performed (new)
number of carotids performed within 14
days of onset of symptoms
Carotid 30 day mortality and stroke rate
(new)
All vascular performance data will be
presented in November of each year to
coincide with National Vascular Database
data collection completion and report
publication.
Cardiology
The Trust introduced reporting on cardiology
standards in the 2010 Quality Report and we
have made significant improvements since
then. We have recruited additional
consultants, opened our cardiac centre and
opened a second catheterisation laboratory.
We have also been recognised by our local
commissioners (Surrey and Hampshire) as
the key provider of primary percutaneous
coronary intervention services (a non-surgical
procedure used to treat the narrowed
coronary arteries of the heart).
With the rationale of ensuring that continued
improvements are made to the cardiology
services, the focus will be on the
achievement of the following standards:
85% of eligible patients receive treatment,
call to balloon within 150 minutes (new)
85% of eligible patients receive treatment,
door to balloon within 60 minutes
(2012/13 April – December 61%)
85% of eligible patients have an ECG
performed within 15 minutes of arrival
(new)
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 15 of 55
2
30% of eligible patients receive a PCI as
a day case (2012/13 24%)
40% of eligible patients receive a
pacemaker as a day case (2012/13 39%)
Trauma Services
Trauma services look after patients who have
serious and complex injuries that could
potentially result in death or serious disability.
The opening of the new purpose built
emergency department and helicopter pad in
2012 enabled us to improve the quality of
trauma care provided. This was endorsed by
an external review of our services (2012)
which identified that we are a Category 2
trauma centre.
Spinal
The spinal surgical team will start submitting
data to the national BASS registry. The BASS
is the professional society for UK spinal
surgeons and it aims to improve spinal care
by encouraging research, audit and good
clinical practice.
The aim for 2013/14 is to determine quality
indicators from the data submitted to the
BASS registry that identify room for
improvement. It is envisaged that indicators
can be identified following six months of data
collection.
To ensure that we enhance the quality of our
trauma services we will monitor the following
standards in 2013/14 and aim to ensure that:
80% of trauma teams are led by an
emergency department or other
appropriate consultant (2012/13 April –
December 79% average)
analgesia is provided to patients within 15
minutes of arrival (trauma calls)(new)
80% of patients with a head injury will
receive a CT scan within 60 minutes of
arrival (2012/13 April – December 76%
average)
80% of time critical transfers are
completed within one hour (new)
100% of trauma calls and trauma deaths
are reviewed at Mortality & Morbidity
meetings (new)
90% of open fractures receive antibiotics
within one hour of arrival to the
department (new)
*please note that the data for the above
indicators is linked to audit and will be
reported in arrears.
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 16 of 55
2
Priority 3 – Patient Experience
The fundamental purpose of any hospital is
treating the clinical condition of patients.
However, excellent care is about much more
than that. The experience of our patients is of
equal importance to their health outcomes
and is central to our mission to provide high
quality care. With this rationale in mind we
have discussed and agreed the indicators
below together with key stakeholders.
We utilise a number of different resources to
enable us to have a good understanding of
the experience of our patients.
Meeting inpatients’ essential care needs
There are many essential standards of care.
We consider that the following three ‘needs’
are a crucial and basic part of patient care in
our hospital and therefore we will monitor and
improve our performance against these:
95% of inpatients report they are always
treated with dignity and respect (new)
95% of inpatients report that they were
given enough privacy when discussing
their treatment/condition (new)
95% of inpatients report that they receive
the required assistance with
washing/dressing, eating/drinking and
mobilising (new)
Family and Friends Test
The DH has introduced a new measure for
patient experience as part of healthcare
providers’ contracts. The new measure is
called the Family and Friends Test (FFT) and
it requires healthcare providers to ensure that
patients with an overnight stay and those who
attend the emergency department are asked
“How likely are you to recommend our
ward/emergency department to friends and
family if they needed similar care or
treatment”.
The results against this requirement will be
monitored under the patient experience
section.
Patient experience in the emergency
department
In previous quality reports we have focused
on providing information on overall inpatient
satisfaction. We do however also collect and
monitor specific emergency department
patient experience data. For the year ahead
we will monitor an aim to improve our
performance for the following 3 new
indicators:
patients who would recommend the
services to their family or friends if they
require similar treatment (source: FFT)
patients who rate the care/treatment
received as good/very good/excellent –
90%
patients who were involved as much as
they wanted in decisions about their
treatment/care – 90%
Patient experience in maternity
As with the emergency department we have
also been monitoring the patient experience
in our maternity services and specifically we
will monitor and aim to improve on the
following 3 new indicators:
patients who would recommend the
services to their family or friends if they
require similar treatment (new, source:
FFT)
patients who rate the care/treatment
received as good/very good/excellent –
90%
patients who were involved as much as
they wanted in decisions about their
treatment/care – 90%
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2
Carer/relative experience for patients with
a diagnosis of dementia
The Trust has had a focus on improving
services for patients who have a diagnosis of
dementia. We have employed a dementia
nurse specialist, set up a staff training
programme, introduced improved signage
and the butterfly scheme and the ‘this is me’
booklet.
It is well known that people with dementia do
not respond well to changes in environment
and routine and that it is a challenge to collect
intelligence on how they experience care
provided in acute settings. As the Trust is
keen to provide an excellent service we have
therefore introduced a questionnaire which
can be completed by the carer/relative of
patients with dementia. We will in the year
ahead start to collect, monitor and improve
performance against:
percentage of patient carers who would
recommend our services to friends and
family
percentage of patient carers who would
rate the care received by their
relative/friend as good, very good or
excellent
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 18 of 55
2
Statements of Assurance
The national clinical audits and national
confidential enquiries that the Trust
participated in during 2012/13 are as follows;
Review of Services
During 2012/13 Frimley Park Hospital NHS
Foundation Trust (“the Trust”) provided
and/or sub-contracted 24 relevant health
services.
The Trust has reviewed all the data available
to them on the quality of care in 24 of these
relevant services.
The income generated by the relevant health
services reviewed in 2012/13 represents
(£237.3 m) 100 per cent of the total income
generated from the provision of relevant
health services by the Trust for 2012/13.
The Quality Report for “the Trust” has
reviewed a cross-section of clinical data, at
least some of which apply to every clinical
specialty.
Subarachnoid Haemorrhage (study open
at time of reporting)
Alcohol Related Liver Disease
Bariatric Surgery – organisational
questionnaire only
Cardiac Arrest Procedures
The national clinical audits (see table on page
20) and national confidential enquiries the
Trust participated in, and for which data
collection was completed during 2012/13, are
listed below alongside the number of cases
submitted to each audit or enquiry as a
percentage of the number of registered cases
required by the terms of that audit or enquiry.
The data reviewed and presented cover the
three dimensions of quality (Patient Safety,
Clinical Effectiveness, and Patient
Experience) and indicates what if anything
has impeded the objective.
Participation in Clinical Audits
During 2012/13, 37 national clinical audits
and 3 national confidential enquiries covered
relevant health services that “the Trust”
provides.
During 2012/13 the Trust participated in 94%
national clinical audits (29/31) and 100% of
national confidential enquiries (3/3) of the
national clinical audits and national
confidential enquiries which it was eligible to
participate in.
The national clinical audits (see table on page
20) and national confidential enquiries that
the Trust was eligible to participate in during
2012/13 are listed in the table below.
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 19 of 55
% of cases
submitted to
the audit
Participation
Name of audit / Clinical Outcome
Review Programme
Eligible to
participate
2
Children
Neonatal intensive and special care (NNAP)
Paediatric pneumonia (British Thoracic Society)
Paediatric asthma (British Thoracic Society)
Paediatric fever (College of Emergency Medicine)
Epilepsy 12 audit (Childhood Epilepsy)
Paediatric intensive care (PICANet)
Congenital heart disease (Paediatric cardiac surgery) (CHD)
Diabetes (Paediatric) (NPDA)





x
x






–
–

100%
100%
100%
100%
100%
–
–
90%
Emergency use of oxygen (British Thoracic Society)
Adult community acquired pneumonia (British Thoracic Society)
Non-invasive ventilation - adults (British Thoracic Society)
National Cardiac Arrest Audit (NCAA)
Adult critical care (Case Mix Programme – ICNARC CMP)
Potential donor audit (NHS Blood & Transplant)
National emergency laparotomy audit (NELA)










x


nc
100%
100%
100%
–
100%
100%
–








x
nc

nc


100%
–
–
100%
–
100%
100%


x
x


–
–
95%
97%
–
–


100%

x

–
TBC
–






100%
100%
100%
Acute Care
Long Term Conditions
Diabetes (Adult) ND(A), includes National Diabetes Inpatient Audit (NADIA)
Chronic Pain (National Pain Audit)
Inflammatory bowel disease (IBD) - includes Paediatric Services
Parkinson's disease (National Parkinson's Audit)
Chronic Obstructive Pulmonary Disease (COPD)
Adult asthma (British Thoracic Society)
Bronchiectasis (British Thoracic Society)
Elective Procedures
National Joint Registry (NJR)
Elective surgery (National PROMs Programme)
Intra-thoracic transplantation (NHSBT UK Transplant Registry)
Liver transplantation (NHSBT UK Transplant Registry)
Coronary angioplasty
(subscription funded from April 2012)
National Vascular Registry
Adult cardiac surgery audit (ACS)
Cardiovascular disease
Acute coronary syndrome or Acute myocardial infarction (MINAP)
Heart failure (HF)
Sentinel Stroke - National Audit Programme (SSNAP)
Renal Disease
Renal replacement therapy (Renal Registry)
Renal transplantation (NHSBT UK Transplant Registry)
Renal colic (College of Emergency Medicine)
Cancer
x
x

–
–
Yes
–
–
100%
Bowel cancer (NBOCAP)

Yes
Head and neck oncology (DAHNO)
Lung cancer (NLCA)
Oesophago-gastric cancer (NAOGC)



Yes*
Yes
Yes*
in
progress
–
100%
–
Hip fracture database (NHFD)
Severe trauma (Trauma Audit & Research Network, TARN)
Fractured neck of femur
Prescribing Observatory for Mental Health (POMH)
National audit of schizophrenia (NAS)



x
x
Yes
Yes
Yes
–
–
95%
97%
100%
–
–
National Comparative Audit of Blood Transfusion programme

nc
–
Risk factors (National Health Promotion in Hospitals Audit)

nc
–
Care of dying in hospital (NCDAH)

nc
–
Trauma
Blood Transfusion
Health Promotion
End of Life
Yes*; data submission via St Luke’s Cancer Centre at Royal Surrey Hospital
nc; not conducted in reporting year
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 20 of 55
2
The reports of 37 national clinical audits were
reviewed by the provider in 2012/13 and “the
Trust” intends to take the following actions to
improve the quality of healthcare provided
(please note that not all reports of audits
undertaken were made available in the
reporting year):
TARN; we have significantly improved our
data completeness and data submissions
to the database which has resulted in
excellent compliance rates and valuable
data on our services
Renal Colic; local data systems are to be
amended to ensure that a pain score can
be recorded electronically
Fractured Neck of Femur; following the
audit a re-audit has been planned which
will use both patient notes rather than just
the electronic system to enhance the data
accuracy around analgesia giving times.
The involvement of nursing staff in pain
management will be altered and a nurse
led proforma will be developed to support
this. Training will be provided on fascia
iliac blocks.
National Comparative Audit 2012 of blood
sample collection and labelling; following
a review of the recommendations we
have had a meeting with the Community
Midwifery Matron to discuss the report
and potential strategies, such as
improving processes around taking blood,
and exploring training needs.
The Transfusion Practitioner team will
continue to focus on training, assessment
with Skills Blitz and any relevant
opportunities.
To comply with BCSH Recommendations,
the Blood Transfusion Policy for
adult/paediatric policy will be amended to
include an agreed protocol to cover
clinical situations where it is unavoidable
that the clinician has to hand a
transfusion sample over to another
member of staff (for example when the
transfusion sample is taken as part of a
complex clinical procedure).
FPH is compliant with other BCSH
Recommendations, but in line with their
recommendation that hospitals regularly
measure their mislabelling/miscollection
rates in order to benchmark their
progress, FPH Transfusion Practitioner
team will add this audit to their audit
schedule.
Lung cancer (NLCA); data completeness
and processes has placed us above the
national average so our aim is to sustain
this in the next round. The audit identified
that treatments were generally good
however there were queries about the
lower than average numbers of patients
receiving chemotherapy (46% FPH; 56%
national), radiotherapy (18% FPH; 19%
national). We will speed up the diagnostic
pathway to ascertain if it is this that is
impacting on prognosis.
The reports of 259 local clinical audits were
reviewed by the provider in 2012/13 and the
Trust intends to take the following actions to
improve the quality of healthcare provided:
one month audit of the emergency
surgical team workload; the audit
collected objective information on the
busiest periods during emergency takes
as well as subjective information from the
team members. Following the audit a
more efficient handover system has been
introduced and staff redeployment and
additional staffing has been introduced.
audit of omacor prescribing in treatment
of hypertriglyceridaemia; the aim of the
audit was to identify current reasons for
prescribing and to monitor clinical
effectiveness. The audit has resulted in a
review of guidelines, a refocus on
education, and the development of local
guidelines
perioperative fasting in children; following
the audit the timings for pre-op drink have
been defined; anaesthetists and surgeons
will liaise with paediatric nursing staff
regarding the operating list, a fasting
guidelines leaflet will be given to parents
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 21 of 55
2
and intraoperative fluids will be given to
avoid dehydration in children
emergency ophthalmic admissions –
streamlining the process; the initial audit
resulted in the introduction of a new triage
sheet and an algorithm for assessment of
low risk cases without the need for
discussion with the emergency doctor.
From the audit it was evident that over
40% of referrals did not need discussion
and that patients were appropriately
triaged with no delay in seeing severe
cases. The introduction of booking
patients according to priority has helped
to free more urgent slots for the most
unwell patients.
Research
The number of patients receiving NHS
services provided or sub-contracted by the
Trust in 2012/13 that were recruited during
that period to participate in research
approved by the research ethics committee
was 1039.
Commissioning for Quality and Innovation
A proportion of the Trust income in 2012/13
was conditional on achieving quality
improvement and innovation goals agreed
between “the 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 2012/13 and the following 12
months period are available online at
http://www. Monitornhsft.gov.uk/sites/all/modules/
fckeditor/plugins/ktbrowser/openTKFile.php?i
d=3275 and/or
http://www.institute.nhs.uk/world_class_com
missioning/pct_portal/cquin.html
For 2012/13 the baseline value of CQUIN
was £5,309,000 (2.5% of total contract
value); in 2011/12 the value was £2,095,000
(1% of total contract value)
The CQUIN schemes covered four national
mandated and three locally defined schemes.
The four nationally mandated goals (total
value 0.5%) were:
Maintain a composite score of 68.9 on
five identified questions (see page 36) of
the CQC national inpatient survey results.
We achieved this CQUIN scheme as our
composite score is 70.1 (value 0.125%)
Assess 90% of patients for their risk of
venous thromboembolism - to be
achieved monthly (see page 25). We
achieved this CQUIN for each of the 12
months (value 0.125%)
Undertake and upload data to the NHS
safety thermometer audit; submit a
minimum of nine out of 12 months (see
page 27). We have provided 100% of
data for nine out of 12 months and have
achieved the CQUIN (value 0.125%)
Dementia; screen patients >75 years
admitted as an emergency, risk assess
those who screen positively and refer
eligible patients to specialist services for 3
out of 12 months at 90%. We achieved
this CQUIN as we screened, risk
assessed and referred more than 90% of
patients during December, January and
February and March (value 0.125%) Also,
see page 33.
The three local schemes (total value 2%)
were:
High Impact Innovations (value 0.5%).
End of Life care (value 0.3 %)
Reduction in non-elective spells (value
1.2%)
Care Quality Commission
The Trust is required to register with the Care
Quality Commission and its current
registration status is registered without
conditions. The Trust has the following
conditions on registration - none
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 22 of 55
2
The Care Quality Commission has not taken
enforcement action against the Trust during
2012/13.
The Trust has participated in one special
review or investigation by the Care Quality
Commission relating to the following areas
during 2012/13;
Information Governance Toolkit
attainment levels
The Trust Information Governance
Assessment Report score overall score for
2012/13 was 76% and was graded GREEN.
Clinical Coding Error Rate
The CQC undertook a responsive review
20.08.2012 and found the Trust fully
compliant with
The 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 that period for diagnosis and
treatment coding (clinical coding) were:
Outcome 1: respecting and involving
people who use our services
Outcome 5: nutritional needs
Outcome 7: safeguarding
Outcome 13: staffing
Outcome 21: record keeping
The Trust intends to take the following action
to address the conclusions or requirements
reported by the Care Quality Commission:
We met all the standards and no actions
were required from the inspection.
2009
%
2010
%
2011 2012*
%
%
Primary diagnosis
incorrect
7.7
8.5
7.5
2.4
Secondary diagnosis
incorrect
6.9
10.7
5
4.0
10.0
Primary procedures
incorrect
2.2
4.7
2.5
0.0
Secondary procedure
incorrect
4.1
2.93
0.5
11.3
Data Quality
The Trust submitted records during 2012/13
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:
99.0% for admitted patient care
99.6% for outpatient care; and
98.6% for accident and emergency care
Which included the patient’s valid General
Practitioner Registration Code was:
99.7% for admitted patient care;
99.8% for outpatient care; and
100.0% for accident and emergency care
Source: Trust Information department, April 2013,
data is presented in percentages
*This audit was only based upon 40 FCEs which
can skew the % error rate
The results should not be extrapolated further
than the actual sample audited and services
audited within the sample are:
2010
2011
2012
Ophthalmology
(100)
Ophthalmology
(100)
Obstetrics (40)
Paediatrics
(100)
All specialties
(100)
Source: Trust Information department, April
2013
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 23 of 55
2
The Trust will be taking the following actions
to improve data quality:
ensuring that NHS numbers coverage is
maximised
supporting the ADT (Admission,
Discharge and Transfer) project to ensure
timely data collection and accurate
allocation of patients’ to the correct
consultant.
continuing a process of internal clinical
coding audits to constantly monitor
clinical coding accuracy
continuing to work with clinicians to
ensure that their data is correctly
allocated on trust systems. This covers
clinical coding and activity capture.
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 24 of 55
2
Monitor data reporting requirements
Monitor is the independent regulator of NHS foundation trusts. As part of their work Monitor set the
Trust guidance on some of the reporting requirements in this report.
From 2012/13 all trusts are required to report against a core set of indicators relevant to the
services they provide, for at least the last two reporting periods, using a standardised statement set
out in the NHS (Quality Accounts) Amendment Regulations 2012; this data is presented in the
same way in all quality accounts published in England. This allows the reader to make a fair
comparison between hospitals if they choose to.
As required by point 26 of the NHS (Quality Accounts) Amendment Regulations 2012, where the
necessary data is made available by the Health and Social Care Information Centre, a comparison
is made of the numbers, percentages, values, scores or rates of each of the NHS foundation trust’s
indicators with
a) the national average for the same; and
b) those NHS trusts and NHS foundation trusts with the highest and lowest of the same.
These requirements are set out in the table below, the table contains data that has been sourced
from the Information Centre (NHS IC), and also shows Frimley Park Hospital locally generated
data, where available.
NHS Outcomes Framework Domains 1 & 2
Preventing people from dying prematurely
Enhancing quality of life for people with long-term conditions
The data made available to the National Health Service trust or NHS foundation trust by the Health
and Social Care Information Centre with regard to—
a) the value and banding of the summary hospital-level mortality indicator (“SHMI”) for the
trust for the reporting period; and
b) the percentage of patient deaths with palliative care coded at either diagnosis or specialty
level for the trust for the reporting period is included to give context.
The Trust considers that this data is as described for the following reasons, taken from national
dataset using data provided.
The Trust has taken the following actions to improve the indicator and percentage in (a) and (b),
and so the quality of its services, see part 3 review of services
Indicator and Scope
Prior Period
Latest Period
Summary Hospital-Level Mortality
Indicator (SHMI):
Oct10-Sep11
Oct11-Sep12
FPH Trust
0.8970
‘as expected’
0.8861
‘lower than expected’
n/a
n/a
1.2295 / 0.6747
1.2107 / 0.6849
Jan11-Dec11
Jan12-Dec12
FPH Trust
0.8644
0.8991
Trusts National Average
0.9930
0.9957
1.2416 / 0.6906
1.1905 / 0.7011
Trusts National Average
Highest (worst) and Lowest (best)
Trust Scores
Highest (worst) and Lowest (best)
Trust Scores
Data Source
NHS IC
(NHS Information
Centre)
HED
(Healthcare
Evaluation Data)
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 25 of 55
2
Palliative Care Indicator:
Percentage of patient deaths with palliative
care coded at either diagnosis or specialty
level for the trust for the reporting period
FPH Trust
Trusts National Average
Highest and Lowest Trust %s
Oct10-Sep11
Oct11-Sep12
21.2%
28.0%
n/a
n/a
41.6% / 0.0%
43.3% / 0.0%
NHS IC
NHS Outcomes Framework Domain 3
Helping people to recover from episodes of ill health or following injury
Our Patient Reported Outcomes Measures (PROMS) following hip or knee replacement
surgery
The data made available to the National Health Service trust or NHS foundation trust by the Health
and Social Care Information Centre with regard to the trust’s patient reported outcome measures
scores for:
(i)
(ii)
(iii)
(iv)
groin hernia
varicose vein
hip replacement surgery, and
knee replacement surgery, during the reporting period.
The Trust considers that this percentage is as described for the following reasons, taken from
national dataset using data provided.
The Trust has taken actions to improve this percentage, and so the quality of its services.
We introduced PROMs in 2009 for patients who had hip and knee replacement surgery, groin
hernia and varicose vein surgery. These measure a patient’s health gain after surgery. The
information is gathered from the patient who completes a questionnaire before and after surgery.
The responses are analysed by an independent company and benchmarked against other Trusts.
For all procedures our performance sits within the 99.8% control limit which can be interpreted that
performance is not significantly different from the national adjusted health gain.
Indicator and Scope
Prior Period
Latest Period
FY09-10
FY10-11
Groin Surgery - FPH Trust
0.089
0.089
Groin Surgery - Trusts National Average
0.082
0.085
0.136 / 0.011
0.137 / 0.024
no score –
insufficient data
0.108
Prior Period
Latest Period
0.094
0.091
0.246 / -0.002
0.155 / -0.007
Hip Replacement Surgery - FPH Trust
0.440
0.395
Hip Replacement Surgery - Trusts National
Average
0.411
0.405
Patient Reported Outcome Measures
(PROMs):
Groin Surgery - Highest (best) and Lowest
(worst) Trust Scores
Varicose Vein Surgery - FPH Trust
Indicator and Scope
Varicose Vein Surgery - Trusts National
Average
Varicose Vein Surgery - Highest (best) and
Lowest (worst) Trust Scores
Data Source
NHS IC
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 26 of 55
2
Indicator and Scope
Hip Replacement Surgery - Highest (best)
and Lowest (worst) Trust Scores
Knee Replacement Surgery - FPH Trust
Knee Replacement Surgery - Trusts
National Average
Knee Replacement Surgery - Highest (best)
and Lowest (worst) Trust Scores
Prior Period
Latest Period
0.514 / 0.287
0.503 / 0.267
0.307
0.317
0.294
0.298
0.386 / 0.172
0.407 / 0.176
Data Source
Our readmissions rate for children and adults
The data made available to the National Health Service trust or NHS foundation trust by the Health
and Social Care Information Centre with regard to the percentage of patients aged—
(i) 0 to 14; and
(ii) 15 or over,
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 Trust considers that these percentages are as described for the following reasons taken from
national dataset using data provided.
The Trust has taken actions to improve this percentage, and so the quality of its services, which
are detailed in our reports.
Readmissions within 28 Days – Under 16:
Percentage of patients aged 0 to 15
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
FY09-10
FY10-11
FPH Trust
8.32%
7.55%
Trusts National Average
10.34%
10.02%
22.53% / 0.0%
14.34% / 0.0%
FY11-12
FY12-13
8.49%
7.97%
Prior Period
Latest Period
Readmissions within 28 Days –16 or over:
Percentage of patients aged 16 or over
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
FY09-10
FY10-11
FPH Trust
10.98%
11.45%
Trusts National Average
11.05%
11.16%
13.17% / 0.0%
12.94% / 0.0%
FY11-12
FY12-13
11.77%
12.17%
Highest (worst) and Lowest (best) Trust %s
FPH Trust
Indicator and Scope
Highest (worst) and Lowest (best) Trust %s
FPH Trust
NHS IC
FPH Data
Data Source
NHS IC
FPH Data
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 27 of 55
2
NHS Outcomes Framework Domain 4
Ensuring that people have a positive experience of care
Our patient experience score for responsiveness to the personal needs of patients
The data made available to the National Health Service trust or NHS foundation trust by the Health
and Social Care Information Centre with regard to the trust’s responsiveness to the personal needs
of its patients during the reporting period.
The Trust considers that this data is as described for the following reasons taken from national
dataset using data provided.
The Trust has taken actions to improve this percentage, and so the quality of its services, which
are detailed in our Trust Board Patient Experience reports; and some of which are outlined in part
3 ‘review of services’ in this report.
Indicator and Scope
Prior Period
Latest Period
FY11-12
FY12-13
FPH Trust
68.9
70.1
Trusts National Average
67.4
Not available at time
of publication
FY11-12
FY12-13
80%
87%
Responsiveness to inpatients’ personal
needs
FPH Trust
Data Source
DH - CQUIN
questions
Local Trust
Questionnaire
(Meridian)
The percentage of our staff who would recommend this trust as a provider of care, to their
family or friends
The data made available to the National Health Service trust or NHS foundation trust by the Health
and Social Care Information Centre with regard to the percentage of staff employed by, or under
contract to, the trust during the reporting period who would recommend the trust as a provider of
care to their family or friends.
The Trust considers that this percentage is as described for the following reasons; taken from
national dataset using data provided.
The Trust has taken actions to improve this percentage, and so the quality of its services, which
are detailed in our Trust Board report.
Percentage of staff who would
recommend the provider to friends or
family needing care
Responding agree & strongly agree
2011
FPH Trust
89%
85%
Trusts National Average
62%
60%
2012
NHS Staff Survey
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 28 of 55
2
NHS Outcomes Framework Domain 5
Treating and caring for people in a safe environment and protecting them from avoidable harm
The percentage of our patients that were risk assessed for venous thromboembolism (VTE
Blood clot)
The data made available to the National Health Service trust or NHS foundation trust by the Health
and Social Care Information Centre with regard to the percentage of patients who were admitted to
hospital and who were risk assessed for venous thromboembolism during the reporting period.
The Trust considers that this percentage is as described for the following reasons: taken from
national dataset using data provided.
The Trust has taken actions to improve this percentage, and so the quality of its services, which
are detailed in our Trust Board quarterly report; some of which some are outlined in part 3 ‘review
of services’ in this report.
Indicator and Scope
Prior Period
Latest Period
Percentage of admitted who were
admitted to hospital and who were riskassessed for Venous Thromboembolism
Q2 12-13
Q3 12-13
FPH Trust
93.7%
93.7%
Trusts National Average
93.8%
94.1%
100% / 80.9%
100% / 84.6%
FY11-12
FY12-13
Highest (best) and Lowest (worst) Trust %s
Data Source
NHS IC
FPH Data
FPH Trust
90.89%
92.94%
The rate per 100,000 bed days of cases of C.difficile infection in our Trust.
The data made available to the National Health Service trust or NHS foundation trust by the Health
and Social Care Information Centre with regard to the rate per 100,000 bed days of cases of
C.difficile infection reported within the trust amongst patients aged 2 or over during the reporting
period.
The Trust considers that this rate is as described for the following reasons; taken from national
dataset using data provided.
The Trust has taken actions to improve this percentage, and so the quality of its services, which
are detailed in our Trust Board Infection Control reports, also refer to part 3 ‘review of services’ in
this report.
Indicator and Scope
Prior Period
Latest Period
FY10-11
FY11-12
FPH Trust
12.1
7.2
Trusts National Average
29.6
21.8
71.8 / 0.0
51.6 / 0.0
Rate per 100,000 bed days of C.difficile
infection that have occurred within the
trust amongst patients aged 2 or over
Highest (worst) and Lowest (best) Trust
Scores
Data Source
NHS IC
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 29 of 55
2
The rate per 100 admissions, of patient safety incidents reported in our Trust.
The data made available to the National Health Service trust or NHS foundation trust by the Health
and Social Care Information Centre with regard to the number and, where available, rate of patient
safety incidents reported within the trust during the reporting period, and the number and
percentage of such patient safety incidents that resulted in severe harm or death.
The Trust considers that this number and/or rate is as described for the following reasons; taken
from national dataset using data provided.
The Trust has taken actions to improve this percentage, and so the quality of its services, which
are detailed in our Trust quarterly Safety reports; some of which some are outlined in part 3 ‘review
of services’ in this report.
Rate of patient safety incidents that
occurred within the trust (100
admissions)
FPH Trust
Highest (worst) and Lowest (best) Trust
Scores
Number of such patient safety incidents
reported that resulted in severe harm or
death
FPH Trust
Percentage of such patient safety
incidents reported that resulted in severe
harm or death
FPH Trust
Highest (worst) and Lowest (best) Trust
Scores
Apr11-Sep11
Apr12-Sep12
6.68
5.58
13.01 / 2.91
14.44 / 3.11
Apr11-Sep11
Apr12-Sep12
NRLS
(National
Reporting and
Learning Service)
NRLS
8
9
Apr11-Sep11
Apr12-Sep12
0.03%
0.04%
2.8% / 0/0%
3.6% / 0.0%
NRLS
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 30 of 55
3
Review of Quality Performance 2012/13
This part of the quality report provides a brief summary on the quality improvement
priorities that were listed in the 2011/12 quality report and our performance against them
during 2012/13.
3
Priority 1 - Patient Safety
In previous years the Trust has focused on
improving practice in a number of patient
safety areas and has completed a significant
number of improvement projects with the aim
of reducing preventable harm. In our previous
strategy (2009 - 2012) the Trust set out to
reduce preventable harm by 30% over three
years and actually reduced harm by 53%. In
our drive to strive for excellence and to
become the safest NHS hospital we aim to
reduce preventable harm by a further 15%
over the next three years (2012 - 2015 quality
strategy).
Sepsis
Sepsis is a life-threatening illness caused by
the body overreacting to an infection. The
body’s immune system goes into overdrive,
setting off a series of reactions that can lead
to widespread inflammation (swelling) and
blood clotting in the body.
In our 2012 Quality Report, as part of the
deteriorating patient work stream and with the
rationale of reducing preventable harm, we
identified that a trust wide sepsis pathway
had been developed and that we would
undertake work to commence data collection
against relevant indicators but specifically
against the provision of antibiotics within 60
minutes of diagnosis in the emergency
department.
We collected data for every month of the year
and the baseline data shows that 33% of all
patients diagnosed with sepsis received
treatment with antibiotics within 60 minutes
and 56% received treatment within 90
minutes.
Nationally there are two standards for the
provision of antibiotics in sepsis. One sets out
that patients who have a neutropenic sepsis
(caused by a condition known as
neutropenia, in which the number of white
blood cells (called neutrophils) in the blood is
low) should receive antibiotics within 60
minutes. We achieved 59% compliance with
this standard. The other standard relates to
other sepsis and requires antibiotics to be
provided within four hours; we achieved this
95% of the time.
Actions we took to improve practice:
continued meetings of the sepsis group
we undertook a pathway compliance audit
and found that the pathway was not as
embedding as we would have envisaged.
The sepsis group therefore decided to
revise the pathway and to reintroduce it
into practice. The revised pathway was
introduced in early 2013 and compliance
will be re-audited in April 2013
continued training programme with
targeted training sessions to relevant
wards and stands at skill blitz days
incorporation of the pathway on the
emergency department IT system
introduction of a red sticker to be included
in patient notes for those with a severe
sepsis
Venous Thromboembolism
Venous Thromboembolism (VTE) is a
condition in which a blood clot (thrombus)
forms in a vein/blood vessel which can lead
to pain and swelling. If the blood clot
becomes dislodged it can travel in the
bloodstream (embolism) and it can potentially
block vital arteries which can be fatal. When
the embolism blocks a vital artery to the lung
it is called a pulmonary embolism (PE).
VTE was identified as a top clinical priority for
the NHS in the 2011/12 operating framework.
In 2011/12 the Commissioning for Quality and
Innovation (CQUIN) payment framework
made a proportion of our income conditional
on a VTE-related requirement which is also
supported by the NICE quality standard.
The VTE risk assessment is governed by
standard national definitions.
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 32 of 55
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The aim for 2012/13 was to assess at least
90% of patients for their VTE risk in every
month of the year. We achieved this in each
month. Our performance this year has seen a
slight improvement from last year as it
improved from 91% to 93%.
In year we undertook four VTE audits and we
also undertook in-depth reviews for every
hospital acquired PE and deep vein
thrombosis (DVT).
The four VTE audits showed a sustained
performance on the appropriate prescribing of
prophylaxis with an average of 97% of
patients receiving appropriate chemical
and/or mechanical prophylaxis.
The Trust reported 60 PE and four DVT
cases. Each of those was subject to an indepth review which showed that the majority
of VTE, were found to be unpreventable.
Unfortunately we have seen an increase in
the number reported as last year we reported
44 PE and 6 DVT cases.
Actions that we undertook to improve practice
further during 2012/13 are:
feedback of audits to all specialities and
discussed at VTE committee and patient
safety steering group.
all preventable PE cases are reviewed at
a root cause analysis meeting led by the
medical director.
an in-depth review was undertaken with
the orthopaedic team which also included
a review of current guidelines for VTE risk
assessment and prophylaxis for patients
discharged with plaster casts in place.
continued training for clinicians.
Catheter Associated Urinary Tract
Infection
A catheter associated urinary tract infection
(CAUTI) is an infection that occurs in
someone who has a tube (called a catheter)
in place to drain urine from the body (no
agreed national definition is available)
Last year we said that we would expand the
focus of the work stream and that we would
as part of the NHS Safety Thermometer
(NHS-ST) collect data on the incidence of
CAUTI as well as the appropriate insertion of
urinary catheters (please refer to next
heading for information on the NHS-ST). To
establish whether a catheter is inserted
appropriately we agreed with lead clinicians
and our commissioners a list of ten clinical
indications for catheterisation.
The data collected with the NHS-ST is set out
in the graph below and shows that the
average incidence (the rate that a new
infection occurs within the sample population
of patients with a urinary catheter) was 11%.
It is evident from the trend line in the graph
that performance has significantly improved
since June 2012.
Source; Safety Thermometer data, March 2013
The NHS Litigation Authority standard on
VTE was assessed and met at the highest
level of three.
Data collection on the appropriate insertion of
urinary catheters shows that 2% (average) of
urinary catheters were inserted
inappropriately; this is a 4% improvement on
the 2011/12 quarter 4 (January – March
2012) audit (6%). This means that since 2012
we have reduced the inappropriate insertion
of urinary catheters from 15% to 2%.
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 33 of 55
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During this year we reviewed the catheter
pathway and we continued our training
sessions.
C. difficile infection (CDI) is a major cause of
antibiotic-associated diarrhoea and colitis (an
infection of the intestine).
NHS Safety Thermometer
The NHS Safety Thermometer (NHS-ST) is
an improvement tool for measuring,
monitoring and analysing patient harm and
harm free care for VTE, pressure ulcers, falls
and urinary catheter associated infection.
Through using the NHS-ST hospitals can
measure ‘harm’ and the proportion of patients
that are ‘harm free’. The NHS-ST provides a
‘temperature check’ as it is a snap shot audit
on one day each month and it can be used
alongside other measures of harm to
measure local and system progress; it is not
intended to be a performance management
tool.
The Trust has made significant improvements
in the number of healthcare-associated
infections over the years and this year we
further reduced MRSA bacteraemia
(bloodstream infection) cases from two
(2011/12) to one, and maintained our low
rates of CDI, with 16 reported cases (15 in
2011/12). This means that over a six year
period we have reduced MRSA bacteraemia
cases by 95% and CDI by 96% putting us
with the best performing trusts regionally and
nationally.
The NHS-ST is governed by standard
national definitions.
We undertook monthly audits using the NHSST and found that on average 95% patients
received ‘harm free’ care. The ‘temperature
checks’ were undertaken by ward managers
and clinical matrons.
In the acute services contract a CQUIN
scheme was included that required the Trust
to upload NHS-ST data to the NHS Institute
for Improvement. We submitted a complete
record of survey data covering 100% of
eligible patients for all relevant measures for
nine months, June 2012 to March 2013.
Hospital Acquired MRSA and C. Difficile
Hospital Associated MRSA and C. Difficile
MRSA is the abbreviation for MeticillinResistant Staphylococcus aureus, which is a
common skin bacterium which has become
resistant to some of the more widely used
antibiotics.
Source: Trust data, April 2013
Both MRSA and C.diff are governed by
standard national definitions.
Hospital Acquired Pressure Ulcers
A pressure ulcer (also known as a pressure
sore or bed sore) is an ulcerated area of skin
caused by irritation and continuous pressure
on part of the body. Pressure ulcers are
categorised in four grades which are linked to
severity. Patches of discoloured skin are
categorised as a grade 1 and the most
severe grade is 4. They are more likely to
occur in people who are under or overweight,
have a poor nutritional status and/or poor
vascular functions.
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 34 of 55
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Our goal in 2012/13 was to achieve a further
reduction of:
•
•
•
•
•
35% in grade 2 pressure ulcers
50% in grade 3 pressure ulcers
zero tolerance grade 4 pressure ulcers
The table below sets out our performance
over the last five years. It is evident from the
data that a significant reduction of 39% was
achieved during 2012/13 for grade 2, 3 and 4
and of 53% over the last five years.
training and awareness included in the
annual patient safety training updates and
in the monthly clinical skill blitz days
participation in the NHS-ST work
programme
Pressure ulcer definitions are governed by
standard national definitions.
Falls resulting in significant injury
A fall is an unintentional loss of balance
causing one to make unexpected contact with
the ground or floor. Falls can results in
significant harm such as severe head injury
or broken bones.
Source; Trust incident data, April 2013
Some of the actions we took to improve
practice and reduce the prevalence of
pressure ulcers are:
•
•
•
•
•
root cause reviews of all grade 2 pressure
ulcers by clinical matrons and ward
managers
all grade 3 pressure ulcers were subject
to a multi-disciplinary in-depth review with
a summary report of the investigation and
actions taken submitted to the Board
a review of our pressure ulcer care
bundle
from the reviews we identified a theme for
patients who are admitted with vascular
disease to one of our wards. As a
preventative measure all patients
admitted to that ward receive a bed with a
pressure relieving mattress unless
clinically not appropriate
a program of audits on nursing practice
was completed
Our aim was to reduce the percentage of falls
resulting in significant harm against activity.
We reported 18 falls resulting in significant
injury, which set against overall activity is
0.03%. 16 falls occurred in inpatient setting
and two falls occurred in outpatient setting.
The rate against activity for solely inpatient
falls equates to 0.06%. This is a reduction
from 2011/12 when we reported 17 falls and
a rate against activity of 0.08% against
activity.
Please note that the number of 17 falls in
2011/12 does not align with the number of 16
presented in the 2012 Quality Report, one of
the in-depth reviews for a fall that occurred in
March 2012 had not been completed at the
time of reporting for the 2012 report.
Each fall resulting in significant harm was
subject to a root cause analysis review and
actions taken from these reviews are:
•
•
•
training for staff relating to fall
management including inclusion of falls
training at monthly skills blitz days and
the roll out of more specific training for
higher risk areas
an additional themed review of those falls
that occurred in the first 6 months
a review of the falls risk assessment; this
now excludes ‘moderate’ risk of falling
and only includes ‘at risk’ or not at risk
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 35 of 55
3
•
•
a further purchase of 16 falls monitors; we
now have 41 in total.
a change of the post fall review template
to ensure proactive responses in practice
for recurrent fallers
Falls resulting in significant harm definitions
are governed by standard national definitions.
Clinical Outcomes
The Trust builds on the established culture of
monitoring clinical outcomes and learning
from best practice examples to improve the
quality of health outcomes for our patients.
Our newly commissioned information system
package, Hospital Episode Database (HED),
allows us to compare our specialty clinical
outcomes nationally to identify areas where
there is room for improvement.
Specialty specific quality dashboards have
been develop; this enables clinical specialties
to monitor their performance closely and it
enables them to anticipate issues during a
period of significant transformation,
implementation of new information
technologies, and stretching financial targets.
Hospital Standardised Mortality Rate
HSMR (Hospital Standardised Mortality
Ratio) is an indicator of healthcare quality and
safety that measures whether the death rate
at a hospital is higher or lower than you would
expect. The expected index for all trusts
across England is an HSMR of 100. So an
HSMR under 100 is better than expected and
a HSMR above 100 is worse than expected
We have made good progress in improving
our Trust mortality ratio in 2012/13. Despite
the highest volume of patients attending the
emergency department, the busiest winter
season on record, and an increased number
of admissions and births our HSMR
benchmarking ratio has improved to 48
(CHKS, January 2013) from 52 last year.
This performance is confirmed by another
indicator for mortality; the Summary Hospital
Mortality Indicator (SHMI). Our SHMI has
slightly increased from 2011/12; 87.08 (12
months rolling number as at March 2012,
HED) to 89.87 (rolling SHMI April 2012 –
January 2013, HED).
The Dr. Foster hospital guide recognised the
Trust’s low mortality amongst one of several
indicators for safe care by awarding the Trust
with the runner up award for Hospital of the
Year.
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 36 of 55
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Indicator
% of eligible patients
receiving thrombolysis
<60 minutes of arrival
(door to needle)
% eligible patients
receive a brain scan <1
hour of arrival (urgent
scans only)
% patients receive a
brain scan < 1 hour of
arrival (all patients)
Source; HED data, May 2013
Mortality data is governed by standard
national definitions.
Transient Ischaemic Attack & Stroke
A transient ischaemic attack (TIA) or 'ministroke' is caused by a temporary disruption in
the blood supply to part of the brain. The
disruption in blood supply results in a lack of
oxygen to the brain. This can cause
symptoms similar to those of a stroke, such
as speech and visual disturbance and
numbness or weakness in the arms and legs.
However, unlike a stroke, the effects only last
for a few minutes and are usually fully
resolved within 24 hours.
During 2012/13 the stroke services saw an
increase in their activity; they admitted 1110
patients to the hyper acute ward which is an
increase of 48% on 2011/12. In addition 573
patients were seen in the TIA clinic.
In the 2012 report we identified “stretch”
targets against nine indicators for stroke and
TIA that we would monitor and aim to
improve on throughout the year. The
performance against these indicators is set
out in the table below.
Indicator
% of direct admission to
acute stroke unit within
4hrs
11/12
12/13
Target
12/13
90%
72%
90%
% patients receiving a
swallow screen < 4
hours of arrival or onset
11/12
12/13
Target
12/13
56%
49%
90%
62%
89%
80%
31%
45%
50%
76%
80%
90%
%of patients receiving a
swallow screen < 4
New
95%
95%
hours of referral to
stroke team
% of patients receiving
an OT assessment < 72
72%
89%
95%
hours
% of patients
discharged under the
35%
36%
40%
early supported
discharge team
% high risk TIA patients
st
treated < 24 hours of 1
59%
75%
60%
contact
% high risk TIA patients
treated < 24 hours of
70%
83%
95%
referral
Source; Trust data, April 2013
From the table it is evident that the Trust did
not meet all the “stretch” targets set; however
on some of the indicators our aspirations
were too ambitious. For instance on the
thrombolysis rate: the Stroke Improvement
National Audit Programme (SINAP) shows
that nationally 48% of eligible patients are
thrombolysed within 60 minutes of arrival and
our performance is comparable at 49%. The
latest stroke guidance from the Royal College
of Physicians (RCP) only provides target
times based around thrombolysis within 4.5
hours of known onset. Our performance
against this guidance is 100%.
The 40% Early Supported Discharge (ESD)
target was set by the Accelerated Stroke
Improvement Metrics from the stroke network
as it is expected that around 40% of people
who have a stroke would be eligible to be
discharged with ESD.
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 37 of 55
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To improve our stroke and TIA services we:
registered with the Sentinel Stroke
National Audit Programme and have been
submitting information to this national
database since January 2013. This will
enable us to compare our performance
with other providers.
introduced a ‘emergency stroke call’
system which has resulted in improved
thrombolysis door to needle times
introduced seven day consultant cover on
the acute stroke unit in June 2012
introduced an out of hours service for
high-risk TIA referrals which has resulted
in an improved service for seeing and
treating patients within 24 hours of their
1st contact with a healthcare professional
reviewed our acute stroke, thrombolysis
and TIA pathways which are currently out
for consultation and agreed the pathways
will be launched along with training for all
staff affected.
continued to undertake root cause
analysis for patients who did not receive
thrombolysis within the agreed
timeframes
started to participate in three new
research trials and are aiming to open a
further three trials in the near future.
Vascular (Abdominal Aortic Aneurysm)
were reviewed during quarter one 2012/13
and therefore they vary from those included
in the 2012 quality report.
The table below sets out the baseline
performance data collected against the nine
indicators:
Vascular Services Performance Indicators
2012
/13
32
70
0
7
7
2.5
47
Emergency AAA procedures performed
Elective AAA procedures performed
30 day mortality for elective AAA
30 day mortality for emergency AAA
Median length of stay elective open AAA
Median length of stay elective EVAR AAA
Open repair for AAA
% of carotid endartectomy (CEA)
100
performed < 2 weeks of symptomatic onset
% of CEA performed < 2 weeks of referral
100
to surgery
Source; Trust data, April 2013
In year we improved the vascular services by:
additional recruitment of 1.6 WTE
vascular specialist nurses; this enabled
the expansion of nurse led clinics and
nurse led ultrasonography of aneurysms.
introduction of telephone follow up for all
patients who underwent an aneurysm
repairs
formal development of a multi-disciplinary
team
pre operation assessment of patients who
are due an amputation surgery to
enhance effectiveness and patient
experience
expansion of our diabetic foot service to
provide vascular cover for Royal Surrey
County Hospital
An abdominal aortic aneurysm (AAA) is a
bulge in the largest blood vessel in the body
caused by a weakness in the blood vessel
wall. As blood passes through the weakened
blood vessel, the blood pressure causes it to
bulge outwards like a balloon.
Acute Myocardial Infarction
The vascular team also saw an increase in
activity. They undertook 102 AAA procedures
and 47 open repair AAA procedures during
2012/13.
Myocardial Infarction (MI) is commonly known
as a heart attack and it happens when a part
of the heart muscle suddenly loses its blood
supply usually due to a blood clot.
As part of the 2012 Quality Report nine
indicators were identified for baseline data
collection to enable improvement targets in
years ahead. Please note that the indicators
The cardiology services at the Trust have
seen a significant increase in activity over the
last year. We treated 3271 people in our
catheterisation laboratories, an increase of
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 38 of 55
3
8% from 2011/12, and 1037 people were
supported in our cardiac step down ward.
Alongside this increased activity we
undertook further upgrade work on the
environment, which has enabled us to move
the cardiac step down ward to the same area
as the catheterisation laboratories,
interventional suite, coronary care unit and
cardiology outpatient clinics.
In last year’s report we selected “stretch”
target for five indicators that we would
monitor and aim to improve performance
against during the year. Performance is
shown in the graph below.
Trauma Services
Trauma services look after patients who have
serious and complex injuries that could
potentially result in death or serious disability.
In line with the cardiology service our
emergency department also saw a significant
increase in activity especially over the winter
period. In total we saw 104,240 patients in
the department. 2012/13 was a challenging
year for the department as significant building
works took place to complete the new
department, enable area moves and
upgrades; we also had to get used to working
in the new environment.
The performance against service standards is
a continuous process and we have been
collecting data on specific trauma service
indicators via the national Trauma Audit and
Research Network (TARN). Over the years
we have built a good profile for TARN
participation (see table below) and the latest
annual data (2011/12) shows an additional
1.3 survivors for every 100 patients (TARN,
April 2013). The table sets out performance
of providers in South West Thames.
Source: Trust data. April 2013
Some of the improvements made to the
service during 2012/13 are that we:
•
•
•
•
•
•
•
employed a heart failure consultant
introduced the ‘consultant of the week’ to
enhance the quality of services provided
as all patients are seen by a consultant
Monday to Friday as well as any new
patients reviewed at the weekend.
expanded the cardiac CT scan services
appointed two new consultants; one
specialised in cardiac intervention and the
other specialised in heart failure
increased outpatient services and clinics
established a cardiac electrophysiology
service which provides comprehensive
care for patients with abnormal heart
rhythms
commenced cardiac research studies and
registries
Source; TARN website, April 2013
In 2012/13 we specifically monitored
performance against four indicators;
Source; Trust data, April 2013
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 39 of 55
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We improved our trauma services by:
opening the newly built emergency
department, which has 25 separate
rooms. The improved environment
enables the Trust to care for seriously
injured patients in one of the biggest
resuscitation areas in Europe and it
enables us to receive patients via air
ambulance directly into the resuscitation
area
increasing and restructuring the staffing
establishment
employing a paediatric nurse practitioner
asking over 100 attendees each month
about their experience in the emergency
department.
Dementia
Dementia is a syndrome (a group of related
symptoms) that is associated with an ongoing
decline of the brain and its abilities.
The Trust has undertaken significant work
over the years to improve the services for
people with a diagnosis of dementia and in
2012/13 the DH as part of the national acute
services contract mandated providers to
collect data against the three following
indicators:
1. % of all patients aged 75 and over who
have been screened following admission
to hospital, using the dementia screening
question
2. % of all patients aged 75 and over who
have been screened as at risk of
dementia and who have had a dementia
risk assessment within 72 hours of
admission to hospital, using the hospital
dementia risk assessment tool
3. % of all patients aged 75 and over,
identified as at risk of having dementia,
who are referred for specialist diagnosis
minimum compliance of 90% against each of
the indicators for three consecutive months.
We used the first part of the year to set up a
data collection system and started collecting
data during October 2012. Over the course of
the following months we increased the
compliance percentage and since December
2012 we have been collecting 100% of the
required data for each of the three indicators.
To improve our services we:
continued to use the ‘butterfly scheme’
and the ‘this is me’ booklet.
appointed a dementia nurse specialist
introduced dementia champions for all
disciplines throughout the Trust; for
example a porter who is a dementia
champion has developed guidance for
other porters to assist them when
accompanying people with dementia
included dementia awareness training as
part of our mandatory training for all
registered and un-registered staff
incorporated dementia friendly design
principles such as improved signage
throughout the Trust. and ensured that
the new emergency department has an
area specifically designed to reduce
stress amongst people with dementia
introduced reminiscence folders that
include activity cards and pictures
trained volunteers to enable them to
assist people with dementia at meal times
developed an intranet site for dementia
which includes leaflets, on-line training,
information
ensured patient carer representatives are
actively involved in the development of
our processes
signed up to the Surrey Carers Strategy
and are part of the Surrey wide Carers
and NHS providers network
Under the DH CQUIN scheme we were
required to provide data for at least three
consecutive months and to achieve a
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 40 of 55
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Patient Experience
The fundamental purpose of any hospital is
treating the clinical condition of patients.
However, excellent care is about much more
than that. The experience of our patients is of
equal importance to their health outcomes
and is central to our mission to provide high
quality care which is the main rationale for the
work we do. The Trust has been utilising a
combination of qualitative (subjective/opinion)
and quantative (objective/factual) patient
feedback/intelligence over the years.
Examples are patient questionnaires, patient
interviews, complaints and compliments as
well as national surveys and patients & carer
experience events. We use hand held
devices in inpatient areas to enable ‘real time’
feedback which we aim to roll out to other
areas such as Outpatient clinics.
Quality of Care & recommend the Trust
Source; Trust data, April 2013
The 2012 national staff survey showed that "If
a friend or relative needed treatment, 85% of
our staff would be happy with the standard of
care provided by us" against a national trust
average of 55% (NHS Staff Survey, 2012).
In the questionnaire we also ask inpatients
how they would rate their care: the graphs
below provide a breakdown of the response
received by answer category.
The Trust has been collecting ‘real time’ data
for more than three years and we do this on a
continuous basis. During this year we
collected feedback from nearly 8000 patients
by using the patient experience survey
system. The feedback was collected from:
5995 inpatients and 171 military
inpatients
325 outpatients
661emergency department attendees
545 maternity service users
153 cancer service users
76 children using paediatric services
Source; Trust data, April 2013
The surveys are tailored to the relevant area
and they are monitored by the departments
and the Board.
One of the satisfaction questions that we
monitor is ‘the percentage of patients who
would recommend our services to family and
friends’. The graph below provides a
breakdown of responses received from
inpatients against each answer category.
The Trust commissions the Picker Institute to
undertake the national surveys on our behalf
as 75 other trusts do. The national inpatient
and Accident & Emergency (A&E) survey
2012 both asked patients to rate their care
from 0 (very poor) to 10 (very good). Our
2012 results show that 28% of inpatients and
23% of A&E attendees had a very good
experience (i.e. scored a 10) and that 83% of
inpatients and 77% of A&E attendees would
rate their care as a seven or above and that
fortunately only 0.4% of inpatients and zero
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 41 of 55
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A&E attendees rated their care as very poor
(Picker Institute, 2013).
Collection of ‘real time’ feedback
In our report last year we set out that we
would encourage ward areas to collect a
minimum of 20 surveys each month. Due to
ward closures, ward moves and the opening
of escalation wards it is difficult to present the
results for each ward area; however overall
each ward area has been collecting inpatient
feedback by using the Trust questionnaire
equating to 5995 completed questionnaires.
Complaints
In 2011/12 our aim was to monitor the
formally written complaints against activity
and not to exceed a rate of 0.07% as well as
implementing zero-tolerance on substantiated
complaints of staff ‘attitude’.
In 2012/13 we received a total of 431 formally
written complaints to the Trust which was 62
more than 2011/12. 30% (133/431) had an
element of communication concerns and out
of these 57 had an element of staff ‘attitude’.
The number of complaints number as a ratio
of activity is 0.06%, which is within the target
that we set of 0.07%.
Every written complaint received that
included a reference to negative ‘staff
perspective’ was reviewed in line with the
NHS complaints process and the relevant
manager was asked to investigate the
specific references made about their staff and
to take appropriate action. In total 57
complaints went through this process and in
all cases the manager investigated if the
concerns raised were substantive and
appropriate actions were taken.
The Trust undertook a mid-year themed
review of all complaints received with a
reference to communication concerns. The
review outcomes were discussed at the Trust
complaints forum. No specific area or staff
group could be identified from the review
however as part of the wider customer
service and patient experience improvement
work we are exploring a training schedule
that is focussed on this.
We have also started to log the thank you
letters received centrally and for 2012/13 we
logged 383 compliments.
Please also see page 30 of the Trust Annual
Report.
Privacy and Dignity
In line with national guidance the Trust aims
to provide same sex accommodation and
bathroom facilities for all inpatient services.
This means that patients should not be cared
for in a bay with members of the opposite sex
nor should they have to pass through an area
with members of the opposite sex to reach
bathroom facilities.
Patients who completed the national inpatient
survey scored as 8.3 out of 10 and those that
completed the national A&E survey scored as
8.6 out of 10 for the provision of privacy when
discussing their condition or treatment. The
question “did you feel you were treated with
dignity and respect” received a score of 9.1
out of 10 for the inpatient survey and 8.8 out
of 10 for the A&E survey (CQC website,
2013). These scores are replicated by the
scores received from the local inpatient
survey where 91% of inpatients said they
“definitely received enough privacy when
discussing their condition” and 96% of
inpatients said that “ward staff always treat
them with dignity and respect”.
To improve privacy and dignity further we:
•
continued with our estate improvement
work by upgrading more wards from 6 to
4 bedded bays and including bathroom
facilities within the bay and also upgraded
the endoscopy department facilities
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 42 of 55
3
•
•
•
opened our new emergency department
and day surgical unit both providing care
in individual cubicles.
undertook privacy and dignity
observational visits jointly with the Frimley
Local Involvement Network
undertook monthly senior nurse reviews
of inpatient ward areas which included a
focus on privacy and dignity
Patient Environment Action Team
The Patient Environment Action Team
(PEAT) self-assessment process is a valued
framework which enables the Trust to
demonstrate how well we are performing in
key areas such as food, cleanliness, infection
control and patient environment.
We set out to maintain our 2011/12
performance of 92%; our PEAT average
score is 92%.
ensure patients have privacy when
discussing their condition or treatment
Our CQUIN target was as a minimum to
sustain our 2011 composite score (average of
all scores) of 68.9 and the Trust’s overall aim
was to improve the 2011 score to 69.9. We
achieved our aim as our 2012 composite
score is 70.1.
Inpatient Survey
Composite Score
2010
2011
2012
68.6
68.9
70.1
Source, CQC, February 2013
As of April 2013 PEAT will be replaced by a
new programme called Patient-Led
Assessments of the Care (PLACE); for further
information please refer to the NHS
information website.
National patient experience CQUIN
scheme
The Department of Health has for the third
year included a patient experience CQUIN
scheme in the contract for acute services. As
in previous years the scheme focussed on
the performance of five questions in the
national inpatient survey, which is undertaken
annually, and improvement of the composite
score, which is the score that results from
averaging the five individual scores. The
questions are:
involve patients in decision making about
their care
ensure patients have someone to talk to
when worried
ensure medication side effects are
explained before discharge
ensure patients know who to contact if
worried about their condition after
discharge
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 43 of 55
3
Performance of Frimley Park Hospital against selected metrics from Monitor
Monitor is the independent regulator of NHS foundation trusts. As part of their work Monitor set the
Trust guidance on some of the reporting requirements in this report. These requirements are partly
set out in the table below:
Monitor
Threshold
FPH
Clostridium Difficile – meeting the Clostridium Difficile objective
14
16

MRSA - meeting the MRSA objective
1
1

All cancers: 31-day wait for second or subsequent treatment
comprising either:
– Surgery
– Anti cancer drug treatments
– Radiotherapy
94%
98%
94%
99.6%
100%
n/a


All cancers: 62-day wait for first treatment, comprising either:
– From urgent GP referral to treatment
– From consultant screening service referral
85%
90%
89.6%
97.1%


Referral to treatment waiting times - % within 18 weeks
- admitted
- non-admitted
- Incomplete pathways
90%
95%
92%
93.1%
97.7%
95.4%
All cancers: 31-day wait from diagnosis to first treatment
96%
99.3%




93%
93%
95.3%
96.2%


95%
95.48%

Compliant

Indicator
Cancer: two week wait from referral to date first seen,
comprising either:
– All cancers
– For symptomatic breast patients (cancer not initially
suspected)
A&E -maximum waiting time of four hours from arrival to
admission/ transfer/ discharge
Stroke Indicator
-
TBC
Certification against compliance with requirements regarding
access to healthcare for people with a learning disability
healthcare for people with a learning disability
NA
Frimley Park Hospital Foundation Trust I 2013 Quality Report I Page 44 of 55
ANNEX
ANNEX I Statements from Council of Governors, OSC and Commissioners
Statement from Surrey Overview and Scrutiny Committee (based on version 2b)
The Health Scrutiny Committee is pleased to be offered the opportunity to comment on Frimley
Park Hospital NHS Foundation Trust Quality Account for 2012/13. The Trust is thanked for its
working with the Health Scrutiny Committee over the last year on the key issue of dementia
services in the acute setting. The Committee endorses the Trust's identified priorities for 2013/14
with the following comments:
The Trust is congratulated on being awarded the runner-up award for hospital of the year by the Dr
Foster hospital guide.
Priority 1 – Patient Safety
The Trust is commended for continuing to look for ways to improve its already excellent patient
safety standards.
Priority 2 – Clinical Outcomes
The Trust is commended for continuing to drive forward key clinical improvements. The
Committee is especially pleased to see a focus on stroke and TIA care.
Priority 3 – Patient Experience
The Trust is commended for continuing to seek patient feedback and to use this in improving
its services. The Committee is especially pleased to see a focus on the care experience for
patients with dementia and their carers or family.
The Committee looks forward to working with the Trust over the next year to monitor all of the
2013/14 priorities via the new Quality Account Member Reference Groups to be set up in June
2013.
Leah O'Donovan
Scrutiny Officer
Adult Social Care Select Committee and Health Scrutiny Committee
Surrey County Council
Statement from Patient Experience and Involvement group (PEIG) on behalf of
Council of Governors (based on version 2b)
A sub-group of the PEIG have reviewed the Quality Report 2013 draft version 2b. As a sub-group
of the Council of Governors (CoG) the PEIG comprises publicly elected Governors, Staff
Governors, Stakeholder Governors and co-opted members with relevant patient expertise and
experience. As such the group is in an ideal position to monitor the quality of service at FPH.
The PEIG have sought to evaluate on-going quality at FPH throughout the year focusing on two
key areas namely:
- is the patient experience excellent in all aspects from pre-admission through to
discharge
- are the procedures and practices geared to ensuring the safety and wellbeing of the
patients?
The PEIG have been assured that quality standards underpin the performance at FPH and that in
addition national standards have been adhered to by FPH. Additionally PEIG members have
worked closely with the Care Quality Commission (CQC) Engagement Project to ensure quality
standards remain at the forefront of FPH thinking and activities.
The sub-group of the PEIG feel that the Report accurately defines the quality standards, the
targets, the achievements and the hospital’s determination to continue to strive for on-going
improvements. Indeed the award by Dr Foster to FPH as runner up for” hospital of the year “is
strong evidence that the quality approach to service provision at FPH is paying dividends.
Other highly commendable achievements include being independently rated as one of the five best
hospitals for quality in the Country based on patient needs and focus. At a more detailed level the
PEIG is kept well briefed and aware of all quality targets and performance against them. The group
is involved in the review of quality priorities and feel that quality issues are taken very seriously by
FPH staff.
Along with other Governors PEIG members are involved in Quality Assurance Walkabouts where
we see first-hand how the ward managers, the nurses and the patients interact. Such close
involvement enables Governors to really get a “feel” as to how FPH is operating and enables the
highlighting of areas requiring attention or improvement.
The achievement against specific targets that the Report contains is best viewed from the
perspective of annual trends. It is very gratifying to note that there has been on-going and excellent
progress in the reduction of cases of MRSA and C Diff despite very challenging targets. The
historical achievements over 6 years show that MRSA cases have been reduced by 95% and C
Diff by 96%, a regional and nationally enviable achievement.
Despite the vast improvement in TIA and stoke there is a need to focus on timing of admission as
well as administration of thrombolysis. Similarly, timings for trauma patients for head injury scans
and laparotomies require extra activity to improve service.
Additionally hospital acquired pressure ulcers continue to come under scrutiny with success in
reducing Grade 4 ulcers but more work is required in reducing Grade 2 and 3 ulcers. A slight rise
in Grade 3 ulcers is noted from 2011/12.
There has been a rise in written complaints received during 2012/13, with communication the main
area of concern; however the actual number of complaints when reviewed against activity is within
the target at 0.06%. This is an area that PEIG will be monitoring closely during 2013.
The group is pleased to note that in line with national concerns specific action is being taken in the
improvement of services for patients with dementia. The PEIG particularly commends the
continued use of the “butterfly scheme” and the “this is me “booklet approaches.
In conclusion the group is satisfied that the Report is a true statement of quality matters at FPH
where strong evidence suggests that Managers and Staff alike are not complacent in quality
matters and take quality issues very seriously to excellent effect.
Nicky Dodsworth
Lead Governor
Statement from North East Hampshire & Farnham Clinical Commissioning Group
(based on version 2b)
North East Hampshire and Farnham (NEHF) Surrey Heath (SH) and Bracknell and Ascot (BaA)
Clinical Commissioning Groups have reviewed Frimley Park Hospital NHS Foundation Trust’s
Quality Account. The Quality Account provides information across a wide range of quality
measures and gives an overview of the quality of care provided by the Trust. There is evidence
that the Trust has relied on both internal and external assurance mechanisms. The Clinical
Commissioning Groups (CCG’s) are satisfied as to the accuracy of the data contained in the
Account. The CCGs acknowledge the inspections by the CQC and that the Trust is meeting all the
essential service standards.
The CCG’s continue to work with Frimley Park Hospital NHS Foundation Trust (FPHFT) in a
number of forums to deliver high quality services for their patients for example the Transformation
Board.
Through the monthly Clinical Quality Review Group meetings, the CCG’s, and the Trust have
worked closely together, focussing particularly on maternity, stroke, A&E, Venous
Thromboembolism and Hospital Acquired infections. There has been improvement in the Venous
Thromboembolism risk assessments. Progress in all areas will continue to be monitored during
2013/14.
Within the report the Trust identifies their achievements to date, and also areas within their service
delivery that require further improvement. The CCG’s will support the Trust in achieving
improvement in the areas identified within the Quality Account through existing contract
mechanisms and collaborative working.
Throughout 2012/13 there have been a number of serious incidents reported relating to pressure
ulcers and patient falls resulting in serious harm. The CCG’s are pleased to note that these areas
are priorities for continued focus by the Trust with a strong commitment to continually improve
patient safety across the healthcare system. In addition the CCG’s note the on-going commitment
to monitoring patient harm through the NHS Safety Thermometer and the aim to reduce pressure
ulcer prevalence during 2013/14. The Trust has demonstrated a reduction in the average falls rate
per bed days and has also achieved a reduction in serious pressure ulcers.
In July 2012 the Trust declared one case of hospital acquired MRSA bacteraemia and the CCGs
note the Trust’s efforts to ensure no further incidents occurred during the year and therefore did not
breach the threshold. The Trust worked hard towards achieving the C Difficile target of 14 for
2012/13. However it has been noted that the organisation breeched the target by two cases. The
CCG’s are aware of the challenge that the Trust faces during 2013/14 with a significantly reduced
target of 8 cases and are committed to joint working on this.
The Trust achieved the national patient experience CQUIN for 2012/13 achieving a composite
score of 70.1. This was an increase of 1.2 on the previous year. In addition Frimley have been
working towards collecting data on patient experience and asking if patients would recommend the
Trusts to friends and family. This will be a CQUIN for 2013/14 and will include all in-patient areas
including maternity and A&E.
The 2013/14 Quality Account priorities are consistent in reducing preventable harm, improving
clinical outcomes and improving the experience of patients accessing these services. This aligns
with the strong focus on quality by all the commissioning CCG’s.
This Quality Account provides a comprehensive overview of the quality of care within the Trust and
the CCG’s look forward to continuing to work alongside the Trust in meeting the quality aspirations
of patients, carers, members of the public, stakeholders, partners and staff.
Annex II Statement of Director’s Responsibilities in Respect of the Quality Report
The Directors are required under the Health Act 2009 and the National Health Service Quality Accounts
Report Regulations to prepare Quality Accounts for each financial year.
Monitor has issued guidance to NHS foundation trust boards on the form and content of annual quality
reports (which incorporate the above legal requirements) and on the arrangements that foundation trust
boards should put in place to support the data quality for the preparation of the quality report.
In preparing the quality report, directors are required to take steps to satisfy themselves that:
the content of the quality report meets the requirements set out in the NHS Foundation Trust Annual
Reporting Manual;
the content of the Quality Report is not inconsistent with internal and external sources of information
including:
o Board minutes for the period April 2012 to April 2013 (the period);
o Papers relating to Quality reported to the Board from April 2012 to March 2013;
o Feedback from the Surrey Heath Clinical Commissioning Group dated 15/05/2013;
o Feedback from the Patient Experience and Involvement Group dated 2012/13 and signed off by the
Council of Governors on 07/05/2013;
o Feedback from the Health Scrutiny Committee for 2012/13 dated 23/04/2013;
o The Trust’s latest complaints report published under regulation 18 of the Local Authority Social
Services and NHS Complaints Regulations 2009, dated September 2012;
o The latest national patient survey, covering 2012/13 , published by the CQC on 16/04/2013;
o The latest national staff survey, covering 2012/13 dated 28/02/2013;
o Care Quality Commission quality and risk profiles dated 31/03/2013; and
o The Head of Internal Audit’s annual opinion over the Trust’s control environment presented to the
Audit Committee on 21 May 2013.
the Quality Report presents a balanced picture of the NHS foundation trust’s performance over the
period covered;
the performance information reported in the Quality Report is reliable and accurate;
there are proper internal controls over the collection and reporting of the measures of performance
included in the Quality Report, and these controls are subject to review to confirm that they are working
effectively in practice;
the data underpinning the measures of performance reported in the Quality Report is robust and reliable,
conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny
and review; and the Quality Report has been prepared in accordance with Monitors annual reporting
guidance (which incorporates the Quality Accounts regulations) (published at www.monitornhsft.gov.uk/annualreportingmanual) as well as the standards to support data quality for the preparation
of the Quality Report (available at www.monitor-nhsft.gov.uk/annualreportingmanual).
The directors confirm to the best of their knowledge and belief they have complied with the above
requirements in preparing the Quality Report.
By order of the Board
Sir Mike Aaronson
Chairman
23 May 2013
Andrew Morris
Chief Executive
Annex III GLOSSARY
Abbreviation
Abbreviation

Target achieved

HSMR
Hospital Standardised Mortality
Ratio
Significant improvement against
target or close to target
achievement
ICD
Implantable CardioverterDefibrillator

Target not achieved
MI
Myocardial Infarction

Good performance
MINAP
Myocardial Ischaemia National
Audit Project

Decreased performance
MRSA
Methicillin Resistant
Staphylococcus Aureus
AAA
Abdominal Aortic Aneurysm
NHS
National Health Service
A&E
Accident and Emergency
ACS
Acute Coronary Syndrome
NICE
National Institute of Health and
Clinical Excellence
ASU
Acute Stroke Unit
NPSA
National Patient Safety Agency
C. Diff
Clostridium Difficile
PE
Pulmonary Embolism
CAUTI
Catheter Associated Urinary
Tract Infection
PCI
Percutaneous Coronary
Intervention
A provider of healthcare
intelligence and quality
improvement services
PCT
Primary Care Trust
CHKS
PEAT
Patient Environment Action
Team
PROMs
Patient Reported Outcome
Measures
RAMI
Risk Adjusted Mortality Index
RCA
Root Cause Analysis
Qtr
Quarter
SHA
Strategic Health Authority
SHMI
Standardised Hospital Mortality
Index
SIRI
Serious Incident Requiring
Investigation
STEMI
ST-Elevation Myocardial
Infarction
TARN
Trauma Audit and Research
Network
VAP
Ventilator Associated Pneumonia
VSQIF
Vascular Society Quality
Improvement Framework
VTE
Venous Thromboembolism
COPD
Chronic Obstructive Pulmonary
Disease
CQC
Care Quality Commission
CQUIN
Commissioning for Quality and
Innovation –incentive scheme
CT-scan
Computerized Axial Tomography
- scan
CVC
Central Venous Catheter
DH
Department of Health
DSU
Day Surgical Unit
Ecoli
Escherichia coli
ED
Emergency Department
ERP
Enhanced Recovery Pathway
FPH
Frimley Park Hospital NHS
Foundation Trust
GTT
Global Trigger Tool
HA
Hospital Acquired
HPA
Health Protection Agency
Annex IV External Audit Data Quality Standards
DATA QUALITY DEFINITIONS
The following information includes the definitions of the quality indicators which were subject to the
external assurance process.
Clostridium Difficile (C. Difficile)
Descriptor: number of Clostridium Difficile infections (see definition) for patients aged 2 or more on
the date the specimen was taken
Data definition: A C. Difficile is defined as a case where the patient shows clinical symptoms of C.
Difficile infection and using the local Trust C. Difficile infections diagnostic algorithm (in line with
DH guidance) is assessed as a positive case. Positive diagnosis on the same patient more than 28
days apart should be reported as separate infections, irrespective of the number of specimens
taken in the intervening period, or where they were taken.
Accountability: acute provider trusts are accountable for all C. Difficile infection cases for which the
trust is deemed responsible. This is defined as a case where the sample was taken on the fourth
day or later of an admission to that trust (where the day of admission is day one).
To illustrate:
• admission day
• admission day + 1
• admission day + 2
• admission day +3 – specimens taken on this day or later are trust appointed
Frimley Park Hospital NHS FT declare all positive tests to the Health Protection Agency who
apportion the case based on their own algorithm, on the basis that results after a hospital stay of
48 hours are likely to be hospital acquired. There have been 16 cases in the current year.
Maximum waiting time of 62 days from urgent GP referral to first treatment for all cancers
Maximum waiting time of 62 days from urgent GP referral to first treatment for all cancers
Descriptor: percentage of patients receiving first definitive treatment for cancer within 62 days
following an urgent GP referral for suspected cancer within a given period for all cancers
Data definition: All cancer two month urgent referral to treatment wait
Denominator: total number of patients receiving first definitive treatment for cancer following an
urgent GP referral for suspected cancer with a given period for all cancers
Numerator: number of patients receiving first definitive treatment for cancer within 62 days
following an urgent GP referral for suspected cancer within a given period for all cancers
About the 62 day pathway
The audit focused on those patients referred urgently by their GP to the Trust with suspected
cancer should be seen, diagnosed and treated within 62 days.
Starting the 62 Day pathway:
The starting point for this period is the receipt of the referral. The original referral can be received
either:
• direct from the General Medical Practitioner/General Dental Practitioner
• via Choose and Book
Receipt of referral is day 0 for the 62 day period.
Ending the 62 Day pathway:
The period end is the first definitive treatment. This start date may differ slightly for different
treatments. The percentage of patients treated within 62 days for 2012/13 was 89.26%
Patient Safety Incidents Reported
Indicator description: patient safety incidents reported to the National Reporting and Learning
Service (NRLS)
Indicator construction: the number of patient safety incidents reported to the National Reporting
and Learning Service (NRLS)
Indicator format: whole number
Safety Incidents Involving Severe Harm or Death
Description: patient safety incidents reported to the National Reporting and Learning Service
(NRLS) where degree of harm is recorded as “severe harm” or “death” as a percentage of all
patient safety incidents reported
Numerator: the number of patient safety incidents recorded as causing severe harm/death as
described as above
The “degree of harm” for patient safety incidents is defined as follows:
• Severe – the patient has been permanently harmed as a result of the patient safety incident
• Death – the patient safety incident has resulted in the death of the patient
Denominator: the number of patient safety incidents reported to the National Reporting and
Learning Service (NRLS)
Indicator format: standard percentage
For the period 2012/13 Frimley Park Hospital NHS Foundation Trust reported a total of 5006
incidents. Of these 10 were reported as severe harm or death, which is 0.2%.
Annex V Limited Assurance Report
Independent Auditor’s Limited Assurance Report to the Council of Governors of
Frimley Park Hospital NHS Foundation Trust on the Annual Quality Report
We have been engaged by the Council of Governors of Frimley Park Hospital NHS Foundation
Trust to perform an independent assurance engagement in respect of Frimley Park Hospital NHS
Foundation Trust’s Quality Report for the year ended 31 March 2013 (the ‘Quality Report’) and
specified performance indicators contained therein.
Scope and subject matter
The indicators for the year ended 31 March 2013 in the Quality Report that have been subject to
limited assurance consist of the following national priority indicators as mandated by Monitor:
1. Number of Clostridium difficile infections; and
2. Maximum cancer waiting time of 62 days from urgent GP referral to first treatment for all
cancers
We refer to these national priority indicators collectively as the “specified indicators”.
Respective responsibilities of the Directors and auditors
The Directors are responsible for the content and the preparation of the Quality Report in
accordance with the assessment criteria referred to in on page 52 and following of the Quality
Report (the "Criteria"). The Directors are also responsible for the conformity of their Criteria with
the assessment criteria set out in the NHS Foundation Trust Annual Reporting Manual (“FT ARM”)
issued by the Independent Regulator of NHS Foundation Trusts (“Monitor”).
Our responsibility is to form a conclusion, based on limited assurance procedures, on whether
anything has come to our attention that causes us to believe that:
The Quality Report does not incorporate the matters required to be reported on as
specified in Annex 2 to Chapter 7 of the FT ARM;
The Quality Report is not consistent in all material respects with the sources specified
below; and
The specified indicators have not been prepared in all material respects in accordance with
the Criteria.
We read the Quality Report and consider whether it addresses the content requirements of the FT
ARM, and consider the implications for our report if we become aware of any material omissions.
We read the other information contained in the Quality Report and consider whether it is materially
inconsistent with the following documents:
Board minutes for the period April 2012 to April2013 (the period);
Papers relating to Quality reported to the Board from April 2012 to March 2013;
Feedback from the Surrey Heath Clinical Commissioning Group dated 15/05/2013;
Feedback from the Patient Experience and Involvement Group dated 2012/13 and signed
off by the Council of Governors on 07/05/2013;
Feedback from the Health Scrutiny Committee for 2012/13 dated 23/04/2013;
The Trust’s latest complaints report titled Compliments, Concerns and Complaints dated
September 2012;
The latest national patient survey, covering 2012/13 , published by the CQC on 16/04/2013;
The latest national staff survey, covering 2012/13 dated 28/02/2013;
Care Quality Commission quality and risk profiles dated 31/03/2013; and
The Head of Internal Audit’s annual opinion over the Trust’s control environment presented
to the Audit Committee on 21 May 2013.
We consider the implications for our report if we become aware of any apparent misstatements or
material inconsistencies with those documents (collectively, the “documents”). Our responsibilities
do not extend to any other information.
We are in compliance with the applicable independence and competency requirements of the
Institute of Chartered Accountants in England and Wales (ICAEW) Code of Ethics. Our team
comprised assurance practitioners and relevant subject matter experts.
This report, including the conclusion, has been prepared solely for the Council of Governors of
Frimley Park Hospital NHS Foundation Trust as a body, to assist the Council of Governors in
reporting Frimley Park Hospital NHS Foundation Trust’s quality agenda, performance and
activities. We permit the disclosure of this report within the Annual Report for the year ended 31
March 2013, to enable the Council of Governors to demonstrate they have discharged their
governance responsibilities by commissioning an independent assurance report in connection with
the indicators. To the fullest extent permitted by law, we do not accept or assume responsibility to
anyone other than the Council of Governors as a body and Frimley Park Hospital NHS Foundation
Trust for our work or this report save where terms are expressly agreed and with our prior consent
in writing.
Assurance work performed
We conducted this limited assurance engagement in accordance with International Standard on
Assurance Engagements 3000 ‘Assurance Engagements other than Audits or Reviews of
Historical Financial Information’ issued by the International Auditing and Assurance Standards
Board (‘ISAE 3000’). Our limited assurance procedures included:
Evaluating the design and implementation of the key processes and controls for managing
and reporting the indicators
Making enquiries of management
Limited testing, on a selective basis, of the data used to calculate the specified indicators
back to supporting documentation.
Comparing the content requirements of the FT ARM to the categories reported in the
Quality Report.
Reading the documents.
A limited assurance engagement is less in scope than a reasonable assurance engagement. The
nature, timing and extent of procedures for gathering sufficient appropriate evidence are
deliberately limited relative to a reasonable assurance engagement.
Limitations
Non-financial performance information is subject to more inherent limitations than financial
information, given the characteristics of the subject matter and the methods used for determining
such information.
The absence of a significant body of established practice on which to draw allows for the selection
of different but acceptable measurement techniques which can result in materially different
measurements and can impact comparability. The precision of different measurement techniques
may also vary. Furthermore, the nature and methods used to determine such information, as well
as the measurement criteria and the precision thereof, may change over time. It is important to
read the Quality Report in the context of the assessment criteria set out in the FT ARM and the
Directors’ interpretation of the Criteria in Annex IV of the Quality Report.
The nature, form and content required of Quality Reports are determined by Monitor. This may
result in the omission of information relevant to other users, for example for the purpose of
comparing the results of different NHS Foundation Trusts.
In addition, the scope of our assurance work has not included governance over quality or nonmandated indicators in the Quality Report, which have been determined locally by Frimley Park
Hospital NHS Foundation Trust;
Conclusion
Based on the results of our procedures, nothing has come to our attention that causes us to
believe that for the year ended 31 March 2013,
The Quality Report does not incorporate the matters required to be reported on as specified
in annex 2 to Chapter 7 of the FT ARM;
The Quality Report is not consistent in all material respects with the documents specified
above; and
the specified indicators have not been prepared in all material respects in accordance with
the Criteria.
PricewaterhouseCoopers LLP
Chartered Accountants
London
24 May 2013
The maintenance and integrity of the Frimley Park Hospital NHS Foundation 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.