Birmingham Children’s Hospital NHS Foundation Trust
Quality Account 2014-15
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Chief Executive’s Statement on Quality
Quality is at the heart of all we do at Birmingham Children’s Hospital - and our number one aim
remains to provide each and every one of our children, young people and families with a safe
environment in which to receive high quality care.
We monitor how we are doing on quality on a daily, weekly and monthly basis to ensure we never
lose sight of what is important to patients. We track not only standard areas like infections rates (for
example MRSA and C-diff), and medication related incidents, but also things that we have
prioritised, such as admitting children and young people from other hospitals who need access to
our specialised services as quickly as possible. These are all reported and scrutinised on a monthly
basis by our Board of Directors, Quality Committee, Performance Board and Clinical Risk and Quality
Assurance Committee.
Our Quality Account captures a selection of these areas - what we call ‘indicators’. This year we are
reporting on fewer indicators, but paying even greater attention to the ones that are the most
important to us and to our Council of Governors, who continue to stay close to this agenda.
We are delighted to be able to demonstrate continued high performance against our nursing care
quality indicators, and our staff survey results, which show that staff feel more engaged, in part
thanks to better communication, and we are particularly proud that 89% would be happy for a friend
or relative to receive our care.
However, we know there are areas where we still need to improve. Our food scores are average,
and BCH is not an organisation that does average. We are also disappointed that all of our hard
work to reduce cancelled operations and MRI waits has not achieved the results we had hoped for
due to even higher rates of demand. Our ambition is to report back with positive outcomes in
2015/16, and our action plans for achieving this can be found in this report.
More widely, some key projects have helped improve quality and safety across our hospital.
Openness is a must to achieve a good safety culture, and we have made it a priority to share more
about where things have gone excellently, as well as where things could have been done better.
This learning goes out to our staff, patients and families, other NHS organisations and the wider
public.
We have also set up a new Safety Faculty of BCH experts to train frontline teams in implementing
their own quality and safety priorities, and we are now designing ‘human factors’, first developed in
the airline industry, into our clinical systems, as this has been shown to reduce safety incidents.
Our unified electronic handover system is being rolled out across all medical specialties, ensuring
consistent information about children and young people is properly shared between teams at all
times. One of the areas where we knew we needed to do better.
This good track record made us the destination for a number of visits from VIPs who wanted to see
our best practice in action. One of these was Health Secretary Jeremy Hunt, who chose our hospital
as the venue for his announcement about how safer cultures can unlock billions of pounds worth of
savings for the NHS. He praised our track record on quality and safety in his speech, and spent time
on a tour of the hospital to see our safety work in practise.
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Finally, I would like to pay tribute to the amazing staff of Birmingham Children's Hospital. Over
3,500 people coming together as a team to provide outstanding care to our children and young
people and families, 24/7, 365 days a year, and together helping to cement our place as one of the
leading Children's Hospitals of the world.
To the best of my knowledge the information contained in this Quality Account is accurate.
Sarah-Jane Marsh - Chief Executive
Priorities for Improvement
‘Every child and young person cared for by BCH will be provided with safe, high quality care and a
fantastic patient experience’.
It is a key priority for the Trust to ensure that the care we give is of the highest quality and safe and
that when children are with us the experience they have when they’re here is a good one.
Our safety strategy helps us focus on ensuring that we continually monitor and improve our systems
for promoting and enhancing patient safety and reducing avoidable harm.
We do this by working in partnership with our children, young people, families and staff to ensure
their opinions are heard, feedback is acted on and lessons are learned. Our Participation and Patient
Experience Strategy ensures that we engage and involve children, young people and families in the
planning, provision and evaluation of all aspects of our services as outlined in section 242 of the NHS
Act.
There are many ways we gather information so we can understand where we need to improve to
make our quality of care better:
Listening to the children, young people and families that use our services - there are lots of
ways they can tell us what they think, and we take account of it all to work out what’s most
important to them:
Complaints, comments and concerns
Surveys
Feedback App
Consultations
Feedback cards
Patient stories
Websites like NHS Choices and Patient Opinion
Social Media
Listening to our staff - The views of the staff who work in our hospital every day are vital and
we encourage them to tell us what they think through surveys, consultations and feedback
events. It’s also really important that we keep an eye on their well being and make sure
they’re fully supported so that they are able to deliver the best services they can.
Listening to others - The views of BCH groups like the Young Person’s Advisory Group help us
focus on how to make the improvements that are needed.
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Analysing information about the quality of services, such as patient safety incidents and
clinical audits.
Using best practice examples - national targets and learning from and benchmarking with
other organisations.
Using this information has helped us to identify Quality Priorities, which are the main areas we want
to focus on to improve quality. This is not an exhaustive list of all our priorities but the key priorities
that relate to the three elements of quality, these are Patient Experience, Clinical Effectiveness and
Safety. The priorities we are reporting on this year are outlined in the table below under the three
quality headings:
Table 1: Priorities reported in our 2014/15 Quality Account
Patient Experience
Clinical Effectiveness
Safety
Food and Nutrition
Cancelled operations
MRI scan waits
Staff Survey
Nursing Care Quality Indicators
Mortality –Zero Avoidable
Deaths
Extravasation injuries
Pressure Ulcers
Reducing Life Threatening
Events, Cardiac and
Respiratory Arrests
These priorities and what we’ve achieved in 2014/15 are set out over the next few pages of this
Quality Account.
After reviewing how often people look at our Quality Account online and in discussion with our
Council of Governors we have chosen this year to reduce our Quality Account to the minimum level
which is mandatory.
We have therefore chosen to not report further on some of the indicators included in our 2013/14
Quality Report which we believe (though still important) do not represent the key priorities we need
to outline in the mandatory content of our 2014/15 report.
These indicators are, play and activities, tertiary inpatient referrals, asthma care, health promotion
reducing MSSA infection, MRSA and medication incidents. Information on play and activities, tertiary
inpatient referrals and health promotion, MSSA, MRSA and medication incidents is reported to
Board of Directors and can be accessed via the link to performance and quality reports below.
The indicators we have included in our Quality Account and a much wider view of how we are doing
in terms of the quality of our services can be found in the performance and quality reports which go
to our Board of Directors on a monthly basis and can be found on our Trust Internet site via the link
below:
http://www.bch.nhs.uk/story/corporate/publicationsreports
Paediatric Asthma audit results can be accessed via the British Thoracic Society website at:
https://www.brit-thoracic.org.uk/clinical-information/asthma/
Information relating to Health Care acquired infections in PICU continues to be monitored via PICU
quality meetings.
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We have continued to work on the sepsis pathway as mentioned in our 2013/14 Quality Account but
have not yet reached stage where this is a reportable measure. Work undertaken so far includes:
The project team is established and the Adult Sepsis 6 tool has been adapted for use in
paediatrics.
The degree of nursing support and training required is being explored.
Data is currently being collated to establish a baseline to track performance following
implementation.
We now have a Lead Nurse for Safety, who is leading on a Nursing Education Programme and the
redesign of the Paediatric Early Warning Score chart, which is use to detect deterioration in a child
or young person’s condition. We are looking at the feasibility of auditing the following stages:
1.
2.
3.
4.
5.
Diagnosis recognition
Time to blood culture taken
Time to prescribe antibiotics
Time to administration of antibiotics
Time that antibiotics stopped if cultures are negative
We are also looking to redesign the neutropenic sepsis pathway. Neutropenic sepsis is a potentially
fatal complication of chemotherapy and early administration of antibiotics has been shown to
significantly reduce morbidity and mortality.
We plan to redesign the neutropenic sepsis pathway to ensure that 90% of patients to achieve a
‘door to needle’ time of < 1hour.
This will focus on neutropenic patients accessing the haematology/oncology outpatient clinic with
signs of sepsis, rather than through the Emergency Department. We are currently reviewing this
existing patient pathway and the barriers to rapid treatment of sepsis. Once this is complete we will
consider options for reviewing the existing pathway.
Palliative and End of Life Care continue to be priorities and are the focus of considerable amounts of
quality improvement work. We currently don’t have well developed indicators that fit within the
definition of the type of measure required for the Quality Account. We will develop measures
around these areas and provide an update in our 2015/16 Quality Account.
Our Palliative and End of Life Care services were reviewed at our request by an external team from
Alder Hey Children’s Hospital in 2014. Following recommendations from that review we are looking
at options to develop and expand our palliative care team.
We will once again this year be publishing some ‘talking heads’ videos to coincide with publication of
our 2014/15 Annual General Meeting. This will include a video relating to the work we are doing to
make sure our clinical services are safe for our children, young people and families. The videos for
our 2013/14 Annual Report can be found via the link below and will be updated in to reflect the
2014/15 Annual Report:
http://www.bch.nhs.uk/corporate/annual-report
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Listening to Patients and Families:
Food and Nutrition
We know that good quality and tasty food helps our children and young people get better more
quickly and it also improves their experience of hospital. We also know that quality of food
continues to be a concern for our children, young people and families. This reflects a wider concern
across the NHS about the standard of food served to patients.
How have we done?
Once again this year we are showing information about how many ‘positive‘ and ‘need to improve’
comments we have received from children young people and families regarding the food we serve.
We are also showing the results of our latest PLACE assessments. PLACE assessments are undertaken
by a team of local volunteers and children/young people who work as a team to assess how the
environment supports patients’ privacy and dignity, food, cleanliness and general building
maintenance.
The graph below outlines the number of positive v need to improve comments we received in
2013/14 and the numbers we received in 2014/15:
Figure1: Positive v need to improve comments relating to food in 2013/14 and 2014/15 (date source: patient experience
database)
Once again in 2014 we have had PLACE assessments at our Child and Adolescent Health facility at
Parkview and the main city centre hospital site. Our PLACE food assessment scores are outlined
below:
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Figure 2: PLACE food assessment scores for Parkview and Steelhouse Lane sites 2013 and 2014 (data source: PLACE report
scores)
We have done well in our catering areas. In 2014 we were proud to be awarded one Gold, one
Bronze and two 5-a-Day Healthy Choice Assessment Awards for the retail catering provision in the
‘Healthy Choice Award Scheme’. The Birmingham Healthy Choices Award Scheme recognises those
catering businesses that make available and promote healthier options.
However, in terms of the food we serve to our children and young people in hospital our positive v
need to improve measure is a lot worse than in 2013/14 and although there is a slight improvement
in our main hospital site PLACE score our CAMHS Parkview score is slightly lower. Both our PLACE
scores are slightly below the national average of 88.79. It’s clear we still have a lot to do to make
things better.
What are we doing to improve?
In early 2015 we launched two ‘Making Food Better’ projects, one at CAMHS Parkview and one at
the Steelhouse Lane main Hospital site. We aim to:
Review, revise and improve the food we offer and ensure that children, young people and
their families have a voice in this.
Consider whether mealtimes are at the best times and consider flexible or staggered
mealtimes to suit the age range of children and young people and their varying clinical
needs.
Adopt protected mealtimes when children and young people can eat their food without
interruptions (already in place at CAMHS Parkview).
Involve our Young Peoples Advisory Group (YPAG) in our Making Food Better projects,
including food tasting sessions.
•
Attending Parkview weekly community meetings to get feedback on food.
We will continue to analyse how we’re doing throughout the year and will report on our annual
performance in our 2015/16 Quality Account.
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Listening to Patients and Families:
Cancelled Operations
We have focussed on cancelled operations for our last three quality accounts and this remains one
of our most significant challenges. We have seen rising demand for our services and based on our
planning for the future we think this will continue.
It is clear that cancelled operations remain a source of concern for our children, young people and
families and our hard working staff. Cancelling operations is stressful and inconvenient for children,
young people and families as it can disrupt work, travel and child care arrangements. We know there
have been examples of children and young people who have been cancelled several times for the
same operation and we have heard stories from families of the impact this can have on the whole
family.
It is also difficult and stressful for our staff to explain to anxious children, young people and their
families that an operation has had to be cancelled and for them to not be able to deliver the
treatment a child needs at the time we said we would.
How have we done?
Once again we have been working extremely hard in the past year to try and make things better. It’s
been a challenging year for as in the very busy winter period we saw even higher numbers than
usual of children and young people needing to come into hospital as emergencies.
Figure 3: Cancelled operations national definition – comparative performance 2012/13, 2013/14 and 2014/15 (data source
ORMIS theatre system)*
* Please note that in our 2013/14 Quality Account our October 2013/14 level of cancelled
operations cancelled on the day (national definitions was noted as 46. This was an error and a
process of internal validation has concluded the true figure is the 20 outlined in the graph above.
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The graph above shows the number of patients who were cancelled on the same day based on a
national definition of ‘Cancelled by a hospital for non medical reasons on the day of admission or
after admission’. This is a figure we report nationally.
However this definition doesn’t include all patients who have their operations cancelled. There have
still been a high number of operations cancelled by the hospital in 2014/15 of which 414 fit the
criteria for national reporting.
The chart below shows the reasons for cancellation of all patients cancelled by the hospital in
2014/15.
Figure4: Cancelled operations 2014/15 by reason for cancellation (data source: ORMIS theatre system)
We have not met our 2014/15 target, with the percentage of operations cancelled on the day at
1.63% compared to our target of 0.8%. The total number of cancelled operations remains high and
we have a number of patients who have had their operations cancelled more than once.
The biggest reasons for cancellations in 2014/15 were emergencies and trauma patients taking
priority (22.2%), bed shortage (17.2%), patient not suitable for operation (16.9%) and operation not
necessary (12.2%). Our cancelled operations rate still needs a lot of improvement but we have
cancelled 72 fewer patients on the day than in 2013/14.
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What are we doing to improve?
Bed capacity
Once again this winter we opened seven additional beds to admit children and young people as
emergencies and try and reduce the numbers of patients we cancel. We have continued to work
hard on the ‘flow’ of children and young people through the hospital. We have asked Newton, an
external company to help us look at the reasons children and young people are waiting to move
through the hospital or go home. Based on this work we will be doing more to reduce delays and
make sure children and young people can leave hospital quickly when they are fit to go home.
This will help us make sure beds are free for children and young people after they have had their
operations.
PICU capacity
Capacity in our intensive care unit (PICU) remains a challenge and bed capacity has a particularly big
impact on our Cardiac Surgery operations. In July 2014 we took more than 40 staff from out hospital
and other NHS colleagues in the West Midlands to a two day ‘Critical Care Summit’ to look at how
we could make the best use of our critical care capacity.
The team identified six important pieces of work we need to do to improve bed availability on our
PICU. Some of these pieces of work involve making sure we have the right environment elsewhere in
the hospital to safely treat some of the children and young people on PICU. We have launched our
Critical Care Programme led by our Chief Medical Officer to make this happen.
Theatre capacity
In early 2015 our Board of Directors made a decision to invest £35 million to build a new clinical
building on the Steelhouse Lane site. This will include three new operating theatres.
It will be at least two years until these new theatres are ready so there is more we are doing in the
meantime to improve our theatre capacity. We’ve introduced a new mobile theatre unit which will
help us increase our surgical activity and is less vulnerable to cancellation issues such as lack of bed
capacity as there are eight beds linked to the mobile unit that are only used for this purpose.
We have also improved the way we book our operating lists to make sure they are used as efficiently
as possible and avoid over-runs which could lead to cancellations, using an electronic system called
HEIDI.
Improving processes
We have continued to look at other ways of improving the processes that support getting children
and young people operated on at the right time. A surgical flow coordinator post was trialled and
made permanent which has really helped with managing bed challenges and making sure patients
get their operation on the day it was planned to take place.
We will improve and extend our pre-assessment service to help identify earlier potential issues with
children and young people being ready for their operation that could lead to cancellation.
We will continue to do everything we can to reduce our cancelled operations and report back on
progress in our 2015/16 Quality Account.
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Listening to Patients and Families:
MRI Scan Waits
In our last Quality Account we described how patients, families and staff have told us that the waits
for MRI scans cause anxiety, and we and our Commissioners (who pay for our services) see it as a
key challenge for us to address.
Coming to hospital for a test such as a MRI scan can be a key step in a child or young person’s
pathway and understanding their treatment needs. Waiting for these tests can be an anxious time
for children, young people and families.
Our plan was to reduce the number of children and young people waiting more than six weeks to
zero by June 2014.
How are we doing?
The graph below shows the number of children and young people who were waiting over six weeks
for an MRI scan (the purple bars on the graph). This is based on a ‘snap-shot’ census date at the end
of each month. The blue bars for April and May 2015 are our estimate of the number of children and
young people who will be waiting over six weeks.
Figure 5: Number of patients waiting over six weeks at month end for MRI scans (based on DMO1 census dates)
A significant number of children and young people have waited over six weeks for an MRI scan. This
is disappointing as we have missed the target we set ourselves. There are various reasons for this.
It’s been a difficult year in terms of very high demand particularly in winter. We have also had some
unexpected downtime (when the scanner is working and needs repair) on our MRI machines. Also
some plans we had for training of radiographers didn’t happen as fast as we had hoped which made
it difficult for us to extend the hours of scanning time we provide at weekends.
We know that not meeting our target this isn’t good enough and we are again aiming to make sure
no child or young person waits more than six weeks during 2015/16.
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What are we doing to improve?
We are doing a number of things to reduce the wait times for MRI:
We will continue to provide additional general anaesthetic sessions (both in-week and
weekend) for MRI;
We are working with Aston University to us their 3T MRI scanner generating additional
capacity;
We will continue to clinically review patients waiting more than six weeks;
We will put additional staffing in place to manage extended routine working to Saturdays;
We are providing bank holiday scanning sessions;
A new Consultant Radiologist started in January 2015;
We have started a new Consultant rota generating additional capacity to report on scans.
We will continue to do everything we can to reduce MRI waits and report back on progress in our
2015/16 Quality Account.
Listening to our Staff:
Staff Survey
Our staff are critical in all that we do at the hospital and without them we wouldn’t be able to
provide the high quality care that we do. Knowing how our staff feel about our services is an
important indicator of quality. There is also a lot of evidence that shows that staff satisfaction and
motivation has a real impact on the quality of care that they deliver.
The NHS Staff Survey is one important way that we can understand how our staff feel about the
quality of care we give and how they feel about working here.
How have we done?
Figure 6: 2010,2011, 2012,2013 and 2014 Staff survey results based on responses to ‘care of patients is my Trust’s
top priority’ and ‘if a friend or relative needed treatment, I would be happy with the standard of care provided by
the Trust’(data source: CQC national staff survey report)
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Figure 7: 2013 Staff survey results – Staff satisfaction scores 2013, 2014 and comparative Acute Specialist comparison score
for 2014 (data source: CQC national staff survey report)
43% of our staff completed the staff survey in 2014 compared to 59% in 2013.
There has been improvement in our results in 2014/15 but we would like to do much better. Our
overall satisfaction score has increased and is slightly higher than the Acute Specialist Trusts
elsewhere in the NHS.
The improvement in our survey results this year which demonstrates that the focus we have put on
teams and staff support is making a difference to how our staff are feeling, which we know helps
them provide the best possible care.
What are we doing to improve?
We have been doing a lot to improve, which has had an impact. We will continue too:
Give staff access to wellbeing and resilience resources
Focus on the role staff play in our safety strategy
Improve the appraisal process for staff
Develop our ‘Caring for Team BCH’ programme
Improve our leadership training based around our Trust values
Celebrate our BCH staff ‘Star of the Month’ as nominated by staff, patients and families
Develop our ‘Team Player’ training programme
We have a lot of work we want to do to improve and we will report on these indicators again in our
2015/16 Quality Account.
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Providing Even Better Nursing Care:
Nursing Care Quality Indicators (NCQIs)
Our Nursing Care Quality Indicators help us to understand if we are delivering excellent high quality
nursing care for our children and young people. They continue to be really important measures that
we are getting the essentials of nursing care right which has a huge impact on the quality of care and
experience of our children and young people.
How have we done?
The graph below shows how we did for each NCQI since September 2013:
Figure 8: % Compliance NCQI performance September 2013 –March 2015(data source VESPER NCQI reporting tool)
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As in 2014/15 we have continued to perform well in each indicator showing we continue to provide
high quality nursing care. We will continue to report our NCQIs to our Board of Directors via the
Trust Quality Report.
What are we doing to improve?
In February 2014 a dedicated Lead Nurse for Safety joined our team. They are reviewing the Nursing
Care Quality Indicators to ensure that they remain current and important to our staff and that we
are measuring what parents and young people think is important.
We will continue to report on our NCQIs in our next Quality Account. More detail about two specific
measures linked to our NCQIs relating to pressure ulcers and extravasation is outlined later in the
Quality Account.
Providing the Safest Possible Care:
Acute Life-Threatening Events (ALTEs), Cardiac Arrests and Respiratory
Arrests
Good monitoring on wards means that we will pick up deteriorating patients more quickly and avoid
preventable emergency and life-threatening events.
How have we done?
We look at all these events to decide if they were predictable and preventable. This helps us
understand if there are things we can do better and help us improve the care we give.
Last year we outlined the rate of emergency events per 1000 admissions. In line with what is
reported to our Board of Directors and what we believe is a better way of illustrating how we are
performing we are including two graphs that show the total number of emergency events (of the
four different types of events) for each month in 2013/14 and 2014/15. The graphs are illustrated
below:
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Figure 9: Number of emergency events March 2013 to April 2014 (data source: resuscitation team database)
Figure 10: Number of emergency events April 2014 to April 2015(data source: resuscitation team database)
We have continued to perform well with low levels of cardiac arrests, respiratory arrests and acute
life threatening events (ALTEs), which means that we are monitoring and escalating clinical
deterioration in a timely manner.
We have had no ALTEs, respiratory or cardiac arrests that were seen to be both predictable and
preventable in 2014/15. There was one cardiac arrest on our intensive care unit in 2014 which was
felt by one of the clinical teams involved may have been preventable. This particular incident
involved a difficult clinical decision on whether to re-open the chest of a patient who had heart
problems. Re-opening the chest makes the child or young person vulnerable to infection. On balance
in discussion with the teams it was felt this incident wasn’t preventable.
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What are we doing to improve?
We will continue to review each event to identify any learning that could prevent or help predict
events in the future.
We have two projects in place to improve even further the way we prevent children and young
people deteriorating. The first of these is our S.A.F.E project. This involves the use of ‘safety huddles’
where clinical teams get together to brief each other to make sure everyone is informed and up to
date with a child and young person’s condition and has the same understanding of plans to care for
them.
Evidence suggests this improves safety and quality and helps to ensure prompt action if a patient
begins to get sicker. The huddles have been tested on our Paediatric Assessment Unit. We are going
to learn from this testing and plan to introduce a ‘whole hospital huddle’.
We have a really exciting and innovative project called RAPID (Real-Time Adaptive Predictor
Indicator of Deterioration). The project will use wireless sensors to track vital signs such as heart
rate, breathing rate and oxygen levels to better predict when a child may be deteriorating to avoid
them going into cardiac arrest. This is an ‘early warning system’ with potential to save lives. We are
working with other organisations such as the McLarens Formula One team to develop the
technology.
Making sure we prevent the deterioration of the health of our children and young people’s remains
a key measure of quality of care and we will report on this again in 2015/16. We will let you know
how the two projects we have mentioned have been going as well.
Providing Even Better Nursing care:
Extravasation harm
When medicine is given into a vein, it can leak into and damage the surrounding tissue and cause a
potentially serious injury. This can be a particular problem for the very small babies that we treat.
How are we doing?
We began measuring our extravasation harm rate using a tool called SCAN (Safer Children Audit No
Harm) in November 2013 and we have been better able to monitor how often extravasation harm
occurs.
During 2015/16 we will be continuing to work with a group called HAELO (which consists of other
children’s hospitals) to develop the Children and Young People’s Safety Thermometer. During
2014/15 we have submitted data to test the definitions of the identified harms.
From April 2015 we will be submitting data on extravasations into the national New Generation
Safety Thermometer portal which will be really useful because we will be able to compare how we
are doing with other hospitals and learn from each other to make things better.
The graph below shows the prevalence of extravasations detected based on test data we have been
using to develop the Children and Young People’s Safety Thermometer. The prevalence rate of 0.6%
outlined for August 2014 to April 2015 below is slightly lower than the rate of 0.8% suggested by the
data we published in our 2013/14 Quality Account. This is based on test data so we still have more
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work to do to make sure the data is as good as it can be and it is easy to compare and track how we
are doing.
We believe this rate is still too high and we can do better. We have worked hard with others to
develop a measurement tool to help us understand how we are doing. In 2015/16 we hope this tool
will really help us benchmark ourselves against other children’s hospitals, target more improvements
and help us set a goal for improvement.
Figure 11: Prevalence of extravasation August 2014-April 2015 (based on test data submitted for development of the
Children and Young Peoples Safety Thermometer)
What are we doing to improve?
Monthly data has shown where incidents have occurred and we have targeted education to nurses
in those areas to help them improve the care they give. We will use the data we are gathering to
understand what measures and goals we can define to reduce harm from extravasation.
We will report on this indicator in our 2015/16 Quality Account and we hope to be able to share
some of the benchmarked data from the Paediatric Safety Thermometer.
Providing Even Better Nursing Care:
Pressure Ulcers
Some of our patients - in particular the sickest patients on our intensive care unit are at risk of
developing pressure ulcers which, if left untreated, can become very serious. We are working toward
the complete eradication of pressure ulcers, in line with the ambition of the whole NHS.
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How have we done?
The graph below shows the prevalence of pressure ulcers detected based on test data we have been
using to develop the Children and Young People’s Safety Thermometer. This is based on test data so
we still have more work to do to make sure the data is as good as it can be and it is easy to compare
and track how we are doing.
Looking at previous data and this test data our prevalence of pressure ulcers remains low. We will
hopefully be able to see how we compare to other hospitals regarding pressure ulcers via the New
Generation Safety Thermometer and also track how we are doing and make sure we target any
improvements needed if we see our rate of pressure ulcers increase.
Figure 12: Prevalence of pressure ulcers August 2014-April 2015 (based on test data submitted for development of the
Children and Young Peoples Safety Thermometer)
What are we doing to improve further?
As with extravasations mentioned earlier we will hopefully be able to see how we compare to other
hospitals regarding pressure ulcers via the New Generation Safety Thermometer in 2015/16. Also we
will continue to track how we are doing and make sure we target any improvements needed if we
see our rate of pressure ulcers increase.
We don’t intend to report on this indicator in our next Quality Account unless we see any areas of
concern or our rate of pressure ulcers increases.
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Providing the Safest Possible Care:
Mortality
Sadly due to the fact we care for some extremely sick children and young people we know that some
of them will die whilst in our care. At Birmingham Children’s Hospital we continue to review every
single death that occurs to make sure there were no avoidable factors and check that the clinical
care we are delivering is of the best quality.
We continue to look at our overall death rate per 1,000 admissions. Also we have specific ways of
looking at the deaths in some of our most complex and high risk areas with some of the sickest
children and young people (such as our PICU and cardiac surgery departments) to understand if the
numbers of deaths are within the expected range given the complexity of our patients.
How have we done?
Figure 13: Deaths per 1000 admissions comparative figures 2013/14 and 2014/15
(data source: Governance Support Unit)
In 2014/15 deaths per 1,000 admissions have remained at a very similar level to the previous year.
To make sure we learn any lessons about how we deliver the best care each death is individually
reviewed by the team who cared for the patient. In turn we then have a process where experienced
senior nurses review the reports produced by the clinical teams.
If it is felt there may be issues around quality of care which need further scrutiny a senior doctor
from another team will review the report and may recommend it is looked at by our Mortality
Review Committee.
20
Figure 14: PICU CUSUM monitoring (data source: PICANET)
We continue to monitor deaths on our PICU using the CUSUM method outlined in figure 24 above.
This is a statistical way of helping us identify unexpected deaths. Using the CUSUM method we
haven’t identified any systemic care failings on PICU which have contributed towards any of the
deaths.
Our PICU team also submits data to a database called PICANet which enables them to benchmark
our unit against other PICUs. This information continues to indicate we are well within the expected
range for deaths within our PICU given the range of conditions of the children and young people we
care for.
Figure 15: Cardiac Surgery CUSUM monitoring (data source: Cardiac Services CUSUM monitoring)
21
Our cardiac surgery team also uses a CUSUM methodology to analyse the deaths which occur under
their care. There continues to be no concern that any of the deaths in cardiac surgery were
avoidable in 2014/15. The team also submits data to the national Cardiac Clinical Audit Database
(CCAD) and use a further method called Variable Life Adjusted Display (VLAD) to look at mortality.
Using this method, outcomes continue to be better than expected given the complexity of the
children and young people the team treat.
What are we doing to improve?
We will continue to monitor mortality rates in a number of different ways to ensure that any
concerns are identified and that we learn from every death in case there was anything we could
have done differently.
Our clinical teams and safety team have been working hard in 2014/15 to make sure each death is
reviewed as quickly as possible. This is important as we want to learn any lesson on how we improve
care as quickly as we can and help families during this incredibly difficult time to know their child
received the best care possible.
Some of the most seriously ill children and young people we treat die while they are here at the
hospital despite the quality of care they receive. Some of the facilities we have for families at the
moment do not provide the privacy, dignity and peace families need as they try to deal with their
loss. In 2015/16 we therefore plan to build Magnolia House, a state-of-the-art, non-clinical facility
where we will be able to support families at the time they need it most.
We will report on our mortality rates again in our 2015/16 Quality Account.
22
STATEMENTS OF ASSURANCE ON THE QUALITY OF OUR SERVICES
Review of Services
During 2014/15 Birmingham Children’s Hospital NHS Foundation Trust provided and/or subcontracted 37 NHS services.
Birmingham Children’s Hospital NHS Foundation Trust has reviewed all the data available to them on
the quality of care in all of these NHS services.
The income generated by the NHS services reviewed in 2014/15 represents 100 per cent of the total
income generated from the provision of NHS services by Birmingham Children’s Hospital NHS
Foundation Trust for 2014/15
Participation in Clinical Audit and National Confidential Enquiries
During 2014/15, nine national clinical audits and one national confidential enquiry covered NHS
services that Birmingham Children’s Hospital NHS Foundation Trust provides.
During 2014/15 Birmingham Children’s Hospital NHS Foundation Trust participated in 100% of the
national clinical audits it was eligible to participate in.
In relation to the one national confidential clinical enquiry Birmingham Children’s Hospital NHS
Foundation Trust had no relevant cases to submit.
The national clinical audits and national confidential enquiries that Birmingham Children’s Hospital
NHS Foundation Trust was able to participate in actually participated in and for which data collection
was completed during 2014/15 are listed below alongside the number of cases submitted to each
audit or enquiry as a percentage of the number of registered cases required by the terms of that
audit or enquiry.
Table 2: National Clinical Audits and National Confidential Enquiries 2014/15 – eligibility, relevance,
participation and percentage cases submitted
NATIONAL CLINICAL AUDITS AND NATIONAL CONFIDENTIAL ENQUIRIES IN WHICH THE TRUST
WAS ELIGIBLE TO PARTICIPATE IN 2014/15
Audit
Relevant
Participation
% Cases
submitted
Childhood epilepsy (RCPH National Childhood Epilepsy
Audit)
Paediatric intensive care (PICANet)
Paediatric cardiac surgery (NICOR Congenital Heart Disease
Audit)
Diabetes (RCPH National Paediatric Diabetes Audit)
Inflammatory Bowel Disease (IBD)
Cardiac arrhythmia (Cardiac Rhythm Management Audit)
Renal replacement therapy (Renal Registry)
Severe trauma (Trauma Audit & Research Network)
Mental Health programme: National Confidential Inquiry
into Suicide and Homicide for people with Mental Illness
(NCISH)
Yes
Yes
100%
Yes
Yes
Yes
Yes
Ongoing
100%
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
100%
60%
100%
100%
100%
No cases
were
relevant to
submit in
2014/15
23
The reports of 9 national clinical audits were reviewed by the Trust in 2014/15 and the Trust intends
to take the following actions to improve the quality of healthcare provided:
Inflammatory Bowel Disease (IBD):
Improve the audit participation (although BCH is the leading participant in the country
already)
We have started collecting Quality of Life Scores for the IBD patients
The reports of 58 local clinical audits were reviewed by the Trust in 2014/15 and the Trust intends to
take the following actions to improve the quality of healthcare provided:
Pain at home after daycase surgery:
Regular use of analgesics (maximum dose) according pain ladder advised for more painful
procedures and increased parental education.
ECG changes and cardiac manifestations in patients with organic academia:
Undertake regular holter monitoring.
Heart Valve Bank – SOP 22 (Issuing Tissue Externally):
Current paperwork and checklist updated for the process and relevant standard operating
procedure updated.
Number of missed/omitted doses of core drugs on Paediatric Intensive Care:
Doctors prompted to avoid prescribing medicines within shift changeover times to avoid
missed doses;
Introduction of antibiotics in pre-packed syringes to reduce preparation delays;
Education of all staff in the importance of reporting medication errors.
Management of children with Congenital Adrenal Hyperplasia (CAH):
Guidelines drafted for the management of CAH in infancy.
Monitoring drug treatment in ADHD:
Growth charts placed in patient notes and updated;
Blood pressure centile charts placed in all notes;
Purchase of a suitable sphygmomanometer with a small cuff for younger children.
Appropriateness of non-medical requesters in Radiology:
Radiology has updated requesters list to reflect Advance Nurse Practitioners requesting
radiology examinations.
24
Participation in Clinical Research
The number of patients receiving NHS services provided by Birmingham Children’s Hospital NHS
Foundation Trust that were recruited during that period to participate in research approved by a
research ethics committee was 1047
Figure 16: Participation in clinical research. Number of patients recruited into research approved by a research ethics
committee 2010/11 – 2014/15
Use of the CQUIN Framework
A proportion of Birmingham Children’s Hospital NHS Foundation Trust’s income in 2014/15 was
conditional upon achieving quality improvement and innovation goals agreed between Birmingham
Children’s Hospital NHS Foundation Trust and any person or body they entered into a contract,
agreement or arrangement with for the provision of NHS services, through the Commissioning for
Quality and Innovation (CQUIN) payment framework.
Further details of the agreed goals for 2014/15 and for the following 12 month period are available
electronically at http://www.england.nhs.uk/wp-content/uploads/2014/02/sc-cquin-guid.pdf
The value of the CQUIN schemes is the equivalent of 2.5% of contract income, the table shows this
calculated for planned income.
Table 3: Schemes agreed for Commissioning Quality and Innovation (CQUIN) framework 2014/15
CCGs
Goal
1a
1b
2a
2b
3
4
5
Goal Name
FFT - Implementation of Staff FFT
FFT - Early Implementation
FFT - Increased or Maintained Response
Rate (ED)
FFT - Increased or Maintained Response
Rate (Inpatients)
SCAN - Paediatric Safety Thermometer
Demonstrating Improvement through
Organisational Learning
Reducing medicines related risk
Weight
Value
Value of
income lost
0
0
£20,303
£81,212
£174,026
End of year
performance
All targets met
All targets met
Q2 , Q3 & Q4
targets met
Q2, Q3 & Q4
targets met
All targets met
All targets met
7%
7%
4%
£81,212
£81,212
£40,606
4%
£40,606
7%
15%
15%
£174,026
All targets met
0
£20,303
0
0
25
6
7
8
9
Total
Learning from Safeguarding Concerns
Public Health - Obesity
Public Health - Healthy Hospital
Public Health - MECC
15%
10%
7%
10%
100%
£174,026
£116,017
£81,212
£116,017
£1,160,170
All targets met
All targets met
All targets met
All targets met
0
0
0
0
£40,606
Weight
Value
6%
6%
3%
£209,751
£209,751
£104,875
End of year
performance
All targets met
All targets met
All targets met
Value of
income lost
0
0
0
3%
£104,875
All targets met
0
6%
19%
25%
19%
6%
0%
6%
£209,751
£629,253
£839,004
£629,253
£209,751
£0
£209,751
All targets met
All targets met
All targets met
All targets met
All targets met
All targets met
All targets met
0
0
0
0
0
0
0
100%
£3,356,015
0
£4,516,185
£40,606
NHSE
Goal
Goal Name
1a (i)
1a (ii)
1a
(iii)
1a
(iv)
1b
2
3
4
5
6
7
FFT - Implementation of Staff FFT
FFT - Early Implementation
FFT - Increased or Maintained Response
Rate (ED)
FFT - Increased or Maintained Response
Rate (Inpatients)
FFT - Mental Health
SCAN - Paediatric Safety Thermometer
PIC - unplanned readmissions (WC7)
Cancer MDT
CAMHS 1 - Improving Physical Healthcare
Clinical Utilisation tool
CAMHS: Assuring appropriateness of
unplanned admissions (MH17)
Total
Grand Total
The monetary total for the amount of income conditional upon achieving CQUIN goals in 2014/15
and the monetary total for the associated payment in 2013/14 are detailed below:
Table 4: CQUIN income data 2013/14 and 2014/15
2013/14
2014/15
Total value of CQUIN targets (based on planned income)
£4,582,127
£4,516,185
Income not achieved
£0
£40,606
% of income not achieved
0%
0.9%
Care Quality Commission
Birmingham Children’s Hospital NHS Foundation Trust is required to register with the Care Quality
Commission (CQC). Its current registration status is Green without any conditions.
Registered to carry out the following legally regulated services:
Transport services, triage and medical advice provided remotely
Treatment of disease, disorder or injury
Assessment or medical treatment for persons detained under the Mental Health Act 1983
Surgical procedures
Diagnostic and screening procedures
Management of supply of blood and blood derived products
26
The Care Quality Commission has not taken enforcement action against Birmingham Children’s
Hospital NHS Foundation Trust during 2014/15.
Birmingham Children’s Hospital NHS Foundation Trust has not participated in special reviews or
investigations by the Care Quality Commission during 2014/15.
Data Quality
Birmingham Children’s 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:
99.07% for admitted patient care;
99.38% for outpatient care;
98.85% for accident and emergency care.
The percentage of records in the published data which included the patient's valid General
Practitioner Registration Code was:
96.94% for admitted patient care;
97.52% for outpatient care;
97.53% for accident and emergency care.
Birmingham Children’s Hospital NHS Foundation Trust’s Information Governance Assessment Report
overall score for 2014/15 was 83% and was graded green (satisfactory).
Birmingham Children’s Hospital NHS Foundation Trust was subject to the Payment by Results clinical
coding audit during the reporting period by the Audit Commission and the error rates reported in
the latest published audit for that period for diagnoses and treatment coding (clinical coding) were:
Table 5: Payment by results coding audit 2014/15 - % coding errors rates
Diagnoses
% Error rate
Treatment (procedure)
Primary
Secondary
Primary
Secondary
9.5%
6.3%
3.6%
11.3%
196 cases (spells) were reviewed within the sample.
The local focus for this sample of 196 spells was Orthopaedics/Hand and Upper Limb Services and
Paediatric Surgery/Gastroenterology.
Birmingham Children’s Hospital will be taking the following actions to improve data quality:
Training at the West Midlands Clinical Coding Academy has been made available for each
clinical coder and will continue to be available in 2015;
27
Clinicians have been reminded of the importance of completing a KMR1 form postoperatively/post procedure;
The coding policy and procedure document has been updated by the Clinical Coding
Manager;
A reminder system has been put in place in clinical coders’ diaries to prompt checking of
histology results
A comments section has been added to the Lorenzo patient information coding screen to
note if any changes have been made at clinical specialty coding validation meetings.
Note: the results of the audit should not be extrapolated further than the actual sample audited.
Performance against National Priorities
Table 6: Performance against National priorities 2014/15
National Priority
Target
Performance 2014/15
C-Diff
0 cases per year - locally agreed
threshold
1 case or less per year - locally agreed
threshold
Pre 48 hours
Target met – no cases
Post 48 hours - 10% reduction
Target met
Surgery (94%)
100%
Anti cancer drug treatments (98%)
100%
Radiotherapy (94%)
N/A
From GP referral to treatment (85%)
89% (this equates to 8.5 out 9.5
patients. 0.5 indicates
Birmingham Children’s Hospital
saw the patient for their first
appointment and another
provider gave treatment).
From consultant screening service
referral (90%)
100%
MRSA
MSSA
All cancers; 31 day wait for
second or subsequent
treatments
All cancers: 62 day wait for
first treatment
All cancers: 31 day wait from
diagnosis to first treatment
(96%)
All cancers: two week wait
from referral to date first
seen (93%)
Total time in A&E
18 weeks
18 week RTT (patients on an
Target met – no cases
Monitoring only (but reduced)
98%
100%
95% of patients’ time taken from arrival
to discharge/admission < 4 hours.
95.15%
90% admitted patients at the end of
each month
95% non admitted patients at the end of
each month
90.4%
95.6%
92.29%
28
incomplete pathway)*
Single Sex Accommodation
Breaches
Emergency Readmissions
Operations cancelled on the
day by the hospital
Cancelled operations and
those not admitted within 28
days
Certification against
compliance with
requirements regarding
access to healthcare for
people with a learning
disability
0 breaches
0 breaches
Emergency readmissions within 28 days
of discharge from hospital as a % of all
relevant admissions.
<=0.8% each quarter across the year
9.2%
Readmit >95% of those patients we
cancel within 28 days
Target achieved > 95% in all
quarters 2014/15
1.63%
Fully compliant
18 weeks RTT (patients on an incomplete pathway
Unknown clock starts
The Trust is required to report performance against three indicators in respect of 18 week Referralto-Treatment 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.
Under the rules for the indicators, the Trust is required to report performance against the 18 week
target for patients under its care, including those referred on from 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.
Although providing this information is required under the national RTT rules, and there is a standard
defined Inter Provider Administrative Data Transfer Minimum Data Set to facilitate sharing the
required information, 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
29
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.
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.
The absence of timely sharing of data by referring providers impacts the Trust’s ability to monitor
and manage whether patients affected are receiving treatment within the 18 week period set out in
the NHS Constitution, and requires significant time and resource for follow-up.
Data assurances and actions for improvement
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 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
Undertaking sample audits in the form of cross checks between RTT teams
Core National Indicators
Due to the time it takes central bodies to collate and publish some of the data, sometimes
comparative figures are not available at all (N/A). It should also be appreciated that some of the
‘Highest’ and ‘Lowest’ performing Trusts on some of the data may not be directly comparable to
Birmingham Children’s Hospital.
There are several core national indicators that are not applicable to Birmingham Children’s Hospital,
because they relate to adult patients/services only, or due to the specialist nature of many of our
services.
Hospital Readmissions: The percentage of patients readmitted to Birmingham Children’s Hospital
within 28 days of being discharged in 2014/15
The Health and Social Care information Centre has advised that the publication of emergency
readmissions to hospital within 28 days of discharge indicators has been delayed this year while
their production is brought in-house from an external contractor.
The table below therefore outlines Birmingham Children’s Hospitals performance relating to
readmissions in2013/14 and 2014/15 broken down by 0-14 and 15 and over age ranges
30
Age Group
0-15
Readmissions
1774
FCE’S
18302
%
9.7%
16 or over
105
1051
10.0%
All ages
1879
19353
9.7%
0-15
16 or over
All ages
1667
73
1740
17944
1031
18975
9.3%
7.1%
9.2%
2013/14
2014/15
Our 2014/15 28 re-admission rate is also outlined in table 6 ‘performance against core national
indicators’.
Birmingham Children’s Hospital NHS Foundation Trust considers this data as prescribed for the
following reason:
Readmissions continue to be monitored on a specialty by specialty basis to identify any areas of
concern. No specific areas of concern have been identified in 2014/15. Birmingham Children’s
Hospital plans to take the following actions to improve the quality of its services: we will continue to
monitor readmissions on a specialty by specialty basis and investigate any areas of concern.
Staff Survey: Percentage of staff who would recommend the Trust to family or friends
BCH 2013
BCH 2014
2014 Specialist Acute
Trust Average
2014
Specialist
Acute Trust
Lowest
2014 Specialist Acute
Trust Highest
84%
89%
89%
73%
93%
Birmingham Children’s Hospital NHS Foundation Trust considers that this percentage is as described
for the following reason:
We are pleased to note our score has improved since 2013 and ranks with the average for the
Specialist Acute Trusts in 2014.
Birmingham Children’s Hospital plans to take the actions outlined on previous pages of the Quality
Account (under Staff Survey indicators) to improve the quality of its services.
C.difficile: rate per 100,000 bed days of cases of C.difficile infection reported within the Trust
amongst patients aged 2 or over
BCH
2013/14 –
whole Year
BCH
2014/15- whole
year
2014 National trust
Average*
2014
Highest Trust*
2014
Lowest Trust*
0
0
13.9
37.1
0.0
*Latest available comparative data from the HSCIC Information portal
31
Birmingham Children’s Hospital NHS Foundation Trust considers that this rate is as described for the
following reason:
The information above is based on the latest available data from the HSCIC information portal which
covers January to March 2014.
In 2014/15 we had no cases of C.difficile at Birmingham Children’s Hospital.
Birmingham Children’s Hospital intends to take the following action to improve this rate and so the
quality of it services by continuing to enforce actions which are contributing to zero rate of
infections.
Patient Safety Incidents: the number and rate of patient safety incidents reported, and the
number and percentage of such patient safety incidents that resulted in severe harm or death:
Number of patient
safety incidents
(acute specialist)
Rate of patient
safety incidents
per 1000 bed days
(acute specialist)
Number and % of
patient safety
incidents reported
as resulting in
severe harm
Number and % of
patient safety
incidents reported
as resulting in
death
1st October
2013 -31st
March
2014
1st April 2014
– 30th
September
2014*
BCH
BCH
1st October
2014-31st
March
2015
1st October
2013 -31st
March 2014
1st April 2014 –
30th September
2014
NRLS Cluster
(Acute
Specialist)
Median
Average*
NRLS Cluster
(Acute
Specialist)
Median
Average*
820.5
1,285
29.6
1,556
35.92
1,584
30.0
Lowest: 119
Highest: 2,619
31.0
35.92
Lowest: 13.4
Lowest: 17.63
Highest: 82.9
Highest: 94.84
2 (0.1%)
6 (0.4%)
Lowest: 0
(0%)
Highest: 26
(2.2%)
7 (0.5%)
17 (1.1%)
Lowest:85
Highest:
1,985
0.5 (0.1%)
3 (0.2)%
758.5
0 (0%)
2 (0.25%)
Lowest: 0 (0%)
Highest: 24
(1.8%)
0(0%)
0 (0%)
Lowest: 0
(0%)
Lowest: 0 (0%)
Highest: 7
(0.5%
Highest: 17
(1.1%)
*Latest available comparative data from the HSCIC Information portal
32
Birmingham Children’s Hospital NHS Foundation Trust considers that this rate is as described for the
following reason:
At BCH we report any death which is unanticipated or requires the activation of an arrest call/CPR as
an incident. Whilst the impact is recorded as ‘death’ this does not typically represent a causal link to
a patient safety incident. As there is not a nationally established and regulated approach to
reporting and categorising patient safety incidents, different trusts may choose to apply different
approaches and guidance to reporting, categorisation and validation of patient safety incidents.
Birmingham Children’s Hospital NHS Foundation Trust intends to take/has taken the following
actions to improve this number and/or rate, and so the quality of its services, by:
We investigate and learn from every incident;
We take actions to address safety issues identified through safety monitoring and analysis;
We carry out an annual safety culture survey of our clinical staff;
We carry out regular audits of incident reports to identify any staff groups, wards or
departments that may not be reporting all incidents;
A lower than expected number of reported incidents is one of the measures we use to
identify possible issues on wards or departments through our Safety Dashboard;
We run a Safety Hotline which trainee doctors can use to report any safety concerns and
obtain advice;
We run an advice service specifically for trainee doctors (Trainee Advice and Liaison Service
– TALS), which mirrors the processes of our Patient Advice and Liaison Service (PALS);
Implementation of actions arising from reviews of incidents is robustly monitored;
Incidents are analysed to identify themes and significant safety issues.
STATEMENTS FROM STAKEHOLDERS
Birmingham Health Overview and Scrutiny Committee
Birmingham Health Overview and Scrutiny Committee have declined to provide a statement relating
to the 2014/15 Quality Account.
Healthwatch Birmingham
It is with pleasure that Healthwatch Birmingham has reviewed Birmingham Children’s Hospital NHS
Foundation Trust 2014-15 quality account.
Firstly, we would like to praise the honesty and openness of the report, there appears to be an open
and learning culture within the hospital. We are pleased to read about the Trust implementing SAFE
huddles, we believe that these initiatives will increase patient care and communication between
staff. The sharp reduction in pressure ulcers was also pleasing to read (from 20% - 0.3%) and the
hospital has been extremely effective in this area. Healthwatch Birmingham is also pleased to see
33
that Nursing Care Quality Indicators all scored extremely high and the Trust has performed well in
each indicator with pain and skincare indicators performing particularly well.
It was pleasing to see that staff view the care of patients is the Trust top priority and see this figure
increase year on year since 2010. However it was disappointing to read that only 43% of staff
completed the staff survey, a 16% decrease on last year. We would urge the Trust to engage with
staff to ensure a higher completion rate so that the Trust can gain a fuller picture.
We are pleased to see that waiting times for MRI scans have overall reduced. However we are
concerned that waiting times are increasing again but we fully support the measures that you have
put in place to improve waiting times. Similarly, upon reviewing the figures for cancelled operations,
we are disappointed to read that the Trust has not met its annual target for cancelled operations
and it still remains the Trust’s biggest challenge. On this basis, we would like to see this improved as
a priority next year. We are pleased to read about increasing bed capacity and the launching of the
Critical Care Programme. We hope that patient’s will be part of this process and look forward to
reading about their involvement.
PLACE inspections were also slightly below the national average. Nutrition also appears to be a
source of concern with patients feeding back that food requires improvement with a 13% increase
on last year. We welcome your actions to improve nutrition and food within the Hospital; we will
look with interest to see these improved next year.
Feedback from patients throughout the year has been positive overall – particularly in the areas of
quality of care, staff attitudes and cleanliness. We commend the Trust for their work in this area.
Thank you for giving us the opportunity to review the Trust’s Quality Account.
Candy Perry
Interim Director, Healthwatch Birmingham.
15th May 2015
Council of Governors
The Council of Governors is pleased to review and comment on Birmingham Children’s Hospital NHS
Foundation Trust’s Quality Account 2014/15.
The Account this year is more concise than in previous years and covers only those matters deemed
mandatory by the Department of Health and Monitor. The Council agreed to this approach. The
Council are aware that the Trust proposes to prepare ‘talking head’ videos again this year (which can
be accessed via the Trust website) to demonstrate how they assess the quality of services they
deliver and how they are committed to continuous evidence based quality improvement. The
approach of using written evidence and social media will ensure that information regarding the
quality of Trust services is delivered to the widest possible audience.
Overall, the Council are content that the Account focuses appropriately on the performance of the
Trust against its key priorities. The Council are pleased that the Trust continues to be transparent
about where it has not met its objectives. The Account provides a thorough and well balanced view
of safety, patient experience and clinical effectiveness. We consider it accurately reflects the
experience of the Council throughout the year via our overview of quality and performance
34
information, such as quality and performance reports, and the various walkabouts we have
undertaken.
The Council are obviously concerned that the Trust is not meeting its objectives in relation to the
length of MRI waits, cancelled operations and the quality of food, which all impact on patient
experience. The Trust data in respect of cancelled operations and waiting times for MRI scanning
shows how creating capacity to meet predicted demand remained a significant challenge against a
backdrop of exceptional demand in 2014/15.
The Council have looked closely at food provision this year. We have undertaken a food quality
walkabout, spoken directly to patients about their experiences and scrutinised our service providers.
We identified that the Trust faces particular difficulties as our patient population are children.
Children do not necessarily like food that is good for them! We agree that the Trust needs to remain
committed to the provision of healthy meals but must work with the patients to improve
satisfaction. Food is an incredibly important component in helping our patients to get better more
quickly and we are content that the Trust is doing its best to identify the difficulties, such as the
speed of delivery from production, and look at best practice from other organisations, technology
and human factors to produce improvements. We have challenged those responsible for the service
to make improvements over the coming year and we will review the feedback next year to ensure
that improvements are being made.
The Council are aware that the Trust is disappointed not to have achieved the results they have
striven for despite their hard work in relation to the few objectives that have not been met. The
Council note the comprehensive action plans in place to address these issues and are confident that
improvements will be made. We will review progress over the coming year.
The Trust continues to invest a considerable amount of resource in looking after its most valuable
asset – its staff – by promoting staff engagement, listening and communication. The Council do not
think that the Account reflects the full extent of the fantastic work that has been undertaken in this
area given the limited scope of the Account this year. The Council would like to highlight that they
have been delighted by some of the innovative ways in which the culture of openness and
transparency has continued to be promoted within the Trust, such as the staff experience team, the
creation of a cultural ambassador post and a variety of initiatives around team making / playing. The
staff survey indicators have shown improvement this year and this continues to be a priority. With
resources being ever more stretched and the demands being placed on the staff being ever greater,
it is vital that the trust invest in their well-being.
The Trust has continued their commitment to capturing the views of the patients in multiple ways,
such as via the patient feedback app, and acting on the information received as quickly as possible.
These are challenging times for the Trust and the NHS as a whole. Demand for our services continues
to grow and we have important decisions to make in respect of our future estate. The Governors are
confident that the Trust has the strong leadership and financial control necessary to be in a good
position to plan for the future without affecting safety, patient experience and clinical effectiveness.
Indeed, we are confident that the leadership within the Trust will make improvements in its
performance indicators over the course of the year.
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Council of Governors of Birmingham Children’s Hospital NHS Foundation Trust
14th May 2015
Birmingham South Central Clinical Commissioning
Birmingham South Central Clinical Commissioning Group (BSC CCG), as coordinating commissioner
for Birmingham Children’s Hospital NHS Foundation Trust (BCH), welcomes the opportunity to
provide this statement for their 2014/15 Quality Account.
A draft copy of the Quality Account was received by BSC CCG on the 24th April 2015 and the
statement has been developed from the information presented to date. Feedback on the draft
account has also been received from Birmingham Cross City CCG and NHS England Area Team,
including specialised commissioning.
We have reviewed the content of the Quality Account and confirm that it complies with the
prescribed information, format and content as set out by Monitor and NHS England. The information
provided within this account is, to the best of our knowledge, accurate and fairly interpreted.
The account captures progress made by the Trust in 2014/15, identifies where further improvement
is required and details the actions needed to achieve these goals. We support the priorities set for
this year and recognise the areas identified by the Trust where more focus is required.
The number of cancelled operations and waiting times for MRI scans continue to present the Trust
with significant challenge despite the focus on these areas throughout the year. Moving forward
these will remain a key priority in 2015/16 for improvement. We are working closely with BCH and
NHS West Midlands England to monitor the effectiveness of initiatives being implemented to
address these issues. In particular, there is focus on the impact of these waits on patient safety and
patient experience.
The report clearly reflects that the Trust is a learning organisation that is continually striving to
improve the quality of care across its services, with an open and transparent culture in place. This is
particularly evident through the innovative methods of capturing real time feedback from children,
young people and families, with examples of how this experience continues to drive improvement.
We welcome the continued focus on improving patient safety and recognise the positive steps that
are being taken. The Trust has introduced two new projects to improve further the prevention of
children and young peoples’ clinical condition deteriorating. The first of these involves the use of
‘safety huddles’ where clinical team get together twice a day to brief each other, making sure that
the child’s condition has been assessed and that the plan of care is appropriate. The initiative is
being tested on the Paediatric Assessment Unit with plans to introduce a ‘whole hospital huddle’.
The second project RAPID (Real-Time Adaptive Predictor Indicator of Deterioration) supports the
child and young people safety thermometer as a predictor of deterioration. The project uses wireless
sensors to monitor vital signs to better predict when a child may be deteriorating to avoid them
going into cardiac arrest. We will continue to monitor the progress of these and other current safety
initiatives throughout the year.
Over the past year the Trust has reported one serious incident classified as a “Never Event”. The CCG
attended the root cause analysis meetings for this incident and received assurance that learning has
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been identified and robust actions put in place in order to prevent recurrence of these types of
incident. Updates on progress against the action plan and dissemination of learning will be received
at the CCG / BCH Clinical Quality Review Group (CQRG) meetings.
We have made some specific comments to the Trust directly in relation to the quality account which
we hope will be considered as part of the final document. These include; addition of supporting
narrative and data related to complaints, the management of Serious Incidents, staff survey
responses and other quality data and inclusion of further information on CQUIN outcomes. It would
be helpful to see some evidence of benchmarking performance against other Children’s hospitals to
include mortality rates, for example, in cardiac surgery. Safeguarding issues are not covered
sufficiently within this Quality Account; it would be helpful to include some narrative to support the
work being done, including the number of staff who have received safeguarding and deprivation of
liberty training during the year.
Through this quality account and the ongoing quality assurance process, BCH have demonstrated
their commitment to continually improve the quality of services provided to children, young people
and families. As coordinating commissioner, we look forward to continuing to work in partnership
with the Trust and supporting them to deliver these quality priorities.
Dr Raj Ramachandram
Chair – Birmingham South Central Clinical Commissioning Group Quality and Safety Committee
22nd May 2015
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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 2010 as amended 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-March 2015;
o Papers relating to quality reported to the Board over the period April 2014-March
2015;
o Feedback from the commissioners dated 22nd May 2015;
o Feedback from governors dated 14th May 2015;
o Feedback from Birmingham Healthwatch dated 15th May 2015
o The national staff survey 2014;
o The Head of Internal Audit’s annual opinion over the trust’s control environment
received at Audit Committee 28th April 2015;
o CQC Intelligent Monitoring Reports 2014/15
The Quality Report presents a balanced picture of the NHS Foundation Trust’s performance
over the period covered;
the performance information reported in the Quality Report is reliable and accurate;
there are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Report, and these controls are subject to review to
confirm that they are working effectively in practice;
the data underpinning the measures of performance reported in the Quality Report is robust
and reliable, conforms to specified data quality standards and prescribed definitions, is
subject to appropriate scrutiny and review; and the Quality Report has been prepared in
accordance with Monitor’s annual reporting guidance (which incorporates the Quality
Accounts regulations) (published at www.monitor-nhsft.gov.uk/annualreportingmanual) as
well as the standards to support data quality for the preparation of the Quality Report
(available at www.monitor-nhsft.gov.uk/annualreportingmanual)).
The Directors confirm to the best of their knowledge and belief they have complied with the above
requirements in preparing the Quality Report.
By Order of the Board
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Dame Christine Braddock, Chairman
Sarah-Jane Marsh, Chief Executive
21st May 2015
How we have engaged people in setting priorities for improving quality
Foundation Trust Governors
At quarterly meetings Governors are provided with our Quality Report, Resources Report and
information on Trust developments.
Each Governor receives a copy of the papers from each public Board of Directors meeting.
Governors take part in scheduled Quality Walkabouts.
At meetings of the Council of Governors, governors take part in additional Quality Walkabouts
and visit new developments to better understand the Trust’s services and the issues that are
important to patients, families and staff.
Twice a year we hold a joint meeting between the Council of Governors and the Board of
Directors to consider the future strategy of the Trust and developments within the Trust and the
NHS which are relevant to the Trust’s strategy.
The Governors Scrutiny Committee is an active sub-committee of the Council of Governors which
provides a forum for more detailed debate and challenge on quality and resources issues and
strategic developments.
The Governors selected one of the quality indicators for review by the External Auditor and also
asked for another indicator to be audited additional to Monitor’s requirements.
Our Staff
Our Quality Walkabouts involve engagement with staff as well as patients and families.
Surveys, including the national annual Staff Survey and our own Staff Safety Survey.
Regular staff polls.
Staff attendance at public Board meetings.
Chief Executive Briefings.
Our New ‘in-Tent 2 listen’ staff events.
Our patients and families
Quality Walkabouts.
PLACE assessments.
Direct patient feedback through feedback cards, feedback app and other means.
Patient stories which accompany reports to the Board to help bring issues to life.
Focus Groups on particular issues.
Mystery Shoppers.
Taking account of concerns raised through formal complaints and the PAL Service.
Surveys and consultation on potential new developments.
Parent representatives on the Learning Disabilities Steering Group.
Feedback from CAMHS parents and young people by way of an exit interview (Chi Esq).
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How to provide feedback on the Quality Report
Despite the improvements in the quality of services we have seen over the last year, we know we’re
always learning about how things can be done even better.
At the heart of everything we do are our patients, their families and the communities that we serve.
That’s why we’re always interested in hearing from you – whether you have a suggestion on how we
can provide care more innovatively, or whether you had an experience you think we could improve
on.
We actively encourage people to get in touch and stay in touch with us, so if you have any ideas
about how we could make this Quality Account even better we’d like to hear from you.
To tell us about what you think, please contact our Communications Department on:
 0121 333 8535
 communications.department@bch.nhs.uk
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