Quality Accounts
2014/2015
Delivering Outstanding Patient Care
April 2015
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QUALITY ACCOUNTS
What are the Quality Accounts and why are they so important?
Quality Accounts are an annual report to the public about the quality of services that healthcare providers
deliver and their plans for improvement.
The purpose of the quality account is to enable:

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Patients, their carers and families to make informed choices about the provider of their
healthcare.
Boards of NHS providers to report on their services and to set their priorities for the following
year.
Healthcare providers measure the quality of the services they provide by looking at:


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Patient safety.
The effectiveness of treatments that patients receive.
Patient feedback about the care provided.
Our Quality Account contains information about the quality of our services, the improvements we have
made during 2014/15 and sets out our key priorities for the forthcoming year. The report also includes
feedback from our patients on how well they think we are doing.
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Foreword from the Chief Executive
The Robert Jones & Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
has continued to maintain its ambition of ‘Delivering Outstanding Patient Care’,
supported by the Trust’s five-year Quality Strategy, which ensures that quality
and patient safety are at the heart of everything we do.
These Quality Accounts set out our key achievements in 2014/15, as well as
sharing our priorities for 2015/16 and we hope that this will provide our
patients, their families and carers with confidence in the quality of our services.
The Trust has maintained low infection rates, with no MRSA bacteraemia
since 2006 and low surgical site infection rates. We ensure ongoing
monitoring and surveillance of all infections, as well as regular monitoring of
ward and department level practices.
The Trust has continued to use the “Safety thermometer” to monitor incidents of harm to patients in the
course of their hospital treatment and has consistently scored over 98% of patients having received “no
new harms” whilst at the Trust, which exceeded the target of 95%. Learning from all patient safety
incidents is promoted throughout the Trust with examples of good practice shared at a variety of
meetings.
At the end of 2014/15, work started on a multi-million pound scheme to transform existing hospital
facilities, including four new clean air Theatres, a High Dependency Unit and an Admission on Day of
Surgery Unit. A new dedicated Bone Cancer Centre with inpatient and clinic facilities and a flexible multiuse ward will be built on the first floor. This represents a tremendous development for patients, allowing
more patients to be treated in state of the art facilities in cancer care and operating theatres. This
investment supports the hospital’s position as the leading centre for orthopaedic excellence in the UK.
The Trust has continued to use a ward based nursing assessment process, ‘STAR’ (Sustaining quality
Through Assessment and Review) to provide assurances with regard to 14 standards based upon
national recommendations. All seven adult inpatient wards have now been assessed, with six wards
achieving green star status in 2014/15.
Work on ensuring a dementia-friendly hospital has continued, with the introduction of the Blue Butterfly
scheme and dementia screening for all patents over 75 in the pre-operative assessment unit. Both
clinical and non-clinical staff have undergone training to enable them to support patients with dementia.
The Trust plans to continue this work in 2015/16 by developing a dementia friendly environment across
the organisation.
The most recent national staff survey found that 93% of staff would recommend the hospital to their family
and friends; this is the highest score in the NHS. Staff are very proud of the service that they deliver,
giving patients even more confidence in the care and treatment provided by the hospital.
The Trust continues to receive excellent patient feedback and is one of the top performing NHS Trusts in
the country. It was also amongst the best performing Trusts in eight of the ten sections in the National
Inpatient Survey 2014.
I am pleased to confirm that the Board of Directors has reviewed the 2014/15 Quality Accounts. There
are a number of inherent limitations in the preparation of Quality Accounts which may impact the reliability
or accuracy of the data reported. These include:
 Data is derived from a large number of different systems and processes. Only some of these are
subject to external assurance, or included in internal audits programme of work each year.
 Data is collected by a large number of teams across the Trust alongside their main
responsibilities, which may lead to differences in how policies are applied or interpreted. In many
cases, data reported reflects clinical judgement about individual cases, where another clinician
might have reasonably have classified a case differently.
 National data definitions do not necessarily cover all circumstances, and local interpretations may
differ.
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
Data collection practices and data definitions are evolving, which may lead to differences over
time, both within and between years. The volume of data means that, where changes are made,
it is usually not practical to reanalyse historic data.
The Board of Directors have sought to take all reasonable steps and exercise appropriate due diligence
to ensure the accuracy of the data reported, but recognises that it is nonetheless subject to the inherent
limitations noted above. Following these steps, to my knowledge, the information in the document is
accurate, with the exception of the matters identified in respect of the 18 weeks referral to treat (RTT)
indicator, as described on page 16
W ENDY FARRINGTON CHADD
CHIEF EXECUTIVE
ROBERT JONES AND AGNES HUNT ORTHOPAEDIC NHS FOUNDATION TRUST
MAY 2015
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CONTENTS
What are the Quality Accounts and why are they so important? .......................................... 2
Our Priorities .............................................................................................................................. 6
Review of Last Year’s Priorities .............................................................................................. 6
Our Priorities for 2015/16 ........................................................................................................ 8
STATEMENTS OF ASSURANCE FROM THE BOARD ............................................................ 11
Review of Services ............................................................................................................... 11
Clinical Audit ......................................................................................................................... 11
Research .............................................................................................................................. 12
Commissioning for Quality & Innovation (CQUIN) Payment Framework ............................... 12
Statements from the Care Quality Commission .................................................................... 15
Data Quality .......................................................................................................................... 15
Information Governance Toolkit Attainment Levels ............................................................... 16
Clinical Coding Error Rate .................................................................................................... 16
Performance against the relevant indicators and performance thresholds set out in Appendix
A of the Risk Assessment Framework .................................................................................. 16
National Quality Indicators .................................................................................................... 19
Local Quality Indicators......................................................................................................... 26
Workforce Factors ................................................................................................................ 52
Statement from Local Healthwatch ........................................................................................... 53
Statement from Health & Adult Social Care Scrutiny Committee .............................................. 53
Statement from Shropshire Clinical Commissioning Group ....................................................... 54
Statement of Directors’ Responsibilities in Respect of the Quality Report ................................. 55
Appendix A ............................................................................................................................... 60
Local Clinical Audits .............................................................................................................. 60
Appendix B ............................................................................................................................... 64
Quality Accounts Glossary .................................................................................................... 64
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Our Priorities
Review of Last Year’s Priorities
Last year we set ourselves the following three key priorities:
 Introduction of the Medicines Safety Thermometer
 Continued roll-out of the STAR (Sustaining quality Through Assessment and Review) system
 Roll-out of pre-operative dementia screening
Introduction of the Medicines Safety Thermometer
Why this was a priority
The introduction of the Medicines Safety Thermometer (which is a national measurement tool for
improvement that focuses on medication reconciliation) is in addition to our established incident reporting
system, and any errors highlighted during the data collection process are reported and investigated as
per our existing incident reporting policy. Monthly data from all wards is submitted to a national database
which supports sharing and learning with other organisations. The Trust has used the data as a baseline
to inform and direct improvement efforts.
What we did in 2014/15
We introduced the initiative to the senior nurses and pharmacists within three areas chosen to pilot the
scheme in April 2014. All ward managers and area pharmacists were introduced to the paper work and
shown the national data base. In May we were able to commence data collection for all eight areas. Over
the months we hit the target dates for the data entry onto the national platform with our data is being used
to build a clearer national picture regarding medicines safety.
How we did in 2014/15
We have already seen the benefit of this scheme with changes in practice made as a result of the
evidence gathered.
 We have introduced cards on all ward areas, to be placed on patients beds/tables to inform them
they had a medication due whilst they were absent encouraging them to inform the staff of their
return.
 We have introduced a process of peer review of the medication charts following the completion of
a medication round. Where any gaps in documentation can be reviewed and acted upon in a
timely manner.
We aim to review in detail a full 12 months’ worth of data in May where we will develop an action plan on
which to base future improvements.
Continued roll-out of the STAR (Sustaining quality Through Assessment and Review)
system
Why this was a priority
The Robert Jones & Agnes Hunt Orthopaedic Hospital (RJAH) NHS Foundation Trust vision is: “To be the
leading centre for high quality, sustainable orthopaedic and related care, achieving excellence in both
experience and outcomes for our patients”. It is essential to have robust measures in place to capture
assurance on the fundamentals of care which is monitored and reported from ward to the board. There
needs to be a continued approach and sustainability to improve and for the RJAH to continue fostering a
culture of safety for the patients we serve.
The STAR (Sustaining Quality Through Assessment & Review) performance assessment framework is a
structured process linking to the 6 C’s Nursing strategy, Essence of Care standards and Care Quality
Commission (CQC) fundamental standards. The 14 standards set within the framework are measured by
collating evidence through observation of care, reviewing written documentation, and speaking with both
patients and staff. Each standard is subdivided into three elements, Environment, Care, and Leadership.
This is to reflect those aspects of practice that are necessary for the efficient running of wards.
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The assessments are carried out by the Matron for Quality & Safety, who works with the ward manager
and divisional Matron to ensure that an action plan is agreed and implemented. Re-assessment is based
on the level achieved.
The STAR assessment was developed and piloted on three wards in 2013/14 and has been rolled out
across all adult wards in 2014/15.
What we did in 2014/15
The STAR performance assessment framework has been undertaken on all the adult wards within the
trust. A specific STAR assessment document has been developed for Alice Ward which focuses on
paediatric care, along with Theatres, Recovery and Anaesthetics who have also developed and produced
a STAR performance assessment framework document specific to these three areas.
How we did in 2014/15
The results so far for adult wards are below, and are presented in a way to demonstrate how wards have
progressed and sustained in their achievement to 3 STAR status, which is the highest rating. As indicated
below the Trust has achieved the CQUIN (Commissioning for Quality & Innovation) target to have four
wards at 3 STAR (green) status. Currently there are six wards at 3 STAR status.
Alice
STAR Rating at
first
assessment
TBC
STAR Rating
at second
assessment
TBC
Clwyd
2
3
Gladstone
2
2
Kenyon
2
3
Ludlow
2
3
3
Powys
2
3
3
Sheldon
2
2
3
3
TBC
TBC
TBC
TBC
1
2
2
3
Ward/Dept.
Theatre/Recovery
Wrekin
STAR Rating at
third
assessment
TBC
STAR Rating at
fourth
assessment
TBC
The STAR assessment document undergoes an annual review which was undertaken in November 2014.
This is done as new initiatives and quality/safety standards are introduced, to ensure compliance, and to
enable the trust to assess specific areas that have been identified locally which require improvements.
There has been the development of Quality Boards for patients, visitors and staff to view ward
performance on quality and safety. This has been successful and informative for patients and staff and
demonstrates our open and transparent approach in the quality of care delivered.
We have also developed staff quality and safety boards, which provide staff with relevant information on
the ward’s performance and ‘knowing how we are doing’, on a month by month basis.
Roll-out of pre-operative dementia screening
Why this was a priority
The National Dementia Strategy “Living well with Dementia” 2009 set out 17 recommendations for the
NHS, local authorities and other organisations to take to improve dementia care services which focus on
three key themes:
 Raising awareness and understanding of dementia
 Early diagnosis, intervention and support
 Living well with dementia
In order to work in partnership at a local and national level towards achieving these national strategic
drivers, the Trust continued with the following aims:
 To ensure and implement best practice.
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To adopt and deliver on the dementia national guidance and quality standards within the
organisation working within the local health and social care economy.
To establish clear clinical leadership relating to dementia.
To provide further training for staff to care for patients who are suffering with dementia and their
relatives/carers.
The Commissioning for Quality and innovation (CQUIN) Framework for dementia aims to support
improvements in the quality and innovation of dementia services. The RJAH have participated in the
national CQUIN, and developed a locally agreed CQUIN with commissioners in prioritising dementia care
and agreed to undertake dementia screening for patients aged 75 or over, who were seen in preoperative assessment by a nurse practitioner. The purpose of this CQUIN is to incentivise the
identification of patients who could potentially have early signs of dementia and impaired understanding
and to prompt appropriate referral back to the GP for further assessment and investigations.
Dementia screening improves dementia and delirium care, including sustained improvement in:
 Finding people with dementia
 Assessing
 Investigating their symptoms
 Referring for support
What we did in 2014/15
Assessment is fundamental to good care and vital in the provision of support to patients in the early
identification of memory/reasoning problems.
A dementia assessment supported by using an agreed screening assessment tool was introduced using
trigger questions, and the 6 CIT (6 Item Cognitive Impairment Test). This was introduced within the preoperative assessment unit working with all nurses. There was some training involved to undertake the 6
CIT questions and to ensure all staff were fully briefed in the process and collecting the data. The tool
was discussed with the pre-operative anaesthetist clinical lead and a pro-forma/standard letter was
developed for follow up in community. This letter highlights the 6 CIT score, should the patient score
above 8, and suggests to the GP further investigation if he/she feels appropriate. In addition to this, the 6
CIT screening tool has also been incorporated into the Digital pre-operative information
The Trust also introduced the ‘Butterfly Scheme’ within the pre-operative department. The Butterfly
Scheme allows people whose memory is permanently affected by dementia to make this clear to hospital
staff and provides staff with a simple, practical strategy for meeting their needs. The patients receive
more effective and appropriate care, reducing their stress levels and increasing their safety and wellbeing.
How we did in 2014/15
The process was introduced as a paper exercise using the documentation during November/December
2014, and went live in January 2015.
The pre-operative screening tool has been undertaken by the nurse practitioners with just over 90% of
eligible patients undergoing dementia screening.
Our Priorities for 2015/16
In line with the Trust’s Quality Improvement Strategy, and in discussion with the Board of Directors,
Council of Governors and other relevant stakeholders (including the Patient Panel and commissioners),
the Trust has identified the following three key priorities for 2015/16:
Safety
Zero tolerance to Wrong Site Procedures
Wrong site surgery is on the list of Never Events set out by the Department of Health. During 2013/14
and 2014/15 the Trust had two Never Events, as well as four serious incidents, which, although not
classed as Never Events, involved patients being given wrong site nerve blocks. A number of changes
were implemented and the Trust processes were recently audited by the Trust’s Internal Auditors, who
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gave a finding of significant assurance with minor improvements. The Trust would like to ensure that
these changes are sustainable and has set a priority of ensuring zero tolerance to wrong site procedures
in 2015/16.
All wrong site procedure incidents are reported as Serious Incidents; these are reported to the Board on a
monthly basis, with the Quality & Safety Committee reviewing the subsequent investigation report.
Effectiveness
Implementation of the STAR assessment in Theatres
Part of our Quality Strategy 2014-2017 is to provide care to our patients, which is safe, effective, caring
and responsive to the needs of the population we serve. This links into one of our strategic aims ‘to be the
provider of choice for patients through the provision of safe, effective, high quality orthopaedic and related
care.
The STAR (Sustaining Quality Through Assessment & Review) performance assessment framework is a
structured process linking to the 6 C’s Nursing strategy, Essence of Care standards and Care Quality
Commission (CQC) fundamental standards. It enables staff to have specific aims and objectives to
support them in the direction of which our quality improvement purpose is delivered highlighting areas for
quality improvement in delivering safe care. The STAR assessment has already been implemented on all
adult wards and is now being adapted for the Theatres Environment. The development of the Theatre
STAR assessment provides a framework to further enhance monitoring processes and provide assurance
to the Trust Board.
The assessment will be carried out by the Matron for Quality & Safety, who works with the departmental
managers to ensure that an action plan is agreed and implemented following each assessment. Reassessment is based on the level achieved which is the same as the ward’s process. Results of the
STAR assessments will be reported to the Quality & Safety Committee as part of regular quality reporting.
Patient Experience
Rollout of Dementia Friendly Environment across the organisation.
Dementia generally causes progressive changes in how people interpret what they see hear and feel.
People with dementia often find it difficult to orientate to an unfamiliar environment and have a reduced
stress threshold to environmental challenges.
As the Kings Fund (2012) highlights, the design of the built environment can significantly help in
compensating for the memory loss and communication problems associated with dementia, as well as
supporting the continued independence of people in hospital who have dementia. New projects are
demonstrating that relatively inexpensive interventions, such as changes to lighting, flooring, and
improved signage can have a significant impact. (Taken from Dementia: Commitment to the care of
people with Dementia in hospital settings RCN Jan 2012)
Linking in with these principles are other initiatives and standards for which the Trust needs to provide
evidence of compliance, for example the Care Quality Commission (CQC) standards, Patient Led
Assessment of Care Environment (PLACE), productive ward initiatives, STAR (Sustaining Quality
Through Assessment & Review) assessment, and our commitment to the Trust’s Quality Strategy and
Trust values. Having a clear strategy which encompasses all of these will help to support and move
forward in promoting a dementia friendly environment.
Undertaking this as a priority will raise more awareness of the importance of creating a dementia friendly
environment and improving care of people living with dementia. There has been some positive work in
improving the environment in some areas within the Trust, however there needs to be further work
undertaken as part of a continued journey. What has supported this is a focussed approach, influenced
by national and local agendas, and the development of the RJAH task and finish project group which has
involved clinical and estates staff, as well as patient panel members. The task and finish group has
already done a lot of work in the improvement of the environment and this will continue during 2015/16
with clear aims and objectives in implementation, working in collaboration with other estates projects.
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The Adult Safeguarding Committee will review progress throughout the year and a re-audit of the
environment will be undertaken towards the end of 2015/16 to assess progress, and compliance.
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STATEMENTS OF ASSURANCE FROM THE BOARD
These statements of assurance follow statutory requirements for the presentation of Quality Accounts, as
set out in the Department of Health’s regulations on Quality Accounts and the additional reporting
requirements set by Monitor.
Review of Services
During 2014/15, The Robert Jones & Agnes Hunt Orthopaedic Hospital NHS Foundation Trust provided
three NHS services, in musculo-skeletal surgery, medicine and rehabilitation. The Robert Jones & Agnes
Hunt Orthopaedic Hospital NHS Foundation Trust has reviewed all the data available to them on the
quality of care in all of these 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 NHS services
by The Robert Jones & Agnes Hunt Orthopaedic Hospital NHS Foundation Trust for 2014/15.
The data reviewed covers the three dimensions of quality:
 patient safety
 clinical effectiveness
 patient experience
Clinical Audit
During 2014/15, three national clinical audits and one national confidential enquiry covered NHS services
that the Robert Jones & Agnes Hunt Orthopaedic Hospital NHS Foundation Trust provides.
During that period, The Robert Jones & Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
participated in 100% national clinical audits and 100% 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 Robert Jones & Agnes Hunt
Orthopaedic Hospital NHS Foundation Trust was eligible to participate in during 2014/15 are as follows:
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National Confidential enquiry-National Sepsis Audit
National Joint Registry (NJR)
Rheumatoid and early inflammatory arthritis
Elective surgery (National PROMs Programme)
The national clinical audits and national confidential enquiries that The Robert Jones & Agnes Hunt
Orthopaedic Hospital NHS Foundation Trust participated in during 2014/15 are as follows:




National Confidential enquiry-National Sepsis Audit
National Joint Registry (NJR)
Rheumatoid and early inflammatory arthritis
Elective surgery (National PROMs Programme)
The national clinical audits and national confidential enquiry that The Robert Jones & Agnes Hunt
Orthopaedic Hospital NHS Foundation Trust was eligible to participate in and for which data collection
was completed during 2014/15 are listed below alongside that number of cases submitted to each audit
or enquiry as a percentage of the number of registered cases required by the terms of that audit or
enquiry:
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Eligible to participate
% cases submitted
National Confidential enquiry-National Sepsis
Audit
Yes
N/A*
National Joint Registry (NJR)
Yes
99.7%
Rheumatoid and early inflammatory arthritis
Yes
96%
Elective surgery (National PROMs Programme)
Yes
89%
*no eligible patients admitted during the data collection period.
There were no national clinical audit reports relevant to The Robert Jones & Agnes Hunt Orthopaedic
Hospital NHS Foundation Trust in 2014/15. The reports of 32 local clinical audits were reviewed by the
provider in 2014/15 and The Robert Jones & Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
intends to take the actions set out in appendix A to improve the quality of healthcare provided.
In 2014/15, the Trust’s internal auditors gave significant assurance with minor improvement opportunities
on the Clinical Audit processes. This review noted the progress that had been made since the previous
review which had given limited assurance, but that there were some further improvements that could be
made. A full action plan was agreed and the Trust is working to embed these changes.
Research
The number of patients receiving NHS services provided or sub-contracted by The Robert Jones & Agnes
Hunt Orthopaedic Hospital NHS Foundation Trust in 2014/15 that were recruited during that period to
participate in National Institute of Health Research (NIHR) Portfolio research approved by a Research
Ethics Committee was 735 against a target of 1050 (70%).
The Robert Jones & Agnes Hunt Orthopaedic Hospital NHS Foundation Trust was involved in conducting
24 NIHR Portfolio clinical research studies in six specialities during 2014/15, which is decrease of one
study compared to 2013/14. This included commercially, academic and RJAH Trust sponsored studies.
During 2014/15, research at RJAH contributed to 29 publications, which shows our commitment to
transparency and desire to improve patient outcomes and experience across the NHS.
Commissioning for Quality & Innovation (CQUIN) Payment Framework
A proportion (2.5%) of The Robert Jones & Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
contracted income from England in 2014/15 was conditional on achieving quality improvement and
innovation goals agreed between the Trust and its Commissioners through the CQUIN (Commissioning
for Quality and Innovation) payment. Further detail of the 2014/15 agreed goals and new schemes
agreed for 2015/16 are available electronically at www.england.nhs.uk/wpcontent/uploads/2015/02/cquin-15-16-guidance.pdf and are set out in this report.
The final value of the CQUIN scheme for Shropshire and collaborative commissioners in 2014/15 was
circa £983K, and the scheme overseen by Specialised Commissioner for our Spinal Injuries service was
worth an additional circa £259K. For specialised services the percentage attributed to CQUIN is 2.4%.
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Summaries of the 2014/15 schemes are set out in the following tables.
Goal Name
Description of Goal
Goal Weighting
(% of CQUIN
scheme available)
Friends and Family
(national)
Implementation of staff Friends & Family Test (FFT)
and increasing scope to outpatients. Increasing the
response rate to 30% for inpatients.
NHS Safety Thermometer
(national)
Develop an action plan and implement change to
show an improvement in recording of ‘days between’
falls logged on the incident reporting system.
Dementia Screening (national)
Implement national scheme on screening of patients
aged over 75 admitted as an emergency, ensuring
support for carers, and providing clinical leadership to
ensure training for staff.
Pre-operative Dementia
Assessment
(Local)
To screen 90% of patients aged over 75 attending
pre-operative assessment, appropriately refer if
required and ensuring carers feel supported.
15%
Medicines Management
Implementation of national tool for medication errors
and harm. Registration to a national database and
completed training for all wards to have green status
by the end of Q4.
10%
Rollout of Nursing Assessment
and Accreditation System
All wards to be assessed against standards. With a
target of achievement of four wards to have green
status by end of Q4.
15%
DVT (Deep Vein Thrombosis)
Information
Patients/carers are offered verbal and written
information on VTE prevention as part of the
discharge process.
15%
Prevention of site infection
In line with best practice standards to document
temperature intra operatively for all adult inpatients
(excluding day case).
18%
5%
7%
15%
100%
2 CQUIN Scheme coordinated by West Midlands Specialised Services
(Value £259K)
Goal Name
Description of Goal
Goal Weighting
(% of CQUIN
scheme available)
Acute SCIC Outreach to newly
injured patients
Provide SCI service as a face to face outreach to
newly injured patients within 5 days of referral.
35%
Clinically appropriate
telemedicine care
Develop an action plan and implement change to
increase telemedicine care.
35%
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Outcome of CQUIN Schemes
The three national CQUIN goals were fully achieved, covering both CCG and specialised commissioners.
 The results of the inpatient survey exceed the target response rate with a percentage of 54%
against a target of 30% for the last quarter.
 The NHS Safety Thermometer was successfully submitted each month and was achieved by an
increase in average days between falls to 2.6 days against a target of 2.4.
 Achieved 91% screening for dementia for patients over 75 admitted as an emergency.
The local schemes were fully achieve and agreed by Shropshire CCG:
 Achieved 90.15% screening for dementia as part of the pre-operative pathway against a target of
90%.
 Trust registered with national database. All training complete and action plan in place for new
starters. Full monthly data collection completed across all wards since June 2014.
 The STAR performance assessment framework has been undertaken on all the adult wards
within the Trust during 2014/15.
 Data collection has commenced on all adult wards to record venous thromboembolism (VTE)
patient information given pre-operatively.
 The anaesthetic audit on improving patient temperature resulted in 86% compliance in Q4,
achieving the target.
2013/14 CQUIN Scheme
The final payment for the CQUIN scheme in 2013/14 was £977,215 from our English CCGs and £245,714
from our specialised commissioners.
2015/16 CQUIN Scheme
The value of the two schemes in 2015-16 will be 2.5% of total contract value.
A summary of the goals in the new schemes are listed in the tables below.
Schemes coordinate by Shropshire CCG: (£1,000K)
Goal Name
Acute Kidney Injury (AKI)
Dementia
Description of Goal
Goal Weighting
(% of CQUIN
scheme available)
Develop action plan to ensure patients treated for AKI,
have had the necessary tests recorded in there
discharge summary.
10%
To screen patients aged over 75 admitted as an
emergency, ensuring support for carers, and providing
clinical leadership to ensure training for staff.
10.5%
Medicine Management
Utilisation of national tool for medication errors and
harm.
14.5%
Rollout of Nursing Assessment
and Accreditation System
Theatres to be assessed against standards, with a
target of green status by Q4.
10%
DVT Information
Patients/carers are offered verbal and written
information on VTE prevention prior to admission.
15%
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Goal Name
Description of Goal
Goal Weighting
(% of CQUIN
scheme available)
Prevention of site infection
In line with best practice standards to document
temperature intra operatively for all adult inpatients
(excluding Day case).
15%
End of Life
Adopting principles of the AMBER bundle
10%
Reduction of VTE Incidents
Reduction in VTE incidences measured in between
occurrence.
15%
100%
Statements from the Care Quality Commission
The Robert Jones & Agnes Hunt Orthopaedic Hospital NHS Foundation Trust is required to register with
the Care Quality Commission and its current registration is without conditions.
The Care Quality Commission has not taken any enforcement action against the Robert Jones & Agnes
Hunt Orthopaedic Hospital NHS Foundation Trust in 2014/15.
The Robert Jones & Agnes Hunt Orthopaedic Hospital NHS Foundation Trust has not participated in any
special reviews or investigations by the CQC during 2014/15.
Data Quality
The Robert Jones & Agnes Hunt Orthopaedic Hospital NHS Foundation Trust submitted records during
2014/15 to the Secondary Uses Service for inclusion in the Hospital Episode Statistics which are included
in the latest published data. The percentage of records in the published data which included the patient’s
valid NHS number was:
 99.8% for admitted patients care
 100% for outpatient care
The percentage of records in the published data which included the patient’s valid General Medical
Practice Code was:
 100% for admitted patients care
 100% for outpatient care
The Robert Jones & Agnes Hunt Orthopaedic Hospital NHS Foundation Trust will be taking the following
actions to improve data quality:
 Data Quality is part of everyone’s job; the education and inspiration will be led by the data quality
assurance group, which will meet regularly to help facilitate development and change.
 The Trust is committed to a process of continuous improvement in the quality of data collected
and this will continue to increase in importance as we move towards the new age of the
Electronic Health Record.
 As well as establishing a robust training programme another key element to improving data
quality is ensuring robust procedures are in place, which will be reviewed and updated on a
regular basis.
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
Sustain the advanced audit framework that is in place and extend to additional areas within the
Trust.
Information Governance Toolkit Attainment Levels
The Robert Jones & Agnes Hunt Orthopaedic NHS Foundation Trust’s Information Governance
Assessment Report score overall for 2014/15 was 91% and was graded green.
Clinical Coding Error Rate
The Robert Jones & Agnes Hunt Orthopaedic Hospital NHS Foundation Trust was not subject to the
Audit Commission’s Payment by Results clinical coding audit during 2014/15.
An audit of 200 sets of case notes was carried out by an external company (JW Clinical Coding Limited)
as part of the Information Governance process. This audit reconfirmed the high standards achieved by
the coding team – an extract from the report summary is shown below:
Audit Results
Primary diagnosis
correct
Secondary diagnosis
correct
Primary procedures
correct
Secondary
procedures correct
98.50%
95.86%
98.94%
98.41%
The figures far exceed the recommended 95% accuracy for primary diagnoses and procedures and 90%
accuracy for secondary diagnoses and procedures required for Information Governance purposes at
Level 3.
The Robert Jones & Agnes Hunt Orthopaedic Hospital NHS Foundation Trust will be taking the following
actions to improve data quality:
 Continuing with its ongoing programme of internal data quality audits and implementing actions
arising from these as appropriate.
Performance against the relevant indicators and performance thresholds set out in
Appendix A of the Risk Assessment Framework
As a Foundation Trust the Hospital is required to provide Monitor with a quarterly return detailing the
Trust’s performance against the national targets and core standards as outlined in Monitor’s Compliance
Framework for 2014/15. As part of this return, Monitor requires the Trust to confirm its service
performance against the main targets and indicators set out in the 2014/15 Risk Assessment Framework.
The Board of Directors is assured of its position with the quarterly submissions via the existing reporting
structures in place, supporting the sign off of the Trust declarations. These include the integrated
balanced scorecard, reports made directly to the Board and those reviewed by delegated committees of
the Board. The table below sets out the year-end position against those targets and indicators that are
relevant to the Trust:
Referral to
Referral to
treatment time, 18 treatment time, 18
Referral to treatment time, 18 weeks in weeks in aggregate, weeks in aggregate,
aggregate, incomplete pathways
admitted patients
non-admitted
18+
TLS
Target
Actual
Target
Actual
Target
Actual
March
838
5611
92% 85.07%
90% 70.54%
95% 89.46%
2014/15 Annual Average
5938
64604
92% 90.89%
90% 87.62%
95% 97.02%
Target/Indicator, as set
out in Risk Assessment
Framework
The Trust has identified an issue in its 18 week Referral-to-Treatment incomplete pathways reporting
during the year. During the year, it has come to the attention of Trust management that as a result of
- 16 -
validation and exclusion processes, the published indicator includes data for pathways for which the 18
week deadline does not apply and excludes other pathways to which the 18 week deadline does apply. At
the time of reporting, it has not been possible to quantify the impact on the 18 week incomplete
performance indicator however it is likely that these processes would have resulted in the Trust
incorrectly overstating and reporting performance against this indicator. This is currently under review
and there may be some adjustment in the light of this review.
st
As such the table above presents the average of reported performance for the year ending 31 March
2015 as well as the month end figure for 2015 when all the exclusions were no longer applied.
It is clear that there has been an impact on compliance against the target and as a Trust we have taken
steps to identify these processes and ensure that they are no longer applied. In addition we have
formulated an action plan detailing the steps we have taken to improve our performance against this key
indicator and this will be a key priority for the Trust until the performance standards are delivered.
Target/Indicator, as set out in
Risk Assessment Framework
Threshold /Target
Average for 2014/15
Cancer 62 day waits for first
treatment (from urgent GP referral)
Cancer 31 day wait from diagnosis
to first treatment
Cancer 2 week (all cancers)
85%
78.95%
96%
100%
93%
99.41%
Target/Indicator, as set out in
Risk Assessment Framework
Threshold /Target
Year-end Position
Clostridium difficile – meeting the
C. Diff objective
Compliance with requirements
regarding access to healthcare for
people with a learning disability
0
2 cases
Achievement of the six criteria
for meeting the needs of people
with learning difficulties
All six criteria achieved
Unknown clock starts
The Trust is required to report performance against three indicators in respect of 18 week Referral-toTreatment (RTT) targets. For patient pathways covered by this target, the three metrics reported are:
• “admitted” – for patients admitted for first treatment during the year, the percentage who had
been waiting less than 18 weeks from their initial referral;
• “non-admitted” – for patients who received their first treatment without being admitted, or whose
treatment pathway ended for other reasons without admission, the percentage for the year who
had been waiting less than 18 weeks from the initial referral; and
• “incomplete” – the average of the proportion of patients, at each month end, who had been
waiting less than 18 weeks from initial referral, as a percentage of all patients waiting at that date.
The measurement and reporting of performance against these targets is subject to a complex series of
rules and guidance published nationally. However, the complexity and range of the services offered by
the Trust mean that local policies and interpretations are required, including those set out in the Trust
Access Policy.
As a specialist tertiary provider, receiving onward referrals from other trusts, a key issue for our Trust is
reporting pathways for patients who were initially referred to other providers. Depending on the nature of
the referral and whether the patient has received their first treatment, this can either “start the clock” on a
new 18 week treatment pathway, or represent a continuation of their waiting time which begun when their
GP made an initial referral. In order to accurately report waiting times, the Trust therefore needs other
providers to share information on when each patient’s treatment pathway began; however the Trust does
not always receive this information from referring providers. This means that for some patients the Trust
cannot know definitively when their treatment pathway began. The national guidance assumes that the
“clock start” can be identified for each patient pathway, and does not provide guidance on how to treat
patients with “unknown clock starts” in the incomplete pathway metric.
- 17 -
The Trust’s approach in these cases, where information is not forthcoming after chasing the referring
provider, is to treat a new treatment pathway as starting on the date that the Trust receives the referral for
the first time. This approach means that all patients are included in the calculation of the reported
indicators, but may mean that the percentage waiting more than 18 weeks for treatment is understated as
we cannot take account of time spent waiting with other providers which has not been reported to us. Due
to how data is captured, it is not practicable to quantify the number of patients this represents for the year.
Data assurances and actions for improvement
Following a review of internal processes, the Trust has identified that there are potential inaccuracies
relating to our reported RTT incomplete pathways performance during 2014/15.
The inaccuracies have meant we do not comply with the three Referral To Treatment indicators for the
last quarter of 2014/15. Underlying challenges include demand for services; particularly complex
diagnostic imaging, pressure on certain surgical sub specialities due to an increase in referrals and
assurances around our validation processes.
To support the Trust’s recovery plan to ensure compliance with Referral to Treatment indicators the Trust
has commissioned Deloitte LLP to carry out a piece of work to establish the cause of the non-compliance.
The assurance work undertaken by Deloitte LLP in respect of the Quality Report 2014/15 led to a
qualified conclusion on the accuracy of the reported 18 week Referral to Treatment (RTT) incomplete
pathway indicator. The Trust has put in place an action plan in order to address the concerns identified.
This plan includes a review of processes and procedures in place to inform performance reporting of this
indicator. In addition, the action plan outlines steps to be taken to remind staff of the importance of
accurate data entry and recording as well as undertaking sample audits to test compliance in line with
national and local guidance.
Short term actions include:
 Reminding staff of data entry procedures and national RTT guidance
 Identification and investigation of data anomalies
 Review of validation processes and exclusions
 Undertaking sample audits in the form of cross checks between RTT teams
- 18 -
National Quality Indicators
Domain
Indicator
Prevent people
from dying
Mortality
prematurely
Enhancing
Scoring indices – lower
quality of life for
is better
people with longterm conditions
Patient reported
outcome scores (EQ5D)
Helping people
for primary hip
recover from
replacement surgery (NB
episodes of ill
only April to July 2014)
health or
following surgery
Scoring indices – higher
is better
2014/15
National
Average
12 patient
deaths (2 of
which were
unexpected)
Not applicable
0.418
0.442
Royal
National
Orthopaedic
Hospital
NHS Trust
The Royal
Orthopaedic
Hospital NHS
Foundation
Trust
Data not
complete for
2014/15.
Data not
complete for
2014/15.
0.411 in
2013/14
0.479 in
2013/14
Highest score
(where
applicable)
Lowest score
(where
applicable)
Trust statement
The standardised mortality rates for 13
hospitals, produced nationally by Dr
Foster are not applicable to small
specialist Trusts like the Robert
Jones & Agnes Hunt Orthopaedic
Hospital NHS Foundation Trust,
because the numbers of deaths
that occur are too small for change
to be statistically significant.
However, there has been ongoing
monitoring of all deaths which
occur within the Trust for some
years
Data not
Data not
The Robert Jones & Agnes Hunt
0.440
complete for
complete for
Orthopaedic Hospital NHS
2014/15.
2014/15.
Foundation Trust considers that
this score is as described for the
0.545 in 2013/14 0.342 in 2013/14 following reasons:
 The Trust is a specialist
orthopaedic hospital that
continually monitors patient
outcomes and best practice to
ensure the outstanding patient
care and achievements
The Robert Jones & Agnes Hunt
Orthopaedic Hospital NHS
Foundation Trust intends to take
- 19 -
2013/ 14
2012/ 13
18
0.435
Domain
Indicator
2014/15
Data not
available for
2014/15
National
Average
0.283
Patient reported
0.242 in
outcome scores (EQ5D) 2013/14
for revision hip
replacement surgery (NB
only April to July 2014)
Royal
National
Orthopaedic
Hospital
NHS Trust
Data not
complete for
2014/15.
The Royal
Orthopaedic
Hospital NHS
Foundation
Trust
Data not
complete for
2014/15.
0.203 in
2013/14
0.296 in
2013/14
0.365 in 2013/14 0.154 in 2013/14
Data not
complete for
2014/15.
Data not
complete for
2014/15.
Data not
complete for
2014/15.
0.287 in
2013/14
0.331 in
2013/14
0.416 in 2013/14
Highest score
(where
applicable)
Data not
complete for
2014/15.
Lowest score
(where
applicable)
Data not
complete for
2014/15.
Trust statement
2013/ 14
2012/ 13
the following actions to improve
0.242
this percentage, and so the quality
of its services by:
 Continuing to review both
national and local data to
identify any areas where
improvements can be made.
0.301
0.333
0.327
0.245
Insufficient
data
Scoring indices – higher
is better
Patient reported
0.299
outcome scores (EQ5D)
for primary knee
replacement surgery (NB
only April to July 2014)
Scoring indices – higher
is better
Patient reported
outcome scores (EQ5D
for revision knee
replacement surgery (NB
only April to July 2014)
Data not
complete for
2014/15.
0.215 in 2013/14
Data not
available for
2014/15
Data not
available for
2014/15
Data not
complete for
2014/15.
Data not
complete for
2014/15.
Data not
complete for
2014/15.
0.245 in
2013/14
0.245 in
2013/14
0.198 in
2013/14
0.100 in
2013/14
0.290 in 2013/14 0.100 in 2013/14
21.9
Data not
complete for
2014/15.
Data not
complete for
2014/15.
25.4
18.4
21.504
Data not
available
19.814 in
2013/14
23.165 in
2013/14
Data not
available for
2014/15
Data not
available for
2014/15
Data not
available for
2014/15
Data not
available for
2014/15
10.165
Data not
available
8.476 in
13.304 in
16.839 in
8.164 in 2013/14
Scoring indices – higher
is better
Patient reported
21.5
outcome scores (Oxford
score) for primary hip
replacement surgery (NB
only April to July 2014)
Scoring indices – higher
is better
Patient reported
outcome scores (Oxford
score) for revision hip
replacement surgery (NB
only April to July 2014)
0.328
Data not
available for
2014/15
10.165 in
13.1
- 20 -
Data not
complete for
2014/15.
Domain
Indicator
2014/15
2013/14
Scoring indices – higher
is better
Patient reported
15.5
outcome scores (Oxford
score) for primary knee
replacement surgery (NB
only April to July 2014)
Scoring indices – higher
is better
Patient reported
outcome scores (Oxford
score for revision knee
replacement surgery (NB
only April to July 2014)
National
Average
16.7
Royal
National
Orthopaedic
Hospital
NHS Trust
2013/14
The Royal
Orthopaedic
Hospital NHS
Foundation
Trust
2013/14
Data not
complete for
2014/15.
Data not
complete for
2014/15.
14.118 in
2013/14
16.982 in
2013/14
Highest score
(where
applicable)
Lowest score
(where
applicable)
Trust statement
2013/ 14
2012/ 13
2013/14
20.4
14.1
16.311
16.724
9.193
10.087
Data not
available for
2014/15
Data not
available for
2014/15
Data not
available for
2014/15
Data not
available for
2014/15
Data not
available for
2014/15
Data not
available for
2014/15
9.193 in
2013/14
11.348in
2013/14
6.984 in
2013/14
7.749 in
2013/14
15.326 in
2013/14
6.984 in 2013/14
Scoring indices – higher
is better
28 days emergency
readmission data for
adults aged 16 and over
Scoring indices – lower
is better
Data not
available
for last
three years
Data not
available for
last three
years
Data not
available for
last three
years
6.63 in
2011/12
11.45 in
2011/12
10.86 in
2011/12
7.94 in
2011/12
Data not
available for
2014/15
Data not
available for
2014/15
Trust internal
figures – 53
readmissions
in 2014/15
(0.71%)
Data not
available for
last three
years
Data not
available
for last
three years
Data not
available for
last three
years
Data not
available for
last three
years
Scoring indices – lower
is better
3.75 in
2011/12
10.01 in
2011/12
5.46 in
2011/12
6.32 in
2011/12
Responsiveness to the
personal needs of
patients
Data not
available for
2014/15
Data not
available
for
2014/15.
Data not
available for
2014/15.
Data not
available for
2014/15.
28 days emergency
readmission data (for
children aged 0-15)
Ensuring that
people have a
positive
experience of
Data not
available for
last three
years
- 21 -
Data not
available for
2014/15
Data not
available for
2014/15
Data not
available for
2014/15.
Data not
available for
2014/15
The Robert Jones & Agnes Hunt
Data not
Orthopaedic Hospital NHS
available
Foundation Trust considers that
this percentage is as described for
the following reasons:
 data is submitted and checked
on monthly basis as part of
regular reporting.
The Robert Jones & Agnes Hunt
Orthopaedic Hospital NHS
Foundation Trust has taken the
following actions to improve this
percentage, and so the quality of its
Data not
services:
available
 Continued provision of the
wound clinic
 Commencement of discharge
planning at the pre-op
appointments
The Robert Jones & Agnes Hunt
81.6
Orthopaedic Hospital NHS
Foundation Trust considers that
this percentage is as described for
Data not
available
Data not
available
79
Domain
Indicator
care
Scoring indices – higher
is better
2014/15
81.6 in
2013/14
National
Average
68.7 in
2013.14
Royal
National
Orthopaedic
Hospital
NHS Trust
77.8 in
2013/14
The Royal
Orthopaedic
Hospital NHS
Foundation
Trust
78.9 in
2013/14
Highest score
(where
applicable)
Lowest score
(where
applicable)
84.2 in
2013/14
54.4 in
2013/14
Trust statement
2013/ 14
2012/ 13
the following reasons:
 The Trust has a robust patient
experience programme in place,
that facilitates learning and
implementing changes based on
patient experience
The Robert Jones & Agnes Hunt
Orthopaedic Hospital NHS
Foundation Trust intends to take
the following actions to improve this
percentage, and so the quality of its
services:
 Putting in place actions resulting
from the patient survey
 Putting in place actions from the
monthly Sit & See observations
93%
65%
87%
84%
93%
38%
Staff employed by, or
under contract to, the
Trust, who would
recommend the Trust as
a provider of care to their
family & friends
87%
The Robert Jones & Agnes Hunt
Orthopaedic Hospital NHS
Foundation Trust intends to take
the following actions to improve this
percentage, and so the quality of its
services:
 Putting in place an action plan to
address issues arising from the
staff survey results
Scoring indices – higher
is better
Patients who would
recommend the Trust as
a provider of care to their
family & friends (NB:
Scoring system changed
during 2014/15 from
score to percentage)
The Robert Jones & Agnes Hunt
88%
Orthopaedic Hospital NHS
Foundation Trust considers that
this percentage is as described for
the following:
 The Trust has in place a number
of initiatives to ensure that staff
feel supported and valued.
April to August April to
2014 - 91
August 2014
- 75
September
2014 – March September
2015 - 99%
2014 – March
2015 - 95%
April to
August 2014 76.4
September
2014 – March
2015 - 96%
April to August
2014 - 79.8
September
2014 – March
2015 - 99%
- 22 -
N/A
N/A
The Robert Jones & Agnes Hunt
90.27
Orthopaedic Hospital NHS
Foundation Trust considers that
this percentage is as described for
the following:
 The Trust has a robust patient
experience programme in place,
that facilitates learning and
N/A
Domain
Indicator
2014/15
National
Average
Royal
National
Orthopaedic
Hospital
NHS Trust
The Royal
Orthopaedic
Hospital NHS
Foundation
Trust
Scoring indices – higher
is better
Highest score
(where
applicable)
Lowest score
(where
applicable)
Trust statement
2013/ 14
2012/ 13
implementing changes based on
patient experience
The Robert Jones & Agnes Hunt
Orthopaedic Hospital NHS
Foundation Trust intends to take
the following actions to improve this
percentage, and so the quality of its
services:
 Continuing with existing patient
experience initiatives
 Further developing the Trust
patient experience strategy
99.85%
96.1% (April
2014 –
January
2015)
99.5% (April
2014 –
January
2015)
97.6% (April
2014 –
January 2015)
VTE Risk Assessments
Treating and
caring for people Scoring indices – higher
is better
100% (April 2014 74% (April 2014 The Robert Jones & Agnes Hunt
100%
– January 2015) – January 2015) Orthopaedic Hospital NHS
Foundation Trust considers that
this percentage is as described for
the following reasons:
 The Trust has clear processes in
place for ensuring that a VTE risk
assessment is carried out for all
patients.
The Robert Jones & Agnes Hunt
Orthopaedic Hospital NHS
Foundation Trust has taken the
following actions to improve this
percentage, and so the quality of its
services:
 Continuing to carry out regular
audits and monitoring any
instances of non-compliance
- 23 -
99.56%
Domain
Indicator
2014/15
Two cases
(rate not yet
available)
National
Average
Data not
available for
2014/15
Royal
National
Orthopaedic
Hospital
NHS Trust
Data not
available for
2014/15
The Royal
Orthopaedic
Hospital NHS
Foundation
Trust
Data not
available for
2014/15
Data not
available for
2014/15
Data not
available for
2014/15
17.2 in
2013/14
6.3 in 2013/14
0 in 2013/14
37.1 in 2013/14
Highest score
(where
applicable)
Lowest score
(where
applicable)
Rate of hospital-acquired
Clostridium Difficile
amongst patients aged 2
and above
Scoring indices – lower
is better
Rate of patient safety
incidents
Scoring indices – higher
is better
% of patient safety
incidents that resulted in
severe harm or death
Scoring indices – lower
is better
Trust statement
2013/ 14
The Robert Jones & Agnes Hunt
1.9
Orthopaedic Hospital NHS
Foundation Trust considers that
this percentage is as described for
the following reasons:
 data is monitored and reported
on monthly basis
 The Infection Control team work
closely with ward staff and the
microbiology department at the
Royal Shrewsbury Hospital to
ensure good practice in relation
to infection prevention and
control
2012/ 13
3.8
The Robert Jones & Agnes Hunt
Orthopaedic Hospital NHS
Foundation Trust has taken the
following actions to improve this
percentage, and so the quality of its
services:
 Continuing to monitor and report
on any cases on a monthly basis
 Working closely with all clinical
staff to ensure continued good
practice
Data not
available for
2014/15
Data not
available
for 2014/15
Internal data
calculates
rate as 10.1
Data not
available for
2014/15
Internal data
shows 4
patient
safety
Data not
available
for 2014/15
Data not
available for
2014/15
Data not
available for
2014/15
5.8 in
2013/14
6.6 in 2013/14
Data not
available for
2014/15
Data not
available for
2014/15
0.19 in
2013/14
0.22 in
2013/14
- 24 -
Data not
available for
2014/15
Data not
available for
2014/15
Data not
available for
2014/15
Data not
available for
2014/15
. The Robert Jones & Agnes Hunt 8.5
Orthopaedic Hospital NHS
Foundation Trust considers that
this data is as described for the
following reasons:
 The Trust actively encourages
reporting of all incidents and
near misses to ensure a learning
culture throughout the
organisation
The Robert Jones & Agnes Hunt
Orthopaedic Hospital NHS
Foundation Trust intends to take
the following actions to improve this
percentage, and so the quality of its
services:
 Weekly and monthly reviews of
0.04
9
0.1
Domain
Indicator
2014/15
National
Average
Royal
National
Orthopaedic
Hospital
NHS Trust
The Royal
Orthopaedic
Hospital NHS
Foundation
Trust
incidents
resulted in
severe harm
or death
Highest score
(where
applicable)
Lowest score
(where
applicable)
Trust statement
2013/ 14
2012/ 13
all patient safety incidents
 Discussions of learning from
incidents
Data has been taken from the Health & Social Care Information Centre, the NHS Staff Survey, NHS England, the National Reporting & Learning System and the Health Protection
Agency. Not all 2014/15 data was available at the time of producing the report.
- 25 -
Local Quality Indicators1
Patient Safety
Medication Report
The Trust continues to promote the reporting of near misses (e.g. incidents which had the potential to
result in patient harm or have a negative impact on the patient, but did not, due to early identification of
the problem). This is seen to be beneficial and work shared as a result of these incidents reported can
then assist in the prevention of future harms. Table 1 and Chart 1 detail the total number of incidents
reported via Datix (the Trust’s reporting system) and the number of incidents which have or could have
had impact on patient safety.
Table 1
Number of Incidents Reported
Number resulting in unintended changes to patient treatment
2013/14
294
246
2014/15
266
177
Chart 1
Medication incidents continue to be monitored with monthly reporting to the Trust Board. Incidents are
reported in terms of the level of harm caused, which is a new approach for 2014/15. We will continue to
report in this format for 2015-16.
During 2014/15, 266 medication incidents were reported. Of these 177 resulted in an unintended change
to the patient’s treatment. Of those 177 incidents, we reported the following harms:
 16 low harm
 0 moderate harm
 0 severe harm
The harms reported have been where patients have required a further test or closer observations/
monitoring, when this would not otherwise have occurred. We discuss these incidents ensuring staff are
aware of the harms that have occurred and that any learning points are shared to enhance practice and
promote safety across the Trust. This is communicated at senior nurse meetings and the incident action
review committee meetings. We also use these incidents to support staff training.
Following a retrospective review of the 2013 -14 data, reviewing as we do now for the harms, we can
compare 2013-14 to 2014/15 as seen in Table 2:
1
Unless otherwise stated, all data for local quality indicators is gathered and reported internally.
- 26 -
Table 2
No Harm
Low
Moderate
Severe
2013/14
204
17
0
0
2014/15
161
16
0
0
Medication incidents are categorised as shown in Chart 2 into Prescribing, Administration, Dispensing
and Other Incidents. The Trust continues to promote openness and transparency in the reporting of
incidents.
Chart 2
Number of incidents by Category 2014-2015
15
Prescribing
10
Administration
Supply
5
Storage
0
Other
Apr-14
Jun-14
Aug-14
Oct-14
Dec-14
Feb-15
The Trust has implemented the NHS England and MHRA Medicine Safety Officer role. This person is the
Trust’s link with NHS England and the MHRA. This role is intended to simplify and increase reporting,
improve data report quality, maximise learning and guide practice to minimise harm from medication
errors by:

sharing incident data between the MHRA and NHS England reducing the need for duplicate data
entry by frontline staff

providing new types of feedback from the National Reporting and Learning System (NRLS) and
the MHRA to improve learning at local level

clarifying medication safety roles and identifying key safety contacts to allow better
communication between local and national levels

A National Medication Safety Network, a new forum for discussing potential and recognised
safety issues, identifying trends and actions to improve the safe use of medicines. The network
will also work with new Patient Safety Improvement Collaborative
Incidents
At the Robert Jones and Agnes Hunt Orthopaedic NHS Foundation Trust an investigation is completed
for all incidents that occur. The outcomes of investigations are shared with ward and departmental
managers and all incidents are disseminated to the divisional and local meetings, as well as a number of
Trust Committees, and form the basis of several key performance indicators in monthly reports to the
Trust Board.
The Trust continues to use the Datix Incident Reporting system which allows all employees to report
incidents via the Trust intranet. Following upgrade in April 2014 to the software’s latest version the Trust
has taken advantage of enhanced reporting capabilities to enable all Ward Managers to view real-time
reporting of incidents on customised dashboards.
The Datix system also allows regular monitoring of trends which are then provided to the Divisional
Meetings and other Trust committees for analysis. The Trust Board also provides this information to the
Commissioners on a regular basis. Work to improve the reporting culture has resulted in a steady
- 27 -
increase in the number of incidents reported between April 2010 and March 2014, and a decrease in the
number of incidents overdue for investigation. 2027 incidents were reported in 2014/15.
All Incidents reported from April 2012 to March 2015 (source: KPI)
Patient safety incidents, including near misses, are reportable externally via the National Reporting &
Learning System (NRLS). The NRLS releases data quality and patient safety reports every six months,
grouping this information by type of Trust, so RJAH is benchmarked for performance against other acute
th
specialist trusts. The 12 and most recent release of the national patient safety incident report took place
in September 2014 and relates to patient safety incidents occurring between October 2013 and March
2014. The benchmarking report below illustrates the Trust’s performance in that period against peer
organisations.
- 28 -
Source: Organisation Patient Safety Incident Report Release 12 (NRLS)
The Trust (black bar in the chart figure 1) maintained its position in the top quartile of reporters in 201314, reporting 689 patient safety incidents to the NRLS. The median reporting rate in the acute specialist
cluster for the period was 7.63 incidents per 100 admissions and the Trust’s reporting rate was 9.70. The
Trust met national targets of reporting in each month in the period and also met its internal target of
reporting weekly. The NRLS requires incidents to be reported within 28 days of occurrence: 50% of the
Trust’s reports did not meet this target and the Trust is working to improve performance in this area by
adjusting the key performance indicators for incident reporting to include a measurement for days
elapsed between incident occurrence and investigation closure.
Serious Incidents
A serious incident is any incident occuring during NHS care, that results in an unexpected/avoidable
death or severe harm to patients, staff or members of the public, a Never Event (as defined in the Never
Events Framework), a scenario that prevents, or threatens to prevent, an organisation’s ability to continue
to deliver healthcare services, or any allegations or incidents of abuse.
The Trust reported eight serious incidents in 2014/15; however one incident (a patient death) was
subsequently downgraded after the post-mortem confirmed that the patient had died of natural causes.
One of the serious incidents was also reported as a Never Event (wrong level surgery). The graph below
shows the breakdown of Serious Incidents for the past four years:
A full root cause analysis was undertaken for each incident and action plans were put in place as
appropriate. The action plans are monitored through the Trust’s Governance & Risk Management and
Quality & Safety Committees.
Hospital-acquired Infection
Since 2006 the Trust has had no MRSA blood stream infections (where the MRSA bacteria enter the
patient’s blood, leading to serious illness). MRSA is a well-known health care associated infection. It is
estimated that 3% of people carry MRSA harmlessly on their skin, but for hospital patients the risk of
infection may be increased due to wounds, or invasive treatments which make them more vulnerable.
- 29 -
Serious MRSA infection may result in MRSA blood stream infections (bacteraemia). The Trust’s MRSA
blood stream infection target for 2014/15 continued to be zero.
MRSA screening compliance
Identification of MRSA carriers is a key component in the process of reducing the risks of infection and
spread and it is national policy that patients are screened to identify any carriers. The Trust’s MRSA
screening compliance remains above the national target of 95%.
Eligible
patients
Screened
for
MRSA
%
achieved
Apr
14
May
14
Jun
14
Jul
14
Aug
14
Sep
14
Oct
14
Nov
14
Dec
14
Jan
15
Feb
15
Mar
15
1120
1031
1079
1078
1002
1006
1095
1030
889
1078
1004
1109
1120
1031
1079
1078
1002
1006
1095
1029
888
1076
1003
1108
100%
100%
100%
100%
100%
100%
100%
99.9%
99.89
%
99.81
%
99.90
%
99.91
%
Methicillin Sensitive Staphylococcus Aureus (MSSA) Bacteraemia
MSSA, or Methicillin Sensitive Staph Aureus, is the more common sensitive strain of Staphylococcus
Aureus. Up to 25% of us carry this organism on our skin. Mostly it causes us no problems but it can be
a frequent cause of skin, soft tissue and bone infections. As with its more resistant cousin, MRSA,
sometimes, the infection can escape into the bloodstream, producing a “bacteraemia” (i.e. bacteria in
the blood). Unlike MRSA, the majority of the infections will be acquired in the community, and are not
associated with health care. However, some may arise as a consequence of health care, and like
MRSA, it can arise from infected lines that are used to administer medication, and other health care
interventions. We have been asked by the Department of Health to report all MSSA bacteraemia cases,
whether acquired in the community or in hospital, so that we can review the sources and identify
potentially avoidable cases. So far no targets have been set and we do not have easily comparable
information with other hospitals. However interventions to further reduce infections are being put into
place as we gain new information.
The number of cases of MSSA bacteraemia remains fairly static with three cases in 2014/15, compared
with four in 2013/14 and three in 2012/13. In the three cases the samples were taken more than two
days after admission and therefore the infections have been acquired in the trust. All cases are
reviewed by the consultant microbiologist to find the source of infection and a full root cause analysis is
carried out.
Clostridium Difficile
There were two cases of Clostridium Difficile in 2014/15 against a target of zero.
In both of these cases, the Clostridium Difficile infections were unavoidable and there were no lapses in
the care provided.
Surgical Site Infections and general Surveillance (SSI)
Providing data to the Health Protection Agency (HPA) national SSI process enables the Trust to
benchmark on a national basis with other Trusts and promote low Infection rates within the Trust. The
process uses nationally agreed criteria from which the definition of a Surgical Site Infection is formed.
The national requirement for the auditing of SSI in hip and knee replacement patients is one quarter per
calendar year. In recent years audits had been carried out to meet the minimum national standard but the
Trust has the resources to compile a full complement of quarterly audits including spinal surveillance.
The Infection Control Nurse liaises with Consultants concerning any wound infections. The data for
2014/15 has been verified by the Microbiologist and these results have been published.
- 30 -
Procedure
Total Knee Replacement
Total Hip Replacement
Spinal Surgery
January 14 – December 14
Trust infection rate
0.7%
(10 Infections from 1438
Procedures)
0.4%
(7 infections from 1632
procedures)
0.3%
(2 infections from 579
procedures)
National average*
1.1%
1.0%
1.5%
* National Average of hospitals who did not complete post discharge questionnaires.
Over the year the Trust has remained below the national average for surgical site infections. The national
average is taken from trusts who do not undertake post discharge questionnaires.
Wound Clinic
The wound clinic service continues to be available on a regular basis for all patients who have postsurgical wound problems. The clinic prevents patients being unnecessarily readmitted back to RJAH or to
other Trusts, as well as allowing patients to be discharged sooner, who would otherwise remain an
inpatient for daily wound care. It also enables us to monitor patients with problematic wounds. This
continues to be a very valuable service for the patients, their relatives, wards and the consultants.
Health & Safety
Health and Safety Incidents are monitored on an ongoing basis through the year and reported to the
Health and Safety Committee. Those incidents reported that are of a more serious nature and/or result in
more than seven days off work as a result or serious injury such as fractures or dislocations are also
reported to the Health and Safety Executive (HSE) under the Reporting of Injuries Diseases and
Dangerous Occurrences Regulations 2013 (RIDDOR). During 2014/15 there were three incidents that
were reported to the HSE under the requirement of the RIDDOR regulations, which is a 50% reduction in
RIDDOR reported incidents from the previous period.
The 2014/15 Health and Safety Plan was monitored by the Health and Safety Committee. Outcomes
from the plan include:








Revised Health and Safety Policy approved by the Board of Directors
Increase in proactive risk assessments being carried out within the Trust
A reduction in total harm as a result of health and safety incidents
Full library of health and safety information available on the Trust intranet
Annual Health and Safety Report presented at Business Risk and Investment Committee
Health and safety incidents discussed at all relevant Trust committees
Statutory health and safety training rated ‘green’ at year end
Continued engagement with staff side union health and safety representatives
CAS Alerts
The Central Alerting System (CAS) is the web-based portal for distribution of safety alerts from the
Department of Health (DoH) to NHS Trusts. The Health, Safety and Risk Officer is responsible for the
distribution and administration of the CAS alert system. The following table sets out the Patient Safety
Alerts received and the Trust actions:
- 31 -
Patient Safety Alert
NHS/PSA/W/2014/009 - Risk of using vacuum and suction
drains when not clinically indicated
Trust Response
Alert brought to the notice of all relevant personnel
in Trust. No previous incidents have occurred within
the Trust
Alert Status
rd
Action Completed 3 July 2014 as per alert
deadline
NHS/PSA/D/2014/010 - Standardising the early
identification of Acute Kidney Injury
Alert brought to the notice of all relevant personnel
in Trust. Alert discussed at appropriate Trust
Committees (Drugs and Therapeutic)
Action Ongoing (Overdue) - Clinical Lead
nominated due to issues installing AKI algorithm
NHS/PSA/D/2014/010 - STANDARDISING THE
EARLY IDENTIFICATION OF ACUTE KIDNEY
INJURY
We understand from Clinisys that they do not
have the capability to install the AKI algorithm
into a number of systems but they anticipate that
the technology will be available shortly. We
recognise that this means that some
organisations will currently be unable to comply
with all the actions required in the NHS England
Patient Safety Alert ‘Standardising the detection
of AKI’ by the deadline of the 9th March through
circumstances outside their control.
rd
Alert shared with RSH Maternity Unit based at
RJAH
Action Completed 23 June 2014 as per alert
deadline
Alert shared with RSH Maternity Unit based at
RJAH
Action Completed 23rd June 2014 as per alert
deadline
NHS/PSA/W/2014/013 - Risk of inadvertently cutting in-line
(or closed) suction catheters
Alert brought to the notice of all relevant personnel
in Trust. No previous incidents have occurred within
the Trust
Action Completed 1 August 2014 as per alert
deadline
NHS/PSA/W/2014/014 - Risks arising from breakdown and
failure to act on communication during handover at the time
of discharge from secondary care
Alert brought to the notice of all relevant personnel
in Trust.
Responses to alert from RJAH completed by
Surgery Division / Medicine and Rehab Division
Action Completed 6 October 2014 as per alert
deadline
NHS/PSA/D/2014/011 - Legionella and heated birthing
pools filled in advance of labour in home settings
NHS/PSA/W/2014/012 - Risk of harm relating to
interpretation and action on PCR results in pregnant women
- 32 -
st
th
Patient Safety Alert
NHS/PSA/R/2014/015 - Resources to support the prompt
recognition of sepsis and the rapid initiation of treatment
Trust Response
and Pharmacy Department
Alert brought to the notice of all relevant personnel
in Trust.
Alert Status
th
Action Completed 16 October 2014 as per alert
deadline
NHS/PSA/W/2014/016R - Risk of distress and death from
inappropriate doses of naloxone in patients on long-term
opiod/opiate treatment
All staff signposted to UK Sepsis Trusts clinical
toolkits via Trust intranet.
Alert brought to the notice of all relevant personnel
in Trust. No previous incidents have occurred within
the Trust.
NHS/PSA/W/2014/017 - Risk of death and serious harm
from delays in recognising and treating ingestion of button
batteries
Alert brought to the notice of all relevant personnel
in Trust. No previous incidents have occurred within
the Trust.
Action Completed 15 January 2015 as per alert
deadline
Alert brought to the notice of all relevant personnel
in Trust. No previous incidents have occurred within
the Trust.
Action Completed 15 January 2015 as per alert
deadline
NHS/PSA/W/2015/001 - Harm from using Low Molecular
Weight Heparins when contraindicated
Alert brought to the notice of all relevant personnel
in Trust. No previous incidents have occurred within
the Trust.
Action Completed 27 February 2015 as per
alert deadline
NHS/PSA/W/2015/002 - Risk of death from asphyxiation by
accidental ingestion of fluid/food thickening powder
Alert brought to the notice of all relevant personnel
in Trust. No previous incidents have occurred within
the Trust.
Action Completed 16 March 2015 as per alert
deadline
NHS/PSA/W/2015/003 - Risk of severe harm and death
from unintentional interruption of non-invasive ventilation
Alert brought to the notice of all relevant personnel
in Trust. No previous incidents have occurred within
the Trust.
Action Completed 27 March 2015 as per alert
deadline
Alert brought to the notice of all relevant personnel
in Trust.
Action plans to be implemented to minimise risks
during the transitional period.
Action Ongoing due for completion May 2015 in
line with alert deadline
NHS/PSA/W/2014/18 - Risk of death and serious harm from
accidental ingestion of potassium permanganate
preparations
NHS/PSA/W/2015/004 - Managing risks during the
transition period to new ISO connectors for medical devices
- 33 -
th
Action Completed 19 December 2014 as per
alert deadline
th
th
th
th
th
Adult Safeguarding
The Robert Jones & Agnes Hunt (RJAH) NHS Foundation Trust is an organisation which has a culture
that prioritises quality of care, having strong leadership and focus, and good partnership working to
promote the well-being, security and safety of vulnerable adults (adults at risk) who are under our care.
Part of the organisation’s commitment is to work alongside Shropshire and Telford & Wrekin
Safeguarding Adults Board, as well as other partner agencies, to ensure that there are effective robust
systems in place to safeguard ‘adults at risk‘. The hospital is involved in close networking with the local
health economy safeguarding leads and engages in meetings to ensure that effective communication
and interagency team working are delivered.
Quarterly Safeguarding Committee meetings within the RJAH have continued which is a forum to
discuss children and adult safeguarding issues. The committee has the appropriate accountability for
safeguarding across the Trust and reports to the Trust’s Quality and Safety committee.
During 2014/15 the adult safeguarding lead has continued to work with the safeguarding link staff
raising staff awareness about the importance of adult safeguarding. The link staff themselves have
continued to update their knowledge by attending the ‘Adult Safeguarding - Moving Foreword event’
June 2014, and by ensuring their continued professional development and e–learning on adult
safeguarding and dementia care.
The Trust has continued to provide safeguarding vulnerable adults training for all staff, and has
continued to provide specific Mental Capacity training and Deprivation of Liberty Safeguards (DoLS)
training as planned through the Trust training need analysis.
There has been the development of an evidence-based portfolio within the ward areas for staff to refer
to, demonstrating compliance against the CQC Fundamental Standard regulation 13, following the five
key lines of enquiry. Spot checks have been introduced following the process of the key lines of enquiry
to ensure wards and departments of aware of what to do in protecting vulnerable adults.
In addition to this the STAR performance framework incorporates safeguarding which assesses staff
knowledge of policy and procedures.
During 2014/15 there has been a continued increase in dementia training. The bespoke training from
Staffordshire University has helped to equip staff to provide best practice across wards and clinical
areas, and to help staff recognise vulnerable adults who are living with dementia and who could be
potentially at risk. There has also been specific leadership training which has incorporated compassion
in practice, and ensuring patients and their relatives are treated with dignity and respect.
The adult safeguarding lead has reviewed and updated the policy guidelines for people with learning
difficulties/disabilities linking in with the local health economy group. The lead attended a regional
health economy wide learning disability event in the launch of the ‘Making a Difference – the Health
Toolkit’ which will be launched in June 2015.
The Butterfly Scheme launch day was held on the 9th October 2014 at the RJAH. The Butterfly
Scheme allows people whose memory is permanently affected by dementia to make this clear to
hospital staff and provides staff with a simple, practical strategy for meeting their needs. The patients
receive more effective and appropriate care, reducing their stress levels and increasing their safety and
well-being.
Child Safeguarding
The Trust is committed to achieving good outcomes for children and young people between the ages of
0-17yrs of age and has a dedicated orthopaedic children’s ward and outpatients department which
have systems in place to ensure the child’s welfare remains paramount throughout their stay. Staff are
trained to raise concerns and named professionals work closely with staff and other agencies, to
ensure children are safeguarded whilst in our care.
The safeguarding team includes: - The Director of Nursing & Service Delivery as the Executive lead, a
non-executive lead, and the Named Doctor and Nurse. Our Named professionals are clear of their roles
and responsibilities and these are clearly documented in their job descriptions. These named
professionals receive regular supervision and are supported by the local designated team for
Shropshire, Telford and Wrekin.
- 34 -
The Trust holds a quarterly safeguarding children’s committee. This meeting reviews any Trust
safeguarding cases; updates policies and procedures; reviews training compliance and shares current
safeguarding documents to ensure the Trust meets its full range of obligations within the safeguarding
arena. A named professional also attends the Health Governance Safeguarding Children Committee
and one of the executive leads attends the Shropshire Safeguarding Children Board meetings.
The safeguarding web page is a central point for all staff to access safeguarding information. Training
remains high on our agenda and training figures at the end of March 2015 are:
Level 1 – 99%
Level 2 – 79.5%
Level 3 – 75%
Level 4 – 100%
Our target level is 90%. Letters were sent to managers to improve level 2 figures and managers are to
book SSCB training modules for staff requiring level 3 training.
This year the national Child Protection Information Sharing Project is going live and the Safeguarding
Team promotes the sign up to this system.
The introduction of this new resource will mean that when any child uses our services (from England),
we will have access from the national spine (a system that supports the exchange of information
nationally) as to whether the child is on a child protection plan or is a “Looked After” child (i.e. in care).
This will be an invaluable resource for our paediatric team as contact numbers of lead professionals will
be easily accessible for these vulnerable children.
This year we have had safeguarding input with nine inpatients with various concerns under the
safeguarding umbrella. Some cases required minimal intervention however some cases have involved
frequent liaison with community services with input from the named Nurse, Doctor, as well as the local
designated nurse for safeguarding children. The Local Area Designated Office (LADO) was contacted
twice for advice regarding to managing allegation issues, however on both occasions their input was
not required.
The neuromuscular team have also work closely with various social care teams requesting
safeguarding support for many of their children with complex health needs. This year the team have
supported 14 children with complex care requirements using the Common Assessment Framework
(CAF), and six children on protection plans /Looked after care status.
We remain committed to supporting the child and family through difficult times and ensuring the welfare
of the Child remains paramount at all times.
Resuscitation Training
The Trust provides training internally on Basic Life Support (BLS), Immediate Life Support (ILS),
Paediatric Immediate Life Support (PILS) and Advanced Life Support (ALS). ALS, ILS and PILS
continue to be offered to outside agencies as a source of income generation.
In 2014/15, the following training was provided internally:
Training
Attendance
Basic Life Support
Advance Life Support
Intermediate Life Support
Paediatric Life Support
350
12
301
136
% of those required to
complete
100%
100%
92%
100%
Patient Led Assessment of the Care Environment (PLACE) 2014
The Patient-Led Assessments of the Care Environment (PLACE) audit, a self-assessment of a range of
services which contribute to the environment in which healthcare is delivered, was carried out on site
during April 2014.
The aim of PLACE assessments is to provide a snapshot of how an organisation is performing against
a range of non-clinical activities which impact on the patient experience of care – Cleanliness; the
- 35 -
Condition, Appearance and Maintenance of healthcare premises; the extent to which the environment
supports the delivery of care with Privacy and Dignity; and the quality and availability of food and drink.
Assessment teams, all of whom were formally trained, were formed with equal representation from
Trust staff and external patient assessors. The PLACE result is used as a national benchmarking tool.
The 2014 PLACE assessment was undertaken on the 10th and 11th of April 2014 by three teams, each
including two Trust staff members and two patient assessors. All findings were recorded and approved
by the patient assessors before being submitted to the National database. Local actions have been
taken through the Infection Control Committee, with the National position published on August 27th.
The Trust achieved the below scores:
Cleanliness
Food
Privacy, Dignity
and Wellbeing
Condition
Appearance and
Maintenance
2014 RJAH
98.88%
90.68%
91.18%
83.78%
National Average
97.25%
88.79%
87.73%
91.97%
The Trust is placed above average in each metric barring Condition, Appearance and Maintenance,
where the areas for improvement were around signage, waste management, secure storage of
personal possessions and internal fixtures and fittings. The following actions have already been
undertaken:
 Signage has been addressed across the site following a managed scheme that aligned to a
board approved signage strategy, feedback for which has been positive.
 A specific requirement of waste management question is for bins to be solid sided. An exercise
was conducted to understand the cost of replacing all bins with compliant models, but owing to
the cost, circa £55k, the upgrade will following a rolling programme, replacing bins when they
are damaged / corroded. This element, which owing to the question being raised under each
sub heading of the audit, heavily weights the Condition and Appearance score and will
therefore continue skew the score.
 Secure storage is being addressed through a rolling programme of locker replacements.
 The observation of the external auditors was that, following the removal of a fixture / fitting,
work to make good the holes left behind had not been completed. This has since been
addressed by the Estates team.
A Mini PLACE programme is on-going and includes patient assessors for the purpose of monitoring the
Trust’s progress against the agreed action plan.
Clinical Effectiveness
The National Institute for Health & Clinical Excellence (NICE) guidance
In 2014/15 NICE published the following guidance:
Type of guidance
Clinical Guidelines
Interventional Procedures
Technology Appraisal
Medical Technologies Guidance
Diagnostics Guidelines
Public Health Guidance
Highly Specialised Technology Guidance
National Guidance
Quality Standards
Numbers published
18
30
29
6
5
4
1
1
30
A baseline assessment was carried out for all guidance relevant to the Trust and, where appropriate,
audits were undertaken to measure compliance against the guidance. Audits that have been carried
out in 2014/15 in relation to NICE guidance include:
- 36 -







Myocardial Infarction-secondary prevention following a myocardial infarction (Clinical Guidance
102)
RJAH Stroke Rehabilitation Audit (Clinical Guideline 162)
Urological service provision at Midlands Centre for Spinal Injuries (Clinical Guideline 148)
Delirium among In-patients (Clinical Guideline 103)
Botox injections for migraine and tension headaches (Technology Appraisal 260)
Abatcept in Rheumatoid Arthritis (Technology Appraisal 280)
Re Audit of compliance to NICE TAG 143, adalimumab, etanercept and infliximab for
ankylosing spondylitis (Technology Appraisal 143)
Results from these audits are shared in line with the Trust processes and action plans are implemented
as necessary. Appendix one includes details of the audits carried out in 2014/15
NCEPOD
During 2014/15, the Trust agreed to participate in the National Sepsis Audit; however no eligible
patients were identified during the data collection period.
Cancer data (62 days and 31 days)
Data for English patients only, taken from Open Exeter Database
2 week wait - Taken from Report 1.1 - Cancer Two Week Wait
Reporting Period
Total Patients
Treated in Target
% treated in target
Quarter 3
40
53
44
39
53
44
97.50%
100.00%
100.00%
Quarter 4
32
32
100.00%
Annual
169
168
99.41%
Quarter 1
Quarter 2
31 day - Taken from Report 2.1 - 31 Day First Treatment (Tumour)
Reporting Period
Total Patients
Treated in Target
% treated in target
Quarter 4
3
3
1
4
3
3
1
4
100.00%
100.00%
100.00%
100.00%
Annual
11
11
100.00%
Quarter 1
Quarter 2
Quarter 3
62 day - Taken from Report 3.1 - Cancer Plan 62 Day Standard (Tumour)
Reporting Period
Total Patients
Treated in Target
% treated in target
Quarter 3
3
1.5
2.5
2.5
1
1.5
83.33%
66.67%
60.00%
Quarter 4
2.5
2.5
100.00%
Annual
9.5
7.5
78.95%
Quarter 1
Quarter 2
- 37 -
Human Tissue Act
The Designated Individual (consultant lead) and Persons Designate (operational leads) met regularly
throughout the year. Each area has an audit programme in place, which has demonstrated excellent
compliance with the Human Tissue Act requirements throughout the year. An inspection was carried
out by the Human Tissue Authority in February 2015, which identified four minor shortfalls, including
risk assessments and documentation, all of which were addressed immediately. The inspection also
noted many examples of strengths and good practice, including a strong network of Persons
Designate, covering each area of the licence, with good oversight from the Designated Individual, with
a commitment to continual improvement of practices and compliance with requirements of the
legislation.
Patient Experience
National Inpatient Survey 2014
In the 2014 National Inpatient Survey, The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS
Foundation Trust was amongst the best performing Trusts in eight of the ten sections. These were:
 Waiting to get to a bed on a ward
 The hospital and ward
 Doctors
 Care & treatment
 Operations & procedures
 Leaving hospital
 Overall views of care and services
 Overall experience
Patients gave extremely high ratings for various aspects of their experience throughout the hospital,
including for:
 Cleanliness
 Food
 Information provided about all aspects of treatment
 Privacy and Dignity
The response rate for the Trust was one of the highest at 75%, as compared with 47% nationally.
These high scores in the independently monitored Inpatient survey mean that the hospital is doing
things right for patients, both clinically and in providing safety and privacy as well as the support
facilities that patients value when they are in hospital.
Patient Feedback Summary
The table below shows overall patient feedback in 2014/15 compared to 2013/4:
Feedback
Complaints
Local resolution
PALS Concerns
Compliments
2013/14
87
63
484
1026
2014/15
87
59
509
1473
- 38 -
Main reasons for patients contacting the Patient Feedback Team in 2014/15
The main categories for patients raising concerns are set out in the graphs below:
Complaints
- 39 -
The total number of complaints received is only a very small percentage (0.06%) of the Trust’s total
activity, including inpatients and outpatients. The average number of complaints is seven per month,
which is the same as 2013/14.
In 2014/15, the Trust received 87 formal complaints, which is the same number received in the
previous year.
Of the 87 complaints closed by the end of March 2015 (4 were received late in March 2015 and have
not yet been completed), 48% (40) were considered to be ‘upheld.’ In line with the Ombudsman’s
principles a complaint is ‘upheld’ if any single aspect of it is deemed to be well-founded. As of April
2015, complaints will be recorded as being either ‘upheld,’ ‘not upheld,’ or ‘partially upheld.’ This is
following the national changes to the NHS complaints reporting system.
The increase in complaints received in October 2014 could not be pinpointed as relating to any one
particular area of concern or any specific location within the Trust.
Main reasons for making a complaint
The main reasons for patients making a complaint were dissatisfaction with the quality of the nursing
and clinical/medical care, and patient’s dissatisfaction with the outcome of the treatment that they were
provided. On the whole most categories show a decrease from last year. The number of complaints
received regarding the quality of care was 45 (52%) and the number received regarding operational
issues was 42 (48%).
Parliamentary & Health Service Ombudsman
Between April 2014 and March 2015 there were two cases that was referred to the Parliamentary &
Health Service Ombudsman for an independent review, one in October 2014 and the second in March
2015.
The information requested regarding the first case was sent in October 2014, and further information
was requested in February 2015. The information requested was supplied to the Ombudsman in
February 2015 and the Trust is currently awaiting a response from the Ombudsman.
The second case was also a request for information at this stage, and the Ombudsman would then look
to see whether they would investigate the concerns raised. The information requested was sent to the
Ombudsman in March 2015 and the Trust is currently awaiting the final report from the Ombudsman.
During 2014/15 the Ombudsman upheld one case which was registered with them during 2013/14.
Comment Cards
98.7 % of inpatients have rated the Trust as excellent or good, when asked to rate their overall
experience on the Trust comment card. The Trust receives 375 comment cards on average per month.
- 40 -
Patient Advice and Liaison Service (PALS) contacts
In 2014/15, there were 1091 PALS contacts. This was a 7% increase compared to 2013/14. Of these
contacts, 509, (47%) were PALS concerns and the others were requests for help, advice or information.
The top reasons for patients contacting PALS are delays and cancellations for outpatient and inpatient
appointments; the majority of these were for Arthroplasty (hip and knee services) and Spinal disorders
specialties. This is followed by some aspect of care, 42% of which nursing issues and 38% of which
were medical issues.
Locally resolved issues
Where appropriate, members of staff are encouraged to resolve patient concerns as they arise on the
ward or in other departments. There were a total of 59 locally resolved issues raised between April
2014 and March 2015. This is a decrease of four from last year where there were 63 local resolutions.
- 41 -
Changes in Practice as a result of patient feedback raised in 2014/15 – “You said…..We
did….”
In order to identify any opportunities for learning from patient feedback, an action plan is produced for
every complaint and PALS concern. The Patient Relations Manager and the Patient Experience
Manager have been attending the Incident Action Review Committee (IARC) and the Senior Nurses
and Allied Health Professional (SNAHP) meetings to share good practice of complaint handling and
action plan documentation across ward areas. Details of changes are also included on ward quality
boards.
Below are some examples of changes in practice that have been made as a result of patient feedback
since April 2014 across PALS and complaints.
Pre-op manager to revise clinic template
for Arthroplasty (hip and knee) patients
on certain days as the clinic template
needs to reduce amount of patients
seen in clinic to reduce delays. (PALS
September 2014)
Outpatient appointment letters are
being amended to reflect the
updated working hours of the
appointment
booking
clerks.
(Complaint November 2014)
A ‘Staff Bond’ has been devised
by the Spinal Injuries Unit
Manager which takes the form of
a ‘Code of Conduct’ for members
of staff on the unit. (Complaint
December 2014)
New sign for outpatient reception
desk advising patients to take a seat
and wait if they arrive before
reception desk is manned at 7.00
am (PALS December 2014)
As part of the ‘intentional
rounding’, all patients are
checked on at least every one to
two hours and are asked if there
is anything that they need.
(Complaint December 2014)
ADOS to label luggage and store
securely until the patient arrives
on the ward. (PALS November
2014)
Appointment letter changed from
“Please bring any medication you
currently take..." to “Please bring
details of any medication you are
currently taking". (PALS October
2014)
The Trust’s dietician and Medical Devices
team are looking at hydration systems that
would be more suitable for patients that have
muscle spasms as a result of their spinal
injury. (Complaint December 2014)
On Clwyd Ward, for all patients that
are returned to the ward from theatre
at handover time, the nurses who are
just going off shift will attend to the
patient to undertake the observations
etc. (PALS April 2014)
Staff members are being encouraged
to complete documentation within the
patient’s bays. This will ensure that
the nurses are more visible to
patients. (Complaint December 2014)
- 42 -
Patient Panel Activities 2014/15
Highlights from the Patient Panel during 2014/15 have been members getting involved in the ‘Sit and
See’ observations project, dementia environment work on Sheldon ward and supporting the National
Dignity day in February 2015. Two new members have joined and one has left, giving a total of 17
members, comprising previous and current patients as well as local stakeholders; the Welsh
Community Health Council, Healthwatch Shropshire, Foundation Trust Lead Governor, members of the
League of Friends, Oswestry Rheumatology Association, Shropshire Patients Voices Group
Shropshire Dementia Alliance Group and Shropshire back pain support group. From 1st April 2014 a
new post of Assistant Director of Nursing was created, to support the Director of Nursing & Service
Delivery with Nursing and Patient Experience projects.
Panel members are involved in a vast array of activities including attending meetings as the patient
representative to involvement in specific projects.

Patient Panel representatives attend the following meetings:
o Nutrition Steering group
o Clinical Effectiveness Committee
o Clinical Audit Committee
o Equality and Diversity Steering Group
o Dementia Task and Finish Group
o Facilities Committee.

Members have had an input into the following projects:
o PLACE audits
o Nutrition audits
o Outpatient improvement plan
o New Tumour/Theatre build
o Joint school
o Butterfly scheme
o Sit and See observations
o Facilities Survey
o Reading therapy
o Sheldon ward Luncheon clubs
o Reviewing patient information leaflets and posters
o Ward Welcome Packs
o Estates, Sustainability and Way-finding Strategy
o STAR ward-based Nursing assessment scheme
o Website review
o Chaplain process
- 43 -
The Older people/Safeguarding sub group is led by the Matron for Quality & Safety and Adult
Safeguarding Lead and looks at issues to do with safeguarding adults and patients with dementia.
A dementia Task and Finish group on Sheldon has been set up to review the ward environment and
has already undertaken a number of actions to enhance Sheldon ward. The group
consists of three staff members, three members of the patient panel, the Matron for
Quality & Safety, and the Estates Manager. Members have been involved in carrying
out a dementia environment audit of all wards across the organisation and identified
actions. The Poppy Lounge (dementia friendly day room) on Sheldon ward was
finished in October 2014 to coincide with the launch of the Butterfly scheme which
enables staff to respond appropriately and positively not only to people with dementia,
but also to those with memory impairment or temporary confusion. It allows patients
and carers to request care via a discreet Butterfly symbol.
Other activities have included organising luncheon clubs and activities for patients with dementia.
These include a speaker who gave a talk on the history of Oswestry, the Orthopaedic Male voice choir
who sang World War 1 songs, beauty students from Walford and North Shropshire College who
provided hand massage and nail painting, Reading Therapy organised by the Trust Librarian and a
bingo afternoon organised by the local Chaplain. The plan is to continue to hold regular Luncheon clubs
and activities throughout 2015/16.
The Patient Flow/Journey sub group
Panel Members have been involved in improving the patient experience in Outpatients through the
developing of an action plan looking at the environment, communication and waiting times.
Members have also been invited to meetings with the Contractors and Estates staff to provide
comments from a patient perspective on the plans for the new Theatre and Tumour Unit; this includes
overall architecture plans, patient flows, and interior and exterior finishes.
The Estates manager has also informed and consulted the panel about the new Way-finding (signage),
Estates and Sustainability Strategies.
The Patient Experience sub group is led by the Patient Experience Manager. Members are involved
with specific projects to measure the patient experience which include;
‘Sit and See’ Observations, iPad Patient Experience data capture, collecting patient stories from
patients who are on the ward, and patient surveys.
Panel members carried out a survey during a week in January 2015 to ask patients and visitors “what
services or facilities visitors, family and patients value when visiting the hospital and what we could
improve on?”. Results were shared with the Facilities Manager, which included a request for an
increase in the opening hours of facilities, a change machine for the car park and more outdoor seating.
This group has also been involved in organising a Children’s Fun Day in October 2014 to engage with
young patients and collect their feedback about how services can be improved. The Shropshire Youth
Champions were also involved to make the day a success. It was well attended by patients, parents
and staff. Patient Feedback was collected from a variety of methods including writing comments on a
leaf that was put on a tree, a snowball questionnaire challenge as well as the comment cloud.
Following patient feedback there has been a number of suggestions that have been turned into actions
including the purchase of a baby warmer and an Xbox.
The Patient Information/Communication sub group is led by the Patient Experience Manager and
PALS Lead. Members have provided input into reviewing patient information leaflets and posters, the
Trust Welcome pack for patients which is now being used on three wards, patient information boards
and notices on wards including leaflets and posters. One member also attends the Pre-operative
Assessment Joint school education session every Monday as the expert patient.
The Quality and Safety sub group is led by the Clinical Governance Manager who has worked with
clinical staff to carry out spot checks on all of the Care Quality Commission (CQC) 16 Essential
Standards of Quality and Safety. From January 2015, the group has been carrying out inspection using
the new CQC Key Lines of Enquiry, which ask five key questions:
 Is it safe?
 Is it caring?
 Is it effective?
 Is it responsive?
- 44 -
 Is it well-led?
These spot-checks are carried out on a monthly basis and include visiting a variety of clinical areas and
speaking to both staff and patients. Overall the group has found that compliance is very good for all
standards; where minor shortfalls have been identified, action plans have been agreed with the relevant
managers.
Sit and See Observations of care
From April 2014 the Trust has been using a new and exciting Observations of Care tool called “Sit and
See” across all wards and departments. This has replaced the Ward Peer reviews. This simple
observation tool captures and records the smallest things that can make the biggest difference to
patient care, for example a smile, a little banter, a reassuring touch, which can make all the difference
to the patient experience. The observer will sit for between 15- 50 minutes and observe and celebrate
tiny examples of care and compassion or recommend how to improve aspects of care.
Linking in with compassion in practice and developing a culture of compassionate care and the 6 Cs,
these observations provide evidence of staff interaction with patients, visitors and colleagues within the
clinical environment. The tool is a simple recording system which can identify positive, passive and
poor care, the 3 Ps. It enables staff to see care through the patient’s eyes which gives them an
understanding of the difference their interactions can really make to patient dignity, care and
compassion.
The key principles of the ‘Sit & See’ tool:
 Safeguarding adults is about prevention; absence of care and compassion can be the first sign
of a failing environment.
 Celebrate compassionate care by highlighting it.
 Identify shortcomings within the context of positive practice.
 Staff see and understand care through the eyes of the patient.
 High quality nursing care requires the use of the head, the heart, and the hands.
 The small things (for the patient) are often remembered more than anything else.
 Captures evidence of care and compassion in a simple way with agreed standard descriptors.
 The tool records positive examples of care as well as passive or poor examples.
 Observation sessions are 15 minutes – 50 minutes in total
There are 67 ‘Sit and See’ observers trained from a selection of clinical and non-clinical staff, including
medical secretaries, administration staff, healthcare support workers, trained nurses, Patient Panel
members, and Non-Executive Directors. There have been 17 ward/department areas involved in the
observation.
Results of the observations are discussed at the time of the observation with the nurse in charge and a
follow up report is sent to the manager of the ward or department with action points (if any) to take
forward. Any action points are reviewed by the next sit and see observers for the following month to
ensure the actions identified previously have been implemented. The report is shared with
ward/department staff, and is also part of the STAR assessment performance framework as having
been carried out on a monthly basis.
The ‘Sit and See’ observers have generally found it a good tool to observe compassion in practice, and
it is a helpful tool to provide constructive feedback to staff so further improvements can be made to
enhance the patient experience .
- 45 -
Some examples of Positive practice identified from ‘Sit and See’
Parents of children that are an inpatient are
encouraged to be involved in care
Staff Interaction with patients – enjoying banter with
medical staff and housekeepers
Clean and tidy Department and Wards
Quiet and Calm
Curtains drawn and doors closed for privacy
and dignity
Porters creating ‘small talk’ with patients
Staff sat and chatted to the patients prior
to their surgery alleviating any fears.
Patient attended reception - Quietly spoken no
information was overheard
Receptionist has a very good telephone manner
and very courteous on phone and clarifies that
patient has understood what she said
Staff Friendly and Smiley
Very helpful directing patients to xray/toilets
Nurses polite, approachable and professional
Cleaning check lists
completed for each room
Patients called and spoken to
using their first/given names
Witnessed a discharge the patient asked several
questions in which the staff nurse answered
appropriately.
Examples of Passive and Poor themes across the wards and actions identified:Observation: Patient ringing bell in bay – light
was not working to alert staff help was required
Action: Light bulb has now been replaced
Observation: Staff not using hand gel
Action: Constant reminding – posters – infection
control awareness – infection control link nurses
Observation: Notes are visible for each patient
Action: Looking in to new cabinets to keep notes
locked away, as part as the new build
Computer left unlocked with EPR open visible to
anyone.
Action: Staff awareness & information governance
checks
Observation: Patient and family member asked a
nurse if she was going home today, nurse was
unsure of the patients discharge date
Action: New patient bed boards will state
estimated date of discharge as well as other
significant information
:
Observation: Staff walking with cups in front of
patients (clinics)
Action: This is due to not wanting to stop consultants
in clinic, HCA make drinks for them and take them to
their consultant rooms – the use of flasks have been
looked into
Observation: Staff member taking blood did not
use gloves, wearing ring on thumb
Action: staff member spoken to ensure removal
of ring and compliance regarding infection
control standards.
- 46 -
Patient Stories Programme
A Patient Story is presented to the Quality and Safety Committee at the beginning of each meeting.
Patient Panel volunteers are involved in collecting patient stories. Stories have been presented from
patients in the Midland Centre for Spinal Injuries, Sheldon ward, Clwyd ward and Powys ward. Patient
Stories are also shared at the Senior Nurses Forum.
Healthwatch Shropshire have also started to attend once a month in the main entrance to collect
patient stories.
Patients Comments made on NHS Choices Website
During 2014/15, 12 comments have been posted on the NHS Choices website. All of these were
compliments.
Examples of Positive comments:
Patient who stayed on Clwyd Ward found all the staff to be friendly, helpful and efficient and found the
ward to be very tidy and spotlessly clean. The patient was also very satisfied with the food and found
it delicious.
Patient was very satisfied with recent experience and found the staff to be very professional and
attentive, leaving adequate time for questions. Patient would strongly recommend the hospital.
Patient found the hospital to be ‘amazing’ with brilliant Consultants – everyone was friendly and
helpful. Patient also explained that he was treated with respect and involved in decisions at all times.
Patient was very satisfied with his recent appointment, which was on time and the patient was out of
the clinic in less than one hour, having had x-rays and seeing a Consultant - excellent experience!
Patient was extremely pleased with outcome of hip replacement surgery and explained that the
surgeon was very informative with regards to recovery – very impressed. Nursing staff excellent.
Patients Comments made on Patient Opinion Website
During 2014/15, comments were posted on the Patient Opinion website. The majority of these were
compliments. The concerns raised included the new Pain Management Service - having to be referred
to this by their GP, the length of time it takes to receive an appointment with a Consultant and poor
communication between RJAH and the Telford Referral And Quality Services (TRAQS) regarding
appointments.
Examples of Positive comments:
Patient happy that appointment was on time and only had to wait 10 minutes for her scan – very
friendly and informative receptionist.
Patient’s appointment was dealt with very efficiently – all staff lovely and found the automatic check in
great.
Patient was very pleased with treatment and complimented the new extension to the hospital – very
bright and airy, with excellent facilities for patients/carers.
Patient found staff professionalism to be outstanding; skilled attention & examination, perfect
explanation of pros & cons of surgery, effective use of time with all tests/x-ray done before seeing
Consultant – extremely happy.
Patient found his surgery was excellent and the aftercare received was fantastic – very satisfied.
Patient Feedback from iPad project
The Trust has been gathering real-time information relating to patient experience and care delivery as
part of the Quality Improvement Strategy to improve Hospital services.
From April 2014 to March 2015, Patient Advice and Liaison Service (PALS) staff and Patient Panel
volunteers have interviewed 696 patients asking questions about their patient experience on the wards
on the day of discharge.
- 47 -
Six questions were devised by the Senior Nurses’ Forum and the Patient Panel covering areas such
as:
 menu choices
 feeling well cared for
 noise disturbances at night
 being involved and informed about their care
 time taken for call bells to be answered
 frequency of seeing a doctor
Results in 2014/15 show positive overall score and slight decrease in three questions. Results have
been shared with ward managers.
Results below for each question:
iPad results
2013/14
2014/15
% who said they would be extremely likely to recommend the
Trust to friends and family
93%
95%
% who said they always received menu choice requested
88%
86%
% who said they were always felt well cared for by nursing staff
97%
99%
% who said there was no noise disturbance at night
33%
33%
% who said they were always kept informed about their care
87%
82%
% who said call bells answered in under 5 minutes
88%
83%
% who said a doctor spent enough time with you to answer all
your questions after your operation
97%
96%
From April 2015, the iPad questions have been revised to include the following:
What was the main factor that made you decide to choose to come to the RJAH?

When you arrived on the ward did ward staff make you feel welcome?

Did the ward staff introduce themselves before carrying out any care?

To what extent did you have confidence and trust in the nurses treating you?

To what extent did you have confidence and trust in the doctors treating you?

Please select any of options below if you felt they fell below your expectation of the catering service?

How clear was the explanation of what you might expect during your recovery at home and what
complications if any you should be aware of?

Did a member of staff tell you about medication side effects to watch out for when you went home?

Before you left hospital, were you given any written or printed instructions/information about what you
should do or not do after leaving hospital?
Friends and Family Test (FFT)
The Friends and Family Test (FFT) is a single question survey which asks patients whether they would
recommend the NHS service they have received to friends and family who need similar treatment or
care. On discharge, patients are asked to answer the following question: "How likely are you to
recommend our ward to friends and family if they needed similar care or treatment?" They are invited
to respond to the question by choosing one of six options, ranging from "extremely likely" to "extremely
unlikely".
Following a NHS England review of the patient FFT, published in July 2014, it was recommended to
move away from the Net Promoter Score (NPS) and introduce a simpler scoring system in order to
increase the relevance of the FFT data for NHS staff, patients and members of the public. NHS
England is now calculating and presenting the FFT results as a percentage of respondents who
would/would not recommend the service. This change was introduced on 2 October 2014 across all
existing patient FFT settings.
- 48 -
The Trust has been collecting FFT data monthly via the Trust current comment cards and electronically
using volunteers to collect the data in real time using iPad and the Trust website technology.
RJAH FFT results for 2014/15:
Promoters Extremely
Likely
2479
Detractors
- Not at
All
Passive Likely
181
10
Detractors
- Neither
Likely nor
Unlikely
Detractors
- Unlikely
21
5
Don’t
Know
4
Responses from patients have been extremely positive. The Trust’s average monthly NPS was 90.91
which was very similar to the 2013/14 score of 90.41. Looking at the results as a percentage we
scored a monthly average of 98.44% of patients who would recommend the Trust to friends and family,
which is higher than the average score of all NHS Trusts in England which was 94%.
rd
The RJAH achieved the 3 best top score in May 2014 out of 156 NHS Trusts in England with an
th
average monthly rank of 6 position for April 2014 – December 2014, thus making us one of the top
performing NHS Trusts in the country. The average response rate was 33% of all inpatients providing
a response.
Following a review of the Friends and Family Test scoring methodology in July 2014, a decision was
made to move away from the net promoter score and instead use the percentage of respondents that
would recommend/wouldn’t recommend the service. This new scoring methodology was introduced in
September 2014. The graph below shows the Trust’s scores compared to the national scores, the local
area scores and the scores of two other specialist orthopaedic trusts, using the Net Promoter Scoring
system from April 2014 to August 2014 and the new percentage score from September 2014 to March
2015.
- 49 -
The graph below shows the percentage of patients who would recommend the Trust by Ward.
- 50 -
Examples of Compliments received in 2014/15
- 51 -
Workforce Factors
Friends and Family Test
The 2014 staff survey response shows that RJAH achieved the highest score in England with 93% of
staff agreeing they would be happy with the standard of care provided.
2014 Staff Opinion Survey
The 2014 staff opinion survey results showed that the Trust has maintained improvements from last
year in the key areas:





Highest recommendation in England of the Trust to receive treatment, with 93% of staff happy
with the standard of care provided by the Trust
71% of staff would recommend the Trust as a place to work
Overall staff engagement rating was maintained
90% of staff feel encouraged to report clinical errors with 98% of staff saying they have
reported clinical errors when they have seen them
Only 20% of staff feel the Trust would blame staff when reporting errors.
Some existing and new themes were highlighted by the 2014 survey as areas for improvement:
 Having well-structured appraisals
 Reporting good communication between senior management and staff
 Using feedback from patients/service users is used to make informed decisions in their
department
 Staff feeling safe in raising concerns and feeling confident the Trust would address concerns
Although the Trust’s overall staff engagement score is reported as below average compared to
Specialist Acute Trusts, it has maintained the significant improvement made in 2013 in the overall
engagement rating.
- 52 -
Statement from Local Healthwatch
Healthwatch Shropshire is pleased to be invited to consider and comment on the Trust’s Quality
Account for 2014/15.
In the review of last year’s priorities, we are pleased to read of the effort put into addressing the
priorities but it is not always clear how ‘what we did’ and ‘how we did’ has impacted on patient care and
experience. Also, we would like to know what further areas of improvement may be required.
We congratulate the Trust on the high scores achieved for both staff and patients who would
recommend the Trust as a provider of care to their family and friends. We also congratulate the Trust
on once again achieving their MRSA blood stream infection target of zero and also on the consistently
high level of screening for MRSA.
We were also pleased to see the inclusion of a comprehensive report of action taken against patient
safety alerts. Similarly, we were impressed with the detail of action points as a result of local clinical
audits.
When reporting on Ombudsman requests, we are concerned that the outcome of the outstanding case
mentioned in last year’s Quality Account does not appear to have been reported upon in this year’s
Account.
With regards to scores for patient satisfaction by ward, we note that the score for Wrekin ward is
substantially lower this year than the other wards. We would have liked to see this addressed in the
report. We would also like to see the poor score for noise disturbance at night addressed in the section
on patient feedback from iPad project.
We welcomed the section ‘Changes in Practice as a result of patient feedback’ which demonstrated
good, clear examples of positive actions taken. We were similarly impressed with both the positive and
negative examples identified from Sit and See.
It was also pleasing to read of the activities arranged for patients with dementia.
Statement from Health & Adult Social Care Scrutiny Committee
Members of Shropshire Council’s Health and Adult Social Care Scrutiny Committee commend the Trust
on good progress with priorities identified in last year’s Quality Accounts, and agree with the priorities
identified for 2015 – 2016.
They believe the Quality Accounts demonstrate a commitment to continuous, evidence-based quality
improvement and identify where improvements need to be made. They are particularly pleased to
note the actions taken to transform existing hospital facilities.
Members found the Chief Executive’s forward a helpful summary and welcomed the inclusion of a
glossary of terms. They suggest that this be included at the front of the document, rather than at the
end.
Members note that a mismatch of timings means that some performance data is not available for
inclusion in the Quality Accounts, also that Welsh patients are not included in all of the national
indicators in the Accounts. This is outside the control of the Trust.
Members are pleased to note good progress with roll out of the STAR assessment with six out of seven
wards achieving green status which helps to ensure safe, sustainable, consistent and high quality care
for patients within the care of the hospital. Members also congratulate the Trust on achievement of all
CQUIN targets and note that registration with the CQC is without conditions.
Members welcomed hearing the impact of the use of the Medicines Safety Thermometer improvement,
and commend the Rollout of a Dementia Friendly Environment across the organisation which will be
increasingly important in the years ahead.
The Committee welcomes continued engagement between the Trust and the Health and Adult Social
Care Scrutiny Committee in the forthcoming year.
- 53 -
Councillor Gerald Dakin
Chairman, Health & Adult Social Care Scrutiny Committee
Shropshire Council
Statement from Shropshire Clinical Commissioning Group
- 54 -
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 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 and supporting guidance;
 the content of the Quality Report is not inconsistent with internal and external sources of
information including:
o Board minutes and papers for the period April 2014 to March 2015
o Papers relating to Quality reported to the Board over the period April 2014 to March
2015
o Feedback from the commissioners dated May 2015
o Feedback from governors dated February 2015
o Feedback from Local Healthwatch organisations dated May 2015
o Feedback from Overview and Scrutiny Committee dated May 2015
o The trust’s complaints report published under regulation 18 of the Local Authority
Social Services and NHS Complaints Regulations 2009, dated May 2015;
o The latest national patient survey (2014)
o The latest national staff survey (2014)
o The Head of Internal Audit’s annual opinion over the Trust’s control environment dated
May 2015
o CQC Intelligent Monitoring Report dated 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; we have
noted the issue of RTT reporting within the Quality Report.
 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; a review of the controls on RTT identified that
these controls were not working in practice and the results are disclosed in this report. The
performance reported in February 2015 and March 2015 is accurate.
 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
th
Chairman
27 May 2015
Chief Executive
27 May 2015
- 55 -
th
- 56 -
- 57 -
- 58 -
- 59 -
Appendix A
Local Clinical Audits
Title of Audit
218
236
244
301
303
315
Action Points
Re-Audit TKR/THR Therapy
Discharge Audit
Obtain this information from daily/monthly data
collection
 Check whether the revised pathways
prescription chart have made a difference to
recordings
National Comparative Audit
 Identify which members of staff need what
Bedside Transfusion Practice
training and investigate how to incorporate into
other training e.g. consent training
 Documentation and email to all staff stressing
the importance of this
 Disseminate findings from this audit to all
areas involved with CDs particularly the
Re- Audit of controlled drugs policy.
theatres & anaesthetic directorate
 Ensure pharmacy staff give feedback to
departments they have carried out CD audits
Development of lactic acidosis in
patients continuing metformin periContinue metformin peri-operatively
operatively in major surgery - Is it
appropriate and safe?
 At least one tool to be included in the clinical
psychologist initial interview
 Although HADS assessment is done in most
cases undergoing rehabilitation through goal
planning process, the scores need to be
documented in EPR.
Audit on Management of older
 To document findings of ECG in admission
persons with new Spinal Cord
documentation
Injury at MCSI
 Awareness amongst MDT to consider any
onward referral that may be appropriate
following discharge
 To document DNACPR/ Advanced
directive/Living Will after discussing with
patient
Dried Blood Spot Testing,
Need for further clinical data on all positive cases;
Undiagnosed limb girdle muscular
photos, and both clinical and histopathology as well as
dystrophy patients
confirmed genetic reports.
329
Re-audit of Pre-Operative CXR
Reports
331
Availability and use of International
Colour Coding System (ICCS)
Syringe Labels
332
Accuracy of MRI in confirmation of
paediatric hip position following
reduction in patients with DDH
357
Management of Inpatient Falls
Allocation of chest x-rays for early reporting


Consultant Anaesthetist to ensure there is a
named person to take responsibility
Audit to be presented at Anaesthetics Meeting
and ensure all anaesthetists carry out this
procedure.

Report findings to be emailed to all concerned
(paediatric and radiological staff members)

Completion of documentation and pilot within
Trust.
Implement a review across the Trust.

- 60 -
Title of Audit
367 &
13/14_002
Multi centre audit of services and
outcomes for amputees after
treatment for bone or soft tissue
sarcoma & Review of the current
rehabilitation service available to
patients at RJAH
13/14_010
Are appropriate doses of IV
Vancomycin being used for
orthopaedic patients according to
local hospital antibiotic policy?
Action Points
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13/14_012
Safe and Secure Handling of
Medicines Re audit
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13/14_013
Date of surgery following Referral
of a patient with ACL tear
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13/14_016
An Audit of the Quality of
Antimicrobial Prescribing
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13/14_020
13/14_029
Compliance with CCG
requirements to record the Oxford
hip or knee score in the Patient
notes prior to a joint replacement
procedure
Audit of patients treated by means
of a selective dorsal rhizotomy in
Oswestry (NICE IPG 195) Reaudit
of 184
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Ability to record patient score on EPR
Record patient score on EPR
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Reminder email sent to all clinical staff stating
that all parts of the pre and post-operative
clinical assessments must be completed and
all forms correctly filled in
SDR Pathway and Pathway record to be
updated to include revised protocols.
Review patient notes for the three patients
who were non-compliant for pre-operative
imaging
Multi-Disciplinary team meeting within six
months to review the patient notes of those
who were found not to have improved their
GMFM66 and GDI post-operatively
To circulate results to all surgeons inviting
comment before discussion at hand and upper
limb business meeting - email out report to all
upper limb surgeons
poor recording of the Oxford shoulder score
pre-op - letter to Outcomes Manager regarding
the recording of scores
Results to be incorporated into patient
information leaflet at pre-op assessment
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13/14_033
Outcome of Arthroscopic
Subacromial Shoulder
Decompressions
Establish a sarcoma rehabilitation service
specification
Identify patient groups
Establish a Rehabilitation Website
Costing for the new model of rehabilitation
Organise a Well-being days nationally with the
sarcoma charities support.
Ensure awareness and location of AB policy is
incorporated into doctors’ induction training
Distribute and ensure that the flow diagram is
in place and is being followed by all clinicians
Lockable cabinets are required to store patient
own medications. BS2881 cupboards are
required for the area for the segregation and
storage of internal and external medication.
There were 17 actions in total for this re audit
however all actions are complete other than
the above one.
Bi-annual meetings with local GP and
Physiotherapists in order to get them up to
date with current practices
Urgency in arranging an appointment at OPD
for these patients
Fast Track process leading to surgery
Indication for antibiotic to be documented in
notes and on the patients drug chart. The
need for this to be reinforced at doctor’s
induction and through microbiologist attending
medics meeting.
Future antibiotic audits to be broken down into
medical and surgical directorates
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Title of Audit
13/14_058
13/14_059
Healthcare records case note
quality audit
Audit on Supporting Carers of
people with dementia
Action Points
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General improvement of standards
Introduction of Electronic patient record
Review the current carers’ questionnaire
Monthly carers’ survey to be undertaken
Letters to all consultants for information of
completion of patient location, date,
responsible clinical consultant and signature
on histopathology request form
Consideration of altering the format of the form
e.g. red highlight to say 'must be completed' re
location
Re audit of the
Accuracy/Completeness of data on
submitted Histopathology Request
Forms

13/14_067
Consent Training Re-audit

Completion of the consent training
13/14_076
Do patients have documentation on
post op x-rays prior to discharge
from hospital?
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13/14_077
Interim audit of Missed Doses on
the Spinal Injuries Unit
Arthroplasty Staff education
Surgeon Education (and at induction)
A radiograph review prompt on discharge
Develop critical medicines list specific to MCSI
Training around drug chart documentation-All
MCSI staff to become confident with
investigating and understand importance of
undertaking investigation and clear
documentation
Education of patients about the medicines
they are prescribed-Pharmacy staff to engage
with patients
Reduce distractions during medication roundsNurse focus groups to identify improvements
Develop guidance for nursing staff advertising
on how to manage medication which has been
omitted or delayed-New protocol to be
developed.
13/14_060
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14/15_004
14/15_006
Information provided preoperatively to adult diabetic
patients, with respect to their
diabetic medication before surgery
Myocardial Infarction-secondary
prevention following a myocardial
infarction

Extra Pharmacist service in pre-op to cover
Ludlow.

Educating the medical group in the lunch time
meeting and email to the medical group

Maintain focus on sections 1, 6 and 8, where
compliance has decreased
Communication to all staff, where a 100%
compliance of forms is not achieved
Continue to use the communication board to
increase awareness of quality regarding
compliance of the checklist and inform staff if
areas of the form are consistently falling below
100%
Results of the audit to be disseminated once a
month in the Tuesday morning staff briefing
Audit results to be discussed at the monthly
divisional meeting
Agree standardised process
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14/15_012
Re audit of Who Safe Surgery
Checklist Audit
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Title of Audit
Action Points
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14/15_019
Cancer Waiting Times Audit-2013
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14/15_022
Paediatric Consent and Patient
Experience audit
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14/15_033
Reaudit of Botulin Toxin Type A
(BTA) Therapy for Treatment of
Focal Spasticity amongst InPatients of MCSI
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14/15_047
Assessment of the impact of the
new pre-op process on the
collection of mandatory PROMs
data in the pre-op clinical
environment
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14/15_048
Re audit of Case note Availability
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Arrange designated cover for the data tracker
Adopt a monitoring and reporting system
where every patient referred under the cancer
waiting times target can be tracked internally
and upload to the national 'Open Exeter'
Have a reporting system that allows audit of
performance
Every tertiary referral should be checked if it is
on the cancer waiting times database; this
should be electronically checked with 'Open
Exeter' website
Improve the time it takes for imaging to be
completed and reported: Ultrasound scanning
on day of first clinic appointment to identify
those patients that can be taken off the
pathway. Designated MRI and CT slots.
Designated ultrasound guided biopsy slots.
Radiology reports of all imaging performed at
RJAH should be available at the time of MDT
discussion (day 31) 'hot reporting' for patients
referred under the cancer waiting time
pathway
Further negotiations with commissioners
regarding late tertiary referrals.
Improved coordination between
hospitals/secretaries
To have clear documentation of risks/benefits
Share the results with relevant team members
to show findings and importance.
Assessment of outcome following BTA
injection to be included in patient goal planning
process with clear documentation for follow up
in 7-14 days, 4-6 weeks and 3-4 months by
key workers
BTA Injection outcome assessment weeks (12 weeks. /3-4 months) to be notified on the
wall diary next to the patient by key workers.
Doctors to ensure OPD follow up information is
included in the discharge letter for those
patients discharged before outcome
assessment
The results of the re-audit and the action plan
was presented to the MDT at MCSI Clinical
Governance meeting on 04/12/2014
Patient Questionnaires to be prepared out of
clinic hours
Approaching patients in the new waiting area
Postal questionnaires to be used.
Training and Education - email report out to
everyone once approved
Scanning on notes to EPR - implementation of
IHCR
Appendix B
Quality Accounts Glossary
6 Cs
AB
ACL
ADOS
BTA
CAF
CAS
CCG
COPD
CQC
CQUIN
CXR
Datix
DDH
DNACPR
DOLS
ECG
EPR
FFT
HADS
HDU
HPA
HSE
IARC
ICCS
IHCR
IV
KPI
LADO
MCSI
MDT
MHRA
MRSA
MSSA
NCEPOD
NICE
NIHR
NJR
NRLS
OPD
PALS
PLACE
PROM
RCA
RIDDOR
RTT
SCIC
SDR
SNAHP
SSI
STAR
STEIS
TRAQS
VTE
WHO
Care, compassion, competence, communication, courage and commitment
Antibiotics
Anterior Cruciate Ligament
Admit on Day of Surgery
Botulinum Toxin A
Common Assessment Framework
Central Alerting System
Clinical Commissioning Group
Children’s Outpatient Department
Care Quality Commission
Commissioning for Quality and Innovation
Chest X-Ray
Incident reporting system used by the Trust
Developmental dysplasia of the hip
Do Not Attempt Cardiopulmonary Resuscitation
Deprivation of Liberty Safeguards
Electrocardiogram
Electronic Patient Record
Friends & Family Test
Hospital Anxiety & Depression Scale
High Dependency Unit
Health Protection Agency
Health & Safety Executive
Incident Action Review Committee
International Colour Coding System
Integrated Healthcare Record
Intravenous
Key Performance Indicator
Local Area Designated Office
Midland Centre for Spinal Injuries
Multidisciplinary Team
Medicines Health & Regulatory Agency
Methicillin Resistant Staphylococcus Aureus
Methicillin Sensitive Staphylococcus Aureus
National Confidential Enquiries
National Institute for Health & Clinical Excellence
National Institute of Health Research
National Joint Registry
National Reporting and Learning System
Outpatient Department
Patient Advice and Liaison Service
Patient Led Assessment of the Care Environment
Patient Reported Outcome Measures
Root Cause Analysis
Reporting of Injuries, Diseases and Dangerous Occurrences Regulations
Referral to Treatment Time
Spinal Cord Injury Centre
Selective Dorsal Rhizotomy
Senior Nurse & Allied Health Professionals
Surgical Site Infection
Sustaining (quality) Through Assessment and Review
Strategic Executive Information System
Telford Referral and Quality Services
Venous Thrombo-Embolism
World Health Organisation
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