2014/2015
ANNUAL QUALITY REPORT
Contents
4 PART 1: Statement on quality from the chief executive of the Northern Lincolnshire and Goole NHS Foundation Trust 6 About Northern Lincolnshire and Goole NHS Foundation Trust 6 Executive summary of the key points from this year’s Quality Account
6
The Trust’s quality targets and priorities – driving continuous improvement
13 PART 2: Priorities for improvement, statements of assurance from the board and reporting against core indicators
13 2.1 Priorities for improvement: overview of the quality of care against 2013/14 quality priorities
15 2.1a Clinical effectiveness (CE)
16 CE1 – Mortality improvement – Summary Hospital Mortality Indicator (SHMI)
20 CE2 – National Early Warning Score (NEWS)
22 CE3 – Dementia
27 CE4 – National Institute for Health and Care Excellence (NICE) evidence-based practice
30 CE5 Transfer and discharge 35 2.1b Patient safety (PS)
2
91 2.2d Information on the Trust’s use of the CQUIN framework 2.2e Information on Never Events 2.2f Information relating to the Trust’s registration with the Care Quality Commission
2.2g Information on quality of data
92 2.2h Information governance assessment report 2.2i Information on payment by results clinical coding audit
2.3 93 2.3a: Summary Hospital-Level Mortality Indicator (SHMI) Trust performance against core indicators 100 2.3b: Patient Reported Outcome Measures (PROMS) 102 2.3c Readmissions to hospital 102 2.3d Personal needs of patients 104 2.3e Staff recommending Trust as a provider to friends and family 105 2.3f Risk assessed for venous thromboembolism
106 2.3g Clostridium difficile infection reported within the Trust
107 2.3h Patient safety incidents
109 2.3i
Ambulance handover times
111 Part 3:Other information
An overview of the quality of care based on performance in 2013/14 against indicators
The Trust’s quality targets & priorities – driving continuous improvement
36 PS1 MRSA bacteraemia incidence 37 PS2 C. difficile incidence 39 PS3 Safety Thermometer – increase in harm free care (community)
42 PS4 Increase in harm free care (acute) 51 PS5 Patient falls
52 PS6 Pressure ulcers
118 Annex 1: Statements from commissioners, local Healthwatch organisations and overview and scrutiny committees 54 PS7 Nutrition 58 PS8
119 Annex 1.2: Statement from HealthWatch organisations
Hydration
114 3.2 Performance against relevant indicators and performance thresholds 115 3.3 Information on staff survey report
116 3.4 Information on patient survey report
Annex 1.1: Statements from Commissioners 61 2.1c Patient experience (PE)
62 PE1 Friends and Family Test 121 Annex 1.3: Statement from local council overview and scrutiny committees (OSC)
68 PE2
122 Annex 1.4: Statement from the Trust governors’ 71 PE3 Complaints – action plans agreed within timescales
123 Annex 2: Statement of directors’ responsibilities in respect of the Quality Report
73 PE4 Complaints
74
PE5 Pain management
125 Annex 3: Independent auditor’s report to the Board of Governors on the Annual Quality Report 75 PE6 Staff satisfaction: culture change and the morale barometer 79 2.1d: Quality priorities for 2015/16 81 The Trust’s quality targets & priorities – driving continuous improvement
82 2.2 Statements of assurance from the Board
2.2a Information on the review of services 2.2b Information on participation in clinical audits and national confidential enquires
89 2.2c Information on participation in clinical research Complaints
Together
we care, we respect, we deliver
Statement on North Lincolnshire and Goole NHS Foundation Trust Quality Account for 2014/15
128 Annex 4: Glossary 131 Annex 5: Mandatory Performance Indicator Definitions
3
PART 1
Statement on quality from the chief executive of the Northern
Lincolnshire and Goole NHS Foundation Trust
Quality and safety are the overarching priority for Northern
Lincolnshire and Goole NHS Foundation Trust (also referred to as
‘the Trust’ throughout the remainder of this report). There can be no
compromises to this quest for continuous quality improvement.
In pursuit of this goal, during the
2014/15 financial year (comprising
April 2014 – March 2015) the Trust
has endeavoured to strengthen its
commitment to this as depicted by
our visions and values: ‘Together we
care, we respect and we deliver’.
I believe passionately that together
we can deliver safe, quality services
that put our patients, service users
and their carers first. It is heartwarming to hear of all the good
experiences where we achieved
our visions and values, through the
hard work and dedication of our
workforce.
In cases where we fall short of this
aspiration, the Trust Board and I
are keen to hear these experiences
too, so that we understand where
further work is needed and that we
can take action to ensure that the
same issues do not occur again. To
ensure we keep on hearing the good
experiences and opportunities for
improvement, at each one of our
Board meetings we hear from a
patient, service user or carer in their
own words, what we did well or what
we can do better. This is our quest
and this is our commitment to ensure
that we deliver what is at the very
core of our being here.
Within this Quality Account is the
detail behind our commitment
to focus on continuous quality
improvement. You will notice
that the first section relates to our
performance against our own,
internally set quality priorities.
4
Together
To aid our commitment to quality,
you will see that these are not targets
we have simply set ourselves that are
easy to ‘tick off’ as achieved but rather
these are designed to be stretching
and focused on areas where we know
we can do better – some even as a
result of direct patient or service user
feedback.
You will see from this that we have
not always achieved these targets,
and where this is the case we will
continue to strive for compliance –
committed to achieve and embed
quality practice.
You will see from this that we are
committed to quality in an open
and transparent manner, publishing
our self-assessment against these
priorities here, annually, but also
in our monthly quality report,
overseen and scrutinised firstly by
the Qualityand Patient Experience
Committee (QPEC) and then
presented to the Trust Board.
This monthly report is then a public
document available on our internet
site for all our local population to see
and have access to.
Sections two and three of this report
are mandated sections that all NHS
Foundation Trusts have to report
and here again you will see that our
performance with these national
indicators is reported openly and
honestly, with an explanation of
what we are doing in these areas to
continuously improve.
we care, we respect, we deliver
As a result of these processes and
assurance mechanisms, to the best
of my knowledge the information
contained in this document is
accurate.
Our focus on quality and safety
development has been supported
over the last two years with a number
of external scrutiny visits starting
with the visit of Sir Bruce Keogh’s
team, the Care Quality Commission
and Monitor, the Foundation Trust
regulator.
These reviews, though challenging
at the time, have helped us firm up
our plans for quality development
and to add pace to their delivery. As a
result of all this scrutiny, I am deeply
proud of all my colleagues that make
the Trust what it is. Instead of giving
up in the face of these pressures, the
organisation and all its staff have
risen to the challenges.
A key outcome of this is the Trust’s
Quality Development Plan (QDP)
which has become the central
place for all improvement plans to
be stored, monitored, audited and
updated.
While there are no compromises
to quality and safety development,
the Trust, among many other NHS
organisations, faces many challenges
ahead in relation to its financial
sustainability.
You will note from the Trust’s Annual
Report that our commitment to
quality development is delivered
in a complex and challenging
environment. Like other NHS Trust’s
we have faced unprecedented
demands on our services during the
winter and continuing into recent
months, affecting our ability to meet
A&E targets.
While other Trust’s in the region
declared major incidents, effectively
closing their doors to patients, the
Trust remained open and our staff
worked tirelessly to meet these
increased pressures. Again, this is a
source of pride for the Trust Board
and our staff.
Another challenge presently is the
availability of skilled doctors and
nurses for recruitment to posts
within the organisation. As a result of
national shortages, this is a constant
challenge for us to recruit permanent
staff.
our many innovative mechanisms
to secure permanent staff for our
organisation and its patients.
The work will continue and will result
in the need for more changes in the
future.
These challenges illustrate that the
local healthcare environment in
which we operate needs to change
to meet these demands and to
ensure financial sustainability. To
accomplish this, the Trust is working
closely with our local healthcare
community and commissioners on
shaping sustainable services for the
future through Healthy Lives and
Healthy Futures (HLHF). This review of
healthcare services across North and
North East Lincolnshire is linked in to
similar programmes within the East
Riding of Yorkshire and East Lindsey.
In the midst of this complex and
changeable context in which the
Trust operates, the Trust Board and
I are confident and determined that
the Trust’s commitment to quality
will aid the Trust go on developing
and embedding quality practices,
working together to put our patients,
service users and carers first.
This programme of sustainability
aims to ensure that health and care
systems are in place which provide
safe, high quality and affordable
services for the future.
The first phase of this programme
has now been completed and
has resulted in 24/7 hyperacute
stroke services being centralised at
Scunthorpe hospital and ear, nose
and throat (ENT) services being
centralised at Grimsby hospital.
I look forward to outlining our
continuing achievements both
throughout the year in the monthly
quality report as well as next year
in our annual quality account
publication and to recognise the
pivotal role all our staff have in
driving this agenda forward to secure
the best care for our patients. Karen Jackson, Chief executive
This leads to the Trust relying on
temporary and agency posts to
ensure safe staffing levels are
maintained. We will continue with
This, amongst other assurances we
were able to evidence, enabled the
Trust to move out of the ‘special
measures’ placed on it with regard to
quality. This effectively demonstrated
our determination and commitment
to quality development within the
Trust.
This commitment to quality already
demonstrated enables me to
confidently look to the challenges of
the future accepting that there will
also be challenges that we have to
face together.
5
About Northern Lincolnshire and Goole NHS Foundation Trust
Northern Lincolnshire and Goole NHS Foundation Trust (referred to
as ‘The Trust’ throughout this report) consists of three hospitals and
community services in North Lincolnshire and therapy services in
Northern Lincolnshire. In summary these services are:
• Diana, Princess of Wales Hospital
in Grimsby (also referred to as
DPoW),
• Scunthorpe General Hospital
located in Scunthorpe (also
referred to as SGH) and
• Goole District Hospital (also
referred to as GDH),
• Community and therapy services
in North Lincolnshire.
The Trust was originally established
as a combined hospital Trust on April
1 2001, and achieved Foundation
Status on May 1 2007.
It was formed by the merger of
North East Lincolnshire NHS Trust
and Scunthorpe and Goole Hospitals
NHS Trust and operates all NHS
hospitals in Scunthorpe, Grimsby
and Goole.
In April 2011 the Trust became
a combined hospital and
community services Trust (for North
Lincolnshire). As a result of this the
name of the Trust, while illustrating
the geographical spread of the
organisation, was changed during
2013 to reflect the Trust did not just
operate hospitals in the region.
The Trust is now known as Northern
Lincolnshire and Goole NHS
Foundation Trust.
Running four services, separated
by considerable distances, poses
a significant service delivery
challenge, but also allows the
Trust to serve a wider population.
The Trust also provides a range of
services delivered outside of hospital
settings.
Due to these geographical distances
a key way the Trust uses to help
measure and monitor quality of care
is through site by site breakdowns
of performance against various
measures. You will see this illustrated
throughout the following sections of
the report.
Our core business can be
defined as:
• Delivering a full range of
emergency secondary health care
services, including intensive and
high dependency care
• Maintaining a comprehensive
range of planned and unplanned
services, in an environment of
patient choice and contestability
• Ensuring a full range of secondary
care diagnostic services are
available locally.
Unplanned services: statistics
at a glance – during 2014/15:
• 144,996 people attended one
of our accident and emergency
departments, an increase of 7,154
on 2013/14. This equates to 2,788
a week, 397 people a day! This
represents the fifth year increase
in a row.
• 30,834 of these were admitted
as an inpatient to one of our 3
hospitals, an increase of 2,776
seen in 2013/14. This equates to
593 admissions through A&E a
week, 84 people a day! While the
numbers are increasing, so to is the
level of acuity.
Executive summary of the key points from this year’s Quality Account
The Trust’s Quality Account
contains a detailed summary of
performance against its quality
priorities set for the 2014/15
financial year. This full detail is
available within part two of this
report.
Performance against these
indicators and the relationship of
these results to next years (2015/16)
quality priorities is significant,
therefore these two key highlights
are presented as part of this
executive summary.
6
Together
The Trust’s quality targets and priorities –
driving continuous improvement
It is worth noting here, that these targets/quality priorities for the most part are not
nationally or regionally set, rather they are set locally by the Trust. They are selected
as areas of key importance for the Trust to drive and embed continuous quality
improvement. These indicators are not chosen for their ease of completion, resulting
in a report full of green ‘completed’ ticks. These indicators are instead quality focused,
aspirational and stretching. As a result, the executive summary that follows, and
the greater detail within part two of this report presents progress so far, not always
demonstrating that our internal quality targets have been met. Where these have not
been met, an explanation and summary of the work underway are presented and for
the most part, these targets have been selected to stay within the quality report to
drive quality development during 2015/16.
we care, we respect, we deliver
Clinical effectiveness – performance at a glance 2014/15
The following ‘at a glance’ overview of performance is viewed continually throughout the year, and reviewed within the
monthly quality report, as a result these are constantly changing based on the real time nature of these indicators. For full
explanation of the data behind these indicators, see section two of this report.
Quality indicators at a glance; March - 2015
2014/2015 Indicators
Indicator
Time period/RAG
Clinical effectiveness
Most recent data
CE1
Deliver mortality performance within Official SHMI
expected range and improving
(July 13 - June 14)
quarter on quarter, until reported
HED data
SHMI is 95 or lower
(Dec 13 - Nov 14)
Position vs peers
Indicator
CE2
NEWS - Approriate action taken
Change
3.1) Screened for Dementia
3.2) Dementia - screened,
appropriate assessment
3.3) Dementia - appropriate
referral to specialist services
CE4
95
112
R
111
95
Higher than
expected range
R
Within
expected range
Within
expected range
Feb - 2015
Previous
0%
100%
G
100%
0%
100%
G
100%
GDH
0%
100%
G
Trends
Target
95%
100%
Previous
DPoW
1%
95%
G
94%
SGH
2%
96%
G
94%
DPoW
0%
100%
G
100%
SGH
0%
100%
G
100%
DPoW
0%
100%
G
100%
SGH
0%
100%
G
100%
0.9%
82.8%
R
81.9%
0.1%
95.8%
G
95.7%
7.6%
33.57%
R
26%
Transfer of patients for non-clinical reasons
(capacity) to not exceed 20% of the total
Target
108
DPoW
NICE - Compliance with all NICE guidance
Trends
R
SGH
NICE - Compliance with all NICE TAGs assessed
CE5
Previous
109
Feb - 2015
CE3
Comparator
Trends
Target
90%
90%
90%
90% by March
2015
20%
Comment:
• Mortality indicators have been partially met throughout 2014/15 with the Trust’s ‘official’ SHMI being ‘within expected
range’. More recently, following national improvements in mortality and the subsequent rebasing of this relative ratio,
the Trust according to the ‘provisional’ HED SHMI indicator has moved slightly into the ‘higher than expected’ range.
This is for the period November 13 – October 14. Due to the importance of this area, this remains a quality priority for
next year’s monitoring in the monthly quality report and the monthly mortality report
• National Institute for Health and Care Excellence (NICE) guidance is another indicator that has not yet been met, despite
good progress having been made. This is another indicator that remains a part of the quality priorities for next year
• During 2014/15 a mid-year review of the Trust’s Quality Priorities was held, as a result, a new indicator to do with
transfer of patients for non-clinical reasons was set to aid the Trust’s understanding of this important area. To date, the
results from this are aiding the Trust’s Discharge and Transfer working Group. As a result this area will remain a quality
priority for 2015/16
• Transfer and discharge target. No established way of monitoring this important indicator has
been available. To navigate around this issue, the Trust has developed a way of monitoring
this area using one of the central administration systems. While a step in the right
direction, the data output and reported here has recently been validated and
found to be inaccurate. Work is underway to resolve these data concerns,
however in the meantime, this information should be regarded with caution.
7
In support of the above commentary, the quality priorities for next year (2015/16 financial year) are illustrated as follows
with explanations included. For full detail of how these priorities are set, including consultation with patients and
governors, see section 2.1d within this report.
Patient Safety – performance at a glance 2014/15
Quality indicators at a glance; March - 2015
2014/2015 Indicators
2015/16 Quality priorities – clinical effectiveness
Clinical effectiveness:
CE1
Deliver mortality performance within ‘expected range’ and improving quarter on quarter, until reported SHMI
is 95 or better.
CE2
NEWS - in 95 per cent of cases with a NEWs score, appropriate action was taken.
CE3.1
Dementia – 90 per cent of patients aged 75 and over admitted as an emergency to be asked the dementia
case finding question.
CE3.2
Dementia – 90 per cent of the above patients scoring positive on the case finding question to have a further
risk assessment.
CE3.3
90 per cent of the patients identified as requiring referral following risk assessment to be referred in line with
local pathway.
CE4
CE5
Evidence based practice - to increase compliance with NICE guidance with 90 per cent compliance achieved
by the end of March 2016.
Indicator
Patient safety
• Despite an improvement in the levels of compliance with NICE guidance, the target to reach 90 per cent has not yet
been achieved; as a result, this remains a quality priority for the board’s assurance during 2015/16.
For latest news from Northern
Lincolnshire and Goole NHS
Foundation Trust visit our
website at: www.nlg.nhs.uk
Follow the Trust on Twitter: @
NHSNLaG
8
Together
we care, we respect, we deliver
Previous
Trends
Target
(YTD: 1)
1
1
R
0
0
C. Difficile incidence
(YTD: 20)
1
3
G
2
No more than 35
PS3
PS4
Safety thermometer (community)
-1%
96.%
G
97%
95%
DPoW
0.5%
90.7%
R
90.2%
Open and honest initiative - Harm
free care - Saftey thermometer
(‘New’ and “Old’)
SGH
-6%
86.5%
R
92.5%
GDH
4.2%
100%
G
95.8%
Elimiation of avoidable repeat
fallers
DPoW
-1
0
G
1
SGH
0
0
G
0
GDH
0
0
G
0
Reduction in number of
avoidable pressure ulcers
(Grades 2, 3 and 4)
DPoW
-2
1
G
3
SGH
0
0
G
0
0
G
0
Feb - 2015
PS5
PS6
PS7
PS8
• As described in the commentary following the 2014/15 ‘at a glance’ view of performance, a new target to focus the
Trust’s attention on the important area around transfers has been established. This was enacted during the mid-year
review of the indicators. The information is still being evaluated and is supporting the Discharge and Transfer Group’s
work in this area
Feb - 2015
Comparator
MRSA bacteraemia incidence
(For more information on how these priorities are set, see section 2.1d of this report).
• The National Early Warning Score (NEWS) indicator remains for 2015/16, despite the fact that this has been consistently
achieved, the rationale for this is to ensure that practice is truly embedded, hence focussed monitoring will remain in
place within the monthly report
Time period/RAG
PS1
PS2
Previous
GDH
0
Nutrition care pathway was
followed
DPoW
-1%
95%
R
96%
SGH
0%
98%
R
98%
GDH
0%
100%
G
100%
The food record chart completed
accurately and fully, in line with
care pathway
DPoW
1%
90%
R
89%
SGH
7%
93%
R
98%
GDH
0%
100%
G
100%
The fuild management chart was
completed accurately and fully,
in line with care pathway
DPoW
0%
97%
R
97%
SGH
4%
96%
R
92%
GDH
0%
100%
G
100%
Transfer of patients for non-clinical reasons (capacity) to not exceed 20 per cent of the total.
Comment:
Change
95%
Trends
Target
Eliminate ALL
avoidable
repeat falls
50% reduction
(no more than
2 per month)
100%
100%
100%
For full explanation of the data behind these indicators, see section 2 of this report. (For more information on the detail
behind this ‘at a glance’ summary, see section two of this report)
Comment:
• Performance for MRSA bacteraemia and C difficile incidence has been in line with the targets set for the year and when
compared to other local and national providers, significantly less levels of MRSA and C difficle have been reported
• The Safety Thermometer (methodology and components of this indicator are available in more detail within section
two of this report) for the acute Trust have not consistently been achieved, as a result, detailed within the following
section, these remain as quality priorities for 2015/16
• Following last year’s strengthening of the targets around falls and pressure ulcers to the elimination of avoidable
incidents, this remains an area of progress but requires further monitoring, so it is to remain in the list of quality
priorities for 2015/16
• Last year’s establishment of new nutrition and hydration targets have not yet achieved the
targets being aimed for, so it is proposed that these will also remain as priorities.
In support of the above commentary, the quality priorities for next year (2015/16
financial year) are illustrated as follows with explanations included. For full detail of
how these priorities are set, including consultation with patients and governors,
see section 2.1d within this report.
9
2015/16 Quality priorities – patient safety
Patient experience – performance at a glance 2014/15
Quality indicators at a glance; March - 2015
Patient safety:
PS1
PS2
MRSA - 0 MRSA bacteraemia developing after 48 hours into the inpatient stay (hospital acquired).
C Difficile - achieve a level of no more than 21 hospital acquired C. Difficile cases over the financial year
2015/2016.
PS3
Safety Thermometer - provide harm free community care to 95 per cent or more patients - as measured by
the Safety Thermometer.
PS4
Safety Thermometer - provide harm free care to 95 per cent or more (acute) patients - as measured by the
Safety Thermometer.
PS5
Patient falls - Eliminate all avoidable repeat falls (as measured via the root cause analysis undertaken for
every repeat faller).
PS6
Pressure ulcers - a 50 per cent reduction in avoidable grades 2, 3 and 4 pressure ulcers (as measured via the
root cause analysis undertaken for every grade 2, 3 and 4 pressure ulcer).
PS7.1
Nutrition – 100 per cent of patients the care pathway was followed.
PS7.2
Nutrition – 100 per cent of patients identified as requiring it will have their food record chart completed
accurately and fully in line with the care pathway.
PS8
Hydration – 100 per cent of patients identified as requiring it will have their fluid management chart
completed accurately and fully in line with the care pathway.
2014/2015 Indicators
Indicator
Change
Patient experience
PE1
Response rate to friends and
family test within the top 50%
Time period/RAG
Feb - 2015
Previous
Inpatient
Bottom 50%
R
Top 50%
A&E
Bottom 50%
R
Bottom 50%
Feb - 2015
PE2
Re-opened complaints to not exceed
20% of total closed complaints
PE3
Complaints - action plan drafted
Comparator
Previous
G
PE4
PE5
Patients should not have
any unplanned omissions in
providing patient medications
G
100%
90%
8%
100%
G
92%
90%
Previous
72
Q2 2014/15
R
Feb - 2015
20%
Trends
Trends
Previous
Target
Target
50%
(max. 33 per qtr)
44
Trends
Target
DPoW
SGH
No data to report as yet
90%
No data to report as yet
90%
GDH
Patients should not have a delay
of more than 30 minutes in
providing pain relief
DPoW
SGH
GDH
Oct - 2014
July - 2014
PE6
• The above quality priorities for patient safety for 2014/15 illustrate that MRSA, C difficile remain key indicators for
continued monitoring. The C difficile target is to be lowered for 2015/16 from 33 to 21
For full explanation of the data behind these indicators, see section two of this report.
• While the community element of the Safety Thermometer has been achieved over the last five consecutive months, it
has been proposed that this remains to ensure it is embedded.
Target
100%
28
5.8%
Comment:
• Hydration and nutrition, both crucial areas of focus were included last year in the quality indicators, it is proposed to
continue to monitor these during 2015/16 until assurance that these are embedded
Trends
0%
(For more information on how these priorities are set, see section 2.1d of this report)
• Following last year’s strengthening of the falls and pressure ulcer targets these remain priorities for continuous
monitoring during 2015/16
Top 50%
17.3%
Q3 2014/15
Complaints - 50 % reduction in complaints
relating to communication
Target
11.5%
Feb - 2015
Complaints - action plans implemented
Trends
Staff satisfaction - increase in morale/staff
satisfaction
-1
5.3
R
Trends
6.3
Target
2.5% increase
(min. 6.65)
Comment:
• Trust performance with response rate to the national Friends and Family Test has mainly achieved the targets set for
the response rates to the in-patient element. Additional improvements are still needed with regard to A&E response
rates. As a result this is a recommendation for remaining as a quality priority for 2015/16
• The various indicators relating to complaints illustrate that the work and focus on this area has resulted in significant
improvements in the process measures applied. Due to the importance of this area, and the additional work underway
around learning from the themes sitting behind complaints (another quality priority around those dealing with
communication) this area will remain a quality priority for 2015/16
• Another change to the quality priorities agreed last year was around the target relating to pain relief. Compliance with
this indicator has been 100 per cent across the board. As a result, this target was removed and designed to be replaced
with two more detailed indicators relating to omissions in patient medications and ensuring no delays in providing
pain relief. These questions are currently being added to the Nursing Dashboard, so it is proposed that these become
the targets for focussing on during 2015/16.
In support of the above commentary, the quality priorities for next year (2014/15 financial year)
are illustrated as follows with explanations included. For full detail of how these priorities are set,
including consultation with patients and governors, see section 2.1d within this report.
10
Together
we care, we respect, we deliver
11
2015/16 Quality priorities – patient experience
Patient Experience
PE1
Response rate to friends and family test within the top 50 per cent.
PE2
Re-opened complaints to not exceed 20 per cent of total closed complaints.
PE3
Complaints – 90 per cent of action plans following a complaint to be implemented within agreed
timescales.
PE4
Complaints – 50 per cent reduction in complaints relating to communication.
PE5a
Patients should not have any unplanned omissions in providing patient medications.
PE5b
Patients should not have a delay of more than 30 minutes in providing pain relief.
PE6
Staff satisfaction1 – 2.5 per cent increase in morale/staff satisfaction each six months.
PART 2:
Priorities for improvement, statements of assurance from the
board and reporting against core indicators
2.1 Priorities for improvement: overview of the quality of care against 2013/14 quality priorities
Information reported within part 2
Due to the timings necessary to compile the Annual Quality
Account, the most recent information available presented is not
always to the end of the financial year. Despite this at least 12
months trending information is presented where available.
(For more information on how these priorities are set, see section 2.1d of this report)
Priorities for improvement
Rationale for staff satisfaction indicator: This is based on an indicator of nine per cent improvement achieved
between November 2012 and January 2014 and measured through the morale barometer so has some reasoning and
rationale while still being stretching. The means of measurement/data source would be the morale barometer.
This section of the report highlights
during 2014/15 progress towards
achieving the priorities which we set
out in our Annual Quality Account
for 2013/14 for this financial year.
The quality priorities are divided into
three sections:
1
Comment:
• A reduction in re-opened complaints remains a key priority. Following a review of this indicator during the mid-year
review process, the target was tweaked to reflect a more accurate view of this area to a percentage target, not simply a
numerical one. As a result, monitoring of this will continue during 2015/16
• While significant progress has been made with the various process measures around complaints, the Trust has set
an improvement priority around reducing the underlying ‘themes’ identified following a more detailed ‘deep dive’
assessment of the underlying reasons for the complaint. This target is focussing on what are we doing differently as
a result of complaints with a view to learn lessons from. From the review work undertaken, complaints relating to
communication are an important area to focus improvement efforts on
• Staff satisfaction remains quality priority based on the work underway to improve staff engagement and morale,
recognising that happy staff provide high quality care to patients and service users.
• 2.1a Clinical effectiveness
• 2.1b Patient safety
This is overseen primarily by MPAC,
before consideration by the Trust
Board.
• Section 2.1d Quality priorities for
the 2015/16 financial year.
In some cases these new quality
priorities have changed from those
reported on below. Where this is the
case, beneath each indicator, the
rationale for the change is explained.
A note on interpretation of
the following information
Wherever possible throughout this
report, unfamiliar terms or acronyms
have been explained in the body
of the report. Where this has not
been possible due to compliance
with the national template set for
the Trust’s annual quality account
submission, every effort has been
made to ensure the glossary
provides the necessary definition to
aid the reader’s interpretation of this
information.
• 2.1c Patient experience.
During 2014/15 the following
quality priorities were monitored
by the monthly quality report
which is presented and reviewed
on a monthly basis by the Trust’s
Quality and Patient Experience
Committee (QPEC) and the Trust
Board. In addition to this, to ensure
oversight of mortality indicators has
led to the creation of the Mortality
Performance and Assurance
Committee (MPAC).
This has meant that while the
monthly quality report has reported
on all quality indicators, including
those around mortality, a separate
monthly mortality report is also used
to monitor performance against a
comprehensive range of indicators.
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13
Overview of the quality of care against 2014/15 quality priorities:
2.1a Clinical effectiveness (CE)
CE1 Mortality
CE2 National Early Warning Scores (NEWS)
CE3 Dementia
Clinical effectiveness
CE4 Evidence Based Practice (NICE)
CE5 Transfer and Discharge
14
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15
2.1a Clinical effectiveness
CE1 – Mortality improvement – Summary Hospital Mortality Indicator (SHMI)
Introduction to mortality data
During 2013/14, mortality indicators and NHS Trusts’ performance
against them received a lot of attention. This culminated in NHS medical
director Sir Bruce Keogh reviewing 14 NHS Trusts with outlying levels of
mortality.
Northern Lincolnshire and
Goole NHS Foundation Trust
had been aware of its mortality
performance and had been acting
on this information with a view to
understanding and improving the
quality of care provided.
This was reported in some detail
during the previous 2012/13 and
2013/14 annual quality accounts.
Despite this programme of
improvement work, the Trust was
identified as being an outlier in this
area and as a result was one of the
14 Trusts visited by one of Sir Bruce
Keogh’s review teams.
While the identification of these
Trusts was based on their mortality
performance, the review team’s visit
focused on the wider quality of care.
The Trust welcomed the visit and the
review team’s feedback has provided
a useful external view on where
additional improvement is needed.
More detail regarding the action
taken following the Keogh and Care
Quality Commission (CQC) visits and
the progress made by the Trust is
available later on in this report.
Mortality – how is it measured?
In order to report the Trust’s position
on mortality, it is worth explaining
some of the different mortality
measures and how the Trust uses
these internally.
There are two primary ways to
measure mortality, both of which are
used by the Trust:
1. Crude mortality – expressed as a
percentage, calculated by dividing
the number of deaths within the
organisation by the number of
patients treated
2. Standardised mortality ratios
(SMR). These are statistically
calculated mortality ratios that are
heavily dependent on the quality
of recording and coding data.
These are calculated by dividing
the number of deaths within the
Trust by the expected number of
deaths.
• This expected level of mortality
is based on the documentation
and coding of individual, patient
specific risk factors (ie their
diagnosis or reason for admission,
their age, existing comorbidities,
medical conditions and illnesses).
This information is combined
with general details relating to
their hospital admission (ie the
Interpreting Standardised Mortality Ratios:
type of admission, elective for a
planned procedure or an unplanned
emergency admission), all of
which inform the statistical models
calculation of what constitutes
expected mortality.
• As standardised mortality ratios
(SMRs) are statistical calculations,
they are expressed in a specific
format. Based on the average
expected mortality within the UK, an
average ‘expected level’ of mortality
would be expressed as 100. Therefore
an SMR of more than 100 would
be considered to be a higher than
would be expected compared with
the UK average. Conversely, an SMR
of less than 100 would be a mortality
ratio less than would be expected
compared with the UK average.
• While ‘100’ is the key numerical value,
because of the complex nature of
the statistics involved, confidence
intervals play a role, meaning that
these numerical values are grouped
into three categories: “higher than
expected”, “within expected range”
and “lower than expected”. These
categories are based on mortality
performance across the UK, and
using this statistical data and
the confidence intervals for this
information, results in SMRs of both
above 100 and below 100 being
classified as “within expected range”,
therefore the level of 100 does
not in isolation determine a Trust’s
performance in line with mortality
SMRs. For this reason, the Trust looks
at SMR data using funnel charts,
A NOTE OF CAUTION
Standardised mortality ratios (SMRs) must always be interpreted with caution. As these are ratios of actual deaths against
expected levels of mortality they are heavily dependent on data and the accuracy of recording.
Interpretation should be likened to that of a smoke alarm, in the same way as the smoke alarm sounding does not mean there is
definitely a fire, an SMR indicator of above 100 does not definitely indicate a problem. However, just as it would be unwise to ignore
a smoke alarms warning and not investigate, so too is it unwise to ignore an outlying SMR. This is the approach that the Trust takes.
16
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which illustrate the Trust’s relative
position against other UK Trusts
and its categorisation. More
detail regarding the SMRs used is
contained in the next section.
Standardised Mortality
Ratios (SMRs) – which ones
are used by the Trust?
There are a number of different
standardised mortality ratios (SMR)
in use throughout the United
Kingdom. Historically, this has made
understanding and benchmarking
an NHS Trust’s performance against
mortality indicators very difficult.
As a result the NHS commissioned
an ‘official’ standardised mortality
ratio called the Summary Hospital
Mortality Indicator or SHMI.
As this is the ‘official’ NHS mortality
indicator of choice, it is calculated
using a strict methodology which
ensures all NHS organisations are
measured in the same way using the
same indicators. As a result of this,
it allows NHS organisations to be
ranked according to performance.
The Summary Hospital Mortality
Indicator (SHMI) is therefore
designed to bring clarity to quality in
this area. However, a crucial element
of SHMI, which is not immediately
obvious, and therefore can confuse,
is that although SHMI has hospital in
the title, it is not purely an indicator
of in-hospital mortality, it includes
community mortality up to 30 days
following discharge from hospital.
This introduces a significant delay
in publishing information on
the healthcare community. As a
result, when SHMI information is
published each quarter, the time
frame included within the report is
between six and 18 months out of
date.
To illustrate this, in January 2015,
the SHMI was published focusing on
the time frame of July 2013 to June
2014.
Therefore while the SHMI is a useful
tool to aid the Trust’s understanding
of this important area, it has
struggled to use this effectively
in order to monitor ongoing
performance due to the significant
time lag in reporting.
What is Healthcare
Evaluation Data (HED)
As a result of the time lag in
reporting of SHMI, the Trust has
purchased an additional information
toolkit from the University of
Birmingham Hospitals NHS
Foundation Trust, called Healthcare
Evaluation Data (HED).
HED uses the same methodology
as the official SHMI, but enables a
much more recent timeframe to be
reported.
The official SHMI publication in
January 2015 reported data up to
June 2014, the HED information
reports data to the end of November
2014.
This is the only SMR that includes
both in hospital and out of hospital
mortality. It can therefore be viewed
as a wider healthcare community
mortality performance indicator –
not solely a reflection of the Trust’s
performance.
As it is not the official SHMI indicator,
it is treated by the Trust as a
‘provisional’ SHMI indication, but
from rigorous reconciliation work, it
has proved to be an accurate data
source that reflects the official SHMI
on publication.
Another important point to note
regarding SHMI is that because
it includes community mortality
within the indicator, it is based not
only on in-hospital recorded data
but on information from the Office
for National Statistics (ONS).
As a result of this, the Trust uses
both the official SHMI and the HED
provisional SHMI indication as
markers of performance.
How is mortality
performance monitored
within the Trust?
The Trust Board monitors performance
against mortality indicators through a
sub-committee oversight and scrutiny.
This sub-committee of the Trust Board
is called the Mortality Performance
and Assurance Committee (MPAC). It
is chaired by the chairman of the Trust
Board.
The committee oversees all matters
relating to mortality. Its primary form
of intelligence is the monthly mortality
report, which comprehensively
presents a range of different mortality
performance measures, utilising the
official SHMI, the HED provisional
information, crude mortality and an
overview of mortality using other SMRs.
Standardised mortality ratios (SMRs)
like the SHMI are not automatic
markers of poor performance, however,
they should not be ignored. The
analogy of the smoke alarm is very
apt, and the Trust takes the same view
meaning that any SMRs of above
100 are not ignored but proactively
investigated using a number of
methods including more detailed
information reports to obtaining the
medical records of patients having died
and providing assurance that there
are no quality of care concerns. The
Mortality Performance and Assurance
Committee (MPAC) rigorously oversee
these areas and assign specific work
streams as appropriate.
Now that the key terms of reference
have been introduced and explained,
the following section looks at how
the Trust is performing against these
indicators and outlines the work being
undertaken to further focus on quality
improvement.
17
CE1 – Mortality improvement – Summary Hospital Mortality Indicator (SHMI)
The Trust’s provisional HED SHMI in national context
• TARGET: Deliver mortality performance (SHMI) within ‘expected range’ and improving quarter on quarter, on a Moving
Annual Total (MAT) basis at each quarterly publication date until our reported SHMI is 95 or better.
The University of Birmingham Hospitals’ Healthcare Evaluation Data (HED) reporting product allows a more up to date view
of the provisional SHMI indicator, to the end of November 2014. The following funnel plot graph outlines the Trust’s position
in relation to other organisations.
• Achievement (July 2013 – June 2014): Using the official SHMI indicator, the Trust is currently within the ‘expected
range’. Mortality performance the previous quarter was 108, the current official SHMI is 109, so this represents a one
point deterioration. The next official SHMI publication is due in April 2015 for the period of October 2013 to September
2014.
Figure 2
125
National SHMI - 12 months to November 2014
Colour by banding
Higher than expected
120
115
The following chart illustrates the Trust’s most recent SHMI score and ranking in relation to those of all Trusts nationally.
110
Figure 1
National SHMI score range: January 2015 release (covers July 2013 - June 2014 period)
105
120
NLaG
SHMI
The Trust’s official SHMI in national context
Lower than expected
Within expected range
NLaG
Line from column values;
99.8% upper limit
Line from column values;
99.8% lower limit
Line from column values;
95% upper limit
Line from column values;
95% lower limit
100
95
90
100
85
80
80
75
60
70
40
65
20
60
500
1000
1500
2000
2500
3000
3500
4000
Expected deaths
0
Source: Information Services based on the Health and Social Care Information Centre’s data
Key to abbreviations: NLAG – Northern Lincolnshire and Goole NHS Foundation Trust
Source: Information Services based on the Healthcare Evaluation Data (HED)
Key to abbreviations: SHMI – Summary Hospital Mortality Indicator
NLAG – Northern Lincolnshire and Goole NHS Foundation Trust
Comment:
Comment:
• The most recent official SHMI was published in January 2015 and covers the July 2013 to June 2014 time period
• From the most recent information available, using the HED ‘provisional’ SHMI, the Trust’s ranking moves from the “as
expected range” just over the boundary into the “higher than expected” grouping
• The Trust’s SHMI score was 109 – ranking 119 out of the 137 NHS provider organisations included in data set
• The Trust’s ‘provisional’ HED SHMI score is 112.1, ranking the Trust as 134 out of 141 NHS provider organisations
• This continues to be officially within the “as expected range”.
• Data in this analysis should be treated as provisional. From reconciliation work, we know that this data source reflects
previous SHMI publications
• For a more detailed overview of the actions having been taken to improve the Trust’s mortality position and those
being taken now, see section 2.3a of this report.
Has the quality indicator been changed during the year from that set in last year’s
(2013/14) Quality Account? No, there has been no change to this quality priority during the
2014/15 reporting period.
Rationale for changing this quality priority for 2015/16: Not all elements of this
indicator have at present been met. Therefore no change is going to be made to
this indicator and it will continue to be measured during the 2015/16 financial
year.
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19
CE2: National Early Warning Score (NEWS) – appropriate action taken
In 95 per cent of cases with a NEWs score, appropriate action was taken
• TARGET: 95 per cent of patients with a NEWS score, an appropriate clinical response was actioned.
• Achievement (January 2014 – February 2015): The following chart illustrates that this target has been achieved in
the main, with the overall trend showing continued improvements.
Figure 3
In 95% of cases with a NEWS score, appropriate clinical response actioned
100
Percentage completed
99
Introduction to the National Early Warning Score (NEWS)
This important facet of clinical care
has been one of the many areas
of work focussed on as part of the
Trust’s work to improve mortality
performance.
When a patient’s condition
deteriorates, there are a number
of markers that can identify
this, and when appropriately
monitored, these markers can
trigger effective action to prevent
further deterioration. These markers
are often combined together as a
risk calculator. The National Early
Warning Score (NEWS) is a nationally
developed deteriorating patient
score which the Trust has used since
November 2012.
20
Together
The use of the National Early
Warning Score (NEWS) within
the Trust
The National Early Warning
Score (NEWS) was implemented
during November 2012 within
the organisation. Since then the
Trust has gone on to embed this as
standard practice which has led to
great innovations at the patients’
bedside and on ward areas.
The Trust has long provided a clinical
system called Web V which has
historically provided clinicians with
electronic access to pathology and
laboratory results.
This system has over time been
developed to include a range of
other useful functions. As part of this,
the system has evolved to become
an Electronic Patient Record (EPR).
One of the first elements of this
EPR was the development of the
NEWS scoring system as part of the
patient’s bedside documentation.
we care, we respect, we deliver
97
96
95
94
93
CE2 – National Early Warning Score (NEWS)
An important element of
providing effective and safe
care is monitoring a patient’s
condition, identifying any
markers of deterioration and
taking appropriate action to
‘rescue’ them from further
deterioration, preventing
mortality.
98
This has led to the Trust’s large scale
investment in electronic equipment
to enable all previously handwritten
bedside observations to be now
recorded electronically on a variety
of handheld devices by clinical staff.
This is then displayed on electronic
computer screens at the nurses’
station which enables all patient
observations, including the
crucial NEWS score, to be viewed
‘at a glance’ by all healthcare
professionals involved in the
patient’s care.
Crucially, any NEWS scores that
are outside of normal limits are
clearly discernible and ensure
that no matter how hectic the
ward environment, appropriate
action is taken to prevent further
deterioration.
The electronic system also enables
the clinical team to be reminded on
the frequency of such observations.
Aug
13
Sept
13
Oct
13
Nov
13
Dec
13
Jan
14
Feb
14
Trustwide
100
DPoW
99
99
97
99
98
99
99
99
100
99
99
99
99
SGH
99
99
95
98
98
98
99
GDH
100
100
100
100
100
100
Threshold
95
95
95
95
95
95
Mar
14
Apr
14
May
14
Jun
14
Jul
14
Aug
14
Sept
14
Oct
14
Nov
14
Dec
14
Jan
15
Feb
15
99
99
99
100
100
99.7
99.7
100
100
99
99
100
100
100
100
96
98
100
100
100
100
99
100
98
97
99
100
100
100
100
99.4
100
94
97
100
100
100
100
100
100
100
100
93.8
100
100
94
100
100
95
95
95
95
95
95
100
95
95
95
95
95
95
95
Source: Information services, nursing dashboard
Key to abbreviations: DPoW – Diana, Princess of Wales Hospital
SGH – Scunthorpe General Hospital
GDH – Goole District Hospital
NB: As Trust performance with this indicator has been consistently high, for optimal viewing of this information at
individual site level, the above charts axis starts at 93 per cent.
Comments:
• The appropriateness of this assessment is judged by nursing staff undertaking this audit on a monthly basis, using a
standard procedure to ensure a consistent approach
• Performance against this indicator at all sites achieved the 95 per cent target and demonstrated an improvement on
previously reported performance
• Where 100 per cent compliance has not been achieved this is due to the observations not being recorded within the
exact timeframe recommended in accordance with the NEWS score criteria. Observations recorded outside of this
timeframe are marked as a ‘no’ when audited regardless of whether the appropriate escalation has taken place (ie
observations undertaken and recorded at one hour 15 minutes instead of at one hour). There has not
been a failing in escalation to a senior nurse/clinician
Has the quality indicator been changed during the year from that set in last year’s (2013/14)
Quality Account? No, there has been no change to this quality priority during the 2014/15
reporting period.
Rationale for changing this quality priority for 2015/16: As this is an important
indicator supporting the Trust’s focus on continued mortality improvements, this
indicator will remain a priority for 2015/16.
21
CE3.1: Dementia case screening question
CE3 – Dementia
• TARGET: 90 per cent of patients aged 75 and over admitted as an emergency to be asked the following dementia case
finding question:
“Have you been more forgetful in the last 12 months to the extent that it has significantly affected your daily life?”
Dementia is a significant
challenge for the NHS with an
estimated 25 per cent of acute
beds occupied by people with
dementia, their length of stay
is longer than people without
dementia and they are often
subject to delays on leaving
hospital.
Dementia affects an estimated
670,000 people in England, and the
costs across health and social care
and wider society are estimated
to be £19 billion – both figures are
set to rise with the ageing of the
population.
Timely diagnosis can greatly improve
the quality of life of the person
with dementia by preventing crises
(and thus care home and hospital
emergency admission) and offering
support to carers (who are invariably
under stress).
To aid the NHS focus on dementia, a
series of dementia process measures
have been set which aim to improve
dementia risk assessment allowing
for an effective foundation for
appropriate management.
causes of cognitive impairment
alongside their other medical
conditions and to prompt
appropriate referral and follow up
after they leave hospital.
The dementia CQUIN payment is
triggered in three stages:
1. The case finding of 90 per cent
of all patients aged 75 and over
following admission to hospital,
using the dementia case finding
question and identification
of all those with delirium and
dementia
2. The diagnostic assessment and
investigation of 90 per cent of
those patients who have been
assessed as ‘at-risk’ of dementia
from the dementia case finding
question and presence of
delirium
3. The referral of 90 per cent of
those for specialist diagnosis of
dementia and appropriate follow
up.
(Source: DH, 2013, Using the
Commissioning for Quality and
Innovation)
This is designed to bring significant
improvements in the quality of care
and substantial savings in terms
of shorter lengths of stay. To assist
this approach, a Commissioning
for Quality and Innovation (CQUIN)
target has been set.
This CQUIN approach is designed
to incentivise the identification of
patients with dementia and other
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Data quality issues
This indicator was reported on
within the 2013/14 indicators.
However, due to issues in identifying
a reliable monitoring system,
performance reported throughout
the year was not in line with the
90per cent target set. Issues with
the monitoring of this indicator
were confirmed through the use of
an audit assessing this area in more
detail, from the patient’s medical
records.
• Achievement (January 2014 – February 2015): Following some initial problems in ensuring a robust data collection
method for this area between September 2013 and March 2014, since then compliance has been routinely in line with
the target set for this national CQUIN.
NB. Please note earlier comments regarding data quality issues throughout 2013/14.
Figure 4
100
Due to this, performance against
this target, reported prior to March
2014, was based on the paper based
monitoring system which was found
to contain inaccuracies. Therefore
results reported prior to March 2014,
presented over the next few pages,
should be interpreted with caution.
Since March 2014 the Trust has
moved the monitoring of this
important area to an electronic
based monitoring system, housed in
the Trust’s Web V electronic patient
record.
The advantages of this is it ties
in more closely with day-to-day
electronic patient records and
provides visual reminders to ward
staff of the need to undertake
appropriate dementia screening.
176
161
229
258
239
222
230
214
241
251
95
280
259
227
231
204
196
203
181
222
184
60
295
251
169
90
Percentage compliance
Introduction to dementia
80
70
60
55
50
108
121
118
24
40
30
132
164
125
89
79
59
20
10
0
13
Sept
13
Oct
13
Nov
13
Dec
13
Jan
14
Feb
14
Mar
14
Apr
14
May
14
Jun
14
Jul
14
Aug
14
Sept
14
Oct
14
Nov
14
Dec
14
Jan
15
Feb
15
Target
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
DPoW
36%
41%
30%
5%
57%
50%
68%
99%
96%
94%
93%
91%
88%
93%
88%
92%
94%
95%
SGH
49%
58%
55%
11%
86%
81%
83%
96%
95%
96%
98%
95%
95%
94%
97%
94%
94%
96%
Source: NLAG CQUINS data, intranet, information services team
Key to abbreviations: DPoW – Diana, Princess of Wales Hospital SGH – Scunthorpe General Hospital
CQUIN – Commissioning for Quality and Innovation
NB: The above chart’s data labels refer to the number of patients, not the percentage of patients, as illustrated in the chart axis.
Comments:
• The above chart illustrates that compliance with all eligible patients having a dementia screening question has
exceeded the 90 per cent target set with 94 per cent compliance at both SGH and DPOW
• Performance at both sites is being monitored, in both medicine and surgery and critical care groups. The main
reason for this seeming non-compliance appears to be that nursing staff are not completing the screen in the
required initial 72 hour time period despite the flagging on the Web V system.
This concern has been raised by the quality matron with the lead for dementia, with appropriate nursing colleagues
in the groups to manage the non-compliance with required escalation to the general managers, deputy chief
operating officer and the chief operating officer.
23
CE3.2 – Further risk assessment as a result of positive screening question
CE3.3 – Identified patients at risk to be referred in line with local pathway
• TARGET: 90 per cent of patients scoring positive on the case finding question to have a further risk assessment.
• Achievement (January 2014 – February 2015): Following some initial problems in ensuring a robust data collection
method for this area between September 2013 and March 2014, since then compliance has been routinely in line with
the target set for this national CQUIN.
NB. Please note earlier comments regarding data quality issues throughout 2013/14.
Figure 5
• TARGET: 90 per cent of the patients identified as requiring referral following risk assessment to be referred in line with
local pathway.
• Achievement (January 2014 – February 2015): Following some initial problems in ensuring a robust data collection
method for this area between September 2013 and March 2014, since then compliance has been routinely in line with
the target set for this national CQUIN.
NB. Please note earlier comments regarding data quality issues throughout 2013/14.
16
16
26
24
17
22
19
21
19
9
7
13
17
12
3
12
12
100
23
28
13
17
Percentage Compliance
95
14
20
27
5
17
15
17
18
4
16
Figure 6
12
100
21
16
90
9
11
12
7
11
6
11
12
7
9
May
14
Jun
14
Jul
14
Aug
14
Sept
14
7
10
2
9
6
7
8
2
10
10
Oct
14
Nov
14
Dec
14
14
80
18
8
12
12
60
9
85
9
40
80
75
20
18
70
5
3
1
0
2
0
Nov
13
90
Dec
13
2
Sept
13
Oct
13
Nov
13
Dec
13
Jan
14
Feb
14
Mar
14
Apr
14
May
14
Jun
14
Jul
14
Aug
14
Sept
14
Oct
14
Nov
14
Dec
14
Jan
15
Feb
15
Target
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
DPoW
100%
100%
100%
100%
100%
100%
95%
100%
100%
100%
100%
92%
100%
100%
100%
100%
100%
100%
SGH
100%
100%
100%
100%
96%
100%
75%
100%
100%
100%
90%
100%
100%
100%
100%
100%
100%
100%
Source: NLAG CQUINS data, intranet, information services team
Key to abbreviations: DPoW – Diana, Princess of Wales Hospital
SGH – Scunthorpe General Hospital
CQUIN – Commissioning for Quality and Innovation
NB: The above chart’s data labels refer to the number of patients, not the percentage number of patients. Also, the axis starts at
70 per cent.
0
Sept
13
11
4
4
Jan
14
Feb
14
Mar
14
Apr
14
Jan
15
Feb
15
Target
90
Oct
13
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
DPoW
100
100
100
100
100
100
95
100
100
100
100
92
100
100
100
100
100
100
SGH
100
100
100
100
96
100
75
100
100
100
90
100
100
100
100
100
100
100
Source: NLAG CQUINS data, intranet, information services team
Key to abbreviations: DPoW – Diana, Princess of Wales Hospital SGH – Scunthorpe General Hospital
CQUIN – Commissioning for Quality and Innovation
NB: The above chart’s data labels refer to the number of patients, not the percentage number of patients.
Comments:
Comments:
• Since embedding the new system using Web V from March 2014, significant improvements are noted in all areas of
this indicator around dementia
• Since embedding the new system using Web V from March 2014, significant improvements are noted in all areas of
this indicator around dementia.
• For this part of the indicator, DPoW and SGH both reported 100 per cent since September.
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25
Figure 7
Trust dementia screening benchmarked against NHS England statistics
Indicator
Data period
NLsG
National
average
Better /
worse
Local
peer
Better /
worse
Dementia - identification
Jul 14 - Sep 14
93.5%
88.4%
Better
85.9%
Better
Dementia - Further assessment
Jul 14 - Sep 14
97%
93.2%
Better
85.3%
Better
Dementia - Referral
Jul 14 - Sep 14
100%
96.3%
Better
97%
Better
Source: Trust Information Services, derived from NHS England Statistics
Key to abbreviations: NLAG – Northern Lincolnshire & Goole NHS Foundation Trust (The Trust)
National average – performance in other NHS organisations in the UK
Local peer –select group of NHS Trusts with similar characteristics to the Trust
Better / worse – Trust performance compared to peer
Comments:
• When compared to the national and peer average, the Trust performs better in connection with the three components
which make up the dementia screening process.
Has the quality indicator been changed during the year from that set in last year’s (2013/14) Quality Account? No,
there has been no change to this quality priority during the 2013/14 reporting period.
Rationale for changing this quality priority for 2015/16: Until the release of the latest CQUIN scheme to focus on
dementia, the current targets will remain unchanged for 2015/16.
CE4 – National Institute for Health and Care Excellence (NICE) evidence-based practice
Introduction to National Institute for Health and Care Excellence (NICE) guidelines
The National Institute for Health
and Care Excellence (NICE)
provides national guidance and
advice to improve health and
social care. NICE was originally set
up in 1999 to reduce variation in
the availability and quality of NHS
treatments and care.
NICE guidance takes several forms:
• Clinical guidelines (CGs):
provide advice on the
management of individual
conditions. They are
systematically-developed
statements to assist professional
and patient decisions about
appropriate care for specific
clinical circumstances. These may
be as diverse as antenatal care,
breast cancer or schizophrenia.
They are developed in association
with the Royal Medical, Nursing
and Midwifery Colleges
• Technology appraisal
guidelines (TAGs): assess the
clinical and cost effectiveness
of health technologies, such
as new pharmaceutical and
biopharmaceutical products, but
also include procedures, devices
and diagnostic agents. This is
to ensure that all NHS patients
have equitable access to the
most clinically and cost-effective
treatments that are available
• Social care guidance: provide
practical support to practitioners
working in children’s and adult’s
social services, and people that
use these services and their carers
• Cost-saving medical
technologies (MTGs) and
diagnostic agent (DGs) reviews
help facilitate speedy and
consistent access to and use of
these technologies
• Interventional procedures
guidance (IPGs): recommends
whether interventional
procedures, such as laser
treatments for eye problems
or deep brain stimulation for
chronic pain, are effective and
safe enough for use in the NHS
• Public health guidance (PH):
covers disease prevention,
health improvement and health
protection and has influenced
policy and practice in the NHS
and local government on many
of the big issues in today’s
society.
(Source: NICE, 2014, About NICE
(www.nice.org.uk)
Introduction to the Trust’s implementation of National Institute for Health and
Care Excellence (NICE) guidelines
The process by which NICE guidance
is assessed and compliance
determined contains a number of
key steps and requires effective
communication from a wide variety
of Trust staff including frontline staff
who deliver services. A bespoke
system is used to monitor all steps
of the process, which can be divided
into two elements:
1. Process measures – an overview
of compliance against statutory
imposed timescales (in the
case of technology appraisal
guidelines) and those outlined
in the local Trust NICE policy. This
process is designed to ensure
26
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compliance with NICE guidance
is clinically assessed and
determined locally by relevant
clinical staff ie is clinically led
2. Outcome measures – an
overview of all NICE guidance
and the individual clinical
specialties compliance against
each component part that
is of relevance to them. This
is designed to ensure the
Trust knows centrally areas of
non-compliance and can have
an overview on the action
necessary to ensure compliance.
The Trust’s Implementation of NICE
guidance policy outlines the process
for the implementation of new
guidance. This is briefly summarised
below:
• NICE/Quality Administrator
identifies new guidance and lead
groups with the Medical Director
(monthly)
27
• Risk and Governance Facilitators
present new guidance to
governance group to establish
relevance and where guidance is
relevant for the group to identify
the lead clinician to take forward
implementation of the guidance
(within two weeks of guidance
being issued)
• The Trust’s Gap Analysis
Toolkit/baseline assessment is
distributed to lead clinicians
(to be returned within six weeks.
The intention behind this step is
to determine the current level of
compliance and any additional
actions required to ensure full
implementation and adherence to
NICE guidance)
• Returns are monitored and
followed up by the NICE/
qQuality administrator (reminder
sent after three weeks)
• NICE database updated
accordingly to confirm
compliance, action plans
monitored via governance
groups.
Reporting
Overall Trust compliance – all NICE guidance
Due to the nature of the
timescales involved in guidance
implementation, the Trust’s
Governance and Assurance
Committee receive a comprehensive
update on NICE guidance on a
quarterly basis and the Trust’s Quality
and Patient Experience Committee
receive this monthly summary
contained within the Quality Report.
Quarterly/monthly reports are also
provided to all directorates/groups.
As at March 302015, overall Trust compliance is as follows:
CE4 – Compliance with NICE evidenced based practice
Compliance
numbers
Compliance
(%)
337
82.8%
Partial compliance
33
8.1%
Non-Compliant, deviation approved by TG&AC
2
0.5%
Blue
Not yet assessed – OVERDUE
32
7.9%
Red
Non-Compliant
3
0.7%
Total
407
100.0%
Colour
Compliance status
Green
Full compliance
Amber
Yellow
Source: Trust NICE Database
Key to abbreviations: Full compliance – fully compliant as declared by teams assessing guideline relevance
• TARGET: To increase compliance with NICE guidance to 90 per cent by the end of March 2015.
• Achievement (January 2014 – March 2015): The Trust has not yet achieved this quality priority, and this will
therefore remain as an area of focus during 2015/16 as a quality indicator for oversight by the Trust Board.
Partial compliance – some elements of the guideline not yet compliant with
Non-compliant, deviation approved by TG&AC – not compliant with the NICE guideline, and rationale for this presented and approved by the Trust’s Governance and Assurance committee
Not yet assessed – overdue – compliance not yet assessed and deadline missed
Non-compliant – fully non-compliant at present with NICE recommendations
Overall Trust compliance – NICE technology appraisal guidance (TAGs)
As at March 30 2015, Trust compliance with those NICE TAGs that had been assessed using the Trust’s Gap Analysis Toolkit
is as follows:
Compliance
numbers
Compliance
(%)
182
95.8%
Partial compliance
2
1.1%
Non-Compliant, deviation approved by TG&AC
1
0.5%
Blue
Not yet assessed – OVERDUE
5
2.6%
Red
Non-Compliant
0
0.0%
Total
190
100.0%
Colour
Compliance status
Green
Full compliance
Amber
Yellow
Has the quality indicator been changed during the year from that set in last year’s (2013/14) Quality Account? No,
there has been no change to this quality priority during the 2014/15 reporting period.
Rationale for changing this quality priority for 2015/16: As a result of not yet meeting this quality indicator, this will
remain a quality priority for 2015/16, and therefore be monitored in the monthly quality report by the Quality and Patient
Experience Committee (QPEC) and the Trust Board.
Source: Trust NICE database
Key to abbreviations: Full compliance – fully compliant as declared by teams assessing guideline relevance
Partial compliance – some elements of the guideline not yet compliant with
Non-compliant, deviation approved by TG&AC – not compliant with the NICE guideline, and rationale for this presented and approved by the Trust’s Governance and Assurance committee
Not yet assessed – overdue – compliance not yet assessed and deadline missed
Non-compliant – fully non-compliant at present with NICE recommendations
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29
5000
0
16%
16%
Monday
Tuesday
2%
National Avg
4%
Wednesday
6%
8%
Thurdsay
17%
10%
Friday
12%
Saturday
Source: Transfer and Discharge Working Group Report, Trust Information Services
Percentage of delayed bed days - Qtr 3 Oct - Dec 2014
2
4
6
8
10
12
Average length of stay trending
14%
Sunday
0%
5%
10%
GDH
SGH
DPW
15%
Specialty outliers trending
GDH
SGH
DPW
0
NLaG 2.4%
5. Delayed transfers of care
4. Weekend emergency discharge rates
Percentage of total emergencies discharged split
by day of discharge
- most recent month
7%
15%
11%
2.5
2.0
1.5
1.0
0.5
0.0
GDH
DPW
SGH
2
19%
31
* Transfers with a reason of capacity: data validated and found to be inaccurate, this data to be interpreted with caution.
1000
2000
3000
4000
5,429
5,663
6000
GDH
SGH
DPW
423
0
20%
40%
60%
80%
100%
GDH
Number of external ward admissions and transfers to wards
- most recent month
6. Number of external ward admissions and transfers
GDH
SGH
DPW
Percentage (%) of transfers with reason of capacity
DPW
3.5
3.0
3.6%
2.3%
0.0%
2. Specialty outliers
4.0
SGH
0
10
20
30
40
50
GDH
SGH
DPW
60
40%
15%
3. Transfers with reson of capacity
60%
SGH
DPW
Percentage (%) of transfers with reason of capacity
(where reason known) - most recent month
GDH
May 14
4
Jul 14
Jun 14
6
Aug 14
8
Oct 14
Sep 14
10
Nov 14
12 months March 2014 - February 2015
Specialty outliers for ward activity - most recent month
Dec 14
Average length of stay for last 12 months by discharge site
Jan 15
1. Average length of stay
Feb 15
Transfer and discharge working group - Summary dashboard
Apr 14
Mar 14
we care, we respect, we deliver
May 14
Together
Jul 14
30
Jun 14
While a step in the right direction, the data output reported here has recently been validated and found to be
inaccurate. Work is underway to resolve these data concerns, however in the meantime, this information should
be regarded with caution.
Aug 14
There has been no established way of monitoring this important indicator. To navigate around this issue, the Trust
has developed a way of monitoring this area using one of the central administration systems.
Oct 14
On the table opposite (Transfer and discharge working group - Summary Dashboard), you will see this indicator
presented in the third column.
Sep 14
“3. Transfers with a reason of capacity”
Nov 14
NB: – Data quality concerns:
Jan 15
This stocktake will take into account
good practice from other Trusts in
terms of patient flows and will be a
key element of the KPMG review.
Dec 14
An internal stocktake is being
undertaken against the original
issues which were identified in the
report and which, in turn, led to a 39
point action plan being put together
by the Trust.
Feb 15
The Trust received an internal audit
report in January 2014 giving
limited assurance in terms of the
management of the transfer of care
and discharge arrangements.
Jul 14
The most recent reports (which
cover the 12 month period to
the end of December 2014 and
January 2015) have been expanded
to include more indicators and
a summary dashboard. New
information which is now included in
the monthly report covers weekend
discharge rates, delayed transfers of
care, number of consultant episodes
in a single spell and throughput by
ward.
2. Stocktake of current
position
Aug 14
• Support for the KPMG
internal audit work on the
bed management/review
of operations centre which
Work has been underway since
December with the information
team to develop the suite of
information which supports the
transfer and discharge programme.
Oct 14
• Stocktake of our current position
against the original East Coast
Internal Audit (Jan 2014)
1. Development and
monitoring of key indicators
The ‘at a glance’ dashboard providing
an overview of these key data items
is included on the following page.
Sep 14
• Development and monitoring of
key indicators – including length
of stay, benchmarked delayed
transfers of care and transfers
between wards (split by site and
reason for transfer). The work
underway now is to convert this
data into usable intelligence
which has an impact on practice
• Multi-agency initiatives across
the health and social care
communities to manage
demand for unplanned care
services.
This report is being shared with key
staff within the Trust and will form
the main agenda item for the next
Transfer and Discharge Working
Group to convert it into a working
knowledge base.
Nov 14
As such a transfer and discharge
group is in place to oversee this area
and work this month is focussing on:
commenced in February 2015
Jan 15
Transfer and discharge is a
crucial element of an effective
and efficient system – one of
the measures of an effective
system will be to achieve a
reduction in the number of
patients who are transferred for
capacity reasons.
Dec 14
Transfer of patients for non-clinical reasons (capacity) to not exceed 20 per cent
of the total transfers.
Feb 15
CE5 Transfer and discharge
3. Bed management/review
of operations centres
The KPMG internal audit review has
been agreed in order to support
the Trust’s work on the transfer of
patients between wards and to
address the question of whether
the operations centres are able
to work effectively. This work
includes a review of the policies and
procedures underpinning transfer of
care (and whether they are used in
practice) and follow up of the actions
from the previous audit.
4. Multi-agency initiatives
• In addition to managing the
significant levels of activity
which have continued through
January and February (and which
has been made more difficult
by outbreaks of diarrohea and
vomiting), the chief officer
of the operations directorate
has been undertaking various
workstreams to promote the
timely discharge of patients
from acute care and, where
appropriate, support the
management of care outside an
acute hospital setting with the
aim of reducing unplanned care
activity:
Plans are in place for this new
service to be established from
April 2015
• The business case for a frail
elderly assessment and support
team (FEAST) at SGH (part
of the Better Care Fund) was
approved at the joint board of
North Lincolnshire Health and
Social Care Partners at the end of
February. This proposal includes
significant investment into
establishing a multi-disciplinary
team
• The Trust continues to work
in partnership with other
organisations to support the
management of patients outside
of an acute setting where this
is appropriate. East Midlands
Ambulance Service (EMAS) has
been supported to undertake a
detailed analysis of calls received
by them for North Lincolnshire
residents who live in care homes
• A significant feature of the FEAST
team proposal is the proactive
discharge of older patients at
various key points - ie prior to
admission from A&E, within
a short stay facility or from
specialty wards
• Working with the Trust’s
community services, they
have been able to review the
ambulance calls for more than
350 people. A report on the
findings is due to be shared
imminently and will highlight
where different pathways could
support alternatives to bringing
patients for hospital based care.
• The next stage is to begin
getting the team in place with an
implementation plan being put
together.
• Home from Home – the Trust is
working with NAViGO to develop
a facility on the DPoW site for the
management of patients with
confusion who also require acute
care for their physical conditions.
• The outcomes of this work for
North Lincolnshire will also
be shared with North East
Lincolnshire colleagues in order
to consider their relevance for
the population who access
DPoW.
Managing increased demand on the Trust’s services
As well reported within the media over the last few months, pressure on Acute NHS Trusts has
been building as demand for A&E and unplanned services has increased year on year.
As referred to during the chief executive introduction, this pressure during 2014/15 winter months resulted
in a number of Trusts implementing their major incident plans due to the demands on their services. The Trust
was no different and faced an increase in demand on both the A&E and admission units.
When looking at the Trust’s average demand, 397 people a day attend our A&E departments, with
approximately 84 people a day requiring admission to the Trust. How is this managed to best effect? To
provide context in how on a day to day basis this constant, often unplanned demand is managed, we asked
our operations centre team for their perspective on what steps are in place to manage this demand and
prevent patients being transferred unnecessarily, for non-clinical reasons.
The operations centre was established in 2011 and provides a centralised resource where operational
teams work from to optimise patient flow throughout all hospital sites in the Trust. They have access to the
very latest information to do with the number of beds available and aim to use these most effectively and
efficiently. They are always looking for innovative ways to increase patient flow throughout the acute Trust
ensuring the finite numbers of beds available are used to best effect possible. Actions taken routinely in this
quest for most effective and efficient management include:
• To support patient flow through the winter months and even now, a seven-day hospital social work team
was introduced with close working links to the operations centre to help minimise delays in transfers of
care between the acute Trust and community services
• Outliers on non-specialty wards are regularly reviewed as part of the medical handover processes so that
medical teams are able to discuss any concerns they have resulting in appropriate medical management
of these patients
• Routine and regular meetings are held with a standardised agenda to ensure that emergency, elective
admissions, staffing issues, gaps requiring staffing redeployment, barriers to pathway progress or
discharge can be discussed and acted upon
• Introduction and regular reviews of the escalation and surge approaches to managing capacity are in
place with clear roles and actions identified
• Weekly meetings regarding winter pressures are held with local commissioners (CCGs), social care, mental
health and ambulance services
• Work to ensure that business presence is available at operations meetings to have access to accurate
elective data to support decision making regarding when and where more extreme action has to be taken
ie cancellation of elective surgery to ensure that patients on cancer or other priority pathways are treated
where possible
• The operations centre works closely with the infection control teams to support management of
outbreaks considering high level of demand for capacity. This results in robust information sharing
with community outbreaks to minimise risk if residents admitted from these areas.
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33
Overview of the quality of care against 2014/15 quality priorities:
2.1b Patient safety (PS)
PS1 MRSA Bacteremia Incidence
PS2C. Difficile
PS3Safety Thermometer (Community)
PS4Safety Thermometer (Acute)
Patient Safety
PS5Falls
PS6Pressure Ulcers
PS7Nutrition
PS8Hydration
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35
PS1 MRSA bacteraemia incidence
PS2 C. difficile incidence
TARGET: 0 MRSA bacteraemia developing after 48 hours into the inpatient stay (hospital acquired).
• TARGET: Achieve a level of no more than 33 hospital acquired C difficile cases over the financial year 2014/15
Achievement (April 2014 – February 2015): One case reported in February 2015.
Figure 8
• Achievement (April 2014 – February 2015): 20 cases. The Trust has achieved this quality priority as illustrated
8
graphically below.
Hopsital acquired MRSA bacteraemias (post 48 hours)
Figure 9
Jan
Feb
Dec
Oct
Nov
Sep
Jul
2013/2014
Aug
Jun
Apr
May
Mar
Jan
Feb
Dec
Oct
Nov
Sep
Jul
2012/2013
Aug
Jun
Apr
May
Mar
Jan
Feb
Dec
Oct
Nov
Sep
Jul
Aug
Jun
Apr
May
3
2
1
2013/2014
Jan
Feb
Dec
Oct
Nov
Sep
Jul
Aug
Jun
Apr
May
Mar
Jan
Feb
Dec
Oct
Nov
Sep
Jul
Aug
Jun
Apr
2012/2013
May
Mar
Jan
Feb
Dec
Oct
Nov
Sep
Jul
Aug
0
Jun
0
4
Apr
1
5
May
2
Number of C. Difficile infections (n=)
Number of MRSA bacteraemias (n=)
Hospital acquired Clostridium Difficile infections
6
3
NLaG
Target
7
2014/2015
2014/2015
Source: Trust infection control database, information services team
Source: Trust infection control database, information services team
• February 2015: 0 cases reported at Grimsby hospital
• February 2015: One case reported at Scunthorpe hospital
In 2013/2014 the Trust had five cases of hospital acquired MRSA bacteraemia (post 48 hours)
In 2012/2013 the Trust had two cases of hospital acquired MRSA bacteraemia (post 48 hours)
In 2011/2012 the Trust had four cases of hospital acquired MRSA bacteraemia (post 48 hours)
In 2010/2011 the Trust had eight cases of hospital acquired MRSA bacteraemia (post 48 hours)
Comments:
• Compliance during 2013/14 exceeded the Department of Health target of 0 hospital acquired MRSA Bacteraemia, but
did not exceed the Trust’s regulator, Monitor, target of no more than six
• Three cases of C difficile were identified in February 2015, bringing the cumulative total of 20 confirmed cases since
April 2014. This is significantly less than the maximum target set, the Trust’s performance against this important area is
also illustrated compared with other organisations, nationally and the local peer
• The Trust’s performance against infection control indicators has been excellent and compares favourably to both the
national and local benchmarking, this is illustrated over the page.
Figure 10
Trust performance versus Public Health England and NHS England statistics
Indicator
Data period
NLaG
National
average
Better /
worse
Local
peer
Better /
worse
MRSA bacteria rate per 100,000 bed days (ii)
Jul 14 - Sep 14
0.0
0.7
Better
0.8
Better
C. Difficile infection rate per 100,000 bed days (iii)
Jul 14 - Sep 14
11.2
11.2
Better
12.9
Better
• Since the beginning of the 2014/15 financial year, one hospital acquired MRSA bacteraemias has been identified
Source: Trust information team, derived from Public Health England and NHS England Statistics
• While disappointing to report one case at the end of the reporting period, the Trust’s performance in connection with
infection control indicators has been excellent and performs better than local and national peer benchmarking.
Key to abbreviations: NLAG – Northern Lincolnshire and Goole NHS Foundation Trust (the Trust)
National average – performance in other NHS organisations in the UK
Has the quality indicator been changed during the year from that set in last year’s (2013/14) Quality Account? No,
there has been no change to this quality priority during the 2014/15 reporting period.
Local peer –select group of NHS Trusts with similar characteristics to the Trust
Better / worse – Trust performance compared to peer
Rationale for changing this quality priority for 2015/16: Due to the important nature of this quality indicator, this will
remain a quality priority for 2015/16, and therefore be monitored in the monthly quality report by the Quality and Patient
Experience Committee (QPEC) and the Trust Board.
Comments:
• When comparing the Trust to the national and peer average, the Trust performs better in
these important areas
• As referred to earlier within this report, the Trust has faced significant increases
in demand on its services. While this will inevitably place additional stresses
on the system, it is reassuring to see excellent achievement of these infection
control targets, in this context, and compared with local and national
peers.
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37
To support the Trust’s focussed work around adhering to this quality indicator, the following tables detail the number of C
difficile cases by site that were not preventable, possibly preventable, and preventable.
PS3 Safety Thermometer – increase in harm free care (community)
This assessment and categorisation is based on the director for infection prevention and control (DIPC) review of the case
and the evidence recorded, from this the preventability of the case is decided. Due to the timescales involved for these
DIPC reviews, there will be a delay in reporting the outcomes when compared with the monthly data provided within this
report, therefore the numbers below may differ from the total number of cases detailed on the graph above. Where data is
unavailable, this will be reported at the earliest opportunity in subsequent quality reports.
During 2013/14 the Trust used the NHS Safety Thermometer
methodology to monitor the incidence of harm as a result of their
acute and community care (community care in North Lincolnshire
area only, which became a part of the Trust from April 2011).
Figure 11
C. difficile – preventable, possibly preventable and not preventable
Apr - 14
May - 14
Jun - 14
Jul - 14
Aug - 14
Sep - 14
Oct - 14
Nov - 14
Dec - 14
Jan - 15
Feb - 15
Total
Diana, Princess of Wales
Hospital, Grimsby
No. of cases eligible for DIPC review
2
4
3
3
0
1
3
1
1
0
1
2
1
1
2
25
No. of DIPC reviews outstanding
0
0
0
0
0
0
0
0
0
0
1
1
0
1
2
5
Not preventable
1
2
2
1
0
1
3
1
1
0
0
1
1
0
0
14
Possibly preventable
1
2
0
1
0
0
0
0
0
0
0
0
0
0
0
4
Preventable
0
0
1
1
0
0
0
0
0
0
0
0
0
0
0
2
Q1
Q2
Q3
Q4
2013/14 2013/14 2013/14 2013/14
The NHS Safety Thermometer
provides the ability for ‘a
temperature check’ of harm to be
recorded. It did this by auditing on
a point prevalence basis the care
provided to patients on a given date
each month. This point prevalence
audit provided a ‘snapshot’ view of
harm on that given day each month.
Apr - 14
May - 14
Jun - 14
Jul - 14
Aug - 14
Sep - 14
Oct - 14
Nov - 14
Dec - 14
Jan - 15
Feb - 15
Total
It focusses on harm in four key areas:
• Pressure ulcers grades 2,3 and 4
No. of cases eligible for DIPC review
3
3
1
0
0
0
0
3
0
0
0
1
0
1
1
13
No. of DIPC reviews outstanding
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1
• Falls – all falls reported, even if no
harm occurred
Not preventable
2
2
1
0
0
0
0
2
0
0
0
1
0
1
0
9
Possibly preventable
1
1
0
0
0
0
0
1
0
0
0
0
0
0
0
3
Preventable
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
May - 14
Jun - 14
Jul - 14
Aug - 14
Sep - 14
Oct - 14
Nov - 14
Dec - 14
Jan - 15
Feb - 15
Total
Q1
Q2
Q3
Q4
2013/14 2013/14 2013/14 2013/14
Apr - 14
Scunthorpe General Hospital
No. of cases eligible for DIPC review
0
1
0
0
0
0
0
0
0
0
0
1
0
0
0
2
No. of DIPC reviews outstanding
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Not preventable
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
1
Possibly preventable
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Preventable
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
1
Goole and District Hospital
Q1
Q2
Q3
Q4
2013/14 2013/14 2013/14 2013/14
Figure 12 • VTE – risk assessment,
prophylaxis and treatment of
DVT or PE
As a result, VTE is not included in
the following section pertaining
to community care Safety
Thermometer results.
For the community Safety
Thermometer, VTE is not relevant as
an indicator. In community practice,
patients are not routinely risk
assessed for VTE and any concerns
regarding a patient in this matter
would be referred to the patient’s
GP or to the acute Trust via A&E
attendance.
• TARGET: Provide harm free
community care to 95 per cent or
more patients – as measured by
the Safety Thermometer
• Achievement (April 2014 –
February 2015): 96 per cent. The
Trust has achieved this target for
five consecutive months in a row.
In the same way, prophylaxis, unless
prescribed by a doctor, would
not routinely be commenced by
community staff.
The following table illustrates
the total community cumulative
percentage of harm free care by
month since April 2013.
Cumulative % of Harm Free Care
Site
Q1
Q2
Q3
Q4
Q1
Q2
13/14 13/14 13/14 13/14 14/15 14/15
Oct
14
Nov
14
Dec
14
Jan
15
Feb
15
Community Care Total
93%
95%
95%
95%
97%
96%
91%
93%
94%
94%
95%
Source: NLAG Safety Thermometer data, intranet, information services team
Source: Trust infection control database, information services team
Key to abbreviations: DPoW – Diana, Princess of Wales Hospital
SGH – Scunthorpe General Hospital
DIPC – director of infection prevention and control
GDH – Goole District Hospital • Catheter associated UTIs – those
treated with antibiotics
Due to these differences, the
individual elements of this indicator
have been classed as not applicable
to the community care Safety
Thermometer results.
Key to abbreviations: Total – average performance within North Lincolnshire community care
Old harms – treatment commenced with a pre-existing ‘harm’ ie a pressure ulcer
New harms – identified following commencement of treatment
Comments:
Comments:
• It should be noted that the numbers in the above tables show a site specific breakdown of the same information
reported on the previous page for C difficile at Trust level, therefore the numbers may appear to differ.
• From an analysis of the community data, ‘old’ pressure ulcers have been consistently reported, lowering the cumulative
percentage, and making it difficult to ascertain and report problem areas.
Has the quality indicator been changed during the year from that set in last year’s (2013/14) Quality Account? No,
there has been no change to this quality priority during the 2014/15 reporting period.
Rationale for changing this quality priority for 2015/16: This indicator will remain, however in line with national
guidance, the target will be reduced from 33 to 21.
38
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39
Overall percentage of harm free care – EXCLUDING ‘old’ pressure ulcers
Figure 16
Falls percentage - Harm Free Care
The following table illustrates the overall percentage of harm free care, excluding ‘old’ harms (specifically – excluding ‘old’
pressure ulcers).
Period
Q1
13/14
Q2
13/14
Q3
13/14
Q4
13/14
Q1
14/15
Q2
Oct 14 Nov 14 Dec 14 Jan 15 Feb 15
14/15
The table below outlines performance since January 2014.
Community Care Total
99.3%
98.5%
99.0%
99.3%
99.5%
98.1%
Figure 13
99.4%
99.6%
99.6%
Q4
13/14
Q1
14/15
Q2
14/15
Oct 14 Nov 14 Dec 14 Jan 15 Feb 15
Community Care Total
98.5%
98.8%
98.5%
99.3%
98.4%
98.5%
99.2%
Key to abbreviations: Total – average performance within North Lincolnshire community care
99.5%
Source: NLAG Safety Thermometer data, intranet, information services team
Old harms – treatment commenced with a pre-existing ‘harm’ ie a pressure ulcer
New harms – identified following commencement of treatment
Comments:
• Community harm free care (‘new’ harms only) was 99.2 per cent during January 2015, and has remained consistently
high since monitoring began.
To enable further action to be taken, the overall percentage for community has been broken down into the four component
parts that comprise this indicator.
(Source data for the following tables: NLAG Safety Thermometer data, intranet, information services team)
Old harms – treatment commenced with a pre-existing ‘harm’ ie a pressure ulcer
New harms – identified following commencement of treatment
Period
Q1
13/14
Q2
13/14
Q3
13/14
Q4
13/14
Q1
14/15
Q2
Oct 14 Nov 14 Dec 14 Jan 15 Feb 15
14/15
Community Care Total
97.0%
96.7%
97.0%
97.0%
97.2%
95.3%
96.6%
96.6%
Catheter associated UTIs: percentage - Harm Free Care
Period
Q1
13/14
Q2
13/14
Q3
13/14
Q4
13/14
Q1
14/15
Q2
Oct 14 Nov 14 Dec 14 Jan 15 Feb 15
14/15
Community Care Total
99.1%
99.3%
99.0%
99.6%
99.6%
98.5%
99.3%
99.4%
99.7%
98.9%
Source: NLAG Safety Thermometer data, intranet, information services team
Key to abbreviations: Total – average performance within North Lincolnshire community carR
Old harms – treatment commenced with a pre-existing ‘harm’ ie a pressure ulcer
New harms – identified following commencement of treatment
98.0%
95.8%
Rationale for changing this quality priority for 2015/16: As patient safety is such an important indicator to the Trust, this
will remain as a quality priority for 2015/16 to ensure that practice has become embedded.
Source: NLAG Safety Thermometer data, intranet, information services team
Key to abbreviations: Total – average performance within North Lincolnshire community carE
Old harms – treatment commenced with a pre-existing ‘harm’ ie a pressure ulcer
New harms – identified following commencement of treatment
Pressure ulcers (grades 2, 3 and 4) – New only:
Period
Q4
13/14
Q1
14/15
Q2
14/15
Oct 14
Nov 14 Dec 14
Jan 15
Feb 15
Community Care Total
98.8%
98.9%
99.0%
99.4%
98.7%
99.8%
99.3%
98.9%
Source: NLAG Safety Thermometer data, intranet, information services team
Key to abbreviations: Total – average performance within North Lincolnshire community carE
Old harms – treatment commenced with a pre-existing ‘harm’ ie a pressure ulcer
New harms – identified following commencement of treatment
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98.6%
Has the quality indicator been changed during the year from that set in last year’s (2013/14) Quality Account? No,
there has been no change to this quality priority during the 2014/15 reporting period.
Pressure ulcers (grades 2, 3 and 4) – INCLUDING both old and new:
98.9%
Figure 17
Key to abbreviations: Total – average performance within North Lincolnshire community care
Figure 15
99.2%
Source: NLAG Safety Thermometer data, intranet, information services team
Period
Figure 14
100%
41
Open and Honest Initiative: Safety Thermometer (‘new’ harms only)
PS4 Increase in harm free care (acute)
The NHS Safety Thermometer is
based on a point prevalence analysis
of the care provided to patients
on a given date each month. This
point prevalence audit provided
a ‘snapshot’ view of harm on that
given day each month. It focussed
on harm in four key areas:
• Pressure ulcers grades 2,3 and4
• Falls – all falls reported, even if no
harm occurred
• Catheter associated UTIs – those
treated with antibiotics
• VTE – ‘new’ resulting in treatment
being commenced after
admission.
In November 2013, the Trust was
involved in another important
milestone project – the Transparency
project, now known as the Open and
Honest Care initiative.
This initiative, led by NHS England
is designed to allow a mechanism
for NHS organisations to publish
information on the rates of harm,
patient and staff experience and
staffing levels in ‘real time’, in this
case information pertaining to the
care provided during the preceding
month.
This publication pulls together
information from existing data
allowing for data relating to all
patients, not purely relying on
a snapshot sample, to guide the
Trust in its quest for continuous
improvement around quality and
safety, but also enabling greater
patient choice. This information,
amongst other data, also contains
the previously focussed on Safety
Thermometer information reporting
point prevalence data.
Therefore, in changing the focus of
this following section, the following
benefits are realised:
• All patient harm is now
encapsulated in this report – an
improvement over the previously
used snapshot sample only
approach
• ‘Real time’ information
reporting, providing most recent
information enabling board to
ward assurance.
On one day each month we check to see how many of our patients suffered certain types of harm, some old harms are
present when the patient is admitted so acquired prior to the patient’s care commencing in hospital, others are new,
acquired following admission.
Whilst the headline Open and Honest Care data includes Safety Thermometer data which includes old and new harms, the
chart below excludes old harms – or those a patient presents with prior to admission to the Trust. This section therefore
focusses solely on providing the Trust information on where it needs to ensure continuous quality focus/improvement,
post admission.
Figure 18 The following section will report
harm following care commencement
in the Trust, for the preceding month
for the following key indicators:
• NHS Safety Thermometer (four
key areas – pressure ulcers
(‘new’ and ‘old’), falls, catheter
associated UTIs and ‘new’ VTEs)
– outcomes of point prevalence
data collection
• Pressure ulcers – all incidences
within the preceding month
(hospital acquired)
• Falls – all incidences within
preceding month that led to
either moderate or severe harm.
Trust headline figure: Percentage who did not experience any ‘new’ harms
100
99
98
Percentage %
During 2013/14 the Trust used the NHS Safety Thermometer
methodology to monitor the incidence of harm as a result of their
acute and community care (community care in North Lincolnshire
area only, which became a part of the Trust from April 2011).
Headline figures – Performance as a Trust (‘new’ harms only included):
97
96
95
94
93
Jan
14
Feb
14
Mar
14
Apr
14
May
14
Jun
14
Jul
14
Aug
14
Sept
14
Oct
14
Nov
14
Dec
14
Jan
15
Feb
15
No Harm
94.3%
94.7%
96.3%
97.2%
98.1%
96.4%
97.6%
94.6%
96.9%
96%
95.4%
95.1%
96.6%
97.5%
Target
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
Source: NLAG Safety Thermometer data, information services
Key to abbreviations: No harms percentage - percentage of patients without any ‘new’ harms identified, those identified whilst the patient was in hospital.
Comments:
PS4 Provide harm free acute care to 95 per cent or more patients – as measured
by the Open and Honest Initiative
• TARGET: Provide harm free acute care to 95 per cent or more patients – as measured by the Open and Honest
Initiative
• The trend line in the above chart illustrates that since January 2014 Trust performance has gradually improved in
connection with increased levels of harm free care
• The overall percentage has risen this month to 97.5 per cent.
• Achievement (April 2014 – February 2015): 91.5 per cent. From recent monitoring the number of patients who did
not experience harms has not met the target set, this will remain a quality priority target throughout 2015/16.
42
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43
Open and Honest Initiative: Safety Thermometer (all harms)
Figure 19
Figure 20 Headline figures – Performance at site level (‘new’ and ‘old’ harms included):
The following chart breaks down the overall ‘headline’ figure to site specific detail. This information is for ‘new’ and ‘old’
harms, reported since October 2013.
Headline figures – Performance as a Trust (‘new’ and ‘old’ harms included):
The chart below shows the percentage of patients who did not experience any harm (‘new’ or ‘old’), since October 2013.
100
98
96
95
94
92
90
90
88
86
85
84
82
Oct
13
Nov
13
Dec
13
Jan
14
Feb
14
Mar
14
Apr
14
May
14
Jun
14
Jul
14
Aug
14
Sept
14
Oct
14
Nov
14
Dec
14
Jan
15
Feb
15
No Harm
90%
91.7%
97.2%
94.3%
89.5%
96.4%
93.2%
95.3%
93.2%
93.9%
90.2%
89.3%
89.1%
89.3%
87%
91.5%
89.1%
Target
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
80
Source: NLAG NHS Safety Thermometer, as reported within the open and honest initiative, NHS England
Key to abbreviations: No harms percentage – reported levels of patients not having any new or old harms
75
Comments:
• Harm free care within the acute Trust was provided to 91.5 per cent of patients, this was below the 95 per cent target
set. The trend line demonstrates that performance has been declining
• The above information includes both new and old harms. When considering new harms only (presented on the
previous page) those acquired following admission to the acute Trust has consistently been above 95 per cent. The
Trust does not view it simplistically that old harms are outside of our control, and work is underway to understand
what and where ‘old’ harms, specifically pressure ulcers, present from and what the acute Trust and the community and
therapy services element of the Trust in North Lincolnshire can do to prevent ‘old’ harms. This work is underway and
will be reported and updated on within the monthly quality report.
70
Oct
13
Nov
13
Dec
13
Jan
14
Feb
14
Mar
14
Apr
14
May
14
Jun
14
Jul
14
Aug
14
Sept
14
Oct
14
Nov
14
Dec
14
Jan
15
Feb
15
DPoW
89.1%
91.2%
96.1%
95.6%
86.9%
95.9%
94.8%
95.6%
94.6%
93.7%
92.6%
88.2%
85.4%
93.8%
87.1%
90.2%
90.7%
SGH
90.4%
93.3%
97.2%
93.1%
91.5%
96.6%
92%
94.7%
91.9%
93.8%
87.1%
89.8%
92.9%
85.4%
86.5%
92.5%
86.5%
GDH
91.3%
76.5%
96%
91.3%
96.4%
100%
83%
96.3%
88.9%
100%
100%
100%
91.7%
72.2%
91.3%
95.8%
100%
Target
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
Source: NLAG Safety Thermometer data, as reported within the open and honest initiative, Information Services
Key to abbreviations: DPoW – average performance within North Lincolnshire community carE
SGH – Scunthorpe General Hospital
Goole – Goole and District Hospital
Any harms – ‘new’ or ‘old’ harms, as defined by NHS Safety Thermometer
Comments:
• Goole performance is 100 per cent. As Goole has small numbers of patients compared with the larger hospitals, it is
very susceptible to small number variation
• DPoW and SGH percentage of those who did not experience any harms were 90.7 per cent and 86.5 per cent during
February.
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45
Action now being taken:
Contributing to overall performance in February were the following harms identified:
DPoW:
SGH:
Goole:
• 97.8 per cent had no ‘new’
pressure ulcers, 95.2 per cent had
no ‘old’ pressure ulcers
• 99.1 per cent had no ‘new’
pressure ulcers, 90.9 per cent had
no ‘old’ pressure ulcers
• 100.0 per cent had no ‘new’
pressure ulcers, 100.0 per cent
had no ‘old’ pressure ulcers
• 96.9 per cent were UTI free
• 93.7 per cent were UTI free
• 97.5 per cent had no falls
• 95.9 per cent had no falls
• 95.2 per cent had no falls (one
patient had a fall, but suffered no
harm as a result),
• 5.9 per cent ‘new’ VTEs requiring
treatment following admission.
• 2.5 per cent ‘new’ VTEs requiring
treatment following admission.
• 0.0 per cent ‘new’ VTEs requiring
treatment following admission.
Performance with additional indicators relating to Venous Thromboembolism (VTE) are also captured by the Safety
Thermometer, these are illustrated below for the month of February and also performance trends over time.
Month of February:
DPoW:
SGH:
• 81.1 per cent VTE risk assessment completed, 64.6
per cent VTE prophylaxis given
• 97.7 per cent VTE risk assessment completed, 97.1 per
cent VTE prophylaxis given.
• VTE performance, as monitored by the Safety Thermometer tool methodology, has been monitored for some months
now in the quality report. As a result of previously reporting gaps, appendix 1 of the monthly quality report now
includes a focussed version of this information, presented at individual ward level
• For ease of reference regarding the work underway to improve the quality of care for patients with pressure ulcers,
please see section PS6 within this report.
Safety Thermometer – harm free care benchmarking derived from the Health
and Social Care Information Centre (HSCIC)
The following indicators derived from HSCIC give an indication of the quality of care through a defined measure of harm
free care (Safety Thermometer).
Figure 22
Indicator
Data period
NLaG
National
average
Better /
worse
Local
peer
Better /
worse
Safety thermometer
Harm free care - Acute hospital
Jul 14 - Sep 14
91.2%
93.7%
Worse
92.7%
Worse
Safety thermometer
Harm free care - Community
Jul 14 - Sep 14
94.5%
93.5%
Better
-
-
Source: Information services, derived from HSCIC
Figure 21
Trend over time – VTE risk assessment completion:
Key to abbreviations: NLAG – Northern Lincolnshire and Goole NHS Foundation Trust (the Trust)
100
National average – performance in other NHS organisations in the UK
95
Local peer –select group of NHS Trusts with similar characteristics to the Trust
Better / worse – Trust performance compared to peer
90
Comments:
85
• The period of time presented in the above table, compared with the national average differs to that reported in the
body of the quality report, over the preceding pages
• As illustrated already, performance, measured by harm free care, in the community is performing well, exceeding the
national average
80
75
70
• The acute Trust performance, again as already illustrated, has been declining. Compared with the national average,
and local peer, the Trust performs worse.
May 14
Jun 14
Jul 14
Aug 14
Sept 14
Oct 14
Nov 14
Dec 14
Jan 15
Feb 15
DPoW
85.5%
91.7%
SGH
96.7%
96.3%
92.3%
83%
91.7%
84.2%
74.5%
88.5%
78.1%
81.1%
96.4%
97.3%
96.6%
96.6%
93.4%
93.7%
99.1%
97.7%
Source: NLAG NHS Safety Thermometer, VTE risk assessment completion as reported within the Open and Honest Iinitiative, NHS England
Key to abbreviations: DPoW – Diana, Princess of Wales Hospital
SGH – Scunthorpe General Hospital
VTE risk assessment completed – from the information recorded as part of the dataset for the NHS Safety Thermometer, at the time of the audit, the number of patients with a completed VTE risk assessment form
46
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47
Open and Honest Initiative: Falls
Open and Honest Initiative: Pressure ulcers
Headline figures – Performance as a Trust (new harm only):
Headline figures – Performance as a Trust (new harm only):
The following chart illustrates the number of falls, identified from all reported incidents, since October 2013, including the
level of harm and the falls rate per 1000 bed days. The chart also illustrates the trend over time.
The following chart illustrates the number of pressure ulcers since October 2013, including the level of harm and the
pressure ulcers rate per 1000 bed days. The chart also illustrates the trend over time.
Figure 23
Figure 24 60
3.5
Severe
Death
Falls rate per 1000 bed days
Cumulative number of falls (n=)
2.0
0.08
1.5
0.06
1.0
0.04
0.5
0.02
0.0
0.0
Oct
13
Nov
13
Dec
13
Jan
14
Feb
14
Mar
14
Apr
14
May
14
Jun
14
Jul
14
Aug
14
Sept
14
Oct
14
Nov
14
Dec
14
Jan
15
Key to abbreviations: Cumulative number of falls (n=) – cumulative numbers of falls of all harm severity
Moderate – moderate harm resulting from the fall (see glossary for full definition)
Severe – severe harm resulting from the fall (see glossary for full definition)
Death – death resulting from the fall
Falls rate per 1000 bed days – the number of falls expressed as a percentage rate per 1000 bed days toallow for comparison Comments:
• The above chart reports the harm classifications following falls, specified by the Open and Honest Initiative, specifically
resulting in moderate, severe harm, or harm leading to death
• The falls rate per 1000 bed days allows comparison, despite differing numbers of patients. This peaked in December
at 0.13 per 1000 bed days. This was driven by three patients identified as having a fall resulting in death, as the
classification of harm. All three patients were at SGH.
• In January, an additional patient was also identified as having a fall that resulted in death. This has been grouped
with the three cases from December and all have been escalated as Serious Untoward Incidents (SUIs) for further
investigation. This work is now underway. To date three out of the four are completed and have been submitted to
commissioners for their comments and approval of the investigative work undertaken. Once all are completed, a
meeting will be organised to assess all the incidents, however from each reviewed to date, all were deemed to be
accidents with no common themes arising.
• Action now being taken:
• For ease of reference regarding the work underway to improve the quality of care for patients at risk of falling, please
see section PS5 within this report.
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PU rate per 1000 bed days
2
40
1.5
30
1
20
0.5
10
0
0
Oct
13
Feb
15
Source: NLAG Specific Findings from Open and Honest Initiative, NHS England
Hopsital acquire Grade 4
Rate per 1000 bed days (percentage %)
0.10
Falls per 1000 bed days (percentage %)
2.5
Hopsital acquire Grade 3
50
0.12
Cumulative number of pressure ulcers (n=)
Moderate
3.0
2.5
Hopsital acquire Grade 2
0.14
Nov
13
Dec
13
Jan
14
Feb
14
Mar
14
Apr
14
May
14
Jun
14
Jul
14
Aug
14
Sept
14
Oct
14
Nov
14
Dec
14
Jan
15
Feb
15
Source: NLAG Specific Findings from Open and Honest Initiative, NHS England
Key to abbreviations: Cumulative number of pressure ulcers (n=) – cumulative numbers of all grades
Hospital acquired grade 2 – grade 2 pressure ulcer (see glossary for full definition)
Hospital acquired grade 3 – grade 3 pressure ulcer (see glossary for full definition)
Hospital acquired grade 4 – grade 4 pressure ulcer (see glossary for full definition)
Rate per 1000 bed days – the number of pressure ulcers expressed as a percentage rate per 1000 bed days to allow for comparison
Comments:
• The pressure ulcer rate per 1000 bed days demonstrates an increasing trend over time
• In February the overall number of pressure ulcers was 30 in total, made up of one grade 4 pressure ulcer, 10 grade 3
pressure ulcers and 19 grade 2 pressure ulcers
• In December and January an increased number of grade 2 pressure ulcers can be seen, however this has reduced in
February.
Action now being taken:
• The above chart illustrates the numerical side of this story whilst a more detailed clinical
narrative of the work around this area is contained in section PS6 within this report, to avoid
duplication of key work streams throughout this document.
Has the quality indicator been changed during the year from that set in last year’s
(2013/14) Quality Account? No, there has been no change to this quality priority
during the 2013/14 reporting period.
Rationale for changing this quality priority for 2015/16: As patient safety
is such an important indicator to the Trust, this will remain as a
quality priority for 2015/16.
49
National CQUIN Target: Maintain pressure ulcer rate at or below the baseline
Another CQUIN (Commissioning for Quality and Innovation) relates to the area of pressure ulcers, as reported within the
NHS Safety Thermometer (and reported as part of the Open and Honest Initiative, referred to on the preceding page). The
previous summary of this data has concentrated on new harms resulting from pressure ulcers, for the CQUIN target, all
harms resulting from pressure ulcers are focussed on. The financial value of this CQUIN is £397,277.
This National CQUIN is based on local trending information. The target, as a result of this, is based on the Trust’s previous
median value. When worked out this equated to 5.99 per cent. This has been used to base the target on, specifically that
five consecutive months to the end of March 2015 are lower than 5.99 per cent. The following chart illustrates the Trust’s
current performance against this target.
Figure 25
Pressure ulcer rate percentage (%)
9
NLaG Pressure ulcer rate (per month)
8
PS5 Patient falls
An introduction
using an approved root cause
analysis (RCA) process culminating
in a meeting with ward staff to
determine if the patients fall could
have been avoided or not. Using
the outcomes of this information,
enables us to track progress with
avoiding future falls.
Another element of the NHS Safety Thermometer is patient falls.
The indicator breaks down degrees of harm resulting from a patient
falling within the Trust.
undertaken to reduce falls and
repeat falls is making a difference
to the degrees of harm resulting.
Using this information, the Trust
is able to discern both the rate
of patient falls including trends
over time, while also being able
to determine if the work being
To aid this approach, each repeat fall
reported within the Trust is assessed
7
PS5 – Patient falls – eliminate all avoidable repeat fallers
6
• TARGET: Eliminate all avoidable repeat falls as measured via the root cause analysis undertaken for every repeat faller
5
• Achievement (April 2014 – February 2015): This target has been met in five months over the last 10 months, this is
graphically illustrated below.
4
Falls has been an area of focus for some time within the Trust. The lead quality matron for falls is supporting proactive work
to prevent falls occurring within the acute Trust.
3
2
1
0
Apr
14
May
14
Jun
14
Jul
14
Aug
14
Sept
14
Oct
14
Nov
14
Dec
14
Jan
15
Feb
15
Pressure
ulcers
4.82%
4.43%
5.22%
5.10%
4.99%
7.04%
6.04%
7.06%
7.64%
5.47%
6.65%
Target
5.99%
5.99%
5.99%
5.99%
5.99%
5.99%
5.99%
5.99%
5.99%
5.99%
5.99%
Source: NLAG Specific Findings from NHS Safety Thermometer, NHS England
Comments:
• In September 2014, the Trust’s rate of ‘old’ and ‘new’ pressure ulcers increased above the 5.99 per cent target being
aimed for. This has continued above the target till December 2014. The February 2015 rate was 6.65 per cent. This
CQUIN target is currently not being attained
To achieve this, for every repeat fall a RCA is performed to identify lessons that can be learnt to prevent future patients
falling. As part of the RCA work undertaken, each fall is determined to have been either avoidable or unavoidable. From
April 2014, reported below, the target has been amended to eliminate all avoidable repeat fallers.
The following table provides a summary of performance per month against this target.
Figure 26
Number of
Repeat Fallers
Avoidable
Unavoidable
Q1
Q2
Q3
Q4
Q1
2013 /14 2013 /14 2013 /14 2013 /14 2014 /15
Jul 14
Aug 14 Sep 14
Oct 14
Nov 14 Dec 14
Feb 15
65
65
56
60
56
22
22
15
19
19
24
21
18
14
11
3
5
4
0
1
0
2
0
0
1
0
22%
17%
5%
8%
7%
0%
5%
0%
11%
0%
0%
5%
0%
51
54
53
20
20
22
21
15
17
19
24
20
18
78%
83%
95%
33%
36%
100%
95%
100%
89%
95%
100%
• NB: It should be noted that this information is based on the Safety Thermometer information, a snapshot sample in
time, whereas the preceding page outlined the open and honest dataset, containing all pressure ulcers. This explains
any difference in reported data.
Data Source: Action now being taken:
Key to abbreviations: Avoidable – fall deemed to be avoidable as a result of the Root Cause Analysis (RCA)
• For ease of reference regarding the work underway to improve the quality of care for patients with pressure ulcers,
please see section PS6 within this report.
Jan 15
100% 100%
RCA Records kept by lead quality matron
Unavoidable – fall deemed to be unavoidable
Comments:
• In February, no falls were deemed to be avoidable following the root cause analysis process.
Action now being taken:
• The care rounds form has been amended and now uploaded ready for trial period from April
2015. Utilisation of care rounds to be discussed at matron weekly meeting to ensure
compliance
50
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• The NED challenge meetings continue to be held with one single joint meeting
being held with all four quality matrons in attendance to review progress
against falls, dementia, hydration/nutrition and pressure ulcers.
This is a comprehensive meeting which enables the
team to share ideas across all key
lead areas
51
• Root Cause Analysis (RCA) meetings continue to be held monthly at SGH and DPoW while Goole meetings are held
quarterly. Ward sisters/charge nurses and ward staff attend to review patient cases. RCA meetings to also capture
multiple patient moves as a potential factor to aid understanding of the context
• Medical electronics have been contacted regarding finding available space for the sensor pads to be stored in a central
location for ease of access and stock take purposes to ensure these are available for all ward areas when a patient’s risk
factors merit the use of falls sensors
• Patients with alcohol/drug dependency have been identified as providing challenging issues for both nursing and
medical staff. This is to be escalated further by deputy chief nurse. Ward C6 at DPoW has had seven repeat fallers, six of
whom were related to alcohol
The information below is taken from records kept by the lead quality matron as a result of the RCA work taking place for
patients with grades 2, 3 and 4 pressure ulcers.
In order to determine the local target metrics, total numbers of avoidable grade 2, 3 and 4 pressure ulcers were
identified for quarter one, which resulted in 12 that were deemed to be avoidable following the root cause analysis work
undertaken.
Based on this, setting a 50 per cent reduction target, equates to no more than six pressure ulcers per quarter. Six per
quarter, divided by three months, equates to no more than two avoidable pressure ulcers per reported month.
Figure 27
• Ward 23 at SGH has had 27 repeat fallers, 15 of whom were related to alcohol. Parkinson’s, dementia, delirium and
sepsis featured as other related themes
Number of Grades 2,
3 & 4 Pressure Ulcers
• Charitable Funds Committee has approved the purchase of a further 19 low level beds
Avoidable
• Training on falls prevention continues. This was achieved through a combination of online, face-to-face and work
booklet training.
Has the quality indicator been changed during the year from that set in last year’s (2013/14) Quality Account? No,
there has been no change to this quality priority during the 2014/15 reporting period.
Rationale for changing this quality priority for 2015/16: As patient safety is such an important indicator, the Trust will
continue to monitor this quality priority monthly within the quality report.
Unavoidable
Q1
Total
Q2
Total
Oct
Nov
Dec
14
14
87
85
28
12
24
13%
Jan
Feb
14
Q3
Total
15
15
32
43*
85
50#
30^
6
8
1
24
3
1
28%
21%
25%
4%
28%
9%
5%
75
61
22
23
27
61
33
21
87%
72%
79%
72%
96%
72%
91%
95%
February’s
breakdown
Grade Grade Grade
2
3
4
19
10
1
Source: RCA records kept by lead quality matron
* 15 were not reviewed prior to discharge by tissue viability nurses, due to insufficient capacity in the team.
#
14 were not reviewed prior to discharge by tissue viability nurses, due to insufficient capacity in the team.
^ Three grade 2 pressure ulcers were unverified (two due to patient discharge, prior to being seen, and one patient died), five grade 3s
PS6 Pressure ulcers
require additional information and RCA meetings to be held.
An introduction
• During February the number of pressure ulcers reported was 30, a reduction on the previous month’s total of 50
Patient safety – the Trust’s open and honest approach
As part of the Open and Honest dataset, the Trust publishes the number of grade 2, 3 and 4 pressure
ulcers and undertakes a root cause analysis on all of these.
• To understand this area in more detail a focussed meeting with the chief nurse is being organised alongside a number
of focussed pieces of work are being initiated to assess the relationship between Trust services and ‘old’ pressure
ulcerations, reviewing the information available at each site for trends in relation to bed pressures and the necessity
to transfer patients and the effect of recent Dragon’s Den initiatives to do with pressure ulcer ‘Pressure Ulcer Grading’
wheels and mirrors.
A transparent culture builds public confidence in the nursing care patients receive and ensures organisational
accountability for care.
PS6 Pressure ulcers – 50 per cent reduction in avoidable grade 2, 3 and 4
pressure ulcers
Comments:
Action now being taken:
• A piece of work is underway to ensure all RCAs are received and reviewed in a more efficient manner. Some ward areas
are not returning RCA information in a timely manner so this will be addressed as part of this
• TARGET: Reduction by 50 per cent avoidable grade 2, 3 and 4 pressure ulcers as measured via the root cause analysis
undertaken
• A consultation paper is being written to explore options around delivery of the tissue viability service across the Trust
including the in hospital and community teams
• Achievement (April 2014 – February 2015): This target has not yet been met, therefore this target will remain for
2015/16.
• Ward sisters/charge nurses continue to receive support in completing RCAs in a timely manner and RCA meetings
continue monthly with Ward sisters/charge nurses bringing along staff members to ensure lessons are learned for the
ward teams. Where needed extraordinary RCA meetings are arranged within the same month to
capture any themes and trends
Avoidable grade 2, 3 and 4 hospital acquired pressure ulcers – RCA outcomes –
50 per cent reduction in avoidable grade 2, 3 and 4 pressure ulcers
The Trust has actively been focussed on reducing hospital acquired pressure ulcers. The following table focusses on the
number of potentially avoidable grade 2, 3 and 4 pressure ulcers.
This is first time the root cause analysis work will include grade 2 pressure ulcers as well as previously reported grades 3
and 4. This results in a strengthened quality improvement focussed target.
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• Process for investigating a grade 3/4 pressure ulcer has been reviewed and updated (by the
deputy chief nurse) which has resulted in greater clarity, specifically:
- If a cluster of pressure ulcers are reported within the same week from one
area, this will trigger a multi-disciplinary team review to consider urgent
actions to be taken, including tissue viability nurses/quality
matrons/operational matrons 53
- If two avoidable pressure ulcers are identified within a two month time frame, this will trigger escalation to the
chief nurse for a detailed review of the ward and any contributory factors/risks. Due to this new process the first
escalation meeting was arranged in December for a ward at DPoW
• All dynamic mattresses have to be cleaned off site after each patient. The current contract cannot cope with the
demand for mattress cleaning, the Trust has invested in additional dynamic mattresses but we are not feeling the
benefit as mattresses are waiting for transportation, cleaning and return which can put a mattress out of action for
up to one week. A business case is currently being developed by medical engineering to enable them to process and
clean mattresses; this would require relocation of the medical engineering team/department to give them the space
to clean mattresses
PS7.1 – Nutrition – for 100 per cent of patients the nutrition care pathway was followed:
• TARGET: In 100 per cent of patients, the nutrition care pathway was followed
• Achievement (April 2014 – February 2015): This target has not yet been met, therefore this target will remain for
2015/16.
The following chart illustrates current levels of compliance with using the care pathway following rollout of the MUST
scoring system in September 2013.
Figure 28
100
• The small hand-held mirrors have now been received into the Trust and have been launched, these were purchased
from the Dragons Den work and will aid with the inspection of hard to assess pressure areas.
98
Has the quality indicator been changed during the year from that set in last year’s (2013/14) Quality Account? No,
there has been no change to this quality priority during the 2014/15 reporting period.
Rationale for changing this quality priority for 2015/16: As patient safety is such an important indicator to the Trust, and
as this target has not yet been met, the Trust will continue to monitor this within the monthly quality report.
PS7 Nutrition
With a change in screening tool new
documentation was required which
led to the opportunity to incorporate
92
90
88
86
84
80
PS7 is a new indicator for 2014/15. It has been included as a quality
priority for the Trust Board to ensure patients while in hospital have
this, a crucial element of their care, focussed upon, that of their
nutrition. This focussed quality improvement project relates to the
Trust’s continued work to understand quality related issues affecting
patient safety.
This was implemented within all
adult inpatient ward areas (excluding
maternity, day surgery and
investigations unit).
94
82
PS7.1 Nutrition – for 100 per cent of patients the
nutrition care pathway was followed:
In September 2013 the Trust moved
away from its local screening tool for
nutrition to a nationally validated
tool – the Malnutrition Universal
Screening Tool (MUST).
Percentage (%) completed
96
both nutrition and hydration into
one care pathway.
The MUST screening tool is used to
identify those patients who are at
risk of malnutrition – depending on
the MUST score – a management
plan is then followed for the duration
of the patients stay.
The total MUST score for a patient
is worked out from their BMI, the
amount of unplanned weight loss
they may have and the ‘acute disease
Jan 14
Feb 14
Mar 14
Apr 14
May 14
Jun 14
Jul 14
Aug 14
Sept 14
Oct 14
Nov 14
Dec 14
Jan 15
Feb 15
effect’ (if the patient is acutely ill and
there has been or likely to be no
nutritional intake for >5 days).
Trustwide
84%
92%
93%
88%
93%
95%
94%
90%
94%
93%
93%
95%
97%
97%
DPoW
81%
94%
88%
87%
91%
95%
94%
90%
93%
93%
90%
92%
96%
95%
SGH
85%
89%
96%
88%
95%
95%
94%
90%
94%
93%
94%
98%
98%
98%
GDH
100%
100%
100%
100%
100%
100%
100%
94%
100%
100%
100%
100%
100%
100%
The MUST score triggers appropriate
action, as described below:
Threshold
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
• MUST score of 0: Low risk and
require screening weekly
• MUST score of one: Moderate risk
and require screening weekly,
commencement and completion
of a food record chart, to be
encouraged to have fortified
meals from the food menu,
offered snacks from the Trust
wide snack list
• MUST score of two or more:
High risk and require the same
management as those patients
scoring one plus a referral to the
dietician for a dietetic review.
Source: Information services, nursing dashboard
Key to abbreviations: Trustwide – Northern Lincolnshire and Goole NHS Foundation Trust overall
DPoW – Diana, Princess of Wales Hospital; SGH – Scunthorpe General Hospital
GDH – Goole District Hospital
NB: The above charts axis starts at 80 per cent.
Comments:
• Performance against this indicator at all DPoW and SGH has not yet achieved the 100 per cent target set
• Compliance in February in SGH has remained at 98 per cent and DPoW has dipped slightly to 95 per cent. Goole have
achieved 100 compliance.
• The trend line demonstrates improvement across all three sites.
Action now being taken:
• Introduction of volunteers at mealtimes on some wards to assist patients with eating/drinking
• Expectation that all patients have a MUST screen entered electronically from
November 1
• Additional support has also been agreed by allowing further scrutiny and
challenge from a non-executive director who will join the nursing teams
overseeing this area, providing a fresh pair of eyes to this area
with a view to supporting the team make further
improvements
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55
• Information for patient leaflet on Eating and Drinking Whilst in Hospital approved and uploaded – to be circulated to
wards
The following chart illustrates the current compliance with ensuring the food record chart was used fully and
appropriately.
• Information for patient leaflet on Helping Yourself to Eat Well Whilst in Hospital for patients identified as at risk of
malnutrition written and circulated for comments prior to approval at Information for Patient Group
Figure 29 100
• Creation of an approved nutrition screening tool for paediatrics (PYMS) – implemented during December within
inpatient areas
98
96
Percentage (%) completed
• Creation of a nutrition and hydration care pathway for implementation with the PYMS screening tool within
paediatrics
• The week commencing March 16 2015 was the international nutrition and hydration week. To coincide, a number of
local activities within the Trust to raise awareness were held, these included:
- Nutrition information stands to raise awareness on making correct food choices which included leaflets, word
searches along with hydration products being given out to improve hydration
- Staff, patients and public had a chance to make their own smoothies by pedalling a bike to produce a tasty drink
- Members of the senior management and nursing teams visiting wards, serving tea and cakes, supported by
information for patients
- Information offered on dental hygiene/care
- Experiential feeding was provided by the speech and language team which offered members of the public the
chance to attend and become involved.
94
92
90
88
86
84
82
80
- Colourful children’s ‘Alice in Wonderland’ themed tea party on Rainforest and Disney wards along with ‘change for
life’ information, colouring sheets
- Information on gluten free options
In 100% of patients the food record chart was completed accurately and fully, in line with the care pathway
Jan 14
Feb 14
Mar 14
Apr 14
May 14
Jun 14
Jul 14
Aug 14
Sept 14
Oct 14
Nov 14
Dec 14
Jan 15
Feb 15
Trustwide
93%
95%
95%
88%
97%
94%
96%
93%
94%
96%
94%
90%
88%
92%
DPoW
95%
97%
96%
87%
96%
95%
97%
94%
93%
96%
97%
86%
89%
90%
SGH
90%
93%
93%
88%
98%
93%
95%
92%
96%
94%
91%
93%
86%
93%
GDH
100%
90%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
95%
100%
Threshold
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
Source: Information services, nursing dashboard
Key to abbreviations: Trustwide – Northern Lincolnshire and Goole NHS Foundation Trust overall
DPoW – Diana, Princess of Wales Hospital; SGH – Scunthorpe General Hospital
GDH – Goole and District Hospital
NB: The above charts axis starts at 80 per cent.
Has the quality indicator been changed during the year from that set in last year’s (2013/14) Quality Account? No,
there has been no change to this quality priority during the 2014/15 reporting period.
Rationale for changing this quality priority for 2015/16: As nutrition and hydration are crucial indicators to the Trust, and
as this target has not yet been met, the Trust will continue to monitor this within the monthly quality report.
PS7.2 Nutrition
PS 7.2 is also a new indicator for 2014/15 and continues the nutrition theme, this time focussing on ensuring that those
patients who are identified as moderate to high risk (MUST score >1) have a food record chart commenced and completed
fully in line with the management plan.
PS7.2 – Nutrition – for 100 per cent of patients the food record chart was completed accurately
and fully in line with the care pathway
• TARGET: In 100 per cent of patients, the food record chart was completed accurately and fully in line with the care
pathway
• Achievement (April 2014 – February 2015): This target has not yet been met, therefore this target will remain for
2015/16.
Comments:
• Performance against this indicator has not yet achieved the 100 per cent target set. The trend line no longer shows an
improving performance since January
• During February, compliance at DPoW has improved slightly to 90 per cent from a sharp dip to 86 per cent in
December
• SGH compliance has risen to 93 per cent. Performance at Goole has gone back to 95 per cent.
Action now being taken:
• As a result of previous drops in compliance in this area, all the quality matrons have focused on ensuring that those
patients who are identified as moderate to high risk (MUST score >1) have a food record chart commenced and
completed fully in line with the management plan.
During the nursing dashboard audits throughout the month it was agreed to specifically identify all patients who
have a high MUST score and focus on the food record charts as well as fluid charts where applicable and use the
opportunity to educate staff on the importance of completing these records. This focussed work will continue
for the foreseeable future.
Has the quality indicator been changed during the year from that set in last year’s (2013/14)
Quality Account? No, there has been no change to this quality priority during the 2014/15
reporting period.
Rationale for changing this quality priority for 2015/16: As nutrition and
hydration are crucial indicators to the Trust, and as this target has not yet been met,
the Trust will continue to monitor this within the monthly quality report.
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57
PS8 Hydration
PS 8 is also a new indicator for 2013/14. This illustrates the Trust’s focus on ensuring both nutrition and
hydration needs are met for patients admitted to the Trust.
Effective and consistent fluid management is recognised nationally as being an area of weak practice as demonstrated
in the National Patient Safety Agency (NPSA) (2008) and the National Reporting and Learning System (NRLS) (2008)
evidence.
Comments:
• Performance at SGH has risen to 96 per cent. Performance has remained at 97 per cent at DPoW and at 100 per cent at
Goole.
Action now being taken:
Accurate fluid balance monitoring is an essential tool in the early identification of a patient whose condition is
deteriorating (NPSA 2008) and is strongly recommended by both the NPSA and the National Institute for Clinical
Excellence (NICE, 2007).
• Working towards electronic fluid management charts
Monitoring the hydration status of patients by using fluid management charts is imperative to reducing the risks of
dehydration and the associated complications it can bring.
• Working towards dementia friendly drinking glasses
• Hydrant drinking system, now available to all ward areas with stock held on one ward at each sit,
Progress against this indicator will be monitored throughout the year.
PS8 Hydration – for 100 per cent of patients the fluid management chart was
completed accurately and fully in line with the care pathway.
• TARGET: In 100 per cent of patients the fluid management chart was completed accurately and fully in line with the
care pathway
• Achievement (April 2014 – February 2015): This target has not yet been met, therefore this target will remain for
2015/16.
Figure 30
• Amendment to the fluid management chart to incorporate registered nurse signatures – Following further
amendments and trial on one surgical ward trial to be undertaken within medicine prior to further discussion and
approval at NMAF.
Has the quality indicator been changed during the year from that set in last year’s (2013/14) Quality Account? No,
there has been no change to this quality priority during the 2014/15 reporting period.
Rationale for changing this quality priority for 2015/16: As nutrition and hydration are crucial indicators to the Trust, and
as this target has not yet been met, the Trust will continue to monitor this within the monthly quality report.
In 100% of patients the fluid management chart was completed accurately and fully, in line with the care pathway
100
98
Percentage (%) completed
96
94
92
90
88
86
84
82
80
Jan 14
Feb 14
Mar 14
Apr 14
May 14
Jun 14
Jul 14
Aug 14
Sept 14
Oct 14
Nov 14
Dec 14
Jan 15
Feb 15
Trustwide
87%
86%
88%
88%
88%
89%
91%
88%
89%
86%
87%
96%
95%
96%
DPoW
86%
84%
83%
87%
84%
89%
88%
83%
83%
85%
89%
96%
97%
97%
SGH
87%
87%
91%
88%
90%
88%
94%
91%
94%
84%
83%
95%
92%
96%
GDH
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
Threshold
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
Source: Information services, nursing dashboard
Key to abbreviations: Trustwide – Northern Lincolnshire and Goole NHS Foundation Trust overall
DPoW – Diana, Princess of Wales Hospital; SGH – Scunthorpe General Hospital
GDH – Goole and District Hospital
NB: The above charts axis starts at 80 per cent.
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59
Overview of the quality of care against 2013/14 quality priorities:
2.1c Patient experience (PE)
PE1 Friends & Family Test
PE2 Reduction in Re-Opened Complaints
PE3 Complaints Action Plans Implemented
PE4 Complaints Themes Reduction in Incidence
Patient Safety
PE5 Pain Management
PE6 Staff Satisfaction
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61
Figure 32
PE1 Friends and Family Test
Response Rate: Inpatient Friends and Family – broken down by site
Northern Lincolnshire and Goole
inpatient Friends and family response rate in national context by sites - February 2015
100%
PE1 Friends and Family Test – To have a response rate that achieves a response
rate in the top 50 per cent.
90%
• TARGET: Have a response rate that achieves a response rate in the top 50 per cent.
70%
• Achievement (April 2014 – February 2015): This target has not yet been met, although significant progress is clear
from the inpatient element of the survey. This target will remain for 2015/16.
60%
The Trust has participated in the Friends and Family Test since it was launched across the country. Within 48 hours of receiving
care or treatment as an inpatient or visitor to A&E, patients are given the opportunity to answer the following question:
“How likely are you to recommend our ward/A&E department to friends and family if they needed similar
care or treatment?”
Service users are then asked to answer how likely or unlikely along a six-point scale they would answer the above question.
There is also an opportunity to elaborate on the reasons for their answer and all feedback will be encouraged whether
positive or negative.
GDH - 83.1%
80%
50%
NLaG Trust - 43.1%
National Average - 46.1%
SGH - 44.7%
40%
DPW - 38.1%
30%
20%
10%
0%
This target measures the response rate for patient and service user feedback. When comparing the Trust to the national
landscape, the following charts illustrate the response rate compared to that of other providers.
Source: NHS England, Friends and Family Test data
Figure 31
Key to abbreviations: NLAG Trust – Northern Lincolnshire and Goole NHS Foundation Trust overall
DPoW – Diana, Princess of Wales Hospital; SGH – Scunthorpe General Hospital
National average – the national average response rate
Bars within graph: Each bar represents NHS organisation participating in the friends and family test, providing a league table of performance
70%
Response Rate: A&E Friends and Family – broken down by site
Northern Lincolnshire and Goole
A&E Friends and family response rate in national context by sites - February 2015
Comments:
• During July and August, the Trust moved from the bottom 50 per cent to the top 50 per cent of reporting Trusts.
This was maintained in the subsequent months, until December 2014, where the response rate again dipped below
the national average. In February 2015, the Trust moved into the bottom 50 per cent of reporting Trusts, with a Trust
response rate of 43.1per cent compared to the national average of 46.1per cent.
60%
50%
40%
National Average - 21.9%
30%
NLaG Trust - 16.6%
DPW - 19.2%
20%
SGH - 13.9%
10%
Greater clarity and action to support Friends and Family Test response rate:
• To bring further clarity to individual ward level performance, with a view to identifying exemplar wards, a new addition
to the monthly quality report, is the league table for ward areas, presented in appendix 2 of the monthly quality report.
This report is available on the Trust’s internet site.
• For a further summary of action being taken, see the end of this section for a full summary.
0%
Source: NHS England, Friends and Family Test data
Key to abbreviations: NLAG Trust – Northern Lincolnshire & Goole NHS Foundation Trust overall
DPoW – Diana, Princess of Wales Hospital; SGH – Scunthorpe General Hospital
National average – the national average response rate
Bars within graph: Each bar represents NHS organisation participating in the friends and family test, providing a league table of performance
Comments:
• The response rate at DPOW is close to the national average however the response rate at SGH has dropped to 13.9 per
cent.
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63
In-patient
feedback*
responses
Total
feedback*
Goole
Positive
Total
feedback*
SGH
Positive
responses
Total
feedback*
DPoW
Positive
responses
Total
feedback*
SGH
Positive
responses
DPoW
Total
NHS England is no longer providing a Friends and Family Test score and so the charts presented as follows mirror the national
changes in the analysis of this information, by comparing the percentage of responses which would recommend the Trust
by site with the other UK comparators.
Positive
A&E
Feedback from the Friends and Family Test: A&E – broken down by site
Response rate and feedback summary by site and survey
responses
Figure 33
Q1 13/14
115
97%
82
74%
235
99%
283
97%
48
100%
Q2 13/14
121
92%
44
82%
238
97%
270
97%
47
100%
Q3 13/14
121
97%
40
82%
208
97%
425
95%
35
97%
Jan-14
24
96%
88
83%
133
96%
192
93%
18
100%
Feb-14
128
93%
82
91%
264
98%
358
95%
23
96%
Mar-14
252
96%
84
88%
286
95%
433
94%
27
100%
Apr-14
194
96%
148
88%
196
95%
447
95%
32
100%
May-14
137
97%
169
91%
362
92%
454
96%
24
100%
Jun-14
381
98%
230
90%
368
93%
451
96%
29
100%
Jul-14
286
95%
564
91%
460
95%
608
97%
31
100%
Aug-14
236
94%
233
96%
385
95%
487
100%
40
95%
Sep-14
254
96%
173
91%
409
92%
485
97%
60
100%
Oct-14
274
91%
465
84%
474
93%
496
95%
46
100%
Nov-14
732
90%
534
86%
363
92%
509
95%
46
98%
Figure 33b
Northern Lincolnshire and Goole A&E percentage recommended in national context by sites - February 2015
National Average - 88.4%
NLaG Trust - 83%
DPW - 84%
SGH - 81%
Dec-14
463
88%
498
84%
309
92%
514
93%
49
98%
Jan-15
409
89%
508
87%
341
95%
548
95%
54
100%
Source: NHS England, Friends and Family Test data
Feb-15
481
84%
346
81%
371
94%
505
96%
64
100%
Key to abbreviations: NLAG Trust – Northern Lincolnshire and Goole NHS Foundation Trust overall
DPoW – Diana, Princess of Wales Hospital; SGH – Scunthorpe General Hospital
National average – the national average response rate
Bars within graph: Each bar represents NHS organisation participating in the friends and family test, providing a league table of performance
Source: Information services team
Key to abbreviations: DPoW – Diana, Princess of Wales Hospital,
SGH – Scunthorpe General Hospital,
Goole – Goole District Hospital,
A&E – Friends and Family Test returns from A&E department,
Inpatient – Friends and Family Test returns from in-patient wards.
* ‘Positive feedback’ defined as the percentage of patients/service users answering ‘extremely likely’ and ‘likely’ to the
question:
“How likely are you to recommend our ward/A&E department to friends and family if they needed similar care
or treatment?”
Key to RAG ratings:
Comments:
• A&E feedback for the Trust is 83 per cent which is lower than the national average of 88.4 per cent.
• The percentage recommending has dropped to 84 per cent at DPOW and 81 per cent at SGH.
Positive feedback > 90 per cent
Positive feedback > 80 per cent and < 90 per cent
Positive feedback < 80 per cent
For more information regarding the Friends and Family Test, please follow this link to the NHS England site:
www.england.nhs.uk/statistics/statistical-work-areas/friends-and-family-test/friends-and-family-test-data/
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Feedback from the Friends and Family Test: Inpatient Percentage
Recommended – broken down by site
Comments:
As already introduced, NHS England are no longer providing a Friends and Family Test Score, therefore the following
mirror the national changes in the analysis of this information, by comparing the percentage of responses which would
recommend the Trust by site with the other UK comparators.
Northern
and Goole
inpatient percentage
recommended
in national
context
by sites
- February2015
2015
Figure
34 Lincolnshire
NLaG inpatient
percentage
recommeded
in national
context
by sites
- February
GDH - 100%
100%
SGH - 96%
• In the inpatient element of the Friends and Family Test the Trust performed within 1 per cent of the national average in
terms of feedback and performed above the national average in terms of response rate to the Friends and Family Test.
Action now being taken to improve:
• We are now sending out the quality comments for groups to share and action and are able to pull out themes from
data collected
NLaG Trust - 95%
National Average - 96.3%
• In the last quarter, the Trust (A&E) performed well in terms of feedback from the Friends and Family Test and narrowly
missed the national average for response rate
DPW - 94%
• NETCALL continues to contribute to increased A&E responses. The information services team are doing a piece of work
around the completion of patient data on arrival to improve calls, they recognise this is a Trustwide issue which affects
any call reminder or automated call service
95%
90%
• A&E now have dedicated stands now at each site to enable a central visual point for the completion of cards
85%
• Engagement with clerical teams and nursing teams continues to help raise awareness of Friends and Family Test
• A Polish version of the friends and family cards is being displayed in A&E to guide one of our larger non English
speaking groups enabling them to give feedback if they wish. Translation and easy read versions of Friends and Family
Test will be available on the patient experience web page
80%
75%
• The Task and Finish Group continues to discuss issues monthly
70%
Source: NHS England, Friends and Family Test data
Key to abbreviations: NLAG Trust – Northern Lincolnshire and Goole NHS Foundation Trust overall
DPoW – Diana, Princess of Wales Hospital; SGH – Scunthorpe General Hospital
National average – the national average response rate
Bars within graph: Each bar represents NHS organisation participating in the friends and family test, providing a league table of performance
Comments:
• Improvements within Friends and Family Test and patient feedback continue. A web platform has been costed by a
local company which would support use via tablets and smart phones
• Process improvements are being considered, these include a more permanent resource for data collection and
inputting. Re-useable envelopes for reducing paper waste and improving time management.
Early Implementation for additional Friends and Family Test
• Goole is above the national average performance line
• As from January we are now submitting community and minor injuries unit data to NHS England. There remains no
targets to attain to only that we provide feedback opportunities for our patients
• The percentage of inpatients responding who recommended the Trust has remained at 95 per cent which is just below
the national average of 96.3 per cent. SGH is 96 per cent and DPOW is 94 per cent
• The Friends and Family Test was due to roll out to some additional areas nationally from January and April 2015. The
Trust was asked by its commissioners to commence an early implementer programme from October 2014
For more information regarding the Friends & Family Test, please follow this link to the NHS England site:
www.england.nhs.uk/statistics/statistical-work-areas/friends-and-family-test/friends-and-family-test-data/
Figure 35: How the Trust compares to peer
A summary of the Trust’s performance for the latest quarter (October to December 2014) is shown in the following tables:
Indicator
NLaG
National
average
A&E recommended
87.1%
86.8%
Better
79th
18.8%
Worse
82nd
Better /
worse
Ranking out of
140
A&E response rate
17.6%
(2,966/16,882)
Better /
worse
Ranking out of
140
Indicator
NLaG
National
average
Inpatient recommended
93.8%
94.3%
Within 1%
108th
35.8%
Better
49th
Inpatient response rate
39.7%
(2,808/7,063)
Source: Information services
* Within 1 per cent of the value benchmark. In this case the NLAG rate is within 0.94 per cent of the national average rate.
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• The areas being included are outpatients, day-case areas and community. Currently cards are being made available
in all these areas across site. The emphasis is on ensuring a robust process, capturing all areas and engaging teams to
own the principles of Friends and Family Test, which are active use of feedback for service improvement and increasing
team morale through positive feedback
• All areas went “live” as from April
• Initial work has given some good evidence of engagement and responses
• Submission for community commenced in January with a good return
• The new paediatric cards are now in use and some of the pictorial feedback is encouraging. The cards enable
comments and pictures for the younger children and these seem to be workable
• 2015-2016 Friends and Family Test – Nationally there is no CQUIN attached, and locally the requirements stand at
inpatient 30 per cent and A&E 15 per cent.
Has the quality indicator been changed during the year from that set in last year’s (2013/14)
Quality Account? No, there has been no change to this quality priority during the
2014/15 reporting period.
Rationale for changing this quality priority for 2015/16: As this quality priority
has not yet been met, this will remain as a quality priority for 2015/16.
67
To set a numerically based reduction was therefore deemed unrealistic. Instead of a numerical target, a proportional or
a percentage target would seem more realistic. The same information above has been re-presented using a percentage
indicator below.
Introduction
Figure 37
Complaints are a key source of learning for the Trust and as such much work is underway to ensure that
the Trust responds to complaints in a constructive and helpful manner therefore answering a patient,
relative or carers concerns appropriately.
Secondly as a result of the complaint, appropriate action including learning lessons as a result is also of importance to
the organisation. As part of this, the following sections relating to complaints are designed to ensure the Trust uses this
feedback appropriately.
PE2 – Reduction in re-opened complaints
• TARGET: Re-opened complaints to not exceed 20 per cent of total closed complaints.
• Achievement (April 2014 – February 2015): No target was set for this quality priority, until recently, so limited data is
available. Since December 2014 this target has been met.
Target – Re-opened complaints to not exceed 20 per cent of total closed complaints
Percentage of re-opened complaints (%)
(Re-opened/number closed)
PE2 Complaints
Percentage of re-opened complaints
50
45
40
35
30
25
20
15
10
5
0
Percentage re-opened
Jan
14
Feb
14
Mar
14
Apr
14
May
14
Jun
14
Jul
14
Aug
14
Sept
14
Oct
14
Nov
14
Dec
14
Jan
15
Feb
15
14.9%
18.9%
12.7%
16.9%
26.7%
22.8%
38.1%
37.5%
27.8%
16.2%
25.5%
19.3%
5.8%
17.3%
Since May 2014, the number of reopened complaints had been on average 14 per month which exceeded the target being
aimed for – a 50 per cent reduction, equating to no more than 2.5 per month. This is illustrated in the following statistical
process control (SPC) chart.
Data Source:
Figure 36
As a result of this, at the mid-year review of the quality priorities, the Quality and Patient Experience Committee (QPEC)
agreed to refine this indicator to read:
30
DATIX, performance assurance team
Key to abbreviations: Percentage of re-opened complaints – the percentage of complaints that have been re-opened
Re-opened: Complaints that have been resolved which for any number of reasons require further review.
“Re-opened complaints to not exceed 20 per cent of total closed complaints”
25
As illustrated in the above chart, this target has been met during January and February 2015.
Number (n=)
20
15
10
5
0
Re-opened
2012/2013
Mean
Data Source:
LCL
2013/2014
Feb
Jan
Dec
Nov
Oct
Sep
Aug
Jul
Jun
May
Apr
Mar
Feb
Jan
Dec
Nov
Oct
Sep
Aug
Jul
Jun
May
Apr
Mar
Feb
Jan
Dec
Nov
Oct
Sep
Aug
Jul
Jun
May
Apr
-5
2014/2015
DATIX, performance assurance team
UCL
Key to abbreviations: Re-opened: Complaints that have been resolved which for any number of reasons require further review. Mean – average number of reopened complaints for the period
UCL – upper control limit (see glossary for full definitions regarding SPC terminology)
Over recent months, the number of closed complaints was increased. As a significant proportion of these relate to the
older complaints in the system which made up the ‘backlog’ which QPEC and the board is aware of. It should be expected
therefore that a proportion of those complaints closed will always be re-opened, as a result of the complainant requiring
further assurance.
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Complaints – contextual information – as at the February 13 2015:
To provide further context to the wider complaints management processes within the Trust, the following chart illustrates
trends since 2013. The data has been extracted from DATIX as at February 13 2015.
NLaG Complaints resolution January 2013 - present
Number of new, closed and net open complaints (n=)
Figure 38
PE3 Complaints – action plans agreed within timescales
• TARGET: 90 per cent of action plans following a complaint to be implemented within agreed timescales.
• Achievement (April 2014 – February 2015): Now above 90 per cent. This target has been met.
The policy for the operational management of this area states that where remedial action is identified, an action plan, which
records timescales and responsibilities, will be prepared by the relevant directorate/operational group on the closure of a
concern or no later than three months after closure of the complaint and will be monitored regularly by the operational
group until fully implemented. Whilst this is not a new requirement, the electronic recording of completed actions on DATIX
has not been consistent.
300
275
250
225
200
150
The following table illustrates part one of the process, that of drafting an action plan, for those complaints requiring action,
since April 2013.
125
Figure 39 175
100
75
Q1
Q2
Q3
Q4
Q1
Jul 14 Aug 14 Sep 14 Oct 14 Nov 14 Dec 14 Jan 15 Feb 15
2013 /14 2013 /14 2013 /14 2013 /14 2014 /15
Total number of
complaints closed
106
99
116
163
182
42
32
54
74
47
57
52
52
Total number of
complaints requiring
action plan
49
43
58
47
41
12
13
14
20
16
17
14
17
49
43
57
47
41
12
13
14
20
16
17
14
17
Data Source: DATIX, Performance assurance team
Number of action plans
drafted by Complaints
Team
Key to abbreviations: New – The number of new complaints received in a month regardless of whether or not they were resolved within that month.
% action plans drafted
by Complaints Team
100%
100%
98%
100%
50
25
0
Jan Feb Mar Apr May Jun
Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun
2013
Jul Aug Sept Oct Nov Dec Jan Feb
2014
2015
New
48
66
57
44
49
42
50
55
56
63
73
48
54
40
50
48
23
29
37
31
41
45
44
43
37
35
Closed
37
33
24
45
37
36
26
29
41
41
37
38
47
53
63
65
60
57
42
32
54
74
47
57
52
52
Net open
115 147 169 157 169 169 197 197 195 195 220 221 248 211 202 185 201 170 173 177 172 165 153 158 148 142
Closed – The number of complaints that were resolved within a month regardless of whether they were received within the month or resolved within agreed timescale.
Net open – The total number of complaints currently open; includes new complaints and those unresolved from previous month(s). This includes open ‘on hold’. This includes re-opened complaints.
100% 100% 100% 100% 100% 100% 100% 100% 100%
Data Source: DATIX, clinical and quality assurance team
Key to abbreviations: Closed complaint – the number resolved within the month,
Action plan – a plan to resolve any areas for improvement identified as a result of the complaint,
Action plans drafted by central team – action plan developed as a result of the complaint,
Comments:
Percentage of action plans drafted by complaints team – the number of action plans drafted as expressed by a percentage (%).
• Since February 2014, the number of closed complaints has exceeded the number of new complaints month on
month.
Comments:
Has the quality indicator been changed during the year from that set in last years (2013/14) Quality Account? Yes. As
explained, a numerical target was felt to be an inaccurate way of reliably tracking improvement and performance in general,
especially when balanced with the increasing number of complaints being closed.
• The above table illustrates that phase one of the process, that of drafting an action plan in response to a complaint
(where necessary) by the central complaints team is exceeding the target set for complaint responses.
Step two of the process is implementation by the relevant directorate/operational group of the agreed actions within the
agree three month timeframe following closure of a complaint.
Rationale for changing this quality priority for 2015/16: No further changes are planned in connection with this indicator
since its amendment during the 2014/15 mid-year quality priorities review.
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The following table illustrates the number of action plans that required implementation during each month. The table
then outlines the number of these actually implemented in practice. Due to the aforementioned three month timescale,
the number eligible for completion each month differs from the number drafted in the same month.
Figure 40 Q1
Q2
Q3
Q4
Q1
Jul 14 Aug 14 Sep 14 Oct 14 Nov 14 Dec 14 Jan 15 Feb 15
2013 /14 2013 /14 2013 /14 2013 /14 2014 /15
Number of complaints
action plans requiring
implementation within
month
2
Number of complaint
action plans fully
implemented
2
% of action plans fully
implemented
100%
Data Source: 26
44
55
43
5
1
8
16
7
17
12
11
PE4 Complaints
• TARGET: To achieve a 50 per cent reduction in complaints relating to the specific theme of communication (reported
quarterly)
• Achievement (April 2014 – December 2014): This target has not met been during the 2014/15 financial year. This
will remain a priority for 2015/16 to continue the Trust’s focus on learning from complaints.
In order to understand the ‘themes’ arising from complaints, to enable the Trust to set an improvement trajectory, a detailed
assessment of closed complaints during two separate periods of time was undertaken. The periods of time chosen were
both during quarter 2 (July-September), but separate years:
• Quarter 2, 2012/13,
4
27%
14
32%
12
19%
4
9%
0
0%
0
0%
0
0%
9
56%
6
86%
16
94%
11
11
92% 100%
DATIX, Clinical and quality assurance team
Key to abbreviations: Complaint action plans requiring implementation within month – the number where the action plan deadline agreed ended in this period,
Action plan fully implemented – the agreed plan is fully implemented as a result of the complaint,
Percentage of action plans fully implemented – the number of action plans implemented as expressed by a percentage (%).
Comments:
• This area was one which had been identified as needing to be addressed as a high priority for 2014/15. As described
in the June quality report, a more robust process of monitoring/implementation of the complaint action plans was
introduced and a complaints assistant identified to work with directorates/groups co-ordinate these arrangements.
All complaints closed from July 1 2014 have followed this process.
• As detailed previously significant improvements were expected to take effect from October 1 2014. Since October
2014 the percentage of action plans fully implemented has risen significantly with compliance in February 2015
reaching 100 per cent.
Has the quality indicator been changed during the year from that set in last year’s (2013/14) Quality Account? No,
there has been no change to this quality priority during the 2014/15 reporting period.
Rationale for changing this quality priority for 2015/16: As this quality priority is of key importance to the organisation,
this will remain as a quality priority for 2015/16.
• Quarter 2, 2013/14 – during which time the Keogh review team visited resulting in increased media publicity.
From this analysis, communication was identified as one of the most predominant reasons for the complaint to be
made (55-60 per cent of formal complaints analysed). As a result of this, the Trust has set an improvement trajectory for
complaints relating to communication.
Based upon Q2 2013/14 data as a baseline identified 65 formal complaints over a 3 month (1 quarter) period related to
this theme of communication. Projecting this over the remainder of the year (3 remaining quarters) would equate to 260
complaints per year. A 50 per cent improvement trajectory based on this would be a maximum of 130 complaints per
year. This breaks down to a quarterly target of no more than 32.5, rounded up equals 33.
In this month’s report, the second quarterly information is able to be analysed, this is presented as follows:
Figure 41 Q1 2014/15
(Apr - Jun)
Q2 2014/15
(Jul - Sep)
Q3 2014/15
(Oct - Dec)
Total number of formal complaints received
158
115
132
TARGET BEING AIMED FOR (50% Reduction) – Maximum Per Quarter of:
33
33
33
Total where the theme was determined to be around communication
33 (21%)
44 (38%)
72 (55%)
Comments:
• During quarter 3, a total of 72 complaints relating to communication were received, this is significantly above the
target of “no more than 33 per quarter”.
Action being taken and further theme analysis:
After the detailed analysis reported previously (deep dive review of complaints) further work is ongoing to provide
more detail on the themes arising from that analysis. This work includes reviewing those complaints falling into “general”
categories (eg general medicine, surgery etc) to obtain more understanding of the underlying themes and raising the
issues through various focus groups, governance meetings, study days etc.
In addition a small working group reporting to the Patient Experience Group (PEG) has been formed to also look at these
themes and options which can be considered and implemented both short and long term.
The aim of this is to increase awareness of the themes in order to get those issues addressed at the point of
care and the results of this work will be reported on a quarterly basis with a view to reducing themes
such as “communication” to 50 per cent (or less) than the 2013/14 period.
Has the quality indicator been changed during the year from that set in last year’s
(2013/14) Quality Account? No, there has been no change to this quality priority
during the 2014/15 reporting period.
Rationale for changing this quality priority for 2015/16: This indicator will
remain the same for the 2015/16 monitoring period.
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PE5 Pain management
PE6 Staff satisfaction: culture change and the morale barometer
• TARGET: Patient felt staff did everything to help control pain/improve comfort.
Introduction - Culture change
• Achievement (April 2014 – February 2015): This target was consistently met with 100 per cent reported compliance.
Following the launch of the ‘Together …’ vision and values in
September 2012 much activity has taken place on a corporate level to
weave the values into appropriate business practices. In summary the
work to date has focused on:
Since this indicator was included within the monthly quality report, compliance has been 100 per cent each month. On
the back of recent reflections following ‘patient’s stories’, some of which related to management of pain and administration
of pain relief, this illustrated that the measure being used for this area requires further refinement.
At the same time, the recent guidelines issued by NICE on nursing staffing levels included a number of nursing ‘red flags’ to
help trigger areas for greater nursing scrutiny/management. Two of these ‘red flags’ related to this area, specifically:
• Unplanned omission in providing patient medications,
• Delay of more than 30 minutes in providing pain relief.
Based on this greater guidance, and listening to local patient’s experiences, a proposal was submitted to the Quality
Patient and Experience Committee (QPEC) during the mid-year review of quality priorities to widen PE5 relating to pain
management to include the following two indicators:
• PE5a: 90 per cent of patients should not have any unplanned omissions in providing patient medications,
• PE5b: 90 per cent of patients should not have a delay of more than 30 minutes in providing pain relief.
As a result of this agreement, the nursing dashboard process by which levels of nursing quality are measured on a monthly
basis, evaluating 10 patients on every ward within the Trust, will be amended to have these questions included. As soon as
this information begins to filter through, this will be reported within the monthly quality report.
Has the quality indicator been changed during the year from that set in last year’s (2013/14) Quality Account?
Yes. As the target set was being met consistently, it was decided at the mid-year review to change the target to more
comprehensively assess pain management. Work is now underway to develop data collection systems to enable these
new indicators to be reported within the monthly quality report.
Rationale for changing this quality priority for 2015/16: This amended indicator will remain the same for the 2015/16
monitoring period.
• Human resources and
organisational development
activities – linking the vision
and values to the recruitment,
induction, contract of
employment and appraisal
processes
• Patients and our values –how
we use and learn from patient
stories that have value related
compliments or complaints.
The vision and values group
presently has two patient
representatives as permanent
members to assist with this
• Marketing and branding
– focusing on the on-going
rollout and development of the
‘Together…’ brand
• Reward and recognition – how
we recognise staff and teams
who are excelling at delivering
their services through the values.
Here we aim to learn from
them, share and disseminate
best practice and in doing so
contribute to increase in holistic
team working practices.
The vision and values group
recognises that, as important as
the above activities are, the vision
and values must be ‘lived’ at an
operational level through day-today working practices. To this end
the launch of the values champions
network took place via its inaugural
workshop on February 18 2014. To
date 57 staff have stepped forward
as champions. The above workshop
aims to:
• Equip them with a thorough
knowledge of the values, how
to sell these and techniques
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to overcome any resistance or
apathy the may encounter
• Assist them in identifying how,
in many ways, they are already
‘living’ the values’ and for these
practices to the shared and
disseminated amongst the group
• Identify new ways that they could
deliver the values in their work
place and support them in taking
these back to their areas, and
• Introduce initiatives such as NHS
Change Day, #hellomynameis
etc as means of driving positive
behaviour changes and
innovation in their teams and
areas.
Morale barometer
incorporating the
Friends and Family Test
To date four morale barometer
surveys have been completed, the
last taking place in January 2014.
These results from these surveys
reveal that from Trust embarking on
its culture transformation plan:
• Staff job satisfaction and morale
has increased by c.10 per cent
This has been achieved through
significant investment in staff
engagement, staff suggestion
schemes and increased internal
communications to increase
awareness of Trust activities (to
name just a few of the organisational
development (OD) work streams).
Culture change
measured via the
morale barometer
The workstreams to operationally
weave the Vision and Values (V&V)
into Trust policies and procedures
continue, but in many cases have
been completed. From this work of
particular note is as follows:
• Personal appraisal and
development review (PADR):
Following a successful pilot the
vision and values PADR policy
and revised documentation, a
review has taken place to fine
tune the processes. The revised
documentation firmly links
the PADR process with the pay
progression policy (presently in
draft pending ratification and
implementation). The next stage
to bolster the impact of the
vison and values PADR process
is to link staff high performers
into an internal talent pool for
recruitment and workforce
planning purposes. • Staff: managerial working
relationships, and staffs sense
of ‘engagement’ and ‘voice to
suggest change’ have increased
by nine per cent, eight per cent
and eight per cent respectively.
75
Next steps in vision and values
activity/rollout:
Engagement and Workload
• Collective leadership
linked to vision and values
management/leadership style:
The review into medical staff and
management team relationships
has been completed and
this, together with a series of
recommendations to introduce
‘Collective Leadership” and build
effective medical:management
relationships has been provided
to the chief executive officer,
medical director and director of
organisational developement
and workforce for consideration.
Response rate
Oct-14
Jul-14
Apr-14
Jan-14
Sep-13
May-13
Reflecting back over the last 3 months: How engaged do
you feel with you ward/departments activities and future
developments?
-0.1
-1.1
4.3
5.4
5.4
5.2
4.6
4.4
How well do you feel you can influence service developments or
decision making processes on your ward/department?
-0.2
-1.2
3.4
4.6
4.6
4.4
3.8
3.6
How well do you feel you can influence decision making
processes in the Trust?
0.1
-0.7
2.6
3.3
3.3
3.1
2.7
2.5
0
-0.5
5.3
5.8
6.1
5.8
5.2
5.3
Total
change
Quarterly
change
Oct-14
Jul-14
Apr-14
Jan-14
Sep-13
May-13
Nov-11
As a member of your ward/department’s team how
valued do you feel?
-0.3
-1
4.7
5.7
5.9
5.7
5
5
-
As a member of the Trust how valued do you feel?
-0.3
-1.1
3
4.1
4.2
3.7
3.4
3.3
-
How much satisfaction do you get from working with
your immediate colleagues?
-0.2
-0.6
7
7.6
7.7
7.4
7.2
7.2
-
How much satisfaction do you get from working with
your management team?
0.1
-0.9
4.3
5.2
5.6
5.1
4.6
4.2
-
How much personal satisfaction do you get from
coming to work?
0.1
-1
5.3
6.3
6.4
6.1
5.7
5.5
5.2
Value and satisfaction
• The seventh morale barometer
survey took place in October
2014. All 6,500 staff were invited
to take part and participate in
this quarterly survey. Response
rates to date are illustrated in the
table below:
These survey findings seek to
evaluate the progress being made
on its culture transformation plan
and the mood of staff. The key
findings are displayed in the table
overleaf (please note a score of one
equates to 10 per cent unless the
Quarterly
change
How well do you feel you are able to cope with your current
workload?
Morale barometer
incorporating the
Friends and Family Test
Feedback from staff is that the
surveys are being run too frequently.
As such the surveys will now be run
six monthly. This will also provide
for time between the surveys for
recommendations to be acted upon.
The next survey is scheduled for
April 2015.
Total
change
Total
change
Quarterly
change
Oct-14
Jul-14
Apr-14
Jan-14
Sep-13
May-13
0.3
-1.1
4.3
5.4
5.6
5.3
4.6
4
Total
change
Quarterly
change
Oct-14
Jul-14
Apr-14
Jan-14
Sep-13
May-13
Reflecting back over the last twelve months have you had an
appraisal?
11%
-9%
77%
88%
92%
68%
70%
67%
Did you see your appraisal as a positive experience which let
you plan how you are going to meet your objectives over the
forthcoming year?
13%
-15%
48%
63%
69%
65%
67%
35%
From your appraisal did you and your manager create an
achievable meaningful development plan which will help you
do your job?
15%
-10%
50%
60%
68%
53%
66%
35%
Have you been provided with the time, or support, to start
carrying out the actions on this development plan?
7%
-12%
34%
46%
56%
86%
51%
27%
Communications
How well informed do you feel about what’s happening within
the Trust?
value is displayed as a percentage in
its own right).
The target being aimed for this
indicator is based on an indicator
of 17.5 per cent improvement
achieved between November 2011
and October 2014 and measured
through the morale barometer so
has some reasoning and rationale
whilst still being stretching.
Appraisal and development
The following page contains the
results of the most recently run
morale barometer in October 2014
and presents this compared to
previous surveys recorded in April.
Nov 2011
May 2013
Sept 2013
Jan 2014
Apr 2014
July 2014
October 2014
87
340
545
356
330
496
286
Source: Morale barometer findings, directorate of organisation development and workforce
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77
Summary: Measurement of the quality improvement target around this area
To measure this quality improvement target, the key question highlighted on the previous page, will be used to measure
progress in this area. The question asks:
“How much personal satisfaction do you get from coming to work?”
While all the questions asked as part of the morale barometer are designed to help gauge and measure morale and staff
satisfaction, this key question is designed to measure the workforce job satisfaction which is widely recognised as the
definition of morale.
In order therefore to measure this indicator throughout the 2014/15 year, the baseline for measuring quarter on quarter
progress will be the April 2014 response to this question – 6.4. This weighted score represents a 1.1 improvement on the
same question asked from November 2011 to July 2014 morale barometer.
Using the October 2014 morale barometer information therefore yields a result of 5.3, a reduction of -1.0. This appears on
face value to be a big step backwards akin to the workforce mood found in November 2012. The reasons for this are being
currently investigated by the organisational development team with a report pending.
Has the quality indicator been changed during the year from that set in last years (2013/14) Quality Account? No,
there has been no change to this quality priority during the 2014/15 reporting period.
Rationale for changing this quality priority for 2015/16: During 2015/16, this important area of staff morale and
organisational culture has served as a quarterly update for the Quality and Patient Experience Committee (QPEC) and the
Trust Board. Due to a change in the reporting methodology of the morale barometer, this will be reported in future on a
six monthly basis.
2.1d: Quality priorities for 2015/16
Rationale for quality priorities:
The quality priorities for 2015/16 have been identified as a result of the Trust’s concentrated monitoring of
the previous year’s priorities and are linked to its continuing focus on ensuring patients and service users
are provided with safe and effective care and treatment. A number of the indicators relate to the Trust’s
areas of focus during and throughout 2014/15.
How agreed:
The priorities for 2015/16 have
been agreed by the Trust Board
and by the Quality and Patient
Experience Committee (QPEC). They
have been identified via a number
of mechanisms including the
following:• Discussions with the governors
• Discussions with the
commissioners
• The findings from the national
surveys (out-patient and inpatient)
• The findings from the staff survey
• Findings from patient
satisfactions surveys that are
undertaken by the Trust
• Feedback from patients
using the ‘patient story’ video
approach (played at QPEC and
Trust Board meetings) alongside
face to face patient stories
• The results that are published
within our nursing dashboard
• The data provided by our clinical
systems where we are identified
as being an outlier
• Information from the Care
Quality Commission intelligent
monitoring report
• Information from incidents and
complaints
• Comments received from local
HealthWatch organisations as a
result of discussions around last
year’s Quality Account
• Feedback received and work
undertaken to improve as a
result of the Keogh review’s
findings and now included
within the Trust’s Quality
Development Plan (QDP)
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Taking into account the
wider public views:
The quality indicators are agreed
following discussions with governors
who represent the interests of their
constituents following their election
to this role from public members of
the Trust. The findings from the inpatient and out-patient surveys are
also considered when developing
these proposed indicators to take
into account the views of the wider
public.
Feedback and comments from
the local overview and scrutiny
committees, made up of elected
councillors who represent their
constituents, is also taken into
account when formulating the
proposed new quality indicators.
During 2014/15 another powerful
way of representing the local public
and learning from their experiences
was the ‘patient story’ model, using
video interviews with local patients
explaining their ‘journey’ through the
Trust’s services.
These recordings and also the use
of face to face stories from patients
and the public are a regular feature
at both the Quality Patient and
Experience Committee (QPEC) and
Trust Board meetings and have had
an impact on the quality priorities
chosen.
How progress will
be monitored and
measured:
Progress against these indicators
will be reported monthly using
the monthly quality report. The
indicators include improvement
targets to allow for on-going
measurement.
A selection of methods will be
employed to measure this area
including statistical process control
(SPC) charts, tables and graphs.
The Quality and Patient Experience
Committee (QPEC) and the Trust
Board will receive this report.
To ensure our governors are
involved in the Trust’s the monthly
quality report features as part of
the quarterly Governors Quality
Review Group (QRG). This report
is also shared with the Trust’s
commissioners.
The companion to the monthly
quality report is the monthly
mortality report, this also features
an overview of the organisation’s
focus on mortality and provides
the Mortality Performance and
Assurance Committee (MPAC)
and in turn the Trust Board with
up to date intelligence charting
the Trust’s progress against these
quality focussed
indicators.
79
2015/16 Quality priorities:
Clinical effectiveness:
CE1
Deliver mortality performance within ‘expected range’ and improving quarter on quarter, until reported SHMI
is 95 or better
CE2
NEWS - in 95 per cent of cases with a NEWs score, appropriate action was taken
CE3.1
Dementia - 90 per cent of patients aged 75 and over admitted as an emergency to be asked the dementia
case finding question
CE3.2
Dementia - 90 per cent of the above patients scoring positive on the case finding question to have a further
risk assessment
CE3.3
Dementia - 90 per cent of the patients identified as requiring referral following risk assessment to be referred
in line with local pathway
CE4
Evidence based practice - to increase compliance with NICE guidance with 90 per cent compliance achieved
by the end of March 2016
CE5
Transfer and discharge - Transfer of patients for non-clinical reasons (capacity) to not exceed 20 per cent of
the total
Patient Experience
PE1
Friends and Family Test - to have a response rate that achieves a response rate in the top 50 per cent which
also improves in the quarter one response rate
PE2
Complaints - Re-opened complaints to not exceed 20 per cent of total closed complaints
PE3
Complaints – 90 per cent of action plans following a complaint to be implemented within agreed timescales
PE4
Complaints – 50 per cent reduction in complaints relating to communication
PE5a
Pain management2 - Patients should not have any unplanned omissions in providing patient medications
PE5b
Pain management2 - Patients should not have a delay of more than 30 minutes in providing pain relief
PE6
Staff satisfaction3 – 2.5 per cent increase in morale/staff satisfaction each six months
Rationale for pain management indicator: Pain management and patient comfort is a subjective very personal
measure. From a recent patient story, more emphasis on this area has been placed by the inclusion of two more detailed
quality priorities, based on the NICE guidance on Safe Staffing levels which outlined a number of ‘red flags’ for nursing
concern, these were both listed.
2
Patient safety:
Rationale for staff satisfaction indicator: This is based on an indicator of nine per cent improvement achieved
between November 2012 and January 2014 and measured through the morale barometer so has some reasoning and
rationale whilst still being stretching. The means of measurement/data source would be the morale barometer.
3
PS1
MRSA - 0 MRSA bacteraemia developing after 48 hours into the inpatient stay (hospital acquired)
PS2
C. difficile - achieve a level of no more than 21 hospital acquired C. difficile cases over the financial year
2015/2016
PS3
Safety Thermometer - provide harm free community care to 95 per cent or more patients - as measured by
the Safety Thermometer
PS4
Safety Thermometer - provide harm free care to 95 per cent or more (acute) patients - as measured by the
Safety Thermometer
PS5
Patient falls - eliminate all avoidable repeat falls (as measured via the root cause analysis undertaken for
every repeat faller)
PS6
Pressure ulcers - a 50 per cent reduction in avoidable grades 2, 3 and 4 pressure ulcers (as measured via the
root cause analysis undertaken for every grade 2, 3 and 4 pressure ulcer)
PS7.1
Nutrition - 100 per cent of patients the care pathway was followed
PS7.2
Nutrition -100 per cent of patients identified as requiring it will have their food record chart completed
accurately and fully in line with the care pathway
PS8
Hydration - 100 per cent of patients identified as requiring it will have their fluid management chart
completed accurately and fully in line with the care pathway.
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The Trust’s quality targets & priorities
– driving continuous improvement
It is worth noting here, that these targets/quality priorities for the
most part are not nationally or regionally set, rather they are set
locally by the Trust. They are selected as areas of key importance for
the Trust to drive and embed continuous quality improvement.
These indicators are not chosen for their ease of completion, resulting
in a report full of green ‘completed’ ticks. These indicators are instead
quality focussed, aspirational and stretching. As a result, the executive
summary that follows, and the greater detail within part two of this
report presents progress so far, not always demonstrating that our
internal quality targets have been met.
Where these have not been met, an explanation and summary of the
work underway are presented and for the most part, these targets
have been selected to stay within the quality report to drive quality
development during 2015/16.
81
National clinical audits 2014/15
2.2 Statements of assurance from the Board
National clinical audit title
2.2a Information on 2.2b Information on participation in clinical
the review of services audits and national confidential enquires
During 2014/15 Northern
Lincolnshire and Goole NHS
Foundation Trust provided and/
or sub-contracted 25 relevant
health services.
The Trust has reviewed all the data
available to them on the quality of
care in 25 of these relevant health
services.
The income generated by the
relevant health services reviewed
in 2014/15 represents 100% of the
total income generated from the
provision of relevant health services
by the Trust for 2014/15.
During 2014/15, 33 national
clinical audits and four national
confidential enquires covered
relevant health services that
Northern Lincolnshire and
Goole NHS Foundation Trust
provides.
During that period the Trust
participated in 100 per cent of the
national clinical audits and 100 per
cent national confidential enquiries
of the national clinical audits and
national confidential enquiries which
it was eligible to participate in.
The national clinical audits and
national confidential enquiries that
the Trust was eligible to participate in
during 2014/15 and those in which it
participated in are as follows:
Eligible for
NLAG
NLAG
participated
Number
of cases
submitted
% of number
required
Action
planning
On-going
Deadline May
2015
N/A
Acute care
Adult Community Acquired Pneumonia
Yes
Yes
On-going
Deadline May
2015
Case Mix Programme (CMP)
Yes
Yes
915
100%
Yes
Major Trauma: The Trauma Audit &
Research Network (TARN)
Yes
Yes
332/471
70%
Yes
• The name of the national clinical
audits and national confidential
enquiries listed in HQIP’s quality
account resource
National Emergency Laparotomy Audit
(NELA)
Yes
Yes
232
100%
Awaiting
Publication
National Joint Registry (NJR)
Yes
Yes
693
100%
Awaiting
Publication
• Which ones the Trust were
eligible to participate in
Pleural Procedures
Yes
Yes
32
100%
Yes
National Complicated Diverticulitis
Audit (CAD)
Yes
Yes
42
100%
NB: The following tables list:
Awaiting
• The number of cases submitted
for each audit against the
number required, also expressed
as a percentage (%)
Blood and Transplant
Yes
Yes On-going
On-going
On-going
N/A
• If action planning is taking
place or has been completed to
improve processes and practice
following publication of findings.
National Comparative Audit of Blood
Transfusion programme
1. 2015 Audit of Patient Blood
Management in Scheduled Surgery;
Yes
Yes On-going
On-going
On-going
N/A
2. 2015 Audit of the use of blood in
Lower GI bleeding;
Yes
Yes On-going
On-going
On-going
N/A
3. 2016 Audit of the use of blood in
Haematology (submitted for all)
Yes
Yes On-going
On-going
On-going
N/A
Bowel cancer (NBOCAP)
Yes
Yes
262
Head and neck oncology (DAHNO)
Yes
Yes
50
Lung cancer (NLCA)
Yes
Yes
269
National Prostate Cancer Audit
Yes
Yes
201
Oesophago-gastric cancer (NAOGC)
Yes
Yes
107
Publication
Cancer
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Awaiting
publication
for
comparison
with HES
Yes
(13/14)
83
National clinical audit title
Eligible for
NLAG
NLAG
participated
Number
of cases
submitted
% of
number
required
Action
planning
NLAG
participated
Number
of cases
submitted
% of
number
required
Action
planning
Mental health (care in emergency
departments)
Yes
Yes
100
100%
Awaiting
Publication
National Confidential Inquiry into Suicide
and Homicide for people with Mental
Illness (NCISH)
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Yes
Yes
470
100%
Yes
Yes
Yes
200
100%
Awaiting
Publication
Yes
Yes
893/928
96%
Yes
Elective surgery (National PROMs
Programme)
Yes
Yes
1080
65%
Yes
National Audit of Intermediate Care
N/A
N/A
N/A
N/A
N/A
British Society for Clinical
Neurophysiology (BSCN) and Association
of Neurophysiological Scientists (ANS)
Standards for Ulnar Neuropathy at Elbow
(UNE) testing
N/A
N/A
N/A
N/A
N/A
Mental health
Heart
Acute Coronary Syndrome or Acute
Myocardial Infarction (MINAP)
Yes
Yes
267/425
(deadline not
until June)
63%
Cardiac Rhythm Management (CRM)
Yes
Yes
410/439
93%
Awaiting
Publication
Congenital Heart Disease (Paediatric
cardiac surgery) (CHD)
N/A
N/A
N/A
N/A
N/A
Yes (SGH)
Yes
296
100%
Awaiting
Publication
N/A
N/A
N/A
N/A
N/A
Coronary Angioplasty/National Audit of
PCI
National Adult Cardiac Surgery Audit
National Cardiac Arrest Audit (NCAA)
National Heart Failure Audit
Yes
Yes
Yes
Yes
228/250
91%
270/470
(deadline not
until June)
57%
Yes
(13/14)
Yes
Yes
National Vascular Registry
N/A
N/A
N/A
N/A
N/A
Pulmonary Hypertension (Pulmonary
Hypertension Audit)
N/A
N/A
N/A
N/A
N/A
Long term conditions
N/A
Diabetes (Adult)
Yes
N/A
Yes
N/A
N/A
N/A
14/15
Deadline May
2015
14/15
Deadline
May 2015
Yes (13/14)
14/15
Deadline
June
2015
Diabetes (Paediatric) (NPDA)
Yes
Yes
14/15
Deadline June
2015
Inflammatory Bowel Disease (IBD)
programme
Yes
Yes
42/52
81%
Yes
National Chronic Obstructive Pulmonary
Disease (COPD) Audit Programme
Yes
Yes
191/314
61%
Yes
Renal replacement therapy (Renal
Registry)
N/A
N/A
N/A
N/A
N/A
Rheumatoid and Early Inflammatory
Arthritis
Yes
Yes
25
25%
Awaiting
Publication
National Pregnancy in Diabetes Audit
Yes
Yes DPOW
ONLY
6
100%
Awaiting
publication
Together
Prescribing Observatory for Mental
Health (POMH)
(Prescribing for substance misuse:
Alcohol detoxification)
Older people
Falls and Fragility Fractures Audit
Programme (FFFAP)
National Hip Fracture Database
(submitted for all)
Older people (care in emergency
departments)
Sentinel Stroke National Audit
Programme (SSNAP)
SSNAP Clinical Audit
Other or TBC
Chronic Kidney Disease in primary care
84
Eligible for
NLAG
National clinical audit title
we care, we respect, we deliver
Yes
(13/14)
85
Eligible for
NLAG
NLAG
participated
Number
of cases
submitted
% of
number
required
Action
planning
Epilepsy 12 audit (Childhood Epilepsy)
Yes
Yes
26
100%
Yes
Fitting child (care in emergency
departments)
Yes
Yes
100/100
100%
Awaiting
Publication
National clinical audit title
Women and Children’s
Maternal, Newborn and Infant Clinical
Outcome Review Programme (MBRRACEUK)
Yes
Neonatal Intensive and Special Care
(NNAP)
Yes
Yes
1454
100%
Yes
Paediatric Intensive Care Audit Network
(PICANet)
N/A
N/A
N/A
N/A
N/A
Total:
44
Eligible for NLAG participation:
33
NLAG Participated in:
33
Yes
29
100%
Yes
Eligible for
NLAG
NLAG
participated
Organisational
Questionnaires
Number
of cases
submitted
% of number
required
Action
planning
Sepsis
Yes
Yes
2
9
100%
Awaiting
Report
Gastro Intestinal Haemorrhage
Yes
Yes
2
4
100%
Awaiting
Report
Lower Limb Amputation
Yes
Yes
2
N/A
N/A
Yes
Tracheostomy Care
Yes
Yes
2
14
100%
Yes
Total:
4
4
Eligible for NLAG
participation:
4
The reports of 17 national clinical audits were reviewed by the provider in 2014/15 and the Trust intends to take the following
actions to improve the quality of healthcare provided:
Increased information to patients/carers
• (Epilepsy 12) To ensure patients and carers have a documented discussion in clinics regarding water safety in line with
national recommendations.
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• (National Neonatal Audit
Programme) Increase awareness
of the NNAP results to midwifery
and paediatrics to help improve
the communication process
between staff
• (National Neonatal Audit
Programme) Increased focus
for all NICU Staff on the referral
process for babies regarding
retinopathy of prematurity (ROP)
Screening and to ensure this is
being undertaken within the
screening window
• (UK TARN Trauma Audit) Results
to be disseminated to staff and
raise awareness amongst staff
of recording all data, especially
injury data, in order to obtain
accurate assessment of mortality
National confidential enquires 2014/15
Confidential enquiry
Increased awareness and
education of staff
• (UK TARN Trauma Audit) Staff
submitting data to UK TARN
audit shown how to run
accreditation reports in order
for them to review cases for
any data that may have been
omitted and potentially take
correcting action
• (UK TARN Trauma Audit) Data
collection and submission staff
attended a training session
provided by UK TARN
• (MINAP) To develop ‘guidance
sheets’ for staff collecting the
data to increase he accuracy of
data collection
• (National Hip Fracture Database)
Presented key findings at
Trust surgery and critical care
quality and safety days and
orthopaedics audit meetings to
raise awareness of any problem
areas
• (Elective surgery (National
PROMs Programme) Present
key findings at the general
surgery and orthopaedics audit
meetings to raise awareness of
any problem areas
• (National Hip Fracture Database)
visited to hospital cited in hip
fracture database 2013 report
who have improved time to
surgery and performed well
(Harrogate) to discuss how
improvements have been made
in best practice tariff targets and
look at what lessons may be
transferred to NLAG
• (Paediatric diabetes) Diabetes
nurses have held training
events to inform families of the
‘upbeat’ website and encourage
them to register for easy access
to information regarding
management of diabetes
• (Paediatric diabetes) To review
files of all patients with HBA1c
above 80mmols to ensure
HBA1c levels for these patients is
the best it can be
• (National Prostate Cancer)
Cancer team met with clinical
team to discuss minimum
dataset and data collection
to improve data validity and
consistency as well alleviate
concerns form the clinical lead
regarding data submission
due to suspected issues with
somerset cancer registry
Identified need for further
evaluation/patient surveys
• (National Hip Fracture Database)
To obtain and review all patients
documented as having hospital
acquired pressure sores to
ensure data accuracy
• (National Cardiac Arrest Audit) To
perform root cause analysis on
a sample of in-hospital cardiac
arrests on a monthly basis to
ensure any learning points are
maximised.
Changes to service/process
• (National Neonatal Audit
Programme) To understand and
assess the current methods at
both sites for NICU staff when
referring babies for retinopathy
of prematurity (ROP) Screening,
as this can now be completed in
the first instance as an inpatient
or if unable to, as an outpatient
(within the appropriate
screening time period)
• (UK TARN) To ensure all the data
required for the UK TARN forms
part of the trust-wide emergency
trauma form currently being
developed for use
• (BAUS PCNL and Nephrectomy)
Training offered to consultant
leads and audit liaisons to
show how to upload data on
to the BAUS system, including
downloading our own data and
editing, validating and changing
follow up settings
• (BTS Pleural Procedures Audit) A
change to the documentation
for chest drains has been
proposed, combining two
separate forms into one and
ensuring more pertinent data is
recorded, including prompts for
written consent
• (BAUS PCNL) Downloaded
our own data from BAUS and
analysed and presented findings
to urology audit group to help
data validation and action
planning
• (National IBD Audit) Treatment
pathway document to be
developed
• (ICNARC Case Mix Programme)
Presented findings at quality and
safety day to raise awareness
87
• (National Bowel Cancer Audit) In
order to improve laparoscopic
operation rates the Trust has
recruited a new laparoscopic
colorectal surgeon
• (Paediatric diabetes) Number
of clinics and consultation time
increased to 30 minutes (regular
visit) and 45 minutes
• (BAUS percutaneous
nephrolithotomy - PCNL) In
an attempt to reduce length
of stay the consultant lead
communicated to all that
following an operation on a
Wednesday, earlier nephrostomy
removal can take place in order
to discharge patients prior to the
weekend if no post-operation
bleeding is present
• (BAUS percutaneous
nephrolithotomy - PCNL)
Consultant lead to ensure midstream specimen of urine is
undertaken at pre-assessment of
all PCNL cases to ensure patient
in infection free before operation
takes place
• (BAUS percutaneous
nephrolithotomy – PCNL)
Consultant lead to look at
business case for a machine that
involves using x-rays (highenergy radiation) or ultrasound
(high-frequency sound waves) to
pinpoint where a kidney stone is
and break it in to smaller pieces
so it can be passes, therefore
reducing the need for more
radical surgery
• (National emergency laparotomy
– NELA) Consultant leads at
each site have started drafting
an acute abdomen pathway to
ensure risk scoring is completed
for all patients and all steps of the
pathway are met within certain
timeframes (pre-publication of
results)
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• (NCEPOD Tracheostomy) New
tracheostomy surgical safety
checklist has been constructed
by consultant leads and audit
department in order to comply
with NCEPOD recommendations
within the findings and selfassessment checklist for trusts.
Collaborative/MDT working
to be improved/discussed
• (Neonatal National Audit
Programme) Data validation
continues to be completed every
quarter during the reporting year
to ensure that all appropriate
information has been completed,
with special focus on antenatal
steroids and ROP screening
• (National Hip Fracture Database)
Introduced additional lists for hip
fracture on Tuesdays at DPOW
and weekends at SGH in order to
try to improve time to theatre
• (National Prostate Cancer Audit)
Cancer team constructed a data
collection form for specific use at
MDT in order to aid documentation
and submission of staging to
national audit and improve quality
and validity of data.
The reports of 11 local clinical audits
were reviewed by the provider in
2014/15 and the Trust intends to take
the following actions to improve the
quality of healthcare provided:
Increased awareness and
education of staff
• (Homebirth) Staff awareness
sessions to be delivered on
updated home confinement
guideline and the importance
of documentation
• (Use of customised growth
charts) Refresher training to be
given to staff regarding when
to commence the growth chart
and the process to be followed
depending on measurements
taken.
we care, we respect, we deliver
• (Goole deliveries) development
of new guideline, community
staff inducted in to the Goole
suite and made aware of the
processes and staff refreshed in
protocols in place for high risk
women
• (CQUINS sepsis) Sepsis screening
tool (SST) to be included as part
of the junior doctor induction,
and reminders for its use to
be rolled out as screen savers.
Refresher teaching sessions for
A&E/ECC staff to be carried
• (CQUINS sepsis) Copies of the
SST are stored in the triage room
so that the triage nurse can place
the SST in the notes if he/she
believes it to be a case of sepsis.
Changes to service/process
• (WHO Checklist – Maternity)
Maternity checklist to be
reviewed and revised to better
reflect maternity practice
• (Management of third and
fourth degree tears) Face to face
follow up clinics now reinstated
following an audit showed the
previously agreed telephone
appointments were not taking
place and evidence of the
benefits to the patient of having
a face to face appointment
• (CQUINS medicine discharge
summaries) The discharge letter
template has been amended
so that the ‘procedures and
treatments’ section is now
mandatory. The date of
discharge section is now autopopulated with a confirmation
message for the completing
clinician
• (CQUINS medicine discharge
summaries) The list of consultant
specialties which auto-populates
the specialty field on the
discharge summary has been
reviewed and updated.
• (Monthly and rapid cycle
prescribing audit) The trust are
currently re-designing the drug
prescription charts in order
for it to be more conducive to
meeting national standards
and aid clearer documentation
for both daily and prophylactic
scripts
• (WHO surgical safety checklist)
Pre-list briefing introduced for
both morning and afternoon lists
• (WHO surgical safety checklist)
Associate medical director
of surgery and critical care to
undertake spot checks on the
delivery of the checklist on a
continuous basis
• (NICE TA49 - ultrasound locating
devices for placement of CVC’s)
clinical lead for anaesthetics
working with vascular access
specialists to introduce a booklet
with a checklist in order to
improve documentation of CVC
placement
• (NICE – CG99 Constipation in
children and young people)
New paediatric clinic set up by
consultant and nursing lead to
ensure compliance with NICE
guideline and attempt to reduce
inpatient admissions.
2.2c Information on participation in clinical research
The total number of patients receiving relevant health services
provided or sub-contracted by the Trust in 2014/15 that were
recruited during that period to participate in research approved by a
research ethics committee is not known as this data is not collected.
However, those patients recruited to
NIHR adopted research studies was
1306 as of end January 2015
NB: It should be noted that all
studies opened within the Trust
are subject to rigorous governance
checks which includes submission to
a research ethics committee where
required. Thus additional patients
will be involved in research studies
where by the actual patient accrual is
not reported through R&D as a core
expectation of the Trust at this time
i.e. in house/academic studies that
are not NIHR adopted.
The Trust takes part in clinical
research, this is because it believes
that research is important because
it helps to improve healthcare by
finding out which treatments work
best for patients.
It also gives patients the opportunity
to access novel and innovative
treatments and therapies. Within the
department we have adopted the
NIHR strapline of ‘Today’s research
is Tomorrow’s Treatment’ which
captures the essence of what our
service is about.
The research and development
department offers a central
corporate function within the Trust
and takes an organisational-level
lead in ensuring that research is
conducted and managed to high
scientific, ethical and financial
standards.
The Research and developement
department function is delivered
from two offices based at the
Scunthorpe and Grimsby sites
and is led and managed by the
head of research and professional
development supported by a
team of 11 research nurses, two
data coordinators and a projects
coordinator.
Within the research and
development department,
our aims are:
• To increase the number of
research studies open within the
Trust, including industry studies
that may also generate income.
Such income is then re-invested
within the Trust in the areas of
further research and professional
development,
• To increase the number of
patients recruited to studies
within the Trust thus increasing
the opportunities for patients
to access new and cutting edge
treatments which may not be
offered through routine care
delivery,
• To improve the time that it takes
to open a research study within
the Trust.
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• To continue working with our
research partners in Yorkshire
and Humber to deliver the
National Institute of Health
Research (NIHR) high level
objectives.
The research and development
department is currently supporting
a range of research projects. These
include:
• National Institute of Health
Research (NIHR) Portfolio
adopted research
• Non-Portfolio research
• Commercially Sponsored studies
• Academic and In-House research
studies.
There are currently 87 studies open
to recruitment within the Trust, these
include
• 15 of these studies are
commercial
• 66 are adopted onto the NIHR
(National Institute for Health
Research) Portfolio
• 6 account for other studies which
are currently open.
How the research and
development team help to
deliver research
• Following-up of the patients involved in the studies once the actual
treatment stage has been completed – this can be for a number of years
in some studies
• Collecting the data that contributes to the results of studies. This then
goes onto changing practices and treatments in the future.
We currently have research projects open in the following
areas:
Oncology
Diabetes
Dermatology
Paediatrics
Haematology
Gastrointestinal
Rheumatology
Nursing
Stroke
Obstetrics
ITU
Management
Cardiology
Gynaecology
Surgery
Neurology
The Research and development department is dedicated to supporting
and furthering research, development and innovation within the Trust. The
department provides assistance and guidance on how to:
• Check whether projects are research, service evaluation or audit
• Help and advice on protocol development, study design, data
management and analysis
• Assist in the setup of a study
• Coordinate a submission to the Research Ethics Committee (REC) and
where necessary Medicines and Healthcare Products Regulatory Agency
(MHRA) to facilitate approvals
• Undertake the necessary NHS Trust approval process on behalf of
Northern Lincolnshire and Goole NHS Foundation Trust.
It also provides information about training courses offered by other training
providers in the field of health service research, local and national funding
opportunities and research and development publications.
2.2d Information on
the Trust’s use of the
CQUIN framework
A proportion of the Trust’s
income in 2014/15 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 2014/15 and for the following
12 month period are available
electronically at:
www.england.nhs.uk/wp-content/
uploads/2014/02/sc-cquin-guid.pdf
The areas of care which were
included within the CQUIN scheme
for 2014/15 included the following:• Friends and Family Test
• NHS Safety Thermometer
(Pressure ulcer prevalence)
• Dementia
• Patient experience
The team of nurses and data
coordinators help to deliver research
within our Trust in the following
ways:
• Vision & values appraisals
• By identifying patients
suitable for research studies–
involvement is entirely voluntary
and never undertaken without
formal written consent from the
volunteers
• Quality of electronic discharge
summaries
• By supporting the investigators
in delivering the research studies
on a day by day basis, including
seeing patients in clinics and at
home where required
The monetary total value for
2014/15 CQUIN indicators was £6.14
million. The Trust are currently in
discussions with commissioners
regarding the CQUIN financial value
that the Trust will receive.
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we care, we respect, we deliver
• Implementing sepsis care
bundle
• Clostridium difficile
The amount of income in 2014/15
which was conditional upon
achieving quality improvement and
innovation goals was £6.14 million.
2.2e Information on Never Events
The Trust reported 0 never events during 2014/15.
2.2f Information relating to the Trust’s
registration with the Care Quality Commission
Northern Lincolnshire and Goole NHS Foundation Trust is required to register
with the Care Quality Commission and its current registration status is ‘requires
improvement’. The Trust has no conditions on its registration.
The Care Quality Commission has not taken enforcement action against the
Trust during 2014/15.
The Trust has not participated in any special reviews or investigations by the
Care Quality Commission during the reported period.
Themes arising from the CQC visit of the Trust:
The CQC visit to the Trust during the 2014/15 period identified a number
of themes. These have all become a central part of the Trust’s Quality
Development Plan (QDP) and are monitored by the Trust Board. As this is a
board paper, the full QDP is available for viewing on the Trust’s Internet site. A
high level summary of these themes are presented below:
• Hydration and feeding,
• Care of the deteriorating patient,
• Patient falls,
• Staffing levels,
• Implementation and consistency of clinical strategies and pathways,
• Mixed sex accommodation,
• Dementia care,
• Friends and Family test,
• Improved patient flow,
• Senior medical involvement out of hours,
• Improved clinical leadership,
• Improved record keeping and clinical documentation,
• Complaints and PALS,
• Mandatory training and appraisal,
As you can see many of these areas are reported
within this annual account and form the basis
of the Trust’s focus on Quality during
2015/16.
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2.2g Information on
quality of data
2.2h Information governance assessment
report
The Trust submitted records
during 2014/15 to the
secondary uses service for
inclusion in the hospital
episode statistics which are
included in the latest published
data.
The Trust’s information governance assessment report overall score
for 2014/15 was 66 per cent and was satisfactory.
- Which included the patient’s valid
General Practitioner Registration
Code was:
• 100.0 per cent for admitted
patient care
• 100.0 per cent for outpatient care
• 100.0 per cent for accident and
emergency care.
130
112
116
116
117
118
115
115
111
109
109
109
108
109
Apr 11 - Mar 12
Jul 11 - Jun 12
Oct 11 - Sept 12
Jan 12 - Dec 12
Apr 12 - Mar 13
Jul 12 - Jun 13
Oct 12 - Sept 13
Jan 13 - Dec 13
Apr 13 - Mar 14
Jul 13 - Jun 14
2.2i Information on payment by results clinical
coding audit
114
Jan 11 - Dec 11
110
Oct 10 - Sept 11
• 98.3 per cent for accident and
emergency care.
Figure 42
120
100
90
80
70
The Trust was not subject to the payment by results clinical coding
audit during 2014/15 by the Audit Commission.
60
50
• 96.4 per cent for admitted
patient care
• 99.8 per cent for outpatient care
• The value and banding of the summary hospital-level mortality indicator (“SHMI”) for the Trust for the reporting period;
Jul 10 - Jun 11
- Which included the patient’s valid
NHS Number was:
The data made available to the Trust by the Health and Social Care Information Centre with regard to:
Apr 10 - Mar 11
The percentage of records in
the published data:
2.3a: Summary Hospital-Level Mortality Indicator (SHMI)
2.3 Trust performance against core indicators
Since 2012/13 NHS foundation trusts have been required to report
performance against a core set of indicators using data made available by the
Health and Social Care Information Centre (HSCIC).
For each of these indicators, the number, percentage, value, score or rate (as
applicable) is reported for at least the last two reporting periods (last two years).
As the information has been made available from the Health and Social Care
Information Centre, where possible a comparison has been made for each of
the Trust’s indicators with:
a). The national average for the same;
b). Those NHS Trusts and the NHS Foundation Trusts with the highest and
lowest of the same.
For each of these indicators, the Trust is required to make an assurance
statement in the following format:
Trust
UK average
UK best
UK worst
Source: Health and Social Care Information Centre (HSCIC)
Key to abbreviations: Trust – Northern Lincolnshire and Goole NHS Foundation Trust,
UK average – The United Kingdom average, commonly expressed as 100 – ‘expected mortality’,
UK best – The lowest SHMI scoring Trust/hospital/unit,
UK worst – The highest SHMI scoring Trust/hospital/unit.
Comments:
• The above table illustrates the Trust’s performance against the Summary Hospital Mortality Indicator (SHMI). The SHMI
is a Standardised Mortality Ratio (SMR). SHMI is the only SMR to include deaths outside of hospital in the community
(within 30 days of hospital discharge). This inclusion of community mortality means the information needed to
ascertain this comes from the Office for National Statistics, this results in delay in the reporting of the SHMI. To illustrate
the most recently available SHMI reports performance July 2013 to June 2014
• This delay in reporting makes it difficult for the Trust to continuously in real time monitor this area using SHMI alone,
hence why the Trust uses this in collaboration with the ‘provisional SHMI’ indicator from the Healthcare Evaluation Data
(HED). Using this ‘provisional indicator’ the Trust has access to more timely information which demonstrates further
improvements with mortality performance, illustrated graphically as follows.
The Trust considers that this data is as described for the following reasons
[insert reasons].
The Trust [intends to take or has taken] the following actions to improve
the [indicator/percentage/score/data/rate/number], and so the quality of its
services, by [insert description of actions].
Some of those indicators were not relevant to the Trust; therefore the following
indicators reported on are only those relevant to the Trust.
This information has been presented as follows in table or graphical format, as
most suited to the type of information being presented.
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Figure 43
NLaG - Moving Annual Total (MAT) provisional SHMI
Figure 44
Trust value
Trust
banding
April 2010 – March 2011
1.14
1
January 2012
July 2010 – June 2011
1.12
2
April 2012
October 2010 – September 2011
1.16
1
July 2012
January 2011 – December 2011
1.16
1
October 2012
April 2011 – March 2012
1.17
1
January 2013
July 2011 – June 2012
1.18
1
April 2013
October 2011 – September 2012
1.15
1
July 2013
January 2012 – December 2012
1.15
1
October 2013
April 2012 – March 2013
1.11
2
January 2014
July 2012 – June 2013
1.09
2
Source: Healthcare Evaluation Data (HED), information services team
April 2014
October 2012 – September 2013
1.09
2
Key to abbreviations: NLAG – Northern Lincolnshire and Goole NHS Foundation Trust,
Moving Annual Total (MAT) – A moving annualised average, each months data includes that month plus the 11 months preceding, providing a more reliable presentation of trends over time,
July 2014
January 2013 – December 2013
1.09
2
October 2014
April 2013 – March 2014
1.08
2
January 2015
July 2013 – June 2014
1.09
2
130
NLaG
National average
Official SHMI
120
DPoW
SGH
GDH
110
100
90
Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar
2013
2012
2014
2015
National average – The United Kingdom average, commonly expressed as 100 – ‘expected mortality’,
DPoW – Diana, Princess of Wales Hospital,
GDH – Goole District Hospital,
Provisional SHMI – The Healthcare Evaluation Data (HED) product provides a provisional SHMI on a monthly basis by which the Trust can report mortality in various internal reporting,
Official SHMI – the ‘official’ SHMI publication, published quarterly, illustrates that the ‘provisional’ HED data is a reliable indicator to monitor Trust performance on a monthly basis.
Comments:
• The above chart illustrates that the Trust’s mortality performance has improved at pace. During the past few months
however, the rate of improvement previously seen has slowed at both sites, resulting in a steady trend of at or around
a SHMI score of 108-109. As this is a relative score, benchmarking the Trust to the rest of the UK, if other Trusts improve
at a faster rate, the likelihood the Trust will move back towards the ‘higher than expected’ grouping. The provisional
HED SHMI information has provided the Trust with an insight that this might be happening
• There has been and are still slight differences between the Trust’s individual hospital sites, and there is a significant
difference between the in-hospital element of the SHMI ie deaths taking place at the hospital, and the out of hospital
part of the indicator, ie those deaths that take place within 30 days of discharge home or into the community. Both of
these important elements are monitored monthly by the Trust’s mortality report and the Trust’s Mortality Performance
and Assurance Committee (MPAC) and ultimately by the Trust Board. The Board recognises that the mortality position
is a community wide issue and there needs to be a healthcare community wide focus on this to enable further
improvements to the overall SHMI. The Trust is focusing on working with colleagues from general practice and other
community services to understand this further and take action to improve the out of hospital SHMI
• While 100 is the national average and is commonly defined as ‘expected’ mortality, it is recognised that this statistical
measure is not an absolute indicator of performance. As a result of this, the Health and Social Care Information
Centre (HSCIC) publish an organisation’s position nationally, determining the national best and worst, as well as a
Trust banding, which illustrates if an organisation is statistically an outlier, using 95 per cent confidence intervals. This
banding is illustrated as follows.
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Sample time frame
October 2011
SGH – Scunthorpe General Hospital,
94
Publication date
Source: Health and Social Care Information Centre (HSCIC)
Key to abbreviations: Trust value – The Trust’s SHMI score,
Trust banding – The Trust’s banding – determining if it is an outlier using statistically calculated levels of confidence (95 per cent confidence intervals).
Banding numbers are based on a 95 per cent control limit. The bandings mean:
• 1 – higher than expected
• 2 – as expected
• 3 – lower than expected
As a result of being identified as an outlier between the periods of October 2010 and December 2012, the Trust was one
of 14 inspected by a team from the NHS medical director, Sir Bruce Keogh. This ultimately led to the Trust being placed in
a form of ‘special measures’ with greater level of scrutiny and assistance provided by a partnering arrangement between
the Trust and Sheffield Teaching Hospitals NHS Foundation Trust and a member of Monitor’s executive team working
alongside the Trust. More details from this period are summarised later in this report.
Overseen by the Mortality Performance and Assurance Committee (MPAC) the focussed work ongoing prior to the Keogh
team’s visit, but further strengthened as a result, saw steady improvements illustrated in previous pages charts resulting
in the table above charting the Trust’s steady performance within the ‘as expected’ banding. More work is still needed and
this is underway currently, more detail of this provided in the later section of this report.
a). The percentage of patient deaths with palliative care coded at either diagnosis or speciality
level for the Trust for the reporting period.
95
Figure 45
• The Trust Board, supported by the Mortality Performance Committee, recognises that the mortality position is
a community wide issue and there needs to be a healthcare community wide focus on this to enable further
improvements to the overall SHMI. The analysis of the SHMI indicator within the monthly mortality report includes
a specific breakdown of the SHMI between the in-hospital and out of hospital component parts. This greater
understanding has illustrated a significant gap between the in-hospital ie deaths within the Trust and the out of
hospital ie those deaths that take place within 30 days of discharge home or into the community. This difference is
illustrated in the following chart.
50
45
40
35
30
25
20
Figure 46
15
15.5
10
5
10.6
5.9
6.6
12.5
13.6
13.9
13.8
13.6
13.5
17.8
18.5
8.2
Jul 13 - Jun 14
Apr 13 - Mar 14
Jan 13 - Dec 13
Oct 12 - Sept 13
Jul 12 - Jun 13
Apr 12 - Mar 13
Jan 12 - Dec 12
Oct 11 - Sept 12
Jul 11 - Jun 12
Apr 11 - Mar 12
Jan 11 - Dec 11
Oct 10 - Sept 11
UK worst
Jul 10 - Jun 11
UK best
120
Apr 10 - Mar 11
UK average
130
14.4
0
Trust
Trust provisional SHMI : Full, in hospital and out of hospital Moving Annual Totals (MAT)
110
100
Source: Health and Social Care Information Centre (HSCIC)
UK average – The United Kingdom average,
In hospital SHMI
Out of hospital SHMI
National average
NLaG Full SHMI
Key to abbreviations: Trust – Northern Lincolnshire and Goole NHS Foundation Trust,
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UK best – The Trust/hospital/unit reporting highest percentage levels of palliative care,
Dec
UK worst – The Trust/hospital/unit reporting lowest percentage levels of palliative care.
2012
Jan Feb Mar Apr May Jun
Jul
Aug Sept Oct Nov Dec
Jan Feb Mar Apr May Jun
2013
Jul
Aug Sept Oct Nov Dec
2014
Comment:
Source: HED Information, CHKS
• The above chart illustrates the percentage of patients with a palliative care code used at either diagnosis or specialty
level
Key to abbreviations: NLAG Full SHMI – The Trust’s full combined SHMI (including both in-hospital and out of hospital deaths (within 30 days)
• Palliative care coding is a group of codes used by hospital level coding teams to reflect palliative care treatment of a
patient during their hospital stay. Different statistically calculated Standardised Mortality Ratios (SMR) have treated
this group of patients differently depending on the indicator. Some previously employed SMR indicators including
the Risk Adjusted Mortality Index (RAMI) that the Trust used to use exclude patients with a palliative care code from
the mortality indicator. To ensure this was not exploited for minimising an organisation’s mortality, Trusts are required
to meet strict rules that govern the use of such codes to only those patients appropriately seen and managed by a
specialist palliative care team
NLAG In-hospital SHMI – The in-hospital death rate
• The SHMI does not exclude this group of patients, rather they are included and the appropriate risk factor for each
is statistically determined according to the model. As palliative care coding is a key mortality indicator, the SHMI on
publication each quarter include the above breakdown of data for Trusts to see the proportion of palliative care codes
being used versus the national average
• The above table illustrates the percentage of patients each quarter where palliative care codes have been used in
either the patient’s specific diagnosis or at the specialty team level of those caring for the patient. It is noticeable
during successive quarters of a gradual increase in the level of palliative care codes being used, this demonstrates
some of the work undertaken within the Trust to ensure appropriate palliative care support is provided as and when
needed and improving recording systems to ensure when the palliative care specialist team are involved this is
accurately captured within the hospital coding.
Northern Lincolnshire and Goole NHS Foundation Trust considers that this data is as described
for the following reasons:
• The Trust has been actively pursuing an improvement programme looking at all elements of data related and quality
care related factors that make up the Trust’s overall SHMI. A number of improvements have been made in these areas,
which is demonstrated as helping reduce the Trust’s mortality ratio since reporting of this information in the 2012/13
and 2013/14 Quality Accounts
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NLAG out of hospital SHMI – The out of hospital (within 30 days following discharge) death rate
National Average – the UK average SHMI score, always represented as 100
• There has been and are still slight differences between the Trust’s individual hospital sites, and there is a significant
difference between the in-hospital element of the SHMI ie deaths taking place at the hospital, and the out of hospital
part of the indicator, ie those deaths that take place within 30 days of discharge home or into the community. Both of
these important elements are monitored monthly by the Trust’s mortality report and the Trust’s Mortality Performance
and Assurance Committee (MPC) and ultimately by the Trust Board. The Board recognises that the mortality position
is a community wide issue and there needs to be a healthcare community wide focus on this to enable further
improvements to the overall SHMI. The Trust is focusing on working with colleagues from general practice and other
community services to understand this further and take action to improve the out of hospital SHMI.
The Trust has taken the following actions to improve the indicator and percentage in a and b, and
so the quality of its services by:
• The improvements seen during 2013/14 and 2014/15 are a result of a number of improvement projects assessing
both data quality and clinical care. These improvement projects have been focused and guided
by the monthly provision of the latest data in the comprehensive mortality report, presented
and then scrutinised by the Mortality Performance and Assurance Committee (MPAC). This is
then in turn provided to the Quality, Patient Experience Committee (QPEC) for their
assurance of MPAC’s actions, before finally being presented to the Trust Board
and then becoming publically accessible.
• Another source of valuable information regarding the clinical care and
quality thereof was the use of the ‘mortality trigger tool’
review process which screened out all deaths
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and ensured clinical review of
cases with triggers, both from a
nursing and medical standpoint.
This provided recent quantitative
and qualitative data on clinical
practice. It provided ‘themes’
requiring further focus
• From these two sources of
information (1) the monthly
mortality report and (2) the
‘mortality trigger tool’ review
process, the Trust developed a
focused and targeted quality
evaluation and improvement
programme. As part of this, the
following areas where prioritised
for improvement projects:
Clinical areas – where the
data illustrated highest
levels of mortality:
• Stroke services
• Respiratory medicine
• Gastroenterology
• Sepsis
• Haematology/oncology
• Diabetes and endocrine
• Acute kidney injury/renal failure
‘Themes’ identified as areas
relating to poor quality:
• Hospital acquired pneumonia
• Fluid management
• Cardiac arrests
• Venous thromboembolism (VTE)
• Safe staffing.
Each of these quality improvement
project teams were asked to scope
out the problem, using anecdotal
observations of the teams working
in these areas, the feedback from
the ‘mortality trigger tool’ review
process and the monthly mortality
report.
Once they had identified the main
issues, they began to develop ways
of targeting these issues with a view
to improvement. Each project was
monitored by the centrally held
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mortality action plan. As a result
of these projects the following
improvements were made:
• Centralisation of the hyperacute
stroke service on the Scunthorpe
site to ensure that the specialist
and finite resource was fully
able to deliver 24/7 hyperacute
stroke care. As a result mortality
performance in stroke, looking at
the service as a whole, has seen
significant improvements
• Development and roll-out of
respiratory pathways to enable
admitting teams to prescribe
evidenced-based treatment,
reducing delays to crucial
medications and investigations
• In collaboration with the
respiratory pathways, a sepsis
pathway, a more generic series
of protocols, was designed
and implemented to ensure
that patients on admission
with sepsis receive potentially
lifesaving antibiotics sooner and
more consistently
• Work has begun to redesign
access for emergency patients
requiring urgent endoscopic
assessment with the drafting of
a joint rota between medics and
surgeons
• An AKI guideline, protocol
and improved guidance on
the Web V system, based on
abnormal blood work, have been
developed and are currently
being approved for use
• Increased joint working is the
objective behind new guidelines
to help feed those patients
unable to eat to reduce patient
deterioration but also to lessen
the risk of patients developing
hospital-acquired pneumonia
• Improved guidance, in line
with recently published NICE
guidance, and a bespoke fluid
prescription sheet have been
drafted and are currently being
approved for use
we care, we respect, we deliver
• An improved tool to help
get to the root cause behind
in-hospital cardiac arrests has
been developed and is currently
being piloted. It is hoped this
will provide effective ‘real time’
information demonstrating the
aspects of care that could be
improved in this area to reduce
the number of cardiac arrests or
to work to improve end of life
care planning still further.
The work going forward
into 2015/16
• While these improvement
projects have made good
progress, further improvement
is still possible. As such, recent
changes in the assurance
mechanisms around mortality,
leading to the renaming and
repositioning of the Mortality
Performance Committee (MPC)
to the Mortality Performance
and Assurance Committee
(MPAC), has led to a stocktake
in the plans around mortality
improvement and a refreshed
approach
• The fundamental use of the
monthly mortality report has
not changed. What has changed
however within the report is the
increased use and reliance of the
crude mortality indicator, and
less use and reporting from the
statistical standardised mortality
ratios (SMRs)
The reason for this in part
was the usefulness front line
clinicians found in using these
indicators, and most importantly
how much access they had using
these to access the individual
patient records in order to
scrutinise the level of quality
provided to them from their
services
Using the previously relied upon
data, access to patient level
information to facilitate case
note review was a protracted
process leading to delays and
resulted in their efforts to
review and improve care being
a project, rather than a day to
day part of their management
process arrangements
• The new refreshed mortality
report will be included alongside
the traditional report to begin
with to ensure all users of the
report both internal and external
have access to the information
they have been familiar with
receiving, but, supporting
this, with a view to this being
the report of the future, the
refreshed report will be more
concise and focused primarily on
crude mortality
An additional benefit of crude
mortality is the timeliness of
the data, being only a month
behind the present day. To
further simplify both the process
in reporting this material, but
also the data available to front
line teams, the information each
improvement team will receive
is the refreshed mortality report
with embedded links to enable
them to access the patient
specific information that makes
up the area’s crude mortality
performance for any given
month
This strategic change moves
the ownership of the data
from corporate support team
members to the frontline clinical
teams who ‘own’ the service,
thus enabling them to access
information when it suits them
and their work plans.
• This refreshed mortality report
and the focus on crude mortality,
shows six key clinical groupings
have the greatest levels of
mortality. This is not to imply
these six areas have the highest
levels of ‘excess’ death, rather,
simply these areas are those that
have the highest numbers, so
using the Pareto 80:20 principle,
these are the areas where
greatest levels of improvement,
to the maximum benefit of local
service users, can be gleaned.
• The six areas are unsurprisingly
areas where mortality would
likely be expected and are as
follows:
• Cardiology
• Gastroenterology
• Stroke
• Cancer/end of life care
• Infection/sepsis
• Respiratory
• The fundamental approach to
take now in these areas again
is nothing new. Each have
been asked to ensure they
have a medical lead, nursing
lead, therapy lead and any
other multidisciplinary team
involvement, relevant to their
specific area
Using the refreshed mortality
report and embedded links to
the patient specific detail, each
of these groups is asked to
reflect on the previous actions
taken (for those groups who
have operated previously ie
respiratory) ensure that any
outstanding actions are factored
into their new plans and using
the also refreshed ‘mortality
trigger tool’ review process, now
renamed as the ‘quality of care
outcomes tool’ to illustrate the
process is all about quality not
specifically mortality, review
cases of mortality and determine
which areas of quality could be
improved
basis to attend the Mortality
Performance and Assurance
Committee (MPAC) to feed back
on their progress.
External scrutiny and
the Trust’s support
As referred to in the 2013/14 Quality
Account, the Trust had been selected
as one of 14 NHS Trusts to be visited
by a team led by Sir Bruce Keogh.
While the review was sparked as a
result of the Trust being an outlier
in connection with mortality rates,
the review was very much focused
on overall care quality, not just
mortality. The Trust welcomed this
visit which took place in June 2013
and fully supported the review team.
Arising from the Keogh review,
Monitor, the regulator of Foundation
Trusts, found the Trust in breach of its
licence (specifically the requirement
to secure economy, efficiency and
effectiveness) and in August 2013
the Trust was placed in ‘special
measures’.
The Trust has also received a number
of external reviews and visits since,
including a revisit by some of the
original Keogh team in November
2013 and a re-visit by the CQC in
December 2013. The Trust also
received a CQC visit by the Chief
Inspector of Hospitals in April 2014.
Following the Keogh and CQC
reviews, the Trust commissioned
an external review of the Trust’s
governance arrangements using
KPMG, an external company
providing professional services
including audit.
• Each of the six groups will
be supported to undertake
these projects and to further
support them in unblocking any
obstacles they face during the
course of their improvement
work, each will be invited
on a regular
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Following these visits and the
additional support provided to the
Trust, in July 2014 the Trust was the
second of the 14 ‘Keogh sites’ to be
removed from special measures.
This was following the assurances
gleaned from the site visits but also
from the assurance provided by the
Trust’s rigorous monitoring of the
improvement areas identified via
the various visits, using the centrally
held Quality Development Plan
(QDP).
The QDP is a comprehensive action
plan that includes in one central
place all the recommendations and
actions now being taken following
the Francis Report, and visits by
the CQC and other external bodies
visits ie the Deanery, facilities ‘safe
and secure’ accreditation.
The QDP is further sub-divided into
the various sub-committees of the
Trust board best placed to oversee
and seek assurance on delivery of
the action plans sitting under them.
These sub-committees take regular
delivery of the QDP actions relevant
to them. This is also reported on a
regular basis to the Trust Board.
2.3b: Patient Reported Outcome Measures (PROMS)
The data made available to the Trust by the Health and Social Care
Information Centre with regard to the Trust’s patient reported
outcome measures scores for:
a)Groin hernia surgery
c)Hip replacement surgery
d)Knee replacement surgery.
during the reporting period.
Groin hernia
Trust adjusted
average
health gain
National
average
health gain
April 2010 – March 2011
0.121
0.085
0.156
-0.020
April 2011 – March 2012
0.084
0.087
0.143
-0.002
April 2012 – March 2013
0.083
0.085
0.157
0.015
April 2013 – March 2014
0.051
0.085
0.139
0.008
0.091
0.155
-0.007
0.094
0.167
0.047
April 2012 – March 2013
0.093
0.175
0.023
April 2013 – March 2014
0.093
0.150
0.023
Sample time frame
April 2010 – March 2011
Varicose vein
Hip
replacement
Knee
replacement
Northern Lincolnshire and Goole NHS Foundation Trust considers that the outcome scores are as
described for the following reasons:
• The Trust monitors its participation rates and response rates in relation to the completion of pre-operative and postoperative PROMs questionnaires. Lower than average participation rates were noted for groin hernia but significantly
high participation rates were noted for both Hip and Knee Replacement at 92.5 per cent and 92.4 per cent respectively
• Quarterly reports are received from the Health and Social Care Information Centre that provide progress updates on
both the participation rates and the overall health gain reported by patients.
The figures noted above evidence the positive performance of the Trust in relation to overall health gain with health
gain scores for groin hernia falling slightly below the national average. Health gains for all other clinical procedures are
above the national average for 2013-2014.
b)Varicose vein surgery
Type of surgery
• The Patient Reported Outcome Measure (PROM)s is a national initiative designed to enable NHS trusts to focus on
patient experience and outcome measures
The four areas listed above are nationally selected procedures of which the Trust has no power to influence. This is
illustrated in varicose vein surgery, which the Trust does not provide hence why no data is available.
April 2011 – March 2012
National National
highest lowest
The Trust has taken the following actions to improve these outcome scores, and so the quality of
its services by:
• Discussing the results at the surgery and critical care clinical governance group and presenting to clinicians at the
general surgery clinical audit meetings. The Trust has access to patient level data which is analysed in house and used
to drive further improvements in patient reported outcomes
• Continuing to review participation rates for each clinical procedure with a particular focus on groin hernia, and making
improvements in the internal monitoring of pre-operative questionnaire returns to ensure all eligible patients are
given the opportunity to participate.
Not available
April 2010 – March 2011
0.438
0.405
0.503
0.264
April 2011 – March 2012
0.405
0.416
0.532
0.306
April 2012 – March 2013
0.461
0.438
0.538
0.369
April 2013 – March 2014
0.426
0.436
0.545
0.342
April 2010 – March 2011
0.316
0.299
0.407
0.176
April 2011 – March 2012
0.317
0.302
0.385
0.180
April 2012 – March 2013
0.357
0.319
0.409
0.195
April 2013 – March 2014
0.332
0.323
0.416
0.215
Source: Health and Social Care Information Centre (HSCIC), primary data used
Comment:
• The above table shows the Trust’s reported adjusted health gain, which is a
measure of the patient’s own reported outcome following surgery within
the Trust.
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2.3c Readmissions to hospital
2.3d Personal needs of patients
The data made available to the Trust by the Health and Social Care Information Centre with regard to the
percentage of patients aged:
The data made available to the 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.
a)0 to 15; and
b)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.
Age group
Trust Emergency
readmissions (%)
National readmissions (%)
National
highest (%)
National lowest
(%)
2011/2012
8.56%
10.01%
14.94%
0.00%
2010/2011
8.19%
10.15%
25.80%
0.00%
2009/2010
7.93%
10.18%
31.40%
0.00%
2008/2009
7.59%
10.09%
22.73%
0.00%
2011/2012
9.47%
11.45%
17.15%
0.00%
2010/2011
9.18%
11.42%
22.93%
0.00%
2009/2010
8.92%
11.16%
22.09%
0.00%
2008/2009
8.64%
10.90%
29.42%
0.00%
Time frame
0 to 15
16 or over
Source: Health and Social Care Information Centre (HSCIC)
Comment:
• The above table outlines the percentage rate of emergency re-admissions to the Trust within two primary age groups
(1) 0 – 15 years and (2) 16 years or over. The table also provides peer data with which the Trust can benchmark itself.
The table illustrates that the rate of emergency re-admissions within the Trust has been consistently lower than that of
the national average
• You will notice the above table does not hold the most recent years information. Following consultation with the
Health and Social Care Information Centre (HSCIC), this data is unlikely to be available before the Quality Account
deadline. The work has been taken back in-house from an external agency and the methodology is currently being
reviewed. Any updates will be announced on the HSCIC indicator portal.
Northern Lincolnshire and Goole NHS Foundation Trust considers that this data is as described
for the following reasons:
• The Trust has been consistently below the national rates for re-admissions.
The Trust intends to take the following actions to improve these percentages, and so the quality
of its services by:
• The Trust continues to monitor its readmission rates on a monthly basis and compares these to the national rates in
order to benchmark our performance
• For the 12 month period to September 2014, the Trust continued to perform well – overall, the Trust’s rate of admission
within 30 days was 6.1 per cent compared to a national rate of 6.6 per cent. However, this rate is for the Trust as a whole
but it is not consistent across our two main hospital sites with one site (DPoW) performing better than the other (SGH)
Time frame
Average weighted
score of 5 questions
National average
National highest
National lowest
2013/2014
64.4
68.7
84.2
54.4
2012/2013
68.5
68.1
84.4
57.4
2011/2012
69.0
67.4
85.0
56.5
2010/2011
67.8
67.3
82.6
56.7
2009/2010
67.6
66.7
81.9
58.3
Source: Health and Social Care Information Centre (HSCIC)
Comment:
• The table above highlights the average weighted score for five specific questions. This information is presented in a
way that allows comparison to the national average and the best and worst performers within the NHS
• The above figures are based on the adult inpatient survey, which is completed by a sample of patients aged 16 and
over who have been discharged from an acute or specialist trust, with at least one overnight stay. The indicator is a
composite, calculated as the average of five survey questions from the inpatient survey. Each question describes a
different element of the overarching theme:
“responsiveness to patients’ personal needs”.
1. Were you involved as much as you wanted to be in decisions about your care and treatment?
2. Did you find someone on the hospital staff to talk to about your worries and fears?
3. Were you given enough privacy when discussing your condition or treatment?
4. Did a member of staff tell you about medication side effects to watch for when you went home?
5. Did hospital staff tell you who to contact if you were worried about your condition or treatment after you left hospital?
• Individual questions are scored according to a pre-defined scoring regime that awards scores between 0-100.
Therefore, this indicator will also take values between 0-100
• For each provider an average weighted score (by age and sex) is calculated for each of the questions. Trust scores are
calculated from a simple average of the question scores. National scores are calculated by a simple average of the trust
scores.
The Trust considers that this data is as described for the following reasons:
• The Trust has continued to achieve results that are above the national average and has
made positive progress each year. Performance against the first four questions noted
above has been monitored on a monthly basis by the quality matrons who have
surveyed 10 patients on each ward per month, the outcome being published
on the monthly nursing dashboard. This has enabled wards and departments
to review progress and identify areas for improvement.
• Therefore, the Trust intends to do further analysis to understand the reasons for the differences between the sites and to
share effective practice where this will improve the quality of our services.
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The Trust has taken the following actions to improve this data, and so the quality of its services by:
• The quality matrons will continue to review the Trust’s performance in relation to the personal needs of patients and
will also develop systems to ensure that appropriate contact information is given to patients on discharge.
• The Patient Experience Group has been progressing a number of actions to aim to improve general communication
and the provision of information to patients
• The assistant director of nursing/head of quality has been reviewing the provision of private spaces for use by staff to
support confidential conversations being held with patients and visitors
2.3e Staff recommending Trust as a provider to friends and family
The data made available to the 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.
2.3f Risk assessed for venous thromboembolism
The data made available to the 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.
Trust performance
(%)
National average
(Acute providers)
(%)
National highest
(Acute providers)
(%)
National lowest
(Acute providers)
(%)
Q3 2014/15
96.2%
95.9%
100%
81.2%
Q2 2014/15
95.7%
96.1%
100%
86.4%
Q1 2014/15
95.7%
96.1%
100%
87.2%
Q4 2013/14
95.8%
95.9%
100%
78.9%
Q3 2013/14
95.9%
95.8%
100%
77.7%
Q2 2013/14
95.1%
95.7%
100%
81.7%
Quarter / Year
Trust performance
(%)
National average
(acute Trusts) (%)
National highest
(acute Trusts)
(%)
2014
55%
67%
93%
38%
2013
48%
67%
94%
40%
Q1 2012/13
92.8%
93.4%
100%
80.8%
2012
55%
65%
94%
35%
Q4 2011/12
90.8%
92.5%
100%
69.8%
2011
54%
62%
89%
33%
Q3 2011/12
81.0%
90.7%
100%
32.4%
2010
54%
63%
89%
38%
Q2 2011/12
82.5%
88.2%
100%
20.4%
Q1 2011/12
80.1%
84.1%
100%
15.7%
Q4 2010/11
51.2%
80.8%
100%
11.1%
Q3 2010/11
42.9%
68.4%
100%
0%
Q2 2010/11
38.5%
52.5%
100%
0%
Staff Survey Year
National lowest
(acute Trusts) (%)
Q1 2013/14
95.2%
95.4%
100%
78.8%
Q4 2012/13
91.8%
94.2%
100%
97.9%
Q3 2012/13
94.4%
94.1%
100%
84.6%
Q2 2012/13
93.2%
93.8%
100%
80.9%
Source: Health and Social Care Information Centre (HSCIC)
Comment:
• The above table illustrates the percentage of staff answering that they “agreed” or “strongly agreed” with the question:
“If a friend or relative needed treatment, I would be happy with the standard of care provided by this Trust”.
Source: Health and Social Care Information Centre (HSCIC)
Comment:
Northern Lincolnshire and Goole NHS Foundation Trust considers that this data is as described
for the following reasons:
• Feedback from staff is that they would recommend the Trust as a healthcare provider through their perceptions that
the Trust delivers highly quality, compassionate care and has excellent patient facilities
• The above table illustrates the percentage of patients admitted to the Trust and other NHS acute healthcare providers
who were risk assessed for venous thromboembolism (VTE) since quarter two, 2010/11. As illustrated in the above
table the Trust has consistently achieved above 90 per cent since quarter four, 2011/12 and is now performing on par
with the national average for this indicator.
• Staff feel that they work in an environment that is predominantly free from physical or verbal aggression from patients,
their relatives and/or carers and from other member of staff
Northern Lincolnshire and Goole NHS Foundation Trust considers that this data is as described
for the following reasons:
• Concerns regarding the Friends and Family Test (FFT) relate to perceptions over staff numbers and the sense that they
are not engaged and therefore are unable to influence service developments.
• The Trust is striving to oversee compliance with VTE risk assessments and prophylaxis prescribed. This is accomplished
through monthly reporting within the quality report, ward level performance with the VTE indicators
collected as part of the Safety Thermometer.
• The Trust has taken the following actions to improve this percentage, and so the quality of its services by:
• The organisational development and workforce culture transformation plan aims to directly increase staff
engagement and stimulate a culture where staff feel they can come forward with service improvement ideas.
• To date work on a Trustwide perspective to increase staff voice has included two very successful internal ‘dragon den’
events with 10 service improvement ideas being taken forward, and many receiving national media attention.
The Trust has taken the following actions to improve this percentage, and so
the quality of its services by:
• The Trust reports VTE prophylaxis rates by ward and had action plans to improve
those wards with lower rates. These are constantly monitored and re-visited as
required.
• Further work is on going and remains to increase staff engagement at ward/departmental level through a drive
towards a collaborative, inclusive leadership and management style.
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2.3g Clostridium difficile infection reported within the Trust
• Existing antimicrobials steering group to monitor the antibiotic side of the Clostridium difficile agenda
The data made available to the 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
two or over during the reporting period.
• Appointed non-executive director (NED) lead for the Infection Control Committee
• Development and implementation of a rolling programme of antibiotic prescribing audits reviewed by the steering
group and the site specific Clostridium difficile action groups
Trust performance
per 100,000 bed
days
National average
per 100,000 bed
days
National highest
per 100,000 bed
days
National lowest per
100,000 bed days
April 2013 – March 2014
9.7
14.7
37.1
0
April 2012 – March 2013
17.1
17.3
30.8
0
April 2011 – March 2012
19.8
22.2
58.2
0
April 2010 – March 2011
19.7
29.7
71.2
0
April 2009 – March 2010
19.2
35.3
92.0
0
Time frame
Source: Health and Social Care Information Centre (HSCIC)
• An embedded infection prevention and control zero tolerance framework for improved quality and safety
• Embedded policies and communication aids for the admission, outlying and transferring of patients with infectious
diseases
• To ensure the right level of challenge the Infection Control Committee is formally a sub-committee of the Board
2.3h Patient safety incidents
The data made available to the Trust by the Health and Social Care Information Centre with regard to:
a) The number and, where available, rate of patient safety incidents reported within the Trust during the reporting period,
Trust number
of patient
safety
incidents
reported
Trust rate of
patient safety
incidents reported
per 100 admissions
Large acute Trust
national rate of
patient safety
incidents reported per
100 admission
Large acute national
highest rate per 100
admissions
Large acute
national lowest
rate
per 100 admissions
October 2014 – March 2015
5,358*
Not Available
Not Available
Not Available
Not Available
April 2014 – September 2014
5,163*
Not Available
Not Available
Not Available
Not Available
October 2013 – March 2014
4,574
8.76
7.25
12.46
1.72
April 2013 – September 2013
4,866
9.32
7.08
11.06
3.85
October 2012 – March 2013
4,720
9.20
7.22
12.73
3.04
April 2012 – September 2012
4,487
8.78
6.69
13.61
1.99
October 2011 – March 2012
4,217
8.41
6.22
9.75
1.93
April 2011 – September 2011
4,033
8.04
5.99
10.08
2.75
October 2010 – March 2011
3,733
7.25
5.62
9.91
1.79
• Embedded Trustwide Clostridium difficile prevention action plan which is monitored monthly by the Trust Board and
Infection Control Committee
April 2010 – September 2010
3,626
7.04
5.25
8.65
1.71
• Monthly meetings of site specific Clostridium difficile action groups whose remit is to review each case and monitor
site specific trends and themes. Local action plans are produced and monitored
October 2009 – March 2010
3,069
5.92
5.49
9.19
2.10
Comment:
• The above table illustrates the rate of Clostridium difficile per 100,000 bed days for specimens taken from patients
aged two years and over. The downward trend from the first available data in 2009 is discernible from this table and
the Trust compares favourably to the national average for this indicator.
Northern Lincolnshire and Goole NHS Foundation Trust considers that this data is as described
for the following reasons:
• The Trust continues to make significant progress in reducing the number of Clostridium Difficile cases and remains
below the national average. A trend reported previously of cases deemed unavoidable continues to significantly
outnumber those cases felt to be at least partially avoidable. Nevertheless, work continues to reduce these still further.
The Trust has taken the following actions to improve this rate, and so the quality of its services by:
• The Trust has an evidence based Clostridium difficile policy and patient care pathway
• Multi-disciplinary team meetings are held for inpatient cases to identify any lessons to be learnt and root cause
analysis is conducted for every hospital acquired case and a director of infection prevention and control (DIPC) review
is held where there has been a breach in practice or the patient has died
• For each case admitted to hospital, practice is audited by the infection prevention and control team using the
Department of Health Saving Lives’ audit tools
• Production of a dash board to monitor compliance with the routine deep clean schedule reviewed by the site specific
Clostridium difficile action group
• Embedded training programme that purely focuses on Clostridium difficile issues and care. To support this a
monitoring and feedback mechanism to managers regarding the number of staff attending these sessions
• Use of an alert sticker for patient medical notes and to fit in with the Trust direction of travel in connection with the
development of the electronic patient record, ensured that a Clostridium difficile alert icon has been built in to the
system being used to host this development
• Use of a specific Clostridium difficile discharge letter that is sent to GP’s informing them of the patients result and
informing them of the potential future risks for the patient
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Time frame
Source: April 2010 – March 2013, Health and Social Care Information Centre (HSCIC), April 2013 – March
2014, DATIX
* For the purposes of this report, as national comparative data is unavailable on the NHS Information Centre’s
Portal for the most recent period (April 2014 – March 2015) local data from DATIX has been used
to indicate the number of patient safety incidents. As the national data is unavailable, only the
actual number of incidents reported by the Trust is available.
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Comment:
The above table demonstrates the total number and rate per 100 admissions of patient safety incidents reported within
the period of October 2009 – March 2015.
• The Trust’s average rate of patient safety incidents reported is above the average of other large acute NHS
organisations (illustrated in the table above). Within the Trust staff are encouraged to report all incidents. NHS England
state “Organisations that report more incidents usually have a better and more effective safety culture. You can’t learn and
improve if you don’t know what the problems are”, therefore this number should be seen as encouraging that concerns
regarding patient safety are reported for appropriate escalation and investigation and for remedial action to be taken
to ensure any concerns are learnt from thus reducing the chance of these incidents replicating themselves and leading
to patient harm
Northern Lincolnshire and Goole NHS Foundation Trust considers that this data is as described
for the following reasons:
• The Trust undertakes regular analysis of incident data, producing a wide range of monthly, quarterly and annual
analysis reports which are shared throughout the organisation via a number of committees/groups/forums. These
reports enable aggregate analysis of data, along with analysis of particular hot-spots and trends. The relevant group/
committee review the reports, and consider recommendations, which look to improving patient safety and addressing
known risks identified in these reports.
The Trust has taken the following actions to improve this number and/or rate, and so the quality
of its services by:
• The Trust is continuing to actively encourage and promote incident reporting, and therefore expects the number of
incidents reported to remain high and potentially increase in number in order to continue the work streams focussing
on learning from incidents. The emphasis continues on reducing harm from patient safety incidents, the number
and percentage in figure b) below demonstrates this. This approach is recommended by the National Patient Safety
Agency (NPSA): “Organisations that report more incidents usually have a better and more effective safety culture. You can’t
learn and improve if you don’t know what the problems are.”
• The Trust has formed a number of multi-disciplinary groups focussing on prevention initiatives to reduce the harm
from patient safety incidents, and also to reduce the number of incidents. Examples of these work streams are the
Safer Medication Group which has a formal work programme in place which is taking forward a number of initiatives
and is reviewed on an annual basis to ensure these remain relevant and targeted against known risks
b) and the number and percentage of such patient safety incidents that resulted in severe harm or death.
• A key focus group is the Learning Lessons Review Group which had developed a formal action plan incorporating a
number of patient safety initiatives, including actions to address patient mis-identification, with regular reporting to
the Trust Governance and Assurance Committee.
Trust number
of patient
safety incidents
reported
involving severe
harm or death
Trust rate of
patient safety
incidents reported
involving severe
harm or death
(%)
Large acute Trust
national average
of patient safety
incidents reported
involving severe harm
or death
(%)
Large acute Trust
national highest
rate involving
severe harm or
death
(%)
Large acute Trust
national lowest
rate
involving severe
harm or death
(%)
October 2014 – March 2015
13*
Not Available
Not Available
Not Available
Not Available
April 2014 – September 2014
13*
Not Available
Not Available
Not Available
Not Available
October 2013 – March 2014
9
0.20%
0.61%
2.64%
0.03%
April 2013 – September 2013
13
0.27%
0.71%
2.97%
0.05%
October 2012 – March 2013
10
0.21%
0.79%
3.46%
0.00%
April 2012 – September 2012
8
0.17%
0.71%
2.50%
0.00%
October 2011 – March 2012
10
0.24%
0.75%
3.26%
0.00%
April 2011 – September 2011
8
0.20%
0.77%
2.88%
0.10%
October 2010 – March 2011
5
0.13%
0.92%
4.01%
0.05%
April 2010 – September 2010
6
0.17%
0.75%
2.95%
0.02%
October 2009 – March 2010
9
0.29%
0.64%
1.63%
0.05%
Time frame
• The Trust falls prevention group has in place an action plan incorporating and integrating patient safety preventing
harm from falls initiatives, environmental risk assessments and health and safety risk management initiatives, all
targeted on reducing risk and preventing harm to patients.
• The Trust has also developed a programme of quality and safety half day sessions that run at least quarterly in each
of the Directorate groups. The idea behind these sessions is to enable clinical staff providing the service to be able to
have time to present cases of learning for discussion of lessons learnt and to disseminate good practice.
2.3i Ambulance handover times
In order to understand the patient experience of patients arriving in the Trust’s A&E departments via ambulance, the Trust
have access to information provided to it from the East Midlands Ambulance Service regarding the length of time it takes for
the ambulance crew to handover the care of the transported patient to the receiving team in the Emergency department.
From undertaking local benchmarking, however, through the use of observational audits in the emergency department,
concerns have been raised with regard to the accuracy of this information recorded and collected by the Ambulance
service. To gain assurance regarding the process undertaken to compile this information, the Trust have selected this as its
local indicator for external review by PWC, an external auditor, to assess how the ambulance service data compares to data
collected from the Trust’s systems. The findings from this external audit will help guide future collaborative work with the
ambulance service to improve the reliability and quality of this information.
To set the scene for this improvement project, the following chart illustrates the currently provided data from the ambulance
service in connection with the percentage of cases where the ambulance handover exceeds 15 minutes.
Source: April 2010 – March 2013, Health and Social Care Information Centre (HSCIC), April 2013 – March 2014, DATIX
* For the purposes of this report, as national comparative data is unavailable on the NHS Information Centre’s Portal for the most recent
period (April 2013– March 2014) local data from DATIX has been used to indicate the number of patient safety incidents. As the national
data is unavailable, only the actual number of incidents reported and the Trust’s rate is available.
NB: As stated above, this information should be interpreted with caution, as it is invalidated data from
the ambulance service.
Comment:
• The above table demonstrates the total number and rate per 100 admissions of patient safety incidents involving
severe harm or death reported within the period of October 2009 – March 2014. The Trust has a lower than national
average of patient safety incidents reported involving severe harm or death.
108
Together
we care, we respect, we deliver
109
70
65
Figure 47 60
Percentage (%) of patients having a delayed ambulance handover > 15 minutes
55
50
45
40
35
30
25
20
70
65
Part 3
Other information
60
55
50
45
40
Mar-15
Feb-15
Jan-15
Dec-14
Nov-14
Oct-14
Sep-14
Aug-14
DPW 30
SGH
Peer Avg25
Jul-14
35
An overview of the quality of care based on performance in 2013/14
against indicators
20
Source: Ambulance Service Data, East Midlands Ambulance Service (EMAS)
3.1 Overview of the quality of care offered 2014/15
Key to abbreviations: DPoW – Diana, Princess of Wales Hospital, Grimsby,
SGH – Scunthorpe General Hospital
Peer average – Other local Trusts in Lincolnshire and East Midlands (n=23)
Comment:
The above chart demonstrates the percentage of patients having a delayed ambulance handover of 15 minutes or more.
The following chart illustrates the currently provided data from the ambulance service in connection with the percentage
of cases where the ambulance handover exceeds 30 minutes.
NB: As stated above, this information should be interpreted with caution, as it is invalidated data from the ambulance
70
service.
65
Figure 48
35
(%) of patients having a delayed ambulance handover > 30 minutes
60Percentage
55
25
40 20
35
30
They are selected as areas of key importance
for the Trust to drive and embed continuous
quality improvement.
15
25 10
Mar-15
Feb-15
Jan-15
Dec-14
Nov-14
Oct-14
Sep-14
DPW 0
SGH
Peer Avg
Aug-14
5
Jul-14
20
Source: Ambulance Service Data, East Midlands Ambulance Service (EMAS)
Key to abbreviations: DPoW – Diana, Princess of Wales Hospital, Grimsby,
SGH – Scunthorpe General Hospital
Peer average – Other local Trusts in Lincolnshire and East Midlands (n=23)
Comment:
The above chart demonstrates the percentage of patients having a delayed ambulance handover of 30 minutes or more.
Northern Lincolnshire and Goole NHS Foundation Trust considers that this data requires further validation and accuracy
checking. To establish the accuracy of this information and if the Trust can use this to monitor and improve quality in the
future, an external audit has been undertaken as part of the external assurance process on the annual quality account,
to look into this data in greater detail. The findings of this review work will be available in the near future and as a result
further work will be initiated in response.
110
The Trust’s quality targets
& priorities – driving continuous
improvement
It is worth noting here, that these targets/
quality priorities for the most part are not
nationally or regionally set, rather they are
set locally by the Trust.
30
50
45
Parts 2.1a, 2.1b and 2.1c of this report outlined progress during 2014/15 towards achieving the priorities
for this financial year just ended which the Trust set out in its previous Annual Quality Account for
2013/14. The quality priorities in part two were presented in three distinct sections: clinical effectiveness
(2.1a), patient safety (2.1b) and patient experience (2.1c).
Together
we care, we respect, we deliver
These indicators are not chosen for their ease
of completion, resulting in a report full of
green ‘completed’ ticks. These indicators are
instead quality focussed, aspirational and
stretching.
As a result, the executive summary that
follows, and the greater detail within part
two of this report presents progress so far,
not always demonstrating that our internal
quality targets have been met.
For these indicators selected by the Trust, the full report,
contained within parts 2.1a, 2.1b and 2.1c refer to benchmarked
data, where available, to enable performance compared to other
providers. References to the data sources used are also stated
within these earlier parts of this report and where relevant this
includes whether the data is governed by standard national
definitions.
This information, presented in part two of this report also
illustrates historical data for comparison and trending purposes. If
the basis for calculating data has changed from that of historical
data, this is explained in full detail within section two of this
report.
During 2014/15 the following quality priorities were monitored
by the monthly quality report which was presented and reviewed
on a monthly basis by the Trust’s Quality and Patient Experience
(QPEC) Committee and the Trust Board. The ‘at a glance’ overview
of performance that follows is viewed continually throughout the
year, and reviewed within the monthly quality report, as a result
these are constantly changing based on the real time nature of
these indicators.
A summary of the Trust’s performance against these key
indicators (outlined within part 2 in full) are
summarised below:
Where these have not been met, an
explanation and summary of the work
underway are presented and for the most
part, these targets have been selected to
stay within the quality report to drive quality
development during 2015/16.
111
Clinical effectiveness:
Patient experience:
Quality indicators at a glance; March - 2015
Quality indicators at a glance; March - 2015
2014/2015 Indicators
2014/2015 Indicators
Indicator
Time period/RAG
Clinical effectiveness
Most recent data
CE1 Deliver mortality performance within Official SHMI
expected range and improving
quarter on quarter, until reported
SHMI is 95 or lower
(July 13 - June 14)
HED data
(Dec 13 - Nov 14)
Position vs peers
Indicator
Change
CE2 NEWS - Approriate action taken
3.2) Dementia - screened,
appropriate assessment
3.3) Dementia - appropriate
referral to specialist services
Previous
108
95
112
R
111
95
Higher than
expected range
R
Within
expected range
Within
expected range
Feb - 2015
Previous
0%
100%
G
100%
SGH
0%
100%
G
100%
GDH
0%
100%
G
1%
95%
G
94%
SGH
2%
96%
G
94%
DPoW
0%
100%
G
100%
SGH
0%
100%
G
DPoW
0%
100%
G
100%
SGH
0%
100%
G
100%
0.9%
82.8%
R
81.9%
0.1%
95.8%
G
95.7%
7.6%
33.57%
R
26%
CE5 Transfer of patients for non-clinical reasons
(capacity) to not exceed 20% of the total
Trends
Indicator
PE1
Trends
90%
PE2
PE3
Complaints - action plan drafted
Comparator
Previous
Inpatient
Bottom 50%
R
Top 50%
A&E
Bottom 50%
R
Bottom 50%
Feb - 2015
11.5%
17.3%
Previous
G
Feb - 2015
Complaints - action plans implemented
Complaints - 50 % reduction in complaints
relating to communication
PE5
Patients should not have
any unplanned omissions in
providing patient medications
Trends
Target
Top 50%
Trends
5.8%
Previous
Target
20%
Trends
Target
0%
100%
G
100%
90%
8%
100%
G
92%
90%
Q3 2014/15
PE4
28
72
Q2 2014/15
R
Feb - 2015
90%
Trends
50%
(max. 33 per qtr)
44
Previous
Target
Trends
Target
DPoW
SGH
No data to report as yet
90%
No data to report as yet
90%
GDH
Patients should not have a delay
of more than 30 minutes in
providing pain relief
90% by March
2015
DPoW
SGH
GDH
Oct - 2014
20%
PE6
Patient safety:
Time period/RAG
Feb - 2015
Target
90%
100%
Response rate to friends and
family test within the top 50%
Re-opened complaints to not exceed
20% of total closed complaints
Target
95%
Change
Patient experience
100%
Previous
DPoW
NICE - Compliance with all NICE TAGs assessed
Target
R
DPoW
CE4 NICE - Compliance with all NICE guidance
Trends
109
Feb - 2015
CE3 3.1) Screened for Dementia
Comparator
Staff satisfaction - increase in morale/staff
satisfaction
-1
5.3
July - 2014
R
6.3
Trends
Target
2.5% increase
(min. 6.65)
Quality indicators at a glance; March - 2015
2014/2015 Indicators
Indicator
Change
Patient safety
Time period/RAG
Feb - 2015
Comparator
Previous
Trends
Target
PS1
PS2
MRSA bacteraemia incidence
(YTD: 1)
1
1
R
0
0
C. Difficile incidence
(YTD: 20)
1
3
G
2
No more than 35
PS3
PS4
Safety thermometer (community)
-1%
96.%
G
97%
95%
DPoW
0.5%
90.7%
R
90.2%
Open and honest initiative - Harm
free care - Saftey thermometer
(‘New’ and “Old’)
SGH
-6%
86.5%
R
92.5%
GDH
4.2%
100%
G
95.8%
DPoW
-1
0
G
1
SGH
0
0
G
0
0
G
0
Feb - 2015
PS5
PS6
PS7
PS8
112
Elimiation of avoidable repeat
fallers
Previous
GDH
0
Reduction in number of
avoidable pressure ulcers
(Grades 2, 3 and 4)
DPoW
-2
1
G
3
SGH
0
0
G
0
GDH
0
0
G
0
Nutrition care pathway was
followed
DPoW
-1%
95%
R
96%
SGH
0%
98%
R
98%
GDH
0%
100%
G
100%
The food record chart completed
accurately and fully, in line with
care pathway
DPoW
1%
90%
R
89%
SGH
7%
93%
R
98%
GDH
0%
100%
G
100%
The fuild management chart was
completed accurately and fully,
in line with care pathway
DPoW
0%
97%
R
97%
SGH
4%
96%
R
92%
GDH
0%
100%
G
100%
Together
we care, we respect, we deliver
95%
Trends
Target
Eliminate ALL
avoidable
repeat falls
50% reduction
(no more than
2 per month)
100%
100%
100%
113
3.2 Performance against relevant indicators and performance thresholds
3.3 Information on staff survey report
Summary of performance – NHS staff survey
The Trust’s staff survey results for 2014, as in previous years; reassuringly shows that staff work in a safe
working environment that is predominantly free from harassment, bullying or abuse from patients or
their colleagues.
Performance against the relevant indicators and performance thresholds set out in Appendix B of the Compliance
Framework.
Perhaps most reassuring is that staff feel that their individual and collective roles make a true difference to patients and
that they are satisfied with the quality of the care they and the Trust delivers. This is considered a major achievement since
these indicators featured within the bottom five ranked scores in the previous year’s survey results.
Monitor compliance framework summary
2014/15 2014/15 2014/15 Threshold
Qtr 1
Qtr 2
Qtr 3
Jan 15
Feb 15
Mar 15
Qtr 4
Actual
to date
Weightingt
Target
Weighting
Performance against key thresholds for the period 1st April 2014 to 31st March 2015
1. Infection control*
Clostridium Difficile
1.0
G
G
G
33
2
3
0
20
G
1.0
G
R
R
90%
91.64%
90.50%
90.74%
90.95%
G
1.0
G
G
G
95%
95.21%
95.28%
95.44%
95.31%
G
1.0
G
G
G
92%1.0
95.86%
95.98%
96.68%
96.18%
G
2. Referral to treatment waiting times
Admitted - maximum waititng time of 18
weeks
Non-admitted - maximum waititng time
of 18 weeks
Incomplete - maximum waititng time of
18 weeks
Focusing on the concerns emerging from the survey the Trust aims to focus on three main areas, namely; the quality and
content of appraisals, increasing the impact of listening to patient and staff voice in improving services and the reporting
of incidents.
Detailed performance – NHS staff survey
Response rate is compared with that of the
previous year:
Response rate
3. Cancer***
2013/14
2014/15
Trust
National
average
Trust
National
average
37%
49%
30%
45%
Trust
improvement/
deterioration
-7%
31 day wait diagnosis to treatment
1.0
G
G
G
96%
99.29%
100%
98.54%
99.26%
G
1.0
G
G
G
94%
100%
100%
100%
100%
G
G
G
G
98%
100%
100%
100%
100%
G
i
31 day wait subsequent treatments Surgery
31 day wait subsequent treatments - Anti
cancer drugs
62 wait consultant screening service
intervals
G
G
G
85%
86.74%
95.33%
84.57%
88.84%
G
Top four ranking scores
Trust
National
average
Trust
National
average
Trust
improvement/
deterioration
ii
62 day wait referral to consultation
G
G
G
90%
100%
80%
100%
94.74%
G
i
2 week wait referral to consultation
G
G
G
93%
98.54%
98.11%
98.43%
98.36%
G
Percentage of staff experiencing harassment, bullying
or abuse from patients relatives or the public in last 12
months
23%
29%
27%
29%
+4%
ii
2 week wait brest symptom referrals
G
G
G
93%
95.31%
97.62%
94.74%
95.80%
G
Percentage of staff experiencing physical violence from
staff in last 12 months
2%
2%
1%
3%
-1%
1.0
G
G
R
95%
87.21%
90.75%
92.92%
90.40%
R
Percentage of staff agreeing that their role makes a
difference to patients
86%
91%
93%
91%
+7%
1.0
G
G
G
50%
80%
99%
99%
92%
G
Percentage of staff feeling satisfied with the quality of
work and patient care they are able to deliver
77%
78%
83%
77%
+6%
i
ii
1.0
1.0
4. A&E
A&E 4 hour wait compliance
5. Data completeness community services **
i
Referral to treatment information
ii
Referral information
G
G
G
50%
80%
99%
99%
92%
G
iii
Treatment activity information
G
G
G
50%
78%
77%
77%
77%
G
Access**
12
Access to healthcare for people with
learning disability
0.5
G
G
G
Y/N
Y
Y
Y
Y
Total monitor compliance
1.0
** Forecast position
Monitor compliance rating
G
*** Provisional data
Monitor over ride rating
R
114
Together
we care, we respect, we deliver
Bottom 4 ranking scores:
2013/14
2013/14
2014/15
2014/15
Bottom four ranking scores
Trust
National
average
Trust
National
average
Trust
improvement/
deterioration
Percentage of staff able to contribute towards
improvements at work
65%
67%
61%
68%
-4%
G
* Cumulative figures
For full details and technical specifications from Monitor guiding NHS Trusts how
compliance with the above is to be calculated, please see annex 5.
Top four ranking scores:
Effective team working
Percentage of staff reporting errors, near misses or
incidents witnessed in the
3.71
3.73
3.64
3.74
indicator indicator indicator indicator
-0.7 indicator
74%
84%
87%
90%
+13%
30%
38%
30%
38%
No change
last month
Percentage of staff having well-structured appraisals in
the last 12 months
115
Action plans to address areas
of concerns:
Regarding the bottom ranked
score the Trust has ongoing action
plans and monitoring tools in place
to address the issues relating to
appraisals. Since the staff survey
the current appraisal rate holds at
c.93 per cent for the workforce. This
work continues to be supported by
dedicated training courses for staff
and managers with the delivery of
appraisals monitored centrally within
the Trust. This work not only aims to
ensure all staff receive an appraisal
but that the structure and quality of
the appraisal is meaningful.
Concerns relating to effective teams
is already a feature of on going
activities which strive to equip leaders
with the skills to manage through an
inclusive collaborative style.
To address the concern that 61 per
cent of staff feel they can contribute
toward service improvements
the organisational development
team is preparing for a major piece
of engagement work to listen to
staff and understand the barriers
they feel to coming forward with
service improvement ideas. This
piece of work form one of the three
core oragnisational development
objectives for 2015/16.
In addition to this patient and staff
voice has become a key work stream
and quality indicator through the
newly created ‘Patient and Staff
Experience Group’, a sub-group of
QPEC, which seeks to implement
initiatives that improve the patient
experience and working lives of
staff through listening to their
collective experiences and service
improvement ideas.
Work remains on-going through the
Trust’s risk management department
to encourage staff to come forward
and report incidents, and for
managers to feedback to staff on
the outcome of the investigated
incident.
Future priorities and targets:
Appraisals, the quality of appraisal
and then the time for staff to carry
out both their objectives and
training requirements remains
an on-going priority for the Trust.
Significant investment in training
was made during 2013/14; this work
must now be seen to improve the
perceptions of staff regarding the
quality of their appraisal.
The other main priority is, as
outlined above, to make significant
inroads into addressing staff
concerns regarding staff voice
and engagement. The action plan
that will be developed by the
organisational development team
into how to improve staff voice must
be owned and delivered by the
executive team and Trust Board. It is
expected that this action plan with
recommendations will be available
at the start of quarter 2 2015/16.
Beyond the above two priorities
the Trust remains committed to
the rollout and deliverables with
the Trusts culture transformation
plan. These will directly impact
on improving the effectiveness of
team working whilst providing the
platform to ensure staff remain
happy with the quality of care they
deliver to our patients.
Actions to be taken as a
result
This year the survey showed
improvement within a number of
areas from the previous year and
this remains our focus, that we
are looking at our own results and
targeting improvements. Whilst it is
always good to compare ourselves to
other Trusts it is our own development
that remains our priority.
Some areas of excellent patient
experience are 97 per cent found
the ward, toilets and bathrooms
clean, 77 per cent of patients always
had confidence and trust in the
doctors and felt they were treated
with respect and dignity and 90 per
cent of patients were always given
privacy when being examined.
Areas we have improved in
from previous year :• Mixed sex accommodation
• Pain management
• Information giving pre and post
operatively
• Offering feedback
• Providing information regarding
complaints process.
3.4 Information on patient survey report
These may not necessarily be better
than other Trusts within the survey
Trusts but internally we are moving
forward and that is our ultimate
intention.
Introduction
To improve the quality of services that the NHS delivers it is important to understand what patients think
about their care and treatment. One way of doing this is by asking patients who have recently used their
local health services to tell us about their experiences Northern Lincolnshire and Goole NHS Foundation
Trust took part in the national survey for 2013.
Response rate compared with previous year:
2013
Response rate
116
• Ensuring we look at cancellation
rates
• Nurses and doctors talking over
patients
• Staff on duty
• Staff providing consistent
information
• Staff providing emotional support
• Discharge medication
information.
Equally the inpatient survey provides
one area of feedback for us and we
triangulate this with other areas
of patient feedback to ensure our
direction remains clear.
Work has already begun on some
of the issues above based on that
triangulation process.
Patient stories, which capture
personal patient and relative
experiences are being used to
highlight to staff the impact of their
behaviours have on.
A focus on communication will be
a priority for the Experience Group
this year, this will feed back to QPEC
as the sub-group of the Trust Board.
The goal is to design an action plan
which is very active and frontline
focussed. The group involves
patients to encourage the patient
voice to be present in the setting of
our priorities with this.
Our recruitment team continue to
rise to the challenge with regards to
staffing, we know that nationally this
is problem for many Trusts. Overseas
recruitment and off-site recruitment
fairs are just some of the initiatives
being undertaken.
The twice yearly morale barometer
and findings from the staff Friends
and Family Test help us understand
further how our staff feel, as we
know this is linked to retention of
staff. A report and plan has been
developed from these findings.
Gill’s Story is a key story which has
been viewed at Trust Board and
shared across many forums. It will
continue to be used for training
purposes as we recognise the value
of this very emotive type of learning
lessons.
This inpatient survey provides us
with a wealth of feedback from a
large group of our patients and our
commitment to them is to use that
information to shape our actions for
this coming year.
2014
Trust
National average
Trust
National average
44%
49%
51%
45%
Together
These areas will be:
we care, we respect, we deliver
117
Annex 1: Statements from commissioners, local Healthwatch
organisations and overview and scrutiny committees
Annex 1.1: Statements from Commissioners
Feedback from:
• NHS North Lincolnshire Clinical Commissioning Group
Conclusion
Overall, the Quality Account is well presented and the information included in the report provides a balanced view of the
Trusts performance against it quality indicators for 14/15. The report provides commissioners with useful insights and
assurances on how the Trust delivers its services in line with national and local quality indicators. However, Commissioners
note that the Trusts priorities for 2015/16 are similar to those for 2014/15, suggesting that steady rate of progress has been
made but there is room for further development.
Finally, we confirm that to the best of our knowledge, the report is a true and accurate reflection of the quality of care
delivered by Northern Lincolnshire & Goole Foundation Trust and that the data and information contained in the report is
accurate.
Commissioners remain committed to working with the Trust and its regulators to improve the quality of services available
for the population of each CCG area in order to improve patient outcomes.
• East Riding of Yorkshire Clinical Commissioning Group
• North East Lincolnshire Clinical Commissioning Group
• East Lincolnshire Clinical Commissioning Group
This statement has been prepared in collaboration with NELCCG, NLCCG, ERYCCG and Lincolnshire
East CCG. Commissioners welcome this opportunity to provide feedback to the Trust on the work
already undertaken in relation to quality throughout 2014/15, and areas of work identified for further
development in 2015/16.
Positive Assurance
The Quality Account clearly demonstrates the progress made and challenges encountered by Northern Lincolnshire &
Goole Foundation Trust during 2014/15.
As Commissioners, we are pleased to note the Trusts on-going commitment to the reduction of hospital acquired pressure
ulcers, compliance with the dementia screening indicator, compliance with the NEWS indicator, improved friends and
family response rate (in-patient indicator and A&E indicator), improved compliance with the nutrition and hydration care
pathways and innovative national and international recruitment campaigns.
Evidence of the Trusts commitment to improving performance against the quality indicators (some of which are defined
above) has been demonstrated as part of the new NL&G Quality Contract Review (QCR) meeting. The NL&G QCR meeting
was established in December 2014, the meeting oversees achievement of the national quality standards in line with the
Trusts contract and supports Commissioners to achieve national and local quality standards with the provider, and identify
priority measures that benefit patients and partner organisations’ business plans.
The QCR meeting has been instrumental in improving communication between the Trust and its Commissioners and
raising the profile of a variety of initiatives undertaken by the Trust in relation to the quality agenda. For example; the
improved nutrition care pathway and revised menu option, implementation of the Pressure Ulcer Group (PUG) and
associated pressure ulcer mascot, the pressure ulcer identification wheel and the Pressure ulcers In Paediatrics (PIP)
initiative. Commissioners would like to note that the work undertaken in relation to pressure ulcer management is
exemplary. All of these initiatives provide Commissioners with positive assurance.
Areas Requiring Further Assurance
Commissioners remain concerned with the Trusts performance against its mortality indicator, the number of reopened
complaints and the number of complaints made in relation to communication (this links with patient experience) and the
Trusts approach to the care of adults who are considered to be vulnerable. E.g. lack capacity to make decisions around
their care and support needs, people with a learning disability and people with a mental health condition.
Commissioners would like to see further information in relation to the local population’s requirements, in order to
establish whether this report meets the population’s needs. In terms of format, Commissioners feel that it may be difficult
for patients and the public to work through the document and understand what it means in relation to the quality of
care being provided by the organisation. There don’t appear to be any patient reported outcome measures as part of the
account or details of how the Trusts staff have been engaged in development of this report; these would have been a
useful references for commissioners.
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Annex 1.2: Statement from HealthWatch organisations
Feedback from:
• North East Lincolnshire HealthWatch
• North Lincolnshire HealthWatch
• East Riding of Yorkshire Healthwatch
Statement on North Lincolnshire and Goole
NHS Foundation Trust Quality Account for 2014/15
Healthwatch North Lincolnshire and Healthwatch North East Lincolnshire welcome the opportunity to
make a statement on the Quality Account for Northern Lincolnshire and Goole NHS Foundation Trust
and have agreed to provide a joint statement. Healthwatch North Lincolnshire & North East Lincolnshire
recognise that the Quality Account report is a useful tool in ensuring that NHS healthcare providers are
accountable to patients and the public about the quality of service they provide. The following is the
joint response from North and North East Lincolnshire Healthwatch.
Progress on Priorities for 2014-15
We note that although mortality indicators had been partially met throughout 2014/15, more recently the provisional
data shows some comparative deterioration in the position. Healthwatch is pleased that the target to deliver within the
‘expected range’ remains a quality priority for the Trust over the coming year.
We are pleased to see that the Trust has continued to demonstrate willingness to hear the experiences of patients and
carers and identify opportunities for improvement.
Complaints
It was noted by Healthwatch that complaints about poor communication continue
to be high and it appears to need a lot more work across all levels of staff. It
is encouraging that the Trust aims for a 50% reduction in complaints about
communication as poor communication remains a key theme in feedback
Healthwatch get from patients and carers. Healthwatch North
Lincolnshire are pleased to note that issues regarding
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communication that were raised during the recent Enter and View visits to Scunthorpe General Hospital are being
addressed and improvements are being monitored by the Trust though their Quality Development Plan.
Friends & Family Test
It is noted that the FFT response rate continues to be comparatively low and it is pleasing to see that it remains a priority
to raise this to within the top 50%. However, Healthwatch would like to see the data reported in more detail in the Quality
Account including some analysis of the wealth of qualitative data generated from the open question on the FFT form.
Quality Standards
Healthwatch welcome the additional patient safety measures covering nutrition, feeding and fluid management. We are
pleased to see that the administration of pain medication is being monitored.
There appears to be no quality standard around numbers or percentage of cancelled appointments or length of wait until
first appointment. This is something people draw to our attention and although delays and cancellations may turn into
complaints, not everyone chooses to complain. However, Healthwatch NL and NEL welcome the addition of a quality
measure on the transfer of patients as this will capture any delays in discharge or transfer of patients.
We also note that information on pressure ulcers does not clearly indicate that the majority of patients are found to have
pressure ulcers on admission.
Presentation of NLAG Accounts
The Quality Accounts document was again a very lengthy document and although it fulfils the requirements and
guidance from the DoH and presents a wealth of statistical information, Healthwatch do not perceive it to appeal to the
public. Bearing this in mind, the extraction of the summary into a separate document and compilation of an `easy read’
version is suggested.
Conclusion
Healthwatch has a key role, backed up by statutory powers, to strengthen the voice of local patients and public in all
aspects of commissioning and delivery of health care services. We therefore support the priorities for 2015-2016 in
strengthening performance across all the three areas of clinical effectiveness, patient safety and patient experience.
We look forward to continuing to work more closely with Northern Lincolnshire and Goole NHS Foundation Trust in the
future and seeing how their priorities are developed in 2015-16.
Comments from Healthwatch East Riding of Yorkshire
We are concerned about the low response rate to the Friends and Family Test and urge the Trust to continue to increase
the response rate Trust-wide.
We have formally raised concerns about the cost of parking at Goole District Hospital compared to parking in Goole; we
would also urge the adoption of a pay on exit model.
Annex 1.3: Statement from local council overview and scrutiny
committees (OSC)
Feedback from:
North Lincolnshire Council – Health Scrutiny Panel
North East Lincolnshire Council – Health, Housing and Wellbeing Scrutiny Panel
Lincolnshire County Council – Health Scrutiny Committee
East Riding of Yorkshire Overview & Scrutiny Committee
North Lincolnshire Council – Health Scrutiny Panel’s Quality Accounts comments for Northern
Lincolnshire and Goole Hospitals NHS Foundation Trust
North Lincolnshire Council’s Health Scrutiny Panel welcomes the opportunity to comment as part of Northern Lincolnshire
and Goole NHS Foundation Trust’s (NLG) Quality Account. NLG are a key partner and provider of local services, and
members have built a valuable working relationship with Trust personnel over the previous fourteen years.
The panel conducted a site visit to Scunthorpe General Hospital in September 2014, where members had an opportunity
to visit key wards and clinical areas, and to talk to staff, patients and their families. Feedback was widely positive regarding
professionalism and helpfulness of staff, quality of care and cleanliness. Any issues that were raised by patients and carers
were responded to swiftly and appropriately.
The panel notes with some concern a lack of progress on reducing the SHMI rate. At the time of writing, the HSCIC has yet
to publish their latest data, although we anticipate that the Trust will remain just within the ‘as expected’ category. This
performance has been largely static over the previous year. However, we note the Trust’s latest Mortality Report, which
incorporates more recent Hospital Evaluation Data system provisional figures. This suggests that local performance would
increase into the ‘higher than expected’ range. The panel is, of course, aware of the inexact methodology in this area, the
local ‘in-hospital’ and ‘out-of-hospital’ performance, and also that reducing the SHMI rate requires a wide ownership of coordinated actions. However, as the key acute provider, and an important community provider, we share NLG’s view that
this should remain the highest priority for 2015/16 and beyond. We signal our intent to hold all relevant partners to public
account for improvements in this area. We also welcome NLG’s decision to retain this as a priority.
The panel is encouraged by a refreshing drive to reinvigorate the Healthy Lives, Healthy Futures programme. Clearly,
we acknowledge NLG’s key role within this, working with commissioners and other partners. We note an improved
willingness to address the very real need for reform and integrate Health and Social Care across the South Bank of the
Humber, and potentially within a wider footprint. We share NLG’s view that this is vital to ensure future sustainability,
whilst driving up quality standards. Clearly, we have significant concerns about the current and short-to-medium financial
situation within the local NHS.
The panel very much welcomes each of the clinical effectiveness, patient safety, and patient experience priorities agreed
by the Trust and set out within this document. In particular, we are glad to see priorities aimed at improving services for
those with dementia, and also to assist in reducing the number of problems associated with discharge – possibly the most
common complaint that the panel receives. In addition, we are aware of the link between transfers and the SHMI rate.
Over the previous year, we have expressed concerns raised by local people about several wards at SGH. Whilst we are
aware that the Trust has internal processes in place to set improvement plans and monitor progress,
we intend to continue to ask for evidence of local improvements.
On work-related issues, the Chief Executive and key officers pro-actively provide regular,
constructive updates to the panel on ongoing and developing activities, answering
members’ questions in a frank and open manner. Each contact between the Trust
and the panel through the year has been positive and any queries have resulted in
a swift and comprehensive response, and we thank the Trust for this.
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North East Lincolnshire Council – Health Scrutiny Panel’s Quality Accounts comments for
Northern Lincolnshire and Goole Hospitals NHS Foundation Trust
Unfortunately, no comment on the quality accounts has been received.
East Riding of Yorkshire Council – Health Scrutiny Panel’s Quality Accounts comments for
Northern Lincolnshire and Goole Hospitals NHS Foundation Trust
Unfortunately, no comment on the quality accounts has been received.
Lincolnshire Council – Health Scrutiny Panel’s Quality Accounts comments for Northern
Lincolnshire and Goole Hospitals NHS Foundation Trust
The Health Scrutiny Committee for Lincolnshire recognises the importance of services provided by the Trust to the
residents of Lincolnshire. Unfortunately, the Committee is unable to make a statement on the Quality Account for 20142015, but will continue to work with the Trust and looks forward to participating in the Quality Account process in future
years.
Annex 2: Statement of directors’ responsibilities in
respect of the Quality Report
The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts)
Regulations to prepare Quality Accounts for each financial year.
Monitor has issued guidance to NHS foundation trust boards on the form and content of annual quality reports (which
incorporate the above legal requirements) and on the arrangements that NHS 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 2014/15;
• The content of the Quality Report is not inconsistent with internal and external sources of information including:
• Board minutes and papers for the period April 2014 to March 2015 (the period);
Annex 1.4: Statement from the Trust governors’
The Quality Review Group appreciates the quality of data provided in the Quality Report which enables an accurate
assessment of performance. The SHMI position having been reduced and remained in the “as expected” range for
six consecutive quarters has started to deteriorate which has prompted the Trust to renew and refocus its mortality
improvement work. The impact of these refocused projects will not be reflected in the SHMI position until the end of the
year as the SHMI position is a measure of mortality 6 months previously. Governors will maintain their focus and robust
challenge on this important issue.
• Draft Board minutes from the meeting on 28 April 2015;
• Papers relating to Quality reported to the board over the period April 2014 to March 2015;
• Feedback from commissioners; NELCCG, NLCCG, ERYCCG and Lincolnshire East CCG for 2014/15 dated 04/05/2015;
• Feedback from governors dated 20/05/2015;
• Feedback from Local Healthwatch organisations; Healthwatch North Lincolnshire and Healthwatch North East
Lincolnshire dated 01/05/2015;
• Feedback from Overview and Scrutiny Committee; North Lincolnshire Council – Health Scrutiny Panel dated
05/05/2015;
• The trust’s complaints report published under regulation 18 of the Local Authority Social Services and NHS
Complaints Regulations 2009 for Q1 – Q3 and Trust’s Quality Report to the Board ,dated 28/04/15;
• The 2014 national patient survey;
• The 2014 national staff survey;
• The Head of Internal Audit’s annual opinion over the trust’s control environment dated 13/05/15;
• Care Quality Commission Intelligent Monitoring Report dated March 2014, July 2014 and December 2014;
• 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 Monitor’s annual reporting guidance (which incorporates the
Quality Accounts regulations) (published at www.monitor.gov.uk/annualreportingmanual) as well as the standards to
support data quality for the preparation of the Quality Report (available at www.monitor.gov.uk/annualreportingmanual).
The directors confirm to the best of their knowledge and belief they have complied with the above
requirements in preparing the Quality Report.
By order of the Board
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Annex 3: Independent auditor’s report to the Board of Governors on
the Annual Quality Report
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Annex 4: Glossary
Benchmark Peer Group: Calderdale
and Huddersfield NHS Foundation
Trust, Chesterfield & North Derbyshire
Royal Hospital NHS Trust, Countess of
Chester NHS Foundation Trust, County
Durham and Darlington NHS Foundation
Trust, Doncaster and Bassetlaw Hospitals
NHS Trust, North Cumbria University
Hospitals NHS Trust, North Tees &
Hartlepool NHS Trust, Rotherham NHS
Foundation Trust, Royal Bolton Hospital
NHS Foundation Trust, The Pennine Acute
Hospitals NHS Trust, University Hospitals of
Morecambe Bay NHS Trust
Commissioning for Quality & Innovation
Framework (CQUIN): The CQUIN payment
framework enables commissioners to
reward excellence, by linking a proportion
of English healthcare providers’ income
to the achievement of local quality
improvement goals. Since the first year of
the CQUIN framework (2009/10), many
CQUIN schemes have been developed and
agreed. This is a developmental process
for everyone and you are encouraged to
share your schemes (and any supporting
information on the process you used) to
meet the requirement for transparency
and support improvement in schemes over
time.
Common Cause Variation: an inherent
part of the process, stable and “in control”.
We can make predictions about the future
behaviour of the process within limits.
When a system is stable, displaying only
common cause variation, only a change in
the system will have an impact.
Complaints: The NHS Complaints
Regulations (England) 2009 require that an
offer to discuss the complaint with the
complainant is made on receipt of all
complaints; the discussion to include the
response period (the period within which
the investigation is likely to be completed
and when the response is likely to be sent
to the complainant). The requirement is to
investigate the complaint in an appropriate
manner, to resolve it speedily and efficiently
and to keep the complainant informed as
to progress. The response should be within
6 months or a longer period if agreed with
the complainant before the expiry of that
period.
The Complaints Regulations permit
extensions to the agreed timescale
where this becomes necessary and
in agreement with the complainant. The Trust (as outlined within the Policy for
the Management of Complaints) expects
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that any delay to the agreed response time
is communicated to the complainant, the
reasons explained and an extension agreed.
In respect of monitoring, the Regulations
require (amongst other points) that the
Trust maintain a record of the response
periods and any amendment of that period
and whether the response was sent to
the complainant within the period or any
amendment of that period.
KEY DEFINITIONS TO INTERPRET
COMPLAINTS DATA:
NEW: The number of new complaints
received in a month regardless of whether
or not they were resolved within that
month.
CLOSED: The number of complaints that
were resolved within a month regardless
of whether they were received within the
month or resolved within agreed timescale.
NET OPEN: The total number of complaints
currently open; includes new complaints
and those unresolved from previous
month(s). This includes open ‘on hold’. This
includes re-opened complaints.
RE-OPENED: Complaints that have been
resolved which for any number of reasons
require further review.
Control Limits: indicate the range of
plausible variation within a process. They
provide an additional tool for detecting
special cause variation. A stable process
will operate within the range set by the
upper and lower control limits which are
determined mathematically (3 standard
deviations above and below the mean).
These consist of an upper control limit, a
lower control limit and a mean (average).
Crude Mortality Rate: The crude mortality
rate is based on actual numbers. Unlike
Standardised Mortality Ratios (SMRS) i.e.
SHMI and HSMR which features adjustment
based on population demographics and
related mortality expectations. Crude
mortality is calculated by using as the
numerator the number of patients who
have died divided by the denominator
which in this case is the total population.
Times this figure by 100, equals the crude
mortality percentage (%).
Fall: A sudden, unintended, uncontrolled
downward displacement of a patient’s body
to the ground or other object. This includes
situations where a patient falls while being
assisted by another person, but excludes
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falls resulting from a purposeful action or
violent blow.
Unavoidable Fall: Impossible to avoid
the fall(s) from happening. Describes an
event that could have been anticipated and
prepared for, but that occurs because of an
error or other system failure
Avoidable Fall: The fall(s) could have
been avoided. Recognises that some of
these events are not always avoidable,
given the complexity of healthcare;
therefore, the presence of an event on the
list is not an a priori judgment either of a
systems failure or of a lack of due care
Patient Experience: This Trust has set the
goal of being the hospital of choice for
our local patients. Being the hospital of
choice is a far different thing than being
the hospital of convenience, proximity or
default. We measure patient experience
using methodologies employed by the NHS
National Patient Experience Survey against
two key indicators to help us determine
that our hospitals are the ones our patients
would choose if the practical factors were
removed.
The Wound, Ostomy and Continence Nurses
Society of the US have produced a position
paper which points to a clear definition of
“avoidable” pressure ulcer (WOCNS) March
2009. However, the DH are using a modified
version of the Avoidable d Unavoidable
pressure ulcers definitions from the Centre
for Medicare and Medicaide (CMS) 2004, to
keep with the UK policy Terminology.
The modified definitions are:
AVOIDABLE PRESSURE ULCER:
“Avoidable” means that the person
receiving care developed a pressure ulcer
and the provider of care did not do ONE of
the following:
•
Evaluate the person’s clinical condition
and pressure ulcer risk factors
•
Plan and implement interventions that
are consistent with the persons needs
and goals and recognised standards of
practice within the Trust
•
•
Monitor and evaluate the impact of the
interventions
Revised the interventions as
appropriate
UNAVOIDABLE PRESSURE ULCER:
The Trust uses The Menu Card Survey which
asks five questions relating to patient
experience and is attached to inpatients’
menu cards. It measures the patients’
experience in real time. The questions
asked are all derived from questions that
feature in all National Patient Surveys.
“Unavoidable” means that the person
receiving care developed a pressure ulcer
even though the provider of the care had
done ALL of the following
•
Evaluated the persons clinical condition
and pressure ulcer risk factors
The scores depicted in the graphs reflect
an absolute figure generated by this
methodology (in short – high score is good,
100% would be the maximum achievable
score).
•
Planned and implemented
interventions that are consistent with
the persons needs and goals and
recognised standards of practice within
the Trust
Pressure Ulcer: Definition of Avoidable
and Unavoidable Pressure Ulcer
•
Monitored and evaluated the impact of
the interventions
•
Revised the interventions as
appropriate
The Department of Health (DH) has been
asked to clarify what an avoidable pressure
ulcer is in regards the nurse sensitive
outcome indicators. The DH researched
the availability of definitions, finding that
there are a limited number of definitions in
existence to draw from.
•
The individual person refused to
adhere to prevention strategies in spite
of education of the consequences
of non-adherence and this was
documented.
Pressure ulcer gradings from the European
Pressure Ulcer Advisory Panel (EPUAP):
Category/Grade 1: Non-blanchable
redness of intact skin
Intact skin with non-blanchable erythema
of a localized area usually over a bony
prominence. Discoloration of the skin,
warmth, edema, hardness or pain may also
be present. Darkly pigmented skin may not
have visible blanching.
Further description: The area may be
painful, firm, soft, warmer or cooler as
compared to adjacent tissue. Category/
Stage I may be difficult to detect in
individuals with dark skin tones. May
indicate “at risk” persons.
Category/Grade 2: Partial thickness skin
loss or blister
Partial thickness loss of dermis presenting
as a shallow open ulcer with a red pink
wound bed, without slough. May also
present as an intact or open/ruptured
serum-filled or sero-sanginous filled blister.
Further description: Presents as a shiny
or dry shallow ulcer without slough or
bruising. This category/stage should
not be used to describe skin tears, tape
burns, incontinence associated dermatitis,
maceration or excoriation.
Category/Grade 3: Full thickness skin
loss (fat visible)
Full thickness tissue loss. Subcutaneous
fat may be visible but bone, tendon or
muscle are not exposed. Some slough may
be present. May include undermining and
tunnelling.
Further description: The depth of a
Category/Stage III pressure ulcer varies
by anatomical location. The bridge of the
nose, ear, occiput and malleolus do not
have (adipose) subcutaneous tissue and
Category/Stage III ulcers can be shallow. In
contrast, areas of significant adiposity can
develop extremely deep Category/Stage III
pressure ulcers. Bone/tendon is not visible
or directly palpable.
calculate an average called ‘rate per
1,000 occupied bed days’. This allows us
to compare our improvement over time,
but cannot be used to compare us with
other hospitals, as their staff may report in
different ways, and their patients may be
more or less vulnerable than our patients.
Readmission Rate (RA): This measure
shows the percentage of patients who were
readmitted to hospital as an emergency
within one month of being discharged. It
can serve as an indicator of the quality of
care provided and post-discharge follow
up. A low readmission rate is an indicator
of the quality of care in that it reflects a
healthy care balance. Where rates are low,
patients are not having to come back to
the Trust for care of the same complaint.
Conversely, a high readmission rate
potentially signals that an organisation
is releasing patients home too soon or
otherwise not addressing all elements of
their clinical condition.
Safety Thermometer methodology:
Harm:
•
Catastrophic harm: Any patient safety
incident that directly resulted in the
death of one or more persons receiving
NHS funded care.
•
Severe harm: Any patient safety
incident that appears to have resulted
in permanent harm to one or more
persons receiving NHS-funded care.
•
Moderate harm: Any patient safety
incident that resulted in a moderate
increase in treatment and which
caused significant but not permanent
harm, to one or more persons receiving
NHS-funded care. Locally defined as
extending stay or care requirements
by more than 15 days; Short-term
harm requiring further treatment
or procedure extending stay or care
requirements by 8 - 15 days
•
Low harm: Any patient safety incident
that required extra observation or
minor treatment and caused minimal
harm, to one or more persons receiving
NHS-funded care. Locally defined
as requiring
observation
or minor
Category/Grade 4: Full thickness tissue
loss (muscle/bone visible)
Full thickness tissue loss with exposed
bone, tendon or muscle. Slough or
eschar may be present. Often include
undermining and tunnelling.
Further description: The depth of a
Category/Stage IV pressure ulcer varies
by anatomical location. The bridge of the
nose, ear, occiput and malleolus do not
have (adipose) subcutaneous tissue and
these ulcers can be shallow. Category/Stage
IV ulcers can extend into muscle and/or
supporting structures (e.g., fascia, tendon
or joint capsule) making osteomyelitis
or osteitis likely to occur. Exposed bone/
muscle is visible or directly palpable.
Rate per 1000 bed days: So we can know
if we are improving even if the number of
patients we are caring for goes up
or down, we also
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treatment, with an extended stay or
care requirement ranging from 1 – 7
days
•
None/ ’Near Miss’ (Harm): No obvious
harm/injury, Minimal impact/no service
disruption.
Harm Free Care:
•
•
Safety Thermometer enables the
calculation of the proportion of
patients who received harm free care.
This is calculated by dividing the
number of patients receiving harm
free care (as the numerator) by the
total number of patients surveyed (the
denominator).
Patients with more than one of the
harms listed, will not be classified
as harm free care and are thus not
counted in the numerator. Patients
recorded as having multiple harms are
removed from the numerator in the
same way as those with only one harm.
Proportion of patients with ‘harm free’ care:
•
Those patients without any
documented evidence of a pressure
ulcer (any origin, category 2-4), harm
from a fall in care in the last 72 hours,
a urinary infection (in patients with
a urinary catheter) or a new VTE
(treatment started after admission).
Proportion of patients with ‘harm free’ care –
new harms only:
•
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Those patients without any
documented evidence of a new
pressure ulcer (developed at least
72 hours after admission to this care
setting, category 2-4), harm from a
fall in care in the last 72 hours, a new
urinary infection in patients with a
urinary catheter which has developed
since admission to this care setting,
or a new VTE (treatment started after
admission).
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Sigma: A sigma value is a description of
how far a sample or point of data is away
from its mean, expressed in standard
deviations usually with the Greek letter σ
or lower case s. A data point with a higher
sigma value will have a higher standard
deviation, meaning it is further away from
the mean.
Summary Hospital Mortality Indicator
(SHMI): The SHMI is the NHS ‘official’
Standardised Mortality Ratio (SMR). It is
a method of comparing mortality levels
in different years, or between different
hospitals. As a result, the SHMI is used as a
performance tool to rank NHS organisations
within a league table. The ratio is calculated
by using as a numerator the number
of deaths divided by the denominator,
in this case, the number of ‘expected’
deaths, multiplied conventionally by 100.
Thus, if mortality levels are higher in the
population being studied than would be
expected, the SHMI will be greater than
100. This methodology allows comparison
between outcomes achieved in different
trusts, and facilitates benchmarking. The
outcomes of the SHMI are reported in three
bandings: (1) higher than expected, (2)
as expected and (3) lower than expected.
The SHMI includes not only in-hospital
deaths, but also includes deaths within
the community, occurring within 30 days
of hospital discharge. As a result, it is
dependant not only on in-hospital coded
information, but also on Public Health data,
this results in a delay in reporting. As a
consequence, the quarterly data published
by the Health and Social Care Information
Centre reports on historic information
ranging from 18 months to 6 months. To
illustrate this point, the SHMI information
release in April 2015 reports performance
from October 2013 – September 2014.
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Special Cause Variation: the pattern of
variation is due to irregular or unnatural
causes. Unexpected or unplanned events
(such as extreme weather) can result in
special cause variation. Systems which
display special cause variation are said
to be unstable and unpredictable. When
systems display special cause variation, the
process needs sorting out to stabilise it.
This is most commonly reported using two
types of special cause variation, trends and
outliers. If a trend, the process has changed
in someway and we need to understand
and adopt if the change is beneficial or act
if the change is a deterioration. The outlier
is a one-off condition which should not
result in a process change. These must be
understood and dealt with on their own (i.e.
response to a major incident).
Identifying Special Cause Variation – agreed
rules:
•
Any point outside of the control limits,
•
A run of 7 points all above or below
the central line, or all increasing /
decreasing,
•
•
Any unusual patterns or trends within
the control limits,
The proportion of points within the
middle 1/3 of the region between the
control limits differs from 2/3.
Standard Deviation: Standard deviation is a
widely used measurement of variability or
diversity used in statistics and probability
theory. It shows how much variation or
“dispersion” there is from the “average”
(mean, or expected/budgeted value). A low
standard deviation indicates that the data
points tend to be very close to the mean,
whereas high standard deviation indicates
that the data are spread out over a large
range of values.
Annex 5: Mandatory Performance Indicator Definitions
The following indicators:
• Percentage of incomplete pathways within 18 weeks for patients on incomplete pathways,
• Cancer 31 day, 62 day waits.
Have been subject to external audit in line with the following criteria:
Percentage of incomplete pathways within 18 weeks for patients on incomplete pathways:
• Detailed descriptor: The percentage of incomplete pathways within 18 weeks for patients on incomplete pathways at
the end of the period;
• Numerator: The number of patients on an incomplete pathway at the end of the reporting period who have been
waiting no more than 18 weeks;
• Denominator: The total number of patients on an incomplete pathway at the end of the reporting period.
Accountability: Performance is to be sustained at or above the published operational standard. Details of current
operational standards are available at: www.england.nhs.uk/wp-content/uploads/2013/125yr-strat-plann-guid-wa.pdf
(see annex B: NHS Constitution Measures).
• Indicator format: Reported as a percentage.
Maximum waiting time of 62 days from urgent GP referral to first treatment for all cancers:
• Detailed descriptor: Percentage of patients receiving first definitive treatment for cancer within 62 days of an urgent
GP referral for suspected cancer;
• Data definition: All cancer two-month urgent referral to treatment wait;
• Numerator: Number of patients receiving first definitive treatment for cancer within 62 days following an urgent GP
(GDP or GMP) referral for suspected cancer within a given period for all cancers (ICD-10 C00 to C97 and D05);
• Denominator: Total number of patients receiving first definitive treatment for cancer following an urgent GP (GDP or
GMP) referral for suspected cancer within a given period for all cancers (ICD-10 C00 to C97 and D05);
Accountability: Performance is to be sustained at or above the published operational standard. Details of current
operational standards are available at: www.england.nhs.uk/wp-content/uploads/2013/125yr-strat-plann-guid-wa.pdf
(see Annex B: NHS Constitution Measures).
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