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Contents:
Part 1: ...........................................................................................................................................
Statement on Quality from the Chief Executive ........................................................................... 4
Part 2: ......................................................................................................................................... 5
2.1 Priorities for improvement ..................................................................................................... 5
Review of the priorities for 2014/15............................................................................................. 5
Priorities for the coming year .................................................................................................... 17
2.2 Statements of Assurance from the Board ........................................................................... 23
Income and contracts ............................................................................................................... 23
Participation in Clinical Audit..................................................................................................... 23
Participation in clinical research ................................................................................................ 28
Use of the CQUIN payment framework ..................................................................................... 29
Statements from the Care Quality Commission (CQC) ............................................................. 32
Data Quality .............................................................................................................................. 33
2.3 Reporting against core indicators ........................................................................................ 36
Part 3: Overview of Quality ....................................................................................................... 39
Patient Safety Indicators: .......................................................................................................... 39
Mortality .................................................................................................................................... 39
Healthcare Associated Infections .............................................................................................. 40
Medication errors ...................................................................................................................... 42
Falls .......................................................................................................................................... 42
Incidents ................................................................................................................................... 43
Clinical Effectiveness Indicators:............................................................................................... 46
Readmission rates .................................................................................................................... 46
Cancelled Operations ............................................................................................................... 46
Emergency and Urgent Care .................................................................................................... 47
Patient Experience Indicators: .................................................................................................. 47
Inpatient Experience ................................................................................................................. 47
Emergency Department Patient Experience- ............................................................................ 49
Friends and Family Test ........................................................................................................... 49
2
Delivering Same Sex Accommodation ...................................................................................... 50
Patient Reported Outcome Measures (PROMs) ....................................................................... 50
Complaints ............................................................................................................................... 52
Compliments ............................................................................................................................ 53
Additional Quality Overview ...................................................................................................... 54
Implementing guidance from the National Institute for Health and Care Excellence (NICE) ...... 54
Overview of maternity services ................................................................................................. 54
Overview of cancer services ..................................................................................................... 56
Workforce ................................................................................................................................. 58
The Environment ...................................................................................................................... 62
Approach to Delivering Quality and Service Improvement ........................................................ 64
Annex 1: Statements from commissioners, local Healthwatch organisations and Overview and
Scrutiny Committees................................................................................................................. 66
Annex 2: Statement of Directors’ responsibilities for the Quality Report .................................... 70
Annex 3 - Independent Auditors' Limited Assurance Report……………………………………...72
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Part 1:
Statement on Quality from the Chief Executive
I am very pleased to introduce our Quality Account for 2014/15 which gives information on our
achievements over the past year as well as our priorities for the coming year.
I hope that the Quality Account provides reassurance for local people, patients and their families,
stakeholders and the staff of our Trust that we are committed to continuously improve the high
quality patient care and services that we provide.
During the year we have continued to make progress in obtaining, responding to and acting on
feedback from patients about their experiences at Burton Hospitals. It is our firm intention to learn
from both negative and positive feedback submitted through channels such as the NHS Choices
website and the national Friends and Family Test as well as from peer reviews and national and
local patient surveys.
Our priorities for 2014/15 were underpinned by our Quality Strategy 2013-15, and have seen us
continue to provide services that are consistently safe and effective with a focus on improving the
experiences of our patients.
I am pleased with the quality improvements that we have made this year, which include; the
development of our Ward Assurance Framework, which measures essential nursing care and now
includes day-case services such as the Treatment Centre and the Renal Unit, the introduction of an
innovative patient information monitoring tool which has helped us to reduce pressure ulcers to a
point that we now benchmark better than the national average, and the introduction of an improved
falls risk assessment tool and the launch of our new dementia strategy.
Our priorities for 2015/16, agreed by the Board of Directors following extensive consultation with
patients, staff, stakeholders and members of the public, are:
1) To reduce avoidable harm across the Trust with a particular focus on sepsis, acute kidney
injury (AKI) and catheter associated urinary tract infection (CAUTI)
2) To ensure that our workforce is sufficient in number and equipped with an appropriate level
of knowledge and skills to provide consistently safe and effective care for our patients.
3) To improve patient experience by ensuring a ‘Warm Welcome’ is consistently provided for
our patients
In the past 12 months, the CQC has undertaken one planned visit, combined with an unannounced
visit, to carry out a comprehensive inspection. A subsequent report was received and the Trust has
developed a comprehensive action plan, with support from both senior clinicians and managers, to
address areas identified as requiring improvement in readiness for an inspection expected in early
July 2015.
I am happy to confirm that, to the best of my knowledge, the information contained within this
document is accurate. The Board of Directors at Burton Hospitals NHS Foundation Trust has agreed
the content of this Quality Account and approved the document for publication.
Helen Ashley
Chief Executive - 28 May 2015
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Part 2:
2.1 Priorities for improvement
Developing the Quality Account
The Quality Account reports annually on the quality of services delivered by NHS healthcare
providers to the public. The primary purpose of this document is to allow the Trust to
demonstrate commitment to the delivery of continuous, evidence-based quality care, and to
explain the Trust’s progress over the past year against the priorities identified within the Trust’s
2013/14 Quality Account.
A variety of engagement events took place during 2014/15 with both external stakeholders and
internal staff groups to provide feedback on the Trust’s services. The Trust’s aim going forward
into 2015/16 is to continue to embed the 2013-15 Quality Strategy and to develop this further,
introducing a new Quality Improvement Strategy for 2016 and beyond, to ensure the Trust’s
quality objectives continue to focus on current healthcare priorities.
The quality priorities chosen for the forthcoming year are important to the Trust’s entire service
portfolio and therefore seek to support quality improvement across all sites.
Review of the priorities for 2014/15
The following section reviews the priorities for quality improvement that were identified last year
and provides a summary of the progress towards their achievement:
Priority 1:
Fully embed the Trust’s Quality Strategy across the organisation ensuring that essential
patient care is consistently safe, effective, positively experienced and delivered to a high
standard for all people using our services.
The Trust has further developed our Ward Assurance Framework, originally introduced in April
2012, to provide assurance that essential nursing care is delivered to a high standard. The
Framework now includes specifically tailored audits to measure quality in specialist areas such
as the Emergency Department, Acute Assessment Centre, Maternity and Paediatrics and has
been expanded to include non-ward-based areas such as the Treatment Centre and the Renal
Unit at Samuel Johnson Hospital. Further developments are planned for the Oncology Unit,
Theatres and the Medical Day-case Unit
Board to Ward rounds continue, enabling the Board to have sight of the key issues in care
delivery and take the lead in developing an appropriate culture and climate to have open
discussions, with staff at all levels, about quality.
The Trust continues to measure real time patient experience, which provides an independent
snapshot of the patient experience on each ward, relating to the nine care elements measured.
In addition, the Friends and Family Test helps the Trust to gauge how likely patients and their
carers, as well as staff, are to recommend our services to their friends and family. Now, every
patient using Acute, Emergency, Maternity or outpatient services at the Trust is given the
opportunity to give feedback.
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In 2014 the Trust has successfully embedded its innovative SKINS Communication Tool which
has had a demonstrable impact on the reduction of avoidable, hospital acquired pressure
ulcers. The Tool was shortlisted for the Health Service Journal and Nursing Times national
patient safety awards.
The funnel chart depicted below has been taken from the NHS Safety Thermometer and
illustrates that Burton Hospitals NHS FT, when benchmarked against other NHS Trusts, are
performing better than expected in reported pressure ulcer prevalence; a measure of hospital
and community acquired pressure ulcers combined.
The run chart below demonstrates that there has been a significant improvement in hospital
acquired pressure ulcers since October 2013. We believe that this improvement is as a result of
a combination of factors including; improved reporting at ward level, improved validation of
incidents by the Tissue Viability Team, an investment in pressure relieving equipment,
investment in training for Tissue Viability Champions at ward level and the introduction of the
innovative SKINS communication tool to help alert staff when concerns arise in relation to the
national SKINS care bundle which consists of:





Skin assessment – nurses and care staff must regularly monitor patient skin for
signs of deterioration
Keep moving – patients are encouraged to reposition themselves where possible
but are assisted by nurses and care staff where necessary
Incontinence – assessments are carried out to ensure a patient’s continence needs
are met
Nutrition – patients are assessed and referred to specialist services where required
Surface – nurses and care staff ensure patients are nursed on an appropriate
mattress, their sheets are dry and free from obstruction/wrinkles
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We are also proud of our achievements relating to patient falls. The Trust has reviewed its falls
risk assessment tool to reflect the NICE Guidance (2013) in relation to falls. The new tool is a
functional assessment tailored to the individual’s need which is supported by a care plan and
care bundle. In addition, we have also devised a medication review tool which enables drugs
that are known to contribute to a falls risk to be identified and we have invested in equipment to
help reduce the numbers of patient falls in our care. More information relating to falls can be
found later in the report.
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The run chart below illustrates the proportion of patients who have experienced harm as a result
of a fall in our care since July 2012; this also demonstrates that we benchmark well against the
national average.
Dementia
In November 2014 Burton Hospitals re-launched their Dementia Strategy.
The purpose of the strategy is to set out Burton Hospitals NHS Foundation Trust’s three year
plan for improving care and experience for people with dementia who attend or are admitted to
our Acute and Community Hospitals.
Our Strategic aims are:
 Deliver person centred care that supports the patient with dementia and their carer
 Modernise our approach to improve care and outcomes
 Develop a skilled Enhanced Care Team, together with a skilled effective workforce,
unafraid to champion compassionate, person-centred care
 Develop partnerships to improve care and outcomes
 Become a dementia-friendly organisation with environments that protect patients with
dementia from avoidable harm
Together with the re-launch of the Strategy the Trust has implemented the Forget-Me-Not care
bundle. This bundle provides a structured way of improving the process of care and patients
outcomes.
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The bundle encompasses the following aspects of care:





Hydration and nutrition
Pain control
The ‘This Is Me’ document; designed to promote personalised care
Communication; which focuses on carer and patient involvement
Medication review
In 2014 a Listening into Action event was organised to inform our strategy.
Staff, patients and carers said the following:
The Trust should
develop a garden/
outdoor area
The Trust should
employ an Activities
Coordinator
We want
equality of care
Staff should have
patience to achieve
understanding
Staff should
respect our fears
however irrational
The Dementia Steering Group will focus on improving and enhancing the standards of care for
patients with dementia, promoting carers and recognising the importance of early patient, carer
and family involvement.
The Dementia Steering Group will drive the Trust’s Strategy supporting staff, patients and
carers to enable the aims and objectives to be embedded in everyday practice
Using National Guidance such as the National Audit of Dementia (2011), The National
Dementia Strategy (2009) and the Dementia CQUIN standards the Strategic Group will support
the Operational Group in setting the standards and outcomes expected in the delivery of care
for patients with dementia at Burton Hospitals NHS Foundation Trust.
The Lead Nurse for Dementia continues to work with more than 60 Dementia Champions within
the Trust who have received intensive 2 day training. These champions are based on all wards
and many departments and are promoting excellence in the delivery of care for patients with
dementia.
The Lead Nurse has also devised an assurance tool which focuses on patients with dementia
that will be carried out a monthly basis. The purpose of the assurance tool is to ensure a high
standard of care for patients with dementia at all times and will help embed the 6C’s; care,
compassion, competence, communication, courage and commitment.
The Lead Nurse for Dementia within the Trust continues to network with outside agencies to
provide information to patients and carers of people with dementia within the local community.
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Internal Quality Assurance
The Trust has developed its internal regulation programme to reflect the inspection process
undertaken by the Care Quality Commission. Like the CQC our internal inspectors use
professional judgment, supported by objective measures and evidence, to assess services
against five key questions:





Are they safe?
Are they effective?
Are they caring?
Are they responsive to people’s needs
Are they well-led?
The inspections take place on a monthly basis to identify areas of good practice, or those that
require improvements, so that results can be shared and appropriate actions can be taken
where necessary.
To promote organisation learning in relation to mortality, an electronic database has been
established to enable and support consultants in a consistent review of deaths. The mortality
review tool is based on the Trust’s own paper based mortality review proforma but enhanced
with information used in the national study for reviewing and identifying preventable deaths.
The electronic database utilises automatic e-mail notifications to inform consultants that they
have a mortality review pending and it will also generate messages to other clinical departments
or key individuals, such as the Medical Director, if a review highlights a gap in care or cases
where more specialised advice or review is required. This tool is linked to the Trust’s Electronic
Patient Record System so consultants already have the basic demographic data available to
them when first reviewing the case. In addition, by linking with the clinical coding information,
consultants are able to ensure that correct diagnoses and co-morbidities are captured. The
database enables review of all deaths with a proportion of deaths undergoing further
comprehensive case review if the consultant believes that there are any aspects of the case that
require further information, clarification or issues have been raised that may have led to a poor
outcome.
The tool is searchable and provides reports that can capture actions from the mortality reviews
which will be reported to the Trust Mortality group chaired by the Chief Executive Officer. This
will allow Board level challenge to the Clinical Divisions, to ensure that the Trust’s Mortality
reviews are consistent and robust.
The Trust has developed a Fundamentals of Care programme which will enable us to
demonstrate the pride that Burton Hospitals NHS Foundation Trust takes in providing high
quality, safe, effective care for patients and families.
The working title ‘PRIDE in CARE’ was chosen to tie the Trust PRIDE and CARE objectives
together in a programme that will embody the Trust core values. The programme will enable
staff to focus on their skills and abilities in delivering the care that patients and families expect
and are entitled to receive.
The programme intends to address the Patients Association ‘CARE’ campaign:
This campaign was based on the four most frequent concerns that the Patients Association
received from patients, their relatives and carers, regarding poor patient care:
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C – communicate with compassion
A – assist with toileting, ensuring dignity
R – relieve pain effectively
E – encourage adequate nutrition
It also draws upon the 6Cs campaign launched by the Chief Nursing Officer and be relevant to
many of the core recommendations from the Francis Inquiry (2013)
The PRIDE in CARE programme will enable the Trust to continue the success of the Quality
Strategy (2013-2015) within which safety, effectiveness and the patient experience is central.
It is the Trust’s intention to launch the programme in Autumn 2015.
The 2013/14 Quality Account also identified our priority to focus on ensuring clinical vacancies
are recruited to in a timely manner to ensure optimum staffing levels and skill mix.
Due to the national shortage of registered nurses, the Trust has recruited from both Portugal
and Italy and the majority of these staff have now commenced with us. To ensure our workforce
is fit for purpose going forward, the Trust anticipates that more work will be undertaken on a
partnership basis with other organisations in the local health economy. To be able to do this
effectively will involve the development of new ways of working and new roles. For more
information on staffing, please see the workforce section later in this Quality Account
Priority 2:
Ensure there is a focus on delivering compassionate care, embracing the 6Cs at all levels
of the organisation. All staff will embrace and display the characteristics of care,
compassion, competence, communication, courage and commitment in their interactions
with service users, colleagues and member of the public.
As part of our programme of Listening into Action initiatives, the Trust’s Deputy Chief Nurse led
a work-stream on Compassion in Practice whereby each inpatient ward and some specialist
departments were asked to devise a philosophy of care and relate it to the 6Cs: six enduring
values and behaviours that underpin Compassion in Practice as defined by NHS England. The
examples on the following page were created by our pediatric wards and Short Stay Unit and,
along with the philosophies of care devised by other wards and departments, will form part of
the Trust’s Nursing Strategy.
11
12
In addition, the Trust is using patient stories and has invested in educational resources which
highlight the importance of patients’ perception of staff attitude. The Good Attitude DVD has
been shared with staff, patients and governors at our Patient Experience group and
Professional Forum.
Priority 3:
Continue to develop and improve the experience of our patients, with particular focus on
communication and engaging with the diverse communities that we serve. To further
develop and implement our Community Engagement Programme to ensure our local
community is properly represented and feedback is actively sought.
Summary of Quality Accounts Engagement 2014-15
A limited engagement programme was undertaken from December 2014 to January 2015 to
gauge what is important to our patients and community, and what areas they think we should
improve upon:
Patient /Community Engagement Activities:
Paper and online survey distributed and promoted through:
 Paper surveys available at Queen’s, Samuel Johnson and Sir Robert
Peel Hospital
 Online survey distributed through Voluntary Sector Networks,
Staffordshire and Derbyshire Carers’ Association , Healthwatch and
CCG Patient Panel and GP Patient Participation Groups
 Paper surveys sent out to members of the public responding to
newspaper articles
 Paper surveys distributed by Governors
 Online and paper surveys distributed to Foundation Trust Members
Engagement visits by PPE Advisor and Nursing Quality Lead to:
 Uttoxeter Carers’ Group
 Lichfield Carers’ Group
The survey asked respondents to rate the Trust in the domains of safety, communication,
kindness and compassion and clinical care. The results of the survey echo those of the previous
year’s survey with respondents having the highest level of confidence in safety, kindness and
care. Once again communication was the area with the lowest level of satisfaction from
respondents.
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Although statistical comparisons cannot be made between this year’s and last year’s survey as
respondents are self-selecting and there were half the number of respondents, it is clear that the
highest priority for improvement for patients and members of the public who took part in the
survey is communication.
This was echoed in the conversations with carers who generally expressed satisfaction with
their own care and the care of their loved ones; however some people felt that they were not
kept informed about the care of their relative and that communication was lacking. It was also
suggested that if carers were informed more about the discharge process and what to expect
they could prepare better.
Overall survey scores 2013/14 and 2014-15
2013/14
Safety
70
Kindness and Compassion
69
Communication
58
Clinical Care
70
2014/15
80
81
65
80
We want our patients to get the best care at Burton Hospitals NHS FT and learning about
patient experience helps us to understand what we do well and what we should improve.
All NHS hospitals are asking their patients if they would recommend their services to friends and
family and the results will be published nationally. We will also publish our results on our
website and on our wards and departments so that patients can see how we are doing:
The Trust identified, as a priority, the need to improve the Trust-wide patient experience metrics
from 2013/14. The comparison of results for 2014/5 can be seen in the Patient Experience section
later in this Quality Account.
In 2013/14 the Trust identified the need to ensure that we obtain feedback from a sufficient crosssection of patients to be representative of our local community. The Trust’s patient experience
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survey and the Friends and Family Test (FFT) have demographic questions to enable us to monitor
who is completing the surveys.
The charts below illustrate demographic information for patients who completed the Outpatient
FFT between October 2014 and March 2015.
Age
Ethnicity
Disability
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To encourage participation by the widest range of patients, an easy-read version of the Friends
and Family Test is available, and a Polish and Urdu version of the latest FFT, as well as PALS
and Complaints Leaflets, are being developed in order to encourage and support feedback from
the two largest ethnic groups in the area.
The Patient and Public Engagement Team maintain links with a wide variety of community
groups and organisations to enable feedback across the community, as well as facilitating the
Trust’s Youth Forum and Disability Advisory Groups.
In November 2014, the Trust introduced Housekeepers into each inpatient ward area with a
focus on 11 practice standards, as outlined by the Department of Health 2010, designed to help
improve the patient experience:
1. Patients must be cared for in a well-maintained environment
which is safe, welcoming, comfortable and reassuring
2. There must be a high standard of cleanliness in all areas
3. Patients must be provided with good quality food and drink to
meet individual needs
4. All equipment must be in good working order
5. There must be enough clean linen to meet patients’ needs
6. Patients must be cared for in an environment that minimises the
risk of cross-infection
7. Effective communication must be used to ensure continuity of
patient care
8. Patients must be assured that the care environment complies
with current health and safety regulations
9. Patients must be confident that all necessary supplies are
available at all times
10. Patients’ privacy and dignity must be respected at all times
11. Patients and carers must receive a level of customer care
relevant to their needs
The Housekeepers have been very well received by both patients and ward staff.
The Trust considers complaints and compliments to be a valuable indicator of patient
experience; therefore in our 2013/14 Quality Account we identified our aim to reduce the
number of formal complaints we receive from our patients. For 2014/15, the total number of
formal complaints received was 245; this represents a 48% decrease from the previous year.
For more detailed information on complaints and compliments, please see the complaints
section of this report.
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Priorities for the coming year
It is recommended by the Department of Health that organisations once again choose at least
three priorities for quality improvement.
In identifying the priorities for 2015/16 the Trust has continued to focus on the key aims of the
Quality Strategy 2013/15; ensuring that the quality of care is right first time and reducing
variation in practice. To ensure the Trust quality priorities remain current and relevant, we will
be developing our Quality Improvement Strategy for 2016-18 between April and June 2015.
Priority 1 :
To reduce avoidable harm across the Trust with a particular focus on sepsis, acute kidney injury
(AKI) and catheter associated urinary tract infection (CAUTI)
How does this link to our Quality Strategy?
“We aim to have no avoidable deaths; we will use care bundles to ensure that
patients receive timely and consistent treatment”
Why is this a priority area?
Sepsis arises when the body’s response to an infection damages its own tissues and organs
and can lead to shock, multiple organ failure, and death, especially if it is not recognised early
and treated promptly. Between a third and a half of all patients who have sepsis do not survive.
The ‘Sepsis Six’ is a group of actions that can be taken when a patient is diagnosed with sepsis.
They are designed to treat the condition and if the patient receives these steps quickly, they
have a much better chance of survival. We aim to develop an educational programme to
improve the timely recognition and treatment of sepsis and to implement and embed the Sepsis
Six bundle in three clinical areas initially; the Emergency Department, the Acute Assessment
Centre and ward 11 (male surgery) with the intention of expansion into other key areas in the
future.
Acute Kidney Injury is common, harmful and treatable, occurring in up to 20% of emergency
admissions to hospital, and leading to significantly increased mortality, length of stay and care
costs. Earlier recognition of illness severity and earlier senior clinical involvement in the care of
unwell patients are key to improving the safety, effectiveness and experience of care for
patients admitted to hospital as an emergency (NHS Kidney Care 2015).
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The Trust aims to improve the prevention, detection and management of acute kidney injury
(AKI) in patients admitted as an emergency to hospital.
Urinary tract infections (UTIs) resulting from catheter use are the most common type of infection
affecting people staying in hospital. Despite high hygiene standards in most modern hospitals,
about 1 in 10 people who have a catheter develop a UTI (NHS Choices, 2014).
Data available from the NHS Safety Thermometer demonstrates that our Trust is currently a
negative outlier for patients with catheter associated UTIs.
The Trust will undertake focused work around CAUTI with the aim of reducing the number of
patients with catheters insitu and, as a result, the number of patients who have associated
infections.
What will the Trust do?


Target for 2015/16


Director Leads
Monitored by
Achieve milestones for Sepsis and AKI CQUINs around screening
and training
Recruit to a specialist post to lead on AKI as part of CQUIN
funding
To reduce the number of patients with catheter associated urinary
tract infections (CAUTI) across our Trust by at least 10%.
To develop a robust daily monitoring system for internal reporting
Chief Nurse and Medical Director
CQUINS
Sepsis audit
NHS Safety Thermometer
Reported to Board
Quality Committee
of Directors via
Priority 2:
To ensure that our workforce is sufficient in number and equipped with an appropriate level of
knowledge and skills to provide consistently safe and effective care for our patients.
How does this link to our Quality Strategy?
“…focus clearly on quality and
always place the interests of
patients at the heart of service
delivery”
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Why is this a priority area?
We believe it is important to provide assurance to the Trust as well as reassurance for patients
and their relatives that we are paying adequate attention to safe staffing across our clinical
workforce.
Whilst we already display staffing boards at the entrance of every ward, we are developing
systems of measuring this daily to increase the reliability of nurse staffing information to support
real-time decision making.
The Trust is also implementing a newly developed Medical Workforce Strategy which focuses
on appraisals, training and education, revalidation and job planning for medical staff.
Over the last 12 months our patients have told us that they are not completely satisfied with
some aspects of care:
Question Text
3. Do staff involve you
as much as you want in
decisions about your
care?
4. Do staff explain
things to you in ways
you understand?
5. Have you been able
to get the attention of
staff when you needed
it?
9. If you need help
getting to the toilet or
bathroom, do you get it
in time?
Apr
14
May
14
Jun
14
Jul
14
Aug
14
Sep
14
Oct
14
Nov
14
Dec
14
Jan
15
Feb
15
88
89
91
93
93
92
89
92
92
91
94
93
94
94
95
95
96
93
93
95
96
95
91
90
92
92
91
91
94
90
92
93
93
90
88
93
94
93
90
93
93
94
94
95
Whilst the majority of comments we receive from our patients are positive, the results of the
heat map above are supported by a number of comments from our patients:
The ward is under
staffed. It needs more
nurses first thing in the
morning
There have been occasions when I
haven't been quite happy. For
example I sometimes wait ages to go
to the toilet. I understand they
can't help it because they are so
busy
Staff did not explain anything. I
was put in this bed. My things
were not put away and a family
member had to do that for me
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In addition to safe staffing levels, it is a priority for the Trust to have robust systems in place to
assure ourselves that our nursing workforce is fit for practice. The Depatment of Health
responded to the Mid Staffordshire NHS Foundation Trust Public Inquiry in its report; Hard
Truths: The Journey to Putting Patients First (2014). This report reviewed the recommendations
from Sir Robert Francis and, related to nursing staffing, accepted recommendation 229:
It is highly desirable that the Nursing and Midwifery Council introduces a system of
revalidation similar to that of the General Medical Council, as a means of reinforcing the
status and competence of registered nurses, as well as providing additional protection to
the public.
To support this, a priority for the Trust in 2015/16 will be to ensure that we have robust systems
and process in place to support NMC revalidation through providing comprehensive personal
development plans, education and training and tailored annual appraisals for nursing and
midwifery staff.
What will the Trust do?
In order to assure ourselves that our nursing staffing levels and skill mix are sufficient to meet
our patients’ requirements, the Trust has recently invested in SafeCare; a software package
that links with our electronic rostering system, allowing real-time information to monitor staffing
levels and inform decision making where shortfalls arise. The system will allow the integration
of nursing red-flags; a series of quality indicators, identified by NICE (2014), designed to alert
senior nurses where staffing requirements may need immediate review. The system also
supports the formal biannual establishment review recommended by NICE: Safe staffing for
nursing in adult inpatient wards in acute hospitals (2014).

Target for 2015/16



To embed SafeCare across the inpatient wards within the Trust
by January 2016
To develop and implement a robust process for reporting and
escalating nursing red flags
To ensure the Trust’s nursing workforce is adequately prepared
for the NMC revalidation process from December 2015
To implement the Trust’s Medical Workforce Strategy
Director Leads
Chief Nurse and Medical Director
Monitored by


Reported to Board 
of Directors via

eRostering SafeCare module
Trust appraisal system
People Committee
Quality Committee
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Priority 3:
To improve patient experience by ensuring a ‘Warm Welcome’ is consistently provided for our
patients
How does this link to our Quality Strategy?
“Our goal is to reach the top 20% in the patient
recommender index”
Why is this a priority area?
The NHS Constitution was developed to safeguard the enduring principles and values of the
NHS. It sets out clear expectations about the behaviours of both staff and patients and is
intended to empower the public, patients and staff by setting out existing legal rights and
pledges in one place and in clear and simple language. By knowing and exercising their rights,
the public, patients (their carers and families) and staff can help the NHS improve the care it
provides.
The Constitution consists of 6 core values:






Working together for patients
Respect and dignity
Commitment to quality of care
Compassion
Improving lives
Everyone counts
The NHS Behaviour Framework break down these values further into expected behaviours
and includes elements such as:



Effective and clear communication
Staff should be welcoming and friendly
Staff should say hello and introduce themselves
The Trust will develop a patient experience strategy which will:
1. Significantly improve the level of engagement and interaction with patients & visitors
2. Deliver a real and definable improvement in the perception of the Trust by the public
3. Facilitate consistency across all patient touch points including face to face, telephone,
email & letter
4. Focus on staff engagement in the overall objectives of the Trust, and an understanding
of the importance of their role
We are calling this initiative: ‘Our Warm Welcome’
21


Target for 2015/16


Director Leads
Monitored by
The Trust will develop a ‘warm welcome’ script template that
should reflect the core values and objectives of the Trust, as well
as provide the necessary information to support the patient &
visitor on their journey through the hospital
Train relevant staff on the new script, including the rationale and
benefits underpinning its introduction
Human Resources to ensure the new script becomes part of staff
job descriptions, appraisal process, and new starter training
Survey and measure the impact of the changes on the levels of
customer service and satisfaction after suitable time intervals,
e.g. 3 months, 6 months & 12 months
Chief Nurse and Medical Director
Patient Experience metrics
The Patient Experience Group
Complaints
PALS
Reported to Board
People Committee
of Directors via
22
2.2 Statements of Assurance from the Board
Income and contracts
During 2014/15 Burton Hospitals NHS Foundation Trust provided the Commissioner Requested
Services identified within the NHS standard contract
Burton Hospitals NHS Foundation Trust has reviewed all the data available on the quality of
care in 3 of these relevant health services: the emergency pathway and patient flow; frail elderly
and maternity.
The income generated by the relevant health services reviewed in 2014/15 represents 100% of
the total income generated from the provision of relevant health services by the Trust for
2014/15.
Participation in clinical audit
Clinical audit is a quality improvement process that is defined in full in “Principles for Best
Practice in Clinical Audit” (HQIP 2011). It allows clinicians and organisations to assess practice
against evidence and to identify opportunities for improvement. At a national level, it provides
organisations with information that enables them to measure the effectiveness of their own
sation and practice against national benchmarks.
Burton Hospitals NHS Foundation Trust endeavours to participate in every relevant national
audit, survey, database and register considered to be likely to provide the organisation with the
opportunity to improve patient care. The Trust has not participated in all such national projects,
but those in which it has not participated have been considered in relation to the services
provided and the patient population against a specific guideline agreed and approved by the
Trust, apart for the national pregnancy in diabetes.
During 2014-15, 31 national clinical audits and 4 national confidential enquiries covered relevant
health services that Burton Hospitals NHS Foundation Trust provides. During that period,
Burton Hospitals NHS Foundation Trust participated in 97% of national clinical audits and 100%
of 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 Burton Hospitals NHS
Foundation Trust participated in, and for which data collection was completed during 2014-15,
or was in progress, 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.
Name of project
Type of
care
Eligible to
participate
Participated
Acute coronary
syndrome or
acute
myocardial
infarction
(MINAP)
Heart
Yes
Yes
% of
cases
submitted
100
Comment
23
Adult critical
care (Case Mix
Programme)
Adult
community
acquired
pneumonia
Bowel cancer
Acute
Yes
Yes
Acute
Yes
Yes
Cancer
Yes
Yes
100
Cardiac
arrhythmia
National chronic
obstructive
pulmonary
disease
Coronary
angioplasty
Diabetes (Adult)
National
Diabetes
Inpatient Audit
Heart
Yes
Yes
100
Long-term
conditions
Yes
Yes
100
Heart
Yes
Yes
100
Long-term
conditions
Yes
Yes
100
National
Pregnancy in
diabetes
Diabetes
(Paediatric)
Elective
Surgery
(National
PROMS
Programme)
Epilepsy 12
Long term
conditions
Yes
No
N/A
Long-term
conditions
Other
Yes
Yes
100
Yes
Yes
74.1
(National
rate 76.7)
April 2014September 2014
data
Women’s
and
children’s
Health
Cancer
Yes
Yes
100
Round 2 complete
Yes
Yes
100
Heart
Yes
Yes
100
Inflammatory
bowel disease
Lung cancer
Long-term
conditions
Cancer
Yes
Yes
100
Yes
Yes
100
Maternal, Infant
& Perinatal
Programme
(MBRRACE)
Women’s
and
children’s
Health
Yes
Yes
100
Head and neck
oncology
National Heart
Failure
100
Data collection in
progress
Local summary
completed by a
Surgical Consultant
December 2014
Local summary
presented by
Consultant in April
2015
Findings presented
at the General
Medicine audit
meeting
24
Initial
management of
the fitting child
(CEM)
Women’s
and
Children’s
health
Yes
Yes
42
Mental Health in
ED (CEM)
Assessing
Cognitive
Impairment in
Older People
(CEM)
National cardiac
arrest audit
National
comparative
audit of blood
transfusion
(Readiness for
patient blood
management)
National
emergency
laparotomy
audit (NELA)
National joint
registry
Mental
health
Older
people
Yes
Yes
100
Yes
Yes
98
Heart
Yes
Yes
100
Blood and
transplant
Yes
Yes
N/A
Acute
Yes
Yes
Acute
Yes
Yes
National
prostate cancer
audit
Neonatal
intensive and
special care
(NNAP)
Oesophagogastric cancer
Pleural
procedure
Renal registry
Cancer
Yes
Yes
Women’s
and
children’s
Yes
Yes
100
Cancer
Yes
Yes
100
Acute
Yes
Yes
100
Long term
conditions
Long term
conditions
Yes
Yes
100
Yes
Yes
Older
people
Yes
Yes
100
Clinical
outcomes
review
programme
Yes
Yes
100
Rheumatoid
and early
inflammatory
arthritis
Sentinel stroke
national audit
programme
(SSNAP)
National
Confidential
Enquiry: Sepsis
study
Low numbers (21)
were due to very
few children
attending ED that
meet the audit
criteria
Organisational
survey
Year 2 Data
collection in
progress
100
Data collection in
progress
Data collection in
progress – 3 year
project
25
National
Confidential
Enquiry: Lower
Limb
Amputation
National
Confidential
Enquiry:
Gasterointestin
al Haemorrhage
study
National
Confidential
Enquiry:
Tracheostomy
Care
Clinical
outcomes
review
programme
Yes
Yes
100
Clinical
outcomes
review
programme
Yes
Yes
100
Clinical
outcomes
review
programme
Yes
Yes
100
The reports of 18 national clinical audits were reviewed by the provider in 2014-15 and Burton
Hospitals NHS Foundation Trust intends to take the following actions to improve the quality of
healthcare provided.
National Clinical
Audit
NBOCAP – Bowel
cancer 2013-14
Actions to improve quality
Diabetes
outpatients audit
2012-13
To ensure Diabetes Annual Review Sheet is completed in full for each
patient - Review and improve systems for delivering effective care to
younger people with Type 1 and Type 2 diabetes; learn from the best
performers.
The Trust has a low mortality rate (0%), and a lower than average length
of stay. The following measures have been taken resulting from the
findings of this audit. Every patient admitted with an exacerbation of IBD
should been seen by an IBD nurse and have a stool sample sent, as this
will influence treatment. A local re-audit will take place in 2015-16.
The Trust is in the process of setting up an alcohol Multi-Disciplinary
Team to address alcohol related admissions to the Trust and liaising with
the Clinical Commissioning Group.
UK Inflammatory
Bowel Disease
(IBD) Audit
NCEPOD - Alcohol
Related Liver
Disease (ARLD)
Study
NAP5 Accidental
Awareness during
General
Anaesthetic
Epilepsy 12 Childhood Epilepsy
The contents of the National Bowel Cancer Audit report 2014 provide
assurance to the Trust that surgery and other treatments for colorectal
cancer in Burton are both safe and effective.
The Trust is in the process of developing local guidelines.
We continue to comply with the audit standards, we sustain a paediatric
seizure clinic, which was developed from a previous year audit
recommendation and refer to Birmingham Children’s Hospital
26
National Care of
the Dying Audit
Review the current End of Life guidelines and nursing care plan to
ensure clarity and availability, and to ensure that all End of Life
medications are stock items on all wards that care for dying patients
National audit for
Rheumatoid and
Early inflammatory
arthritis
The interim report in December 2014 showed our department and Trust
to have recruited 50 patients with excellent compliance to NICE Quality
standards. One area which could be improved is the time taken for
referral from primary care and waiting times for 1st appointment. The
latter however depends on various factors, including those that are
outside of the Trust.
Focused delivery of training on wards that receive most tracheostomies
NCEPOD
Tracheostomy
study
NCEPOD Death
following Lower
Limb Amputation
Multi-Disciplinary Team discussions taking place at University Hospital
North Midlands, to improve current patient pathways.
National BTS
Paediatric Asthma
audit
Oesophago-gastric
cancer audit –
(NAODC)
Sentinal Stroke
National Audit
Programme
(SSNAP)
British Thoracic
Society – COPD
audit
National Joint
Registry
A named nurse with a specialist interest in Asthma has been identified to
review all paediatric patients. Discharge leaflets have been updated to
cover inhalers techniques
The national report was discussed at the Multi Disciplinary Team,
patients treatment is carried out in Derby, however actions are in
progress with regards to early diagnosis of Gastric cancers
Results will be considered as part of on-going service development
Maternal, Infant &
Perinatal
Programme
(MBRRACE)
Neonatal Intensive
and Special care
(NNAP)
The report was reviewed at the still birth panel review group meeting,
they also review all intrauterine and still births The review findings were
disseminated unit wide to promote shared learning
An Integrated Care Pathway is being discussed with the commissioners,
and the work is on-going
The Trust was very favourably shown in the National report, both for
compliance, mortality and revision data.
There are no specific action plans needed from the report. Members of
the Orthopaedic department attend the The British Orthopaedic
Association annual meeting where feedback reports are presented.
The report was analysed locally and discussed at the Paediatric audit
meeting, the department is compliant with the audit standards and will
continue to meet these standards.
The reports of 181 local clinical audits were reviewed by the provider in 2014-15 and Burton
Hospitals NHS Foundation Trust intends to take the following actions to improve the quality of
healthcare provided. Below is a selection of local audits in which sustainable change has
resulted from audit findings.
27
Local Clinical Audit Topic
Length of Stay post breast
cancer surgery
Varicose Vein ablation
Management of Acute
Kidney Injury within first 24
hours
Malnutrition Screening Tool
Hepatitis B vaccine
compliance
Caesarean section
anaesthesia
Antenatally detected renal
pelvis dilation
Eye casualty telephone
Actions to improve quality
The audit demonstrate a continuing fall in length of stay after
breast cancer surgery since 2008, with increased patient
satisfaction since the transfer of the majority of breast cancer
resectional work to the treatment centre short stay unit.
Further clinics to be added in order to improve waiting times
for patients
Continue to comply with the Acute Kidney Injury Care Bundle
Nutrition Link Nurses to be named for each ward – to
cascade training to all ward staff
Protocol included in Trust induction for new staff, text
reminders for patients and awareness days.
Quick mix available on epidural trolley, epidurals are
reviewed at every handover – update of chart.
Review and altered local guideline based on best practice
Automated telephone service was introduced, which reduced
interruption to care of patients
Participation in clinical research
The Trust is committed to clinical research as a driver for improving the quality of care and
patient experience. Research also provides an opportunity for staff to develop their own skills
and knowledge. Engagement with clinical research also demonstrates the Trust’s commitment
to testing and offering the latest medical treatments and techniques. This is further evidenced
by engagement with the Primary Care Research Network in an effort to co-ordinate research
activity between primary and secondary care, in order to offer research participation to as wide
a population as possible.
Participation in clinical research demonstrates the Trust’s commitment to improving the quality
of care offered and to make a contribution to wider health improvement. Furthermore, it allows
clinical staff to stay abreast of the latest possible treatment possibilities and active participation
in research leads to successful patient outcomes.
The number of patients receiving relevant health services provided or sub-contracted by the
Trust in 2014/15 that were recruited during that period to participate in research approved by a
research ethics committee was 683.
During the year the Trust were involved in conducting 146 clinical research studies in:








Anaesthetics
Cancer
Stroke
Medicines for children
Dermatology
Respiratory medicine
Gastroenterology
Musculo-skeletal disorders









Dietetics
Diabetes
Cardiology
Reproductive health
Haematology
Metabolic and endocrine disorders
Cardiovascular/Lipids
General Surgery
28
In 2014/15 the National Institute for Health Research (NIHR) supported 143 of these studies
through its research networks.
The Trust aims to complete 100% of these studies as designed within the agreed time and to
the agreed recruitment target. However, recruitment targets and completion dates are
commonly adjusted as research studies progress to take into account, for instance, slower than
expected recruitment which may result in extension of the end date. Conversely, some studies
complete early in the light of conclusive findings at an earlier than expected stage. Most of the
studies undertaken at the Trust are hosted as part of national research and often, recruitment
targets and completion dates are influenced at a national level.
There were 51 clinical staff participating in research approved by a research ethics committee at
the Trust during 2014/15. These staff participated in research covering 16 medical specialties.
Of the 30 studies given permission to start, 95% were given permission by an authorised person
less than 30 days from receipt of a valid completed application. 85% of the studies were
established and managed under national model agreements. Out of the 30 studies permitted to
start, four were eligible to use a ‘research passport’. The research passport scheme is a
nationally adopted process coordinating and streamlining pre-engagement checks for external
staff entering NHS premises to conduct research activities.
In the last year, no publications have directly resulted from the Trust’s involvement with the
NIHR. The Trust is mainly a host site for studies initiated by trial centres elsewhere, and it is
these centres who have responsibility for publishing and disseminating their results.
Use of the CQUIN payment framework
The Commissioning for Quality and Innovation (CQUIN) payment framework enables
commissioners to reward excellence by linking a proportion of providers’ income to the
achievement of local quality improvement goals.
A proportion of the Trust’s income in 2014/15 was conditional on achieving quality improvement
and innovation goals agreed between the Trust and any person or body they entered into a
contract, agreement or arrangement with for the provision of relevant health services, through
the Commissioning for Quality and Innovation payment framework.
The monetary total for income in 2014/15 conditional upon achieving quality improvement and
innovation goals was £3.19m. The monetary total for the associated payment in 2013/14 was
£3.2m.
Further details of the agreed goals for 2014/15 and those for the following 12 month period are
available electronically at:
www.institute.nhs.uk/world_class_commissioning/pct_portal/cquin.html
A summary of developments and achievements and specific performance achieved against
each CQUIN scheme in 2014/15 is detailed in the tables below.
Summary of developments and achievements against the 2014/15 CQUIN schemes
Topic
Friends and Family
( FFT)
Development and Achievements
The Trust has improved the experience of patients in line with domain 4
of the NHS Outcomes framework, by implementing the staff FFT,
implementing the FFT in outpatient and day case settings, and improving
the response rate on wards and the emergency department.
29
Safety Thermometer
Dementia
Promoting Safe and
Effective Care
Reducing
medication errors
and harm to patients
from medication
errors
Improving patient
care – introduce the
sepsis care
pathway.
Amber Care Bundle
Implementation
The Trust has to measured and reduced harm, with a specific focus on
reducing pressure ulcer harm.
The Trust has continued to implemented screening, assessment and
referrals of over 75 year old admissions in order to improve the care of
patients with dementia. The Trust wide implementation included staff
training and awareness, monthly carer surveys together with
implementing drop in clinics to increase support to carers of patients with
dementia
The Trust has improved the pathways for those patients who present with
Ambulatory Care Sensitive Conditions (ACSC), by increasing the number
of those patients discharged within 23 hours, improved diagnosis to
treatment times, and to improve the pathway.
In addition the Trust has been aiming to increase the number of patients
over 75 years of age within 72 hours of admission, and to improve the
discharge summary to GP for each patient.
The national medication Safety Thermometer tool has recently been
launched and the Trust has been collecting data on 3 wards to identify
any safety issues which can result in harm to patients.
The Trust has been implementing the sepsis care bundle in the
Emergency Department and AAC ward.
The Trust has been rolling out the implementation of the care bundle
across the wards for patient who’s recovery is uncertain.pn whom
recovery is uncertain.
Performance achieved against 2014/15 CQUIN schemes – with milestones set throughout
the year.
Topic
Reducing VTE in hospital
Risk assessments
Reducing Hospital Acquired Thrombosis
Target date
Target
Achievement
Monthly
Quarterly
96.75-97.75% Achieved
100%
Achieved
Quarterly
90%
Achieved
Quarterly
100%
Achieved
Supporting carers – monthly surveys
Quarterly
Reports
Achieved
Safer care
Safety Thermometer monthly data
collection
Quarterly
100%
Achieved
Dementia Care
Implement Find, Assess, Investigate, and
Refer standard.
Dementia leadership and training
30
Pressure ulcer reduction – monthly
prevalence of hospital and community
acquired pressure ulcers.
Topic
Q1/2
Less than
National
Prevalence
target
Partially
Achieved
Achieved
Target
Achievement
Q1
Q2
100%
100%
Achieved
Achieved
Q1
Q4
March 2015
50%
50%
100%
Achieved
Achieved
Achieved
Q3/4
Target date
Friends and Family Implementation
Staff F&F
Early Implementation in out patients/day
case settings
Improved Response rates – wards and
emergency dept
Improved Response rate - wards
Safety Thermometer – pressure ulcer
reduction
Reduction in trust pressure ulcer
prevalence
Dementia Care
Implement Find, Assess, Investigate, and
Refer standard.
Dementia leadership and training
Supporting carers – monthly surveys
Promoting Safe and Effective Care
Ambulatory Care sensitive conditions
- Discharge within 23 hours
- Diagnosis to treatment
- Medical take patients via GP/ACS
Patients aged >75years discharged in 72
hours.
Improved information on discharge
summaries
Reducing medication errors and harm
to patients from medication errors
Monthly collection of safety thermometer
data from 3 wards and report on
results/actions
March 2015
<3.2%
Achieved
Quarterly
90%
Achieved
Q4
Q2 and Q4
100%
Reports
Achieved
Achieved
Q3/Q4
Q2/3/4
Q3/4
Q2/3/4
100%
100%
100%
100%
Partial achievement
Q4
100%
Q2/3/4
100%
Improving patient care – introduction the Sepsis Care Bundle
Audit of sepsis tool
Q1
100%
Staff training commence
Q2
25%
Staff training compliance and implement
Q3
50%
care bundle
Staff training compliance and re audit of
Q4
75%
bundle compliance
Not Achieved
Achieved
Not achieved
Partial achievement
Achieved
Achieved
Achieved
Achieved
Achieved
31
Implementation of the amber care
bundle
Development of training schedule/referral Q1
pathway
Number of patients on the bundle and
Q4
number of patients referred to the palliative
care team
100%
Achieved
100%
Achieved
The CQUIN schemes for 2015/16 have been determined following discussions with
Commissioners and also through areas identified nationally as topics for further quality
improvements
Areas for CQUIN payment framework in 2015/16
Topic
Rationale
Acute Kidney Injury
To improve the follow up and recovery for patients who have
sustained an acute kidney injury.
To screen for sepsis for patients whom screening is appropriate,
and rapidly initiate intravenous antibiotics within 1 hour of
presentation.
To identify, assess, investigate refer and inform patients with
dementia, together with delivering training in collaboration with the
health economy.
Reducing the proportion of avoidable emergency admissions to
hospital, reducing follow ups, and reducing length of stay.
Sepsis
Dementia
Promoting Safe and
Effective Care
Statements from the Care Quality Commission (CQC)
In the past 12 months, the CQC has undertaken one planned visit combined with an
unannounced visit to carry out a full inspection at the Trust, which included each of the Trust’s
three locations; Queen’s Hospital in Burton, Samuel Johnson Community Hospital in Lichfield
and Sir Robert Peel Hospital in Tamworth. The planned visit took place on the 24th and 25th of
April 2014, and the unannounced visit took place on the 6th and 7th of May 2014; the
subsequent report was received in July 2014.
Following the inspection, the CQC gave the Trust an overall rating for the Trust as ‘Requires
Improvement’, which was split by the three locations as follows:



Queen’s Hospital - Requires Improvement
Sir Robert Peel Community Hospital - Requires Improvement
Samuel Johnson Community Hospital – Good.
The Inspection identified that 60% of the services were good and highlighted a number of areas
of outstanding practice, including the recognition of the Trust’s Maternity Services by an
independent provider of healthcare intelligence and the enhanced recovery pathway for hip and
knee replacements which had a reduced length of stay.
The report listed 19 recommendations; 14 actions which the Trust ‘must take’ and five actions
that the Trust ‘should take’. Clearly, the Trust’s services can always improve and, in response
32
to the recommendations, a detailed action plan was developed with support from senior
clinicians and managers to address areas identified for improvement. A monthly update is
available on the Trust’s website detailing progress made against the CQC ‘must take’
recommendation and can be accessed via the following link:
http://www.burtonhospitals.nhs.uk/about-us/BHFT%20CQC%20Action%20Plan.pdf
The Director of Governance has collated recommendations from all high external reviews,
including those remaining from the Keogh Review in 2013, CQC and Well Led Review into a
Consolidated Action Plan. This is updated monthly to reflect the progress made by the Trust in
delivering and then embedding the recommendations. The Board of Directors monitors the
delivery of the Consolidated Action Plan, and good progress is being made in completing the
remaining actions.
The CQC have introduced a new approach for the inspection of NHS acute hospitals, which is a
radical change to previous methods. The CQC’s reviews will now address five key questions
about the quality of services: These are:





Safe: are people protected from abuse and avoidable harm?
Effective: does people’s care and treatment achieve good outcomes and promote a
good quality of life, and is it evidence based where possible?
Caring: do staff involve and treat people with compassion, kindness, dignity and
respect?
Responsive: are services organised so that they meet people’s needs?
Well-led: does the leadership, management and governance of the organisation assure
the delivery of high-quality, person-centred care, support learning and innovation, and
promote an open and fair culture?
The CQC has notified the Trust that they will be undertaking an inspection, utilising this new
approach, in early July 2015.
The CQC also notified the Trust that they would be undertaking an announced visit to monitor
the use of the Mental Health Act 1983 (MHA) to provide a safeguard for individual patients
whose rights are restricted under the Act. This was a follow up visit to monitor progress made
against recommendations made following an initial visit in October 2013. The visit was
undertaken on the 29th and 30th of July and the 6th of August 2014. The Trust has made good
progress in delivering these actions; which includes collaborative working with our Mental
Health Commissioning and Provider partners.
The Trust is required to register with the Care Quality Commission and its current registration
status is ‘registered’. The Trust has no conditions on its registration. The CQC has not taken
enforcement action against the Trust during 2014 / 15.
The Trust has not participated in any special reviews or investigations by the CQC during
2014/15.
Data Quality
The Trust collects and uses information on a daily basis which is used to support decision
making by clinicians and managers and for monitoring and research purposes by a range of
external organisations. It is essential that the data is accurate, relevant, reliable, timely,
complete and valid to produce information that is fit for purpose. Good quality information
underpins the effective delivery of patient care and is essential if improvements in quality of care
are to be made.
33
During 2014/15 the following actions to improve Data Quality were carried out:
 The Terms of Reference of the Data Quality Group were revised
 A Work Plan to improve Data Quality was implemented and monitored by the Data
Quality Group.
 An in depth review of GP and GP Practice data was carried out and improvements
made.
 Overall data quality was monitored via high level Key Performance Indicators
 An audit of key data items in Trust systems was carried out as well as a completeness
and validity check
 Standard Operating Procedures for report production were reviewed
 An evaluation of the quality of data in the Meditech system was carried out in
preparation for the Version 6 implementation.
It is essential that Data Quality is not only maintained but improved; therefore the Trust will be
taking the following actions to improve data quality in 2015/16:
 Implementation of a further Data Quality Group work programme.
 Improve the quality of data in the Meditech system prior to transfer to Version 6
 Continue to target key areas such as outpatients, wards, secretarial support to ensure
demographic data is accurate and kept up to date
 Monitoring of compliance with Data Quality standards
NHS number and general medical practice code
Improving the quality of NHS number data (i.e. correctly recording the number for every patient)
has a direct impact on improving clinical safety as the NHS number is the key identifier for
patient records, regardless of how or where a patient accesses care. Accurate information about
the patient is required in all healthcare settings to support clinical care. The consistent use of
the NHS number supports this by linking up elements of a patient’s record across healthcare
organisations providing a way of checking the information is about the right patient.
Accurate recording of the patient’s general medical practice code is essential to enable the
transfer of clinical information about the patient between healthcare providers thus helping to
deliver seamless care for patients. This is particularly important when coming to discharge
patients from hospital.
The Trust submitted records during 2014/15 to the Secondary Uses Service for inclusion in the
Hospital Episode Statistics which are included in the latest published data.
The percentage of records in the data for the period April 2014 to January 2015, the latest data
available, that included the patient’s valid NHS number was:
For admitted patient care;
For outpatient care; and
For accident and emergency care
Trust %
99.9
99.9
99.0
National %
99.2
99.3
95.2
The percentage that included the patient’s valid General Medical Practice Code was:
For admitted patient care;
For outpatient care; and
For accident and emergency care
Trust %
100
99.9
100
National %
99.9
99.9
99.2
34
Information Governance Toolkit attainment levels
Information Governance provides a single framework of requirements, standards, and best
practice covering confidentiality and data protection, corporate information, clinical information,
information governance management, information quality and information security.
The Trust’s Information Governance Assessment Report overall score for 2014/15 was 80%
and was rated green. This is an increase of 4% from 2013/14. The number of requirements
below the minimum Level 2 has reduced from 1 in 2013/14 to zero in 2014/15. A full breakdown
of the position is as follows:
Trust score for attaining information governance standards
Year
2014/15
2013/14
Level 0
Level 1
Level 2
Level 3
0
0
0
1
27
30
18
14
Overall
score
80%
76%
Trust performance is now rated as satisfactory by the Health and Social Care Information
Centre (HSCIC).
Clinical Coding
Clinical coding translates the medical terminology written by clinicians to describe a patient’s
diagnosis and treatment into standard, recognised codes. The accuracy of this coding is highly
important as the data is used for a range of purposes including:




Monitoring provision of health services across the UK
Research and monitoring of health trends
NHS financial planning and Payment by Results (PbR)
Clinical governance
During 2014/15 the Trust implemented a development plan to improve the Clinical Coding
service. This comprised of:





An increase in staffing, revised structure, and addition of specialist roles for
management, audit, and training,
Engagement with clinicians via a monthly Data Quality meeting, externally hosted
workshops, and representation at departmental meetings.
Introduction of a formal training and audit programme
Use of external validation reports to check Coding Data Quality
Piloting a change to the Coding process
The impact on the quality of Coding has been positive with progress being monitored via an
internal Coding Dashboard and external comparison with peers.
The Trust commissioned an audit of Clinical Coding to assess compliance with Information
Governance standards. The audit reviewed 200 sets of case notes from Paediatrics, General
Surgery, Gynaecology, Trauma & Orthopaedics and General Medicine.
The audit
demonstrated that the accuracy level required to comply with Level 2 of the Information
Governance Coding standard was achieved. The results should not be extrapolated further
than the actual sample audited.
35
For 2015/16 the Trust has the following developments planned:



Roll out of the Coding process change to all areas so that Coding is an office-based,
rather than a ward-based activity
Implementation of additional software to allow the real time validation of Coding, support
for audits, and advanced analyses of problems and trends.
Continued development and use of KPIs to monitor Coding quality
The Trust was not subject to the Payment by Results clinical coding audit during 2014/15 by the
Audit Commission.
2.3 Reporting against core indicators
One of the indicators monitored is the Referral to Treatment patient pathways. The Trust has
taken a number of steps in 13/14 to assess the accuracy and reporting of this indicator including
engagement in the National validation programme run jointly by Monitor and the TDA. The
programme reviewed patient records that are recorded as being on an incomplete RTT pathway
and made recommendations to the Trust’s clinical/ management leadership regarding the
potential for removal of those records where the algorithm suggests they should not be on the
18 week PTL submission list. The programme reviewed 13,554 patient records of which they
recommended that 12 patients were removed from out waiting lists.
The Trust also engaged internal audit to review the 18 week processes within the Trust to
ensure quality and accuracy of the data. A comprehensive report was produced with a number
of recommendations which are being actioned currently.
The tables below highlight the Trust’s performance and allow direct comparison of key
performance indicators against national targets.
2014/15 performance against key national indicators, including comparison against
target and previous year’s performance
Target
2014/1
5
2014/1
5
Actual
2013/1
4
Actual
2014/15
Performanc
e Against
Target
2014/15
National*
** Actual
95%
95.0%
96.9%
Green
93.5%
90%
89.2%
88.7%
Red
88.9%
95%
98.6%
98.7%
Green
95.5%
92%
97.2%
94.0%
Green
93.1%
85%
85.1%
84.4%
Green
83.8%
Cancer target - 62 day wait for first treatment from consultant
screening service referral^
90%
98.2%
100%
Green
93.8%
Cancer target - 31 day wait for second or subsequent treatment:
Surgery^
94%
95.9%
97.1%
Green
96.0%
Performance Indicator
Waiting Times in A&E (% under 4 hours) **
Burton, Samuel Johnson Community Hospital and Sir Robert Peel
Hospital
Referral to Treatment Waiting Times - Admitted Pathways
Burton, Samuel Johnson Community Hospital and Sir Robert Peel
Hospital
Referral to Treatment Waiting Times - Non Admitted Pathways
Burton, Samuel Johnson Community Hospital and Sir Robert Peel
Hospital
Referral to Treatment Waiting Times - Incomplete Pathways*
Burton, Samuel Johnson Community Hospital and Sir Robert Peel
Hospital
Cancer target - Urgent referral to treatment of all cancers in 62 days^
36
Cancer target - 31 day wait for second or subsequent treatment: Drug
Treatments^
98%
99.3%
100%
Green
99.7%
Cancer target - Urgent referral for suspected cancers in two weeks^
93%
96.7%
97.3%
Green
94.0%
Cancer target - Two week wait for patients referred with breast
symptoms^
93%
96.8%
96.7%
Green
92.9%
96%
98.4%
97.6%
Green
97.8%
<= 15
20
16
Red
Cancer target - Diagnosis to treatment of cancer in 31 days^
Clostridium Difficile - No. of Cases
^Cancer data for 14/15 is up to Feb'15
*RTT Incomplete pathways figure is as at end of March 2015
**A&E Performance is based on SitRep weeks 1-52 for 2014/15
and not for the Financial Year
**National 2014/15 Actual Data
>Figures cover England only not UK
>RTT data is upto Feb15 only
>Cancer Data is upto Q3 only
NB: The annual data is not available from the HSCIC for NHS trusts with the
highest and lowest result for each of the indicators from the HSCIC
The Board ensures that quality improvement is central to all Trust activities. This is achieved by
routine monitoring, ensuring the Trust participate in national improvement campaigns,
celebrating success with our staff awards and proactively seeking patient views on our services.
For the past two years the Trust has used a number of indicators to measure performance in
relation to quality. These indicators were chosen as they are areas that matter to patients, and
cover the wide range of services that are provided. Performance against these indicators is
shown in the table below with further explanation given in the succeeding sections.
The Trust has taken the following actions to improve the indicators appearing as red in the table
above: The Trust was set a challenging target of the number of cases Clostridium difficile
infections (CDI) following the performance of 13/14 in which 16 cases were reported. The target
for 14/15 was set at a maximum of 15 cases. The Trust is above its full-year trajectory of CDI
reporting total number of cases of 20. During the year the Trust has determined with the
Commissioners, whether or not its cases of CDI are avoidable or unavoidable. This is because
it is acknowledged that there are some cases where the development of CDI is unavoidable
where treatment has been in line with national protocols of antibiotic use. All cases have been
investigated and only one case was determined to have been avoidable.
The Trust also did not achieve the Referral to treatment (RTT) admitted target over the
year. During the second quarter of the year the Trust Board agreed that the focus should be
centred on reducing the elective backlog and recognised the risk to not achieving the 18 week
target. The Trust delivered its commitment to address the 18 week backlog, at the detriment of
the target in Quarter 2, and delivered a sustained referral to treatment performance during the
rest of the year.
37
Performance against local indicators:
Performance Indicator
Patient Safety Measures
Mortality (CHKS RAMI) includes Community Hospitals
Mortality (SHMI) - Oct 2013 - Sep 2014
Mortality (SHMI) Banding - Oct 2013 - Sep 2014
Mortality (SHMI) % of pts admitted to a hospital within the trust
whose treatment included palliative care. - Jul 2013 - Jun 2014
Mortality (SHMI) % of pts admitted to a hospital within the trust
whose deaths were included in the SHMI and whose treatment
included palliative care. - Jul 2013 - Jun 2014
Patients with MRSA infection (rate per 1000 bed days) 2014/15
Patients with C.Difficile infection (rate per 100,000 bed days)
2014/15 includes Community Hosptials
Medication errors (per 1000 inpatient admissions exc. neonates)
inc. Community Hospitals from 2013/14
Clinical Effectiveness Measures
Re-admission rate by age within 28 days of discharge
Re-admission rate overall within 28 days of discharge
Cancelled Operations - excluding Community Hospitals
% of patients waiting less than 4 hours in A&E
% of patients risk assessed for VTE
Patient Experience Measures
Treated with dignity and respect (Treated with Kindness &
Compassion from Apr'13)
Overall Patient Experience Score
Handover times between ambulance crews and A&E staff (%
within 15 minutes)
2014/15
Actual
2013/14
Actual
92
0.96
89
0.98
2 = (As
expected)
2 = (As
expected)
0.96
0.93
18.99
18.74
0.006
0.006
12.95
10.7
6.6
4.8
011.3
15
%
16
11.4
+
%
11.4%
266
95.0%
98.4%
010.3
15
%
16
11.3
+
%
11.1%
189
96.9%
98.2%
96%
95.4%
94%
89.1%
84.7%
79.4%
Note: All the figures include Community Hospitals data except
where stated otherwise
38
Part 3: Overview of Quality
Patient Safety Indicators:
Mortality
There are a number of metrics used to monitor hospital mortality across England. The
predominant measures are SHMI – Standardised Hospital Mortality index (issued by the
Department of Health) and HSMR – Hospital Standardised Mortality Ratio (Dr Fosters). The
latest available mortality rates from both SHMI and HSMR were classified as “better than as
expected”. The reason for the variation between HSMR and SHMI is that they measure slightly
different things. There are 3 main differences.
SHMI measure inpatient and day case deaths, within 30 days of discharge whether in the
hospital or the community. HSMR measure a selected group of inpatient and day case deaths
within 56 diagnostic groups. This is about 80% of deaths in hospital.
HSMR makes a lot more adjustments, based on factors such as deprivation and palliative care,
where SHMI does not.
SHMI attributes death to the hospital at which the patient was last seen, whilst HSMR divides
the attribution between the trusts that the patient has attended.
Current situation
Burton Hospitals NHS Foundation Trust’s current SHMI rate is 0.983; normal is 1.00. The lower
the score the better, so BHFT was rated better than expected. This was for April – June 2014;
the latest available score.
The current HSMR rate for patients is 98, normal is 100, the lower the score the better,
therefore BHFT was better than expected. This was for December 2014; the latest available
score.
HSMR also allows the Trust to scrutinise mortality ratios at specialty level, for specific diagnostic
groups. If a hospital has an unexpected high score, then an alert is sent to the hospital.
Currently there are no alerts for BHFT.
Each month, the HSMR ratio for the Trust is scrutinised, to look for best practice and any
anomalies. This information is reported to a number of groups including the Clinical
Management Committee, Board of Directors and Quality Committee.
In addition, the data is only as good as that inputted, so there has been a great deal of work
supporting the coding team to improve accuracy of the data. Four new trainees were recruited
in July 2014, and we are now recruiting more. It takes about two years to become a fully
competent coder. The Trust has also focused on coding co-morbidities so that the expected
morbidity rate is accurate.
BHFT have now started to use the HED database, designed and managed by Queen Elizabeth
Hospital, Birmingham. This system supports a range of reports, which enable individual doctors
to receive feedback on their mortality ratio.
39
Healthcare Associated Infections
Reducing risk to patients remains the core objective in the delivery of Infection Prevention and
Control services on all Trust sites. The team have been given additional resources to deliver
local audit and national surveillance activity. Intended outcomes of this are to improve the
environment in which patients receive care, and to expand involvement of the Trust in national
surgical site infection surveillance programmes. In addition there is a responsibility to ensure
that staff are protected against potential infection. The latter part of the year saw extensive
training of relevant staff groups in donning and doffing of the specialist equipment necessary in
the unlikely event of a patient suspected of having Ebola arriving at the Trust. The innovative
data collection methodology measuring hand hygiene compliance continues although there
were a number of hardware and software issues during the year. The intended outcome of this
activity is the improvement of hand hygiene compliance in all staff groups.
Meticillin-resistant Staphylococcus Aureus (MRSA) blood stream infections
During the early part of the year two patients were identified in Trust with an MRSA blood
stream infection and were attributed to the Trust by the national Post Infection Review (PIR)
protocol. One of these was due to a clinical infection and the other was a contaminant from a
blood culture where the patient had no clinical signs of infection. The challenge is to achieve the
national and local aspiration to achieve zero cases.
Clostridium difficile (C. difficile) infection
Given the exceptional performance achieved last year the target set for 2014/15 was
challenging with the expectation that the Trust should have no more than fifteen cases for the
whole year. There were also a number of other national changes including a requirement to
determine whether an individual case was unavoidable or due to a lapse in care. Determination
of which cases should be deemed to be either avoidable or unavoidable was delegated to
Commissioners working in conjunction with the reporting Trust.
The Trust had twenty cases this year but following rigorous investigation just one of these was
identified as being due to a lapse in care. The remainder were agreed by our commissioners as
being unavoidable. Our challenge is to ensure that established infection prevention and control
practices continue to contribute to the achievement of our target.
Case data covering an eighteen month period was submitted to Public Health England (PHE)
for additional analysis. Findings indicated that a whole Health Economy approach was required
in order to impact on local rates. In addition patients admitted to the Trust were not typical of the
patient demographic of the rest of the West Midlands.
Meticillin-sensitive Staphylococcus Aureus (MSSA) bacteraemia
National data collection and reporting has been maintained throughout the year. There has
been an increase in the number reported to PHE to forty. The number that would be attributable
to the Trust shows a significant reduction compared to last year falling from nine to five. Root
cause analysis in these cases identified some issues which were rectified at the time of
identification.
Escherichia coli (E.coli) bacteraemia
As yet no national reduction targets have been set for this class of infections which are common
and often linked with urinary tract infections and patients who have indwelling urinary catheters.
Rates have continued to rise this year with one hundred seventy two such infections having
been reported. Of these the overwhelming majority were identified at the time the patient was
admitted rather than a number of days post admission.
40
Hand hygiene
Improving and maintaining compliance with this key activity remains at the heart of the drive to
reduce the risks of patients acquiring infection whilst in the care of the Trust. Direct observation
of practice indicates a high level of compliance but this is flawed as behaviours change when
staff realise that they are being observed. Results from electronic data collection, as part of a
pilot project, are now available to wards which reflect more accurately to what degree hand
hygiene is undertaken at the point of care. The pilot will continue into the coming year with the
active participation of the wards involved.
Infection prevention and control audit and monitoring projects
There have been no significant changes to Infection Control Audits undertaken during 2014/15.
These include isolation capacity and compliance with a range of infection prevention and control
standards. Other audits carried out were:









Management of peripheral intravenous devices
Commode cleaning
MRSA screening
MRSA decolonisation
C difficile
Additional audits in “hotspot” areas, particularly those areas where sporadic cases of C.
difficile infection have occurred
“Bare below elbow” audits
General environmental audits by Matrons and the Infection Prevention & Control Team
Contract monitoring of mattress decontamination supplier
The number of patients requiring MRSA screening reduced significantly from 1 st December
2014. This was the date on which the Trust implemented the new guidance which was
published by the Department of Health in August 2014. The change is a shift from screening all
patients to screening those in higher risk groups only. Local additions to screening categories
can be implemented if local evidence suggests that it is necessary to do so.
Ward commendation scheme
This scheme will continue in the coming year. At its heart is the intention of providing assurance
against a number of practices which place patients at greater risk of healthcare associated
infection. These activities provide triangulation of audit and infection data and thus assurance or
identification of areas where further work is required.
Surgical Site Infection Surveillance (SSIS)
Mandatory participation in national surgical site infection surveillance for hip and knee
replacements has been sustained for the required single quarter per year. It is envisaged that
this will be extended beyond the mandatory to be continuous in orthopaedics. It is further
planned to explore the possibility of increasing SSIS to other categories of general surgery
Outcome Monitoring
Reports are produced and presented to the Infection Prevention Board and to
Committee. These methods ensure that the Board of Directors are fully aware
towards achieving the work set out in the Annual Plan and mandated targets.
reports are provided weekly and monthly to Commissioners. Locally there is
practical input to the functioning of all Divisions within the Trust.
the Quality
of progress
Contractual
written and
Challenges for 2015/16
The Trust continues to work towards circumstances where no patient acquires a preventable
infection whilst receiving care in any of the Trust sites. The externally devised targets will remain
challenging requiring rigorous application of optimal preventative practice by all Trust staff.
41
Surveillance for the early identification of patients with high resistant organisms will continue as
will training for staff in order that they remain adequately protected from avoidable risks.
Medication errors
A medication error is any error in the prescribing, dispensing, or administration of a drug,
irrespective of whether such errors lead to adverse consequences or not. They are the single
most common cause of patient harm. Nationally the rate of medication errors in small acute
Trusts is detailed in the Organisation Patient Safety Incident Report produced by the National
Reporting Learning System (NRLS) for NHS England as being 10% of all reported incidents; in
this Trust the number of reported medication errors was 302; 5.4% of the Trust’s reported
incidents. This represents a 0.7% reduction from 2013/14
The responsibility for the management and learning from medication errors rests with the Trust
Medical Director, supported by the Head of Pharmaceutical Services. The Trust is continually
striving to learn from medication incidents, and a positive reporting culture is encouraged across
the Trust. This is achieved by the completion of incident forms by all staff when they are made
aware of actual or near-miss incidents involving medicines. These reported incidents are
reviewed by the Medication Safety Officer for the Trust, and discussed at the Safe Medication
Practice Group which meets every two months. Any trends, issues or learning which are
identified are actioned via the Quality and Safety Group. Actions which require highlighting more
widely are included as items in the “Medicines Alert Bulletin”. This bulletin is distributed to all
wards and departments. Any medication safety issues which cannot be adequately dealt with
through the Safe Medication Practice Group or the Quality and Safety Group, will be escalated
up to the Trust Clinical Management Committee, chaired by the Chief Executive, via the Head of
Pharmaceutical Services.
Prescribing errors are separately sent to the Post Graduate Clinical Tutor in order for specific
issues to be highlighted to junior medical staff as appropriate and then be used to provide
educational updates. Prescribing errors involving senior medical staff will be reported to the
Medical Director. Dispensing errors are recorded and monitored monthly and are discussed at
the Pharmacy Error Monitoring Group to ensure implementation of safe dispensing practice.
Information is shared within the West Midlands region via the Dispensary Managers Sub-group
of the West Midlands Chief Pharmacists Group to ensure shared learning.
All qualified nurses and junior medical staff must pass a drugs calculation test on appointment,
which helps to ensure that staff have the ability to carry out complex calculations and minimise
any errors from this source. In addition, annual spot checks are carried out with staff by the
Learning and Development and Practice Development Teams.
The Trust’s electronic prescribing and medicines administration system allows the
implementation of a variety of error-reduction strategies. These include warnings associated
with high-risk drugs, dose calculators, drug monographs, interaction warnings, and the
restriction of prescribing by individual password.
Falls
Patient safety is a key focus, especially when providing care and services to older and
vulnerable persons. With people over the age of 65 making up 16% of the population it is not
surprising that they occupy 65% of acute hospital beds. Patient falls account for approximately
40% of patient safety incidents reported to the National Patient Safety Agency (NPSA, 2007)
and may result in injury that can lead to an increased length of stay, additional medical costs
and ultimately a loss of confidence and independence for the patient. 10% of all patients aged
over 65 who fracture their hips will die within 30 days. 50% of fragility fractures go onto fracture
42
their hips and 50% never regain their previous level of mobility. The aging population means
that incidence will increase by 50% by 2030.
In keeping with the above, the NHS Litigation Authority requires evidence of organisational use
of risk assessments, monitoring, implementation and evaluation of appropriate actions in
relation to slips, trips and falls.
Promoting patient dignity, aiming for independence and achieving set rehabilitation goals are
important factors to consider within falls prevention actions in a hospital environment. The Trust,
in accordance with the NICE falls Guidance (2013), has reviewed its falls risk assessment tool.
The new tool is a functional assessment tailored to the individual’s need which is supported by a
care plan and care bundle. The tool requires a simple ‘yes’ or ‘no’ to a series of questions. If the
answer is ‘yes’ to any of the questions the patient is considered to be at risk of falls. Each
question has a preventative measure that can be put in place if the answer is ‘yes’. For
example if a patient has a sensory deficit the action would be to ensure that any aids required,
such as glasses, are available. If the patient has not had their eyesight tested recently then a
plan would be put in place to ensure that this occurred on discharge. These actions form part of
the care bundle. To support the functional falls assessment we have also devised a medication
review tool which enables drugs that are known to contribute to falls risk to be identified and a
medication review to take place. This is particularly crucial in terms of the impact of
polypharmacy in the elderly which predisposes them to a risk of falling. In addition to this we
have hi-low beds and crash mats available to all in patient areas to reduce the risk of harm from
falls.
The frailty pathway was implemented in December 2014. This is supported by a frailty team who
perform a Tinnetti assessment on all patients that trigger a frailty score, and supports and
complements the functional assessment in reducing the risk of falls in the frail older patient.
The Trust has introduced a post-fall assessment form; a combined document for both the nurse
and the doctor to complete. This enables immediate assessment and cohesive working within
the multi-disciplinary team (MDT) to formulate actions and treatment post fall.
When falls do occur processes are in place to review details of the incident at ward level and
action any interventions identified to prevent further falls occurring. A review process led by the
Chief Nurse is also in place for the review of falls resulting in serious harm.
Incidents
NHS Trusts are required to submit the details of patient safety incidents to the National
Reporting and Learning Service [NRLS]. The NRLS, thereafter, provides comparative feedback
to Trusts twice a year. Trusts are able to use this information to identify and tackle areas of low
reporting, as high reporting Trusts are considered to have a stronger safety culture; although the
NRLS recognise that the use of incident reports should never be used as indicators of actual
safety.
It is recognised that, even in organisations with a strong reporting and learning culture, not all
patient safety incidents are recognised and reported by staff. In contrast, lower levels of incident
reporting than peers should not be seen as positive sign, unless there is sufficient evidence
supporting that these lowered rates are as a result of patient safety improvements.
Higher levels of reporting may reflect genuine safety concerns, or may reflect a safer reporting
culture. As organisations vary in the services they provide; the location in which they are
situated and the size of the organisation, comparative figures should be viewed in
context.
43
Burton Hospitals Foundation Trust has a responsibility to comply with legislation, regulations
and standards as well as a common duty of care. The Trust Board promotes and encourages
the development of a positive and fair blame incident reporting culture with an emphasis on
reporting incidents allowing the Trust to continuously learn from incidents and improve the
quality of services to patients, staff and the public.
It should be noted that the incident rate per 100 admissions [based on incidents occurring] for
the period of October 2013 to March 2014 has been recalculated in line with new data submitted
by the Trust to the NRLS. Please note this is the latest data available nationally.
The number of patient safety incidents reported to the NRLS between March 2013 and March
2014 were:
Indicators
Value
Number of patient safety incidents reported
Incident rate per 100 admissions (based on
incidents occurring)
5,534
Number of incidents reported as occurring
4,213
5.79
Incidents reported to the NRLS between 1st April 2014 and 30th September 2014.
Indicators
Incident rate per 100 admissions (based on
incidents occurring)
Value
20.95
Number of incidents reported as occurring
1574
The level of harm to patients reported to the NRLS between March 2013 and March 2014 were:
Degree of harm
No Harm
Low
Moderate
Severe
Death
Total
Number of Incidents
Occurring
1,462
2,022
692
33
4
4,213
Percentage(%)
34.70%
47.99%
16.43%
0.78%
0.09%
100%
44
Level of Harm to Patients
March 2013- March 2014
No Harm
17%
Total
50%
No Harm
Low
Moderate
Severe
Low
24%
Death
Total
Death
0%
Severe
1%
Moderate
8%
The level of harm to patients reported to the NRLS between 1st April 2014 and 30th September 2014.
Degree of harm
Number of Incidents Occurring
No Harm
Low
Moderate
Severe
Death
Total
Percentage(%)
765
697
99
11
2
1574
48.6
44.2
6.2
0.7
0.1
99.8
Level of Harm to Patients between
April 2014 and September 2014
No Harm
24%
No Harm
Low
Moderate
Total
50%
Severe
Low
22%
Death
0%
Death
Total
Severe Moderate
1%
3%
45
The latest data shows that the Trust sits within the lowest 25% of comparative reporting rate,
per 100 bed days for 140 non specialist Acute Trusts. Data provided for previous years was
comparative with 28 organisations also categorised as ‘small acute trusts’; however NRLS have
recently removed this category meaning that BHFT is now benchmarked against much larger
Trusts.
Training programmes have been developed by the Governance and Risk Team to raise
awareness and improve incident reporting, root cause analyses [RCAs] and action planning.
The Trust investigates serious incidents [SI’s] in a thorough way, with added scrutiny and rigour
provided by the Serious Incident Executive Review Group chaired by the Director of
Governance, Chief Nurse and Medical Director.
Analysis of the data is presented via reports to a wide range of groups and committees within
the Trust including Speciality and Divisional Committees; Quality and Safety Group, Health and
Safety Group, and the Risk and Compliance Group. These groups and committees report to the
Quality Committee, a subcommittee of the Trust Board.
Clinical Effectiveness Indicators:
Readmission rates
The NHS Outcomes Framework indicators require trusts to monitor the number of readmissions
within 30 days. There are many reasons why a patient is readmitted into hospital within 30 days
of being discharged. Sometimes this can be a planned re-admittance for clinical reasons.
However, it can sometimes indicate that there were problems with discharge arrangements; the
patient may have been discharged too early or there were insufficient services in place to
support the patient when they returned home. The Trust periodically audits notes of patients
who have been readmitted within 30 days.
For the purposes of the Quality Account however, trusts are required to report on the previous
indicator of readmissions within 28 days. The percentage of the Trust’s readmissions, based on
28 days, is 11.4%. Although this is a slight increase on last year (0.3%), the Trust has worked
on safe discharge from hospital which requires support services to be available from the day of
discharge. These services are generally provided by other organisations with whom the Trust
has continued to work closely with during the year.
This year the Trust has continued the focus on improving discharge planning, engaging the
multi-disciplinary team to ensure that patients are discharged safely when they are medically fit,
linking this with their expected date of discharge (EDD).
Cancelled Operations
Operations are sometimes cancelled for clinical reasons; the patient may be unwell or their
condition may have changed. However, on occasion operations are cancelled for non-clinical
reasons; a bed may not be available or there may be theatre scheduling problems or equipment
failure. Such cancellations can cause great anxiety, distress and inconvenience for patients and
their families.
Following the development of the Elective Admissions Lounge the Trust has developed a
forward predictor tool which gives an early indication of where there could be pressures in the
system relating to elective bed availability. This important tool allows the bed management
teams to put further actions in place to minimise the risk of cancellation due to bed availability. It
is important to note however this cannot predict how many patients will come to the hospital
46
who need to be admitted as an emergency, if this number is high then these patients will take
priority over patients who are having a planned operation.
Emergency and Urgent Care
In recent years the focus across a health system, including hospitals, community services and
primary care has been the length of time people have had to wait to receive treatment within an
Emergency Department. It has been shown that patients who are diagnosed and treated within
4 hours have better clinical outcomes and vastly improved patient experience.
The 4 hour ED waiting time standard remains as a clear indicator of an effective and joined up
emergency and urgent care system care. The Trust and its partners have continued to develop
systems to improve waiting times and reduce delays. 2014/15 has been a challenging year as,
like the majority of NHS hospitals, the number of patients waiting over 4 hours is higher than
anyone would have wished for. The winter of 2014/15 has seen an overall rise in the demand
for emergency and urgent care within the hospital at the same time as seeing an increase in the
number of patients the hospital has been unable to discharge into community services. The
Trust is working with its partners at the Clinical Commissioning Group, Community Trust and
Local Authorities to improve the levels and quality of care provided so patients can be safely
discharges in a timely manner.
In 2014/15 the Trust has continued to develop, with its partners, the service Transformation
Programme to improve the flow of emergency and urgent patients through the hospital and back
in to the community. The Trust has developed a service programme which delivered the
following:




Enhanced bed capacity for emergency and urgent patients by re-aligning its wards to
more accurately reflect the demand for its services
Improvement in Ambulatory Emergency Care, whereby patients who, whilst in need of
urgent care, now have this provided without the need to be admitted to a hospital bed.
Improvements in the pathway for Frail Older People ensuring that admission to a
hospital bed is the last resort.
Improved ward flow and complex discharge processes
The fundamental principle underpinning this programme is to maintain a sustainable service
change to ensure that only patients who absolutely need hospital admissions do so.
Patient Experience Indicators:
Inpatient Experience
The Trust aims to provide the best possible patient experience regardless of the services that
patients may be accessing. Being treated with kindness and compassion is a big part of the
patient experience, along with ensuring that the Trust is responsive to the needs of inpatients,
as it is recognised that often patients can be at their most vulnerable when they have cause to
use hospital services.
A variety of methods are used to gain feedback on what patients and their families think about
the Trust’s services. This includes a number of local surveys that are carried out each month on
all wards and outpatient departments, with a minimum of 20 patients and relatives responding to
surveys. The Trust’s monthly inpatient surveys undertaken anonymously by impartial volunteers
show that the hospital continues to score well in kindness and compassion and responsiveness
47
to patient needs. All questions relating to this have scored an average of 90% or above over the
year and in several areas have shown an improvement.
Question
Have staff done all they can to help you stay clean?
Have you been treated with kindness and compassion by staff?
If you have had any pain, do you think that staff have done all they can to
help control it?
Do you get enough help from staff to eat and drink?
Do staff explain things to you in ways you understand?
Did staff welcome you and show you things you needed to know when you
arrived on the ward?
Have you been able to get the attention of staff when you needed it?
If you need help getting to the toilet or bathroom, do you get it in time?
Do staff involve you as much as you want in decisions about your care?
Score
2013-14
96
95
95
Score
2014-15
98
96
95
94
94
93
97
95
94
92
92
90
92
93
91
Results for National Survey 2014
The Trust performed as well as most other trusts in the National Inpatient Survey 2014 in all key
patient experience domains, and is performing better than most other Trusts on two questions
and worse on two questions.
2014
Domain
Emergency/A&E
Waiting list and planned admissions
Wait to get a bed on a ward
The hospital and ward
Doctors
Nurses
Care and treatment
Operations and procedures
Leaving hospital
Overall views of care and services
Overall experience
Indicator
Worse/ Same
or Better
Same
Same
Same
Same
Same
Same
Same
Same
Same
Same
Same
2014 Survey
Better /
Same or
Worse
Delay at discharge due to waiting for medicines/to see a
Better
doctor/ ambulance
Not having a long delay to discharge
Better
Trust Score
8.6
8.6
7.5
8.2
8.2
8.4
7.6
8.3
7.2
5.6
8.0
Trust score
7.2
8.3
48
Hospital specialist been given all the relevant information
Worse
from the person referring you.
Member of staff explaining how the operation/procedure had
Worse
gone
8.4
7.2
Patient’s overall experience of their care as reported in the National Inpatient Survey is as good
as most other Trusts.
2014
Worse
Same
Better
Overall Impression
/
or Trust Score
Overall, experience on a scale of 0 - very poor to 10 - very
Same
good.
8
Emergency Department Patient ExperienceThe results of the National A&E Survey undertaken in 2014 show that the Trust is performing as
well as most other Trusts who undertook the survey in the 8 domains measured
2014
Domain
Worse/ Same
or Better
Same
Same
Same
Same
Same
Same
Same
Arrival at A&E
Waiting times
Doctors and Nurses
Care and Treatment
Tests
Hospital environment and facilities
Leaving A&E
Trust Score
8.3
6.1
8.1
7.8
8.2
8.7
5.8
Friends and Family Test
All NHS Trusts in England and Wales are expected to ask Inpatients, A&E patients and
Maternity patients the Friends and Family Question. The Friends and Family Test is not
intended to provide comparisons between Trusts or against national scores but as a local
indicator of satisfaction. This is presented as the percentage of patients asked who would
recommend their care in this hospital to family and friends
Month
April
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Inpatient %
A&E %
Maternity %
94.37
93.57
95.24
94.00
89.61
97.59
96.78
90.50
99.27
95.79
89.27
97.57
95.03
90.88
98.60
95.22
90.55
97.16
96.10
95.31
97.19
97.23
93.10
98.03
96.39
94.97
97.75
97.49
97.04
96.72
97.21
96.91
96.59
96.62
94.11
97.82
49
Delivering Same Sex Accommodation
The Trust has continued to work hard through the year with the Estates, Facilities and
operational teams with the aim of complying with same sex accommodation standards and
improving the environment. The Trust continues to declare compliance with the Government’s
requirement to eliminate mixed sex accommodation.
Patient Reported Outcome Measures (PROMs)
The Trust has a requirement to provide details on PROMs for 4 different surgical
procedures. These 4 procedures are unilateral hip replacements, unilateral knee replacements,
groin hernia surgery and varicose vein surgery.
All patients undergoing surgery at the Trust that fall under one of the identified procedures are
asked at pre-operative assessment to complete a questionnaire. All forms that are completed by
patients are returned to Quality Health who are the Department of Health approved contractor.
All consent forms that are completed with regard to a patient’s procedure are held within their
notes.
Staff who are involved with the PROMs programme encourage participation in the
questionnaires at every available opportunity and reiterate the importance to patients of
capturing their feedback. Staff report good rates of participation and willingness by patients to
take part in the survey.
All figures are derived from the Health Episode Statistics (HES) website. The data relating to
the Trust, and nationally, for all procedures in terms of participation at pre-operative and the
response rates of post-operative stages are shown in the tables on the following page. The EQ5D scores and condition specific scores for each procedure are also shown in the following
tables. The EQ-5D score identifies the percentage of respondents who recorded an increase in
their general health following their operation, based on a combination of five key criteria
concerning their general health for each procedure.
The data below is taken from the from the Health Episode Statistics (HES) website for the
reporting period 2014/15; however the complete set of figures are not yet available.
50
The data shown below is for the reporting period of 2013/14. These are the most up to date,
complete set of figures.
51
Complaints
The Trust receives a large amount of feedback about its services from a variety of different
channels. While the majority of patients are satisfied with the levels of care they have received,
there are unfortunately some occasions where patients perceive their experience to have been
suboptimal.
People using the Health Service should feel that they can raise such concerns with a member of
staff. However, if the patient or their relative is not satisfied with the response or would prefer to
talk to someone not directly involved in their care, patients can raise concerns via our Patient
Advice and Liaison Service (PALS), or make a formal complaint. The Trust welcomes this
feedback which allows the issues to be fully investigated and a response provided to the patient,
and if the complaint is upheld, the Trust will take action to try to avoid similar occurrences
happening in the future.
An important part of PALS is to help people to talk through their concerns so that they can
identify the nature of the problem and develop plans to resolve it.
The complaint process was reviewed in 2014/15 and a revised approach has been adopted. All
formal complaints are recorded centrally and then passed to the relevant Head Nurse to appoint
an Investigating Officer. The IO carries out an investigation and provides an overview in
response to the issues raised. The Chief Executive or their appointed designate personally
reviews all complaints before a response is sent to the complainant.
As well as revising how complaints are investigated and owned at directorate level, the Trust
has also introduced the recording of complaint meetings to promote transparency and
openness. Copies of the meeting recordings are provided to the complainant and a copy is
retained by the Trust. There has been an increase in complaint meetings in 2014/15 as it is
recognised this is a more proactive way to really hear and understand the patient/relative
experience from their perspective. Following the Keogh Mortality Review in May 2013, key
performance indicators were agreed for the complaint service, covering a reduction in
complaints, review of complaints of the same theme and agreed days to respond timescales. In
December 2014, the Trust reduced the agreed days for a response to 25 working days from 35
working days.
Action plans are devised and monitored by the relevant area to ensure recurrence of the issues
highlighted is kept to a minimum. Senior Sisters and heads of departments are involved in this
process, sharing issues highlighted with their staff. Individuals who provide complaint action
plans are regularly asked for updates on actions identified until they are completed and signed
off.
During 2014/15, the Trust recorded 245 formal complaints; a 48% reduction from 2013/14
As well as responding to formal complaints, the Trust looks to identify any trends in informal
complaints as well as comments made to the Trust’s PALS officers.
Some of the changes that have been introduced during 2014/15 as a result of complaints
include the following:


Following issues raised relating to a labour experience, a de-brief will be offered to all
families after birth with an explanation of events and to clarify any issues at the time.
Patient notes will be audited by a Senior Midwife to ensure there is supportive
documentation recorded to reflect this.
Resulting from ongoing complaints, specifically related to bereavement, the Complaint
52




Service has liaised with the new Trust Chaplain and there is now a referral process in place
for anyone who might benefit from additional pastoral support from the Chaplain, in addition
to the ongoing support offered by the Complaint Team. There is also the opportunity, where
appropriate, for patients/relatives to share their story/experience with Trust staff.
Following a trauma referral to the MIU, Radiology staff will undergo additional trauma
training and review the pathways and reporting mechanisms to ensure that trauma images
are reported correctly and actioned in a timely manner.
Following feedback from a Cardiology patient, significantly changed results from cardiology
investigations will now be reviewed by the Cardiology MDT for action, to ensure patients
receive an appropriate plan of care following review.
A patient information leaflet has been devised for women who have suffered a suspected
miscarriage to improve information around what to expect and the future monitoring that will
be undertaken.
PALS leaflets are now available in Polish and Urdu and printed on yellow paper with black
ink for those with visual impairment. A newly devised ‘Share your experience’ form is
available to enable making a formal complaint easier.
The Complaint Team has also been externally audited by the local Healthwatch Service and
recommendations to the complaint process/service are being implemented to make the
complaint process easier and organisational learning more effective.
Compliments
Just as complaints allow areas where improvements can be made to be identified, compliments
also allow areas of best practice to be identified, shared and, importantly, fed back to the
relevant staff that their hard work and dedication has been recognised.
Compliments can be received through a number of different channels, many of them informally;
often as staff are simply going about their daily work. Many of the wards receive messages of
thanks and cards which are not officially recorded. However, patients, their carers, families and
general members of the public who do write in to the Trust with a compliment are all recorded
through PALS. The total number of compliments officially recorded for 2014/15 was 791; a 47%
increase from 2013/14.
53
Additional Quality Overview
Implementing guidance from the National Institute for Health and Care
Excellence (NICE)
NICE was established as a Special Health Authority to make recommendations to the NHS on
new and existing medicines, treatments and procedures. NICE guidance is published monthly
and the Trust is notified on the day of publication that it is on the NICE website.
The Trust maintains a policy which is accessible to all employees, outlining the core principles
for a collective approach to planning and enabling the consistent dissemination, implementation
and evaluation of NICE guidance. It is recognised that adequate implementation of NICE
guidelines requires a robust process that involves all Trust staff. Therefore, the Trust has a
NICE group that meets quarterly to; develop a coherent response to published guidance from
NICE, ensure that the Trust considers such guidance and respond / implement the guidance in
an equitable and uniform manner, and identifies and enables resolution of any issues that the
Trust may have with implementation.
In addition, a Trust database (CIRIS) is maintained, which enables the Trust to record
compliance with each piece of guidance and also whether or not it is applicable to the
organisation. The database is used as a location to keep any evidence of compliance such as
audits or Trust policies / guidelines. A separate register of interventional procedures is
maintained and records the approval of any requests to perform procedures that are new to the
Trust.
Overview of maternity services
Maternity provision within Burton Hospitals Foundation Trust is an integrated service, with care
being provided at Queens Hospital, the Midwifery Led Unit at Samuel Johnson Hospital in
Lichfield and in the Community. A multidisciplinary team provide care to approximately 3,350
women per annum, working in close cooperation to provide a seamless journey throughout
pregnancy. Antenatal and postnatal care is delivered across a wide geographical area by the
community midwifery services, who also undertake a small number of home births per year.
Approximately 22% of women who birth with the Trust will have a midwife as their lead
professional; initiatives are in place to increase these numbers.
The Consultant led unit is based at Queens Hospital and compromises of an ante natal clinic,
maternity assessment unit, which includes a 24 hour triage facility, a combined ante natal/ post
natal ward and a central delivery suite. The majority of Midwifery staff rotate on a daily basis to
all areas; this includes Ante-Natal Clinic, Maternity assessment, Delivery Suite, the provision of
caesarean section cover, and the Ante-Natal / Post Natal Wards. The Service is covered by all
Obstetric Consultants, with a designated Service Consultant covering the unit during the week,
with an on call service for the evening and weekends. There is also a dedicated team of
Obstetric Anaesthetic consultants, ensuring senior cover and leading the evolution within this
discipline. Senior Midwifery cover is also provided by both an on call manager and Supervisor of
Midwives. This close working relationship of the multidisciplinary team ensures the service has
a continuum for evolving and ensuring the best journey for all women choosing to birth at the
trust.
2014/15 has seen the addition of a vaginal birth after caesarean section clinic (VBAC), run by
Senior Midwives, which adds to the evolving service provided in the ante natal clinic. This joins
54
the well-established clinics such as, the Anaesthetic clinic to provide an excellent route for
consultation, review and information sharing with women.
The Maternity Assessment Unit (MAU) continues to diversify with the establishment of a
hyperemesis day provision, with the aim of rehydration, symptom control and education, thus
allowing the woman to return home the same day. This has significantly improved the
experience of women who would have previously been admitted to either a gynaecology ward
or maternity with differing length of stays. The introduction of this service has also released
beds, which has positive impacts for the whole Trust. Day care allows for women to be seen on
a regular basis to monitor their care without having an inpatient stay. Triage has proved to be a
valuable service enabling women to be seen by staff quickly and assessed to determine
whether they need to remain in hospital or can go home. Referrals come from Community
Midwives / General Practitioners or within the Unit itself, the provision of such a service
facilitates fewer inpatient stays for women.
The Trust’s Central Delivery Suite compromises of 7 delivery rooms, each with en-suite
facilities. These rooms are adaptable to deliver both high risk and low risk midwifery-led care,
however 2 are more midwifery led in their set up. This include a birthing pool suite, which has
enabled women booking at the at Queen’s site to have water births or labours in water, which
has been well received by our women and families.
This year has also seen the addition of a Bradbury couch and new birthing stool, to provide a
low risk, home from home provision as an alternative to the more traditional facilities. There is a
dedicated Obstetric theatre and recovery area within the footprint of delivery suite, enabling
provision for timely emergencies and elective caesarean sections. It is now two years since the
enhanced recovery programme was introduced for elective caesarean sections.
This
programme is a bundle of ‘best evidence based practices’ with the intention of helping patients
recover faster after surgery with better clinical outcomes and fewer complications. This includes
key steps in the patient’s journey from decision to care in the community following discharge.
The key components to its success are reinforcing the patients expectations around an early
return to ‘normal’ in all aspects of recovery and the collaboration between the woman and the
multidisciplinary team. Those parents who suffer a pregnancy loss are cared for in a dedicated
bereavement suite and supported by a bereavement team. Attached to the footprint of the
central delivery suite is also a level 1 neonatal facility, which is part of the central new born
network.
The Midwifery led unit at the Samuel Johnson Community Hospital in Lichfield provides an
alternative model of maternity care to the community of South Staffordshire and beyond. The
unit has 2 pool rooms, 3 delivery rooms, 2 single rooms and a 4 bedded ward. The unit is
recognized nationally for its excellent promotion of normality, with 52% of deliveries being water
births. It has a growing reputation as a centre for alternative therapies, especially aromatherapy
and reflexology. This year has also seen the provision of support for women with breastfeeding
issues following discharge; they are referred by the community staff. This has had excellent
results and is proving a positive experience for women and their families. This service continues
to evolve with initiatives to constantly provide a high standard of midwifery led care.
Community midwifery is provided across the Burton area to all women living in that geographical
area irrespective of where they choose to deliver their baby. Community midwives employed by
the Trust provide care to women in South Staffordshire, South Derbyshire and North West
Leicestershire, and women may choose to birth at any of the cross border hospitals.
The innovation and high standards of care at Burton Hospitals Foundation Trust led to the
achievement of winning the national CHKS Excellence in Maternity Care Award for the top
maternity service in the country in May 2014.Feedback from CHKS stated the following reasons
for winning the award:
55






MDT working to provide personalised individual care
Open access to all services especially breast feeding support
Fluidity across pathways
Nationally recognised stand-alone Birth Centre
Innovative practice
Exemplary/ award winning bereavement services
It is with this recommendation behind us that we continue to strive to continually develop
excellent maternity services for our women and their families. In March 2015 we undertake
assessment to achieve level 3, Baby Friendly Initiative (BFI) accreditation, towards which the
service is working tirelessly to accomplish.
Overview of cancer services
The National Cancer Peer Review Process has been undertaken annually for many years. Each
year the site specific Multi-Disciplinary Teams (MDTs) are required to review their service
against a set of measures produced by the national team, this then informs the teams work
programme for the coming year. Each MDT is also required to produce an annual report and an
operational policy. These three documents form the main sources of evidence against the
relevant measures.
All results are available to the public via the National Cancer Action Team (NCAT) CQUINS
website.
Burton Hospitals NHS Foundation Trust did not have any external reviews in 2014/15; we did
however have five internal validation panels these were for:
 Lung MDT
 Chemotherapy
 Chemotherapy pharmacy,
 Paediatric Oncology Shared Care Unit (POSCU),
 Colorectal MDT
 Colorectal diagnostics and
 Gynaecology local MDT
Internal validation panels were set up to include:



Cancer Lead Clinician (Chair)
Lead Nurse / Manager Cancer Services
Director / Deputy Director of Operations
Unfortunately we were unable to gain Clinical Commissioning Group attendance at our internal
validation panels this year however this report shall be available for dissemination.
Many of the peer review measures were updated a few weeks before the teams were required
to undertake their assessments, leading to a reduction in compliance for some teams despite
delivering an excellent service.
56
Results of Internal Validation
Site
IV Assessment
Result 2014
Assessment Result 2013 &
Cycle
Gynaecology Locality
Lung
Colorectal Locality
POSCU
Colorectal Diagnostics
Chemotherapy
Chemotherapy Pharmacy
87.5%
93.3%
100%
77.8%
100%
91.7%
100%
93.8% SA
85.7% SA
100% SA
66.7%
100% SA
95.1% SA
85.7% SA
Results of Self-Assessment
Site
Cycle
Progress to date
AOS
SA
Breast
Head & Neck
Locality
Urology
CUP
UGI
Skin Immuno
Skin Locality
Measures
Brain
Sarcoma
HPB
SA
SA
AOS MDT
AOS – IP – MDT
Gen – AOS - MDT
Completed
Completed
Assessment
Result
100%
75%
87.5%
100%
100%
SA
SA
SA
SA
SA
Completed
Completed
Completed
Completed
Completed
83.3%
100%
86.7%
100%
93.8%
SA
SA
-
75%
100%
-
TYA
-
Specialist
Palliative Care
-
Haematology
-
Partnership
Psychology
-
Completed
Completed
For review in 2014, but Trust does not
have a HPB MDT
Work being undertaken to agree and
amend existing pathways currently
with Birmingham exploring transfer to
Nottingham
Removed due to agreement that Trust
is not designated for TYA. Work
needs to be undertaken on referral
pathways and dissemination of these
once WM pathways are in place
Nationally measures suspended, Trust
SPCT and Lead Nurse are involved in
national work to keep up to date with
new measures and plans
Not a requirement as part of this round
of peer review however this process
will be completed by December 2014
with recommendations for the team to
act upon in preparation for the 2015
peer review process.
No Trust measures this year
No Trust measures this year
-
-
-
57
Rehabilitation
CRN
Complimentary
Therapies
-
No Trust measures this year
No Trust measures this year
Suspended
-
The MDTs, on the whole, continue to improve their services despite the challenges of an
increase in urgent cancer referrals and the increasing demands on services generally.
It is evident that MDTs are very proud of the service they provide and this is reflected in the
teams input and energy in preparing the reports for upload and when undertaking the internal
validation.
Workforce
The NHS Constitution and in particular the four Staff Pledges, is at the heart of the Workforce
Strategy. It is recognised that having a highly motivated workforce will have a significant impact
on achieving the high quality care that patients require.
The last 12 months has continued to be a very challenging environment for the Trust but despite
this we have seen staff satisfaction levels in improve in a number of areas related to the Staff
Pledges. The Trust is confident that this will give us a platform to continue to make
improvements in 2015.
Staff Pledge 1
The NHS commits to provide all staff with clear roles and
responsibilities and rewarding jobs for the teams and individuals
that make a difference to patients, their families and carers and
communities.
Staff Pledge 2
The NHS commits to provide all staff with personal development,
access to appropriate training for their jobs and line management
support to succeed.
Staff Pledge 3
The NHS commits to provide support and opportunities for staff to
maintain their health, wellbeing and safety.
Staff Pledge 4
The NHS commits to engage staff in decisions that affect them and
the services they provide, individually, through representative
organisations and through local partnership working arrangements.
All staff will be empowered to put forward ways to deliver better
and safer services for patients and their families.
During this year the independently-run national annual Staff Survey Report has evidenced that
the performance of Acute Trusts across the country has improved slightly from 2013. The
results for Burton Hospitals also show that improvements have been made in a number of
areas. Some of the highlights from the survey relating to these pledges are detailed in the
tables on the following pages.
58
Results from annual Staff Survey showing change in performance at the Trust by Key
Finding (KF) between 2012/13 and 2013/14, and ranking in 2013/14 compared with all
Acute Trusts
Staff Pledge 1
Change since
Ranking compared with
2013 survey
all acute trusts 2014/15
KF1. % feeling satisfied with the quality of
work and patient care they are able to deliver
Better
Better
KF2. % agreeing that their role makes a
No change
difference to patients
Better
KF3. % work pressure felt by staff
No change
Worse
KF4. effective team working Quality of job
No change
design
Worse
KF5. Working extra hours
No change
Better
Staff Pledge 2
Change
since Ranking compared with
2013 survey
all acute trusts
KF6. % receiving job-relevant training, learning
No change
or development in last 12 months
Average
KF7. % appraisal in last 12 months
Best (Highest 20%)
Better
KF8. % having well-structured appraisals in
No change
last 12 months
Average
KF9. % Support from immediate managers
No change
Average
Staff Pledge 3
Change
since Ranking compared with
2013 survey
all acute trusts
KF10. % receiving health and safety training in
No change
last 12 months
Worse
KF11. % suffering work-related stress in last
No change
12 months
Better
KF12. % witnessing potentially harmful errors,
No change
near-misses or incidents
Best (Lowest 20%)
KF13. % reporting errors, near-misses or
No change
incidents witnessed in the last month
Average
KF14. Fairness and effectiveness of incident
No change
reporting procedures
Average
KF15.% staff agreeing that they would feel
No comparator
secure raising concerns about clinical practice
Average
KF16. % experiencing physical violence from
patients, relatives or the public in last 12 Better
months
Best (Lowest 20%)
59
KF17. % experiencing physical violence from
No change
staff in last 12 months
KF18. % experiencing harassment, bullying or
abuse from patients, relatives or the public in No change
last 12 months
KF19. % experiencing harassment, bullying or
No change
abuse from staff in last 12 months
KF20. feeling pressure in last 3 months to
No change
attend work when feeling unwell
Staff Pledge 4
Better
Best (Lowest 20%)
Average
Better
Change
since Ranking compared with
2013 survey
all acute trusts
KF21. % reporting good communication
No change
between senior management and staff
Average
KF22. % able to
improvements at work
Average
contribute
KF23. Staff job satisfaction
towards
No change
No change
Worse
KF24. Staff recommendation of the Trust as a
No change
place to work or receive treatment
Worse
KF25. Staff motivation at work
Better
No change
KF26. % having equality and diversity training
No change
in last 12 months
KF27. % believing the Trust provides equal
opportunities for career progression or No change
promotion
KF28. % experiencing discrimination at work in
No change
last 12 months
Worse
Average
Average
Statutory & Mandatory Training
The Trust is committed to the delivery of a robust Statutory and Mandatory training programme
and during 2014-15 we have seen consistent improvements in the compliance rates for our staff
that have consistently achieved 90%. This has been achieved through developing a blended
learning programme including classroom based and e-learning modules. Almost 40% of our
training is now completed through e-learning modules all of which include competency based
assessment tests.
Medical Workforce Developments
During 2014/15 the Trust developed a Medical Workforce Strategy, the implementation of which
will be monitored through the Board’s People Committee. The Strategy itself has a number of
components including Leadership development, medical engagement and a focus on specialty
areas where there is perceived to be a workforce shortage either now or in the future.
Alongside this the Trust has engaged with a number of working groups for clinicians particularly
relating to the development of the future strategy. It is fully recognised that the Trust needs to
listen to the medical body and use their undoubted skills to help shape the future.
In 2014 we made positive recommendations on 70 doctors representing 34% of the total eligible
doctors, with no referrals for non-engagement.
60
Workforce planning
The Trust produces a five-year workforce plan which is updated on an annual basis and this
informs the educational commissioning intentions for the supply of the Trust’s future clinical
staff. This workforce plan also aligns with the Long Term Financial Model produced for Monitor.
Through careful workforce planning the Trust has again been able to accommodate all newly
qualified nurses and midwives who have recently completed their training through the Trust and
these staff are now actively playing a full part in the delivery of high quality care. Over the last
12 months we have recruited 52 registered nurses from Italy. We have also recruited 80
experienced nurses from the Philippines who are due to commence with Trust by December
2015.
Moving forward the models of health care will inevitably develop and the Trust fully understand
that a very flexible workforce is required to be able to accommodate this. More work will be
undertaken in community settings and the Trust anticipate that more work will be undertaken on
a partnership basis with other organisations in the local health economy. To be able to do this
effectively will involve the development of new ways of working and new roles. The Trust is also
aware of the on-going difficulties around the future supply of medical staff and in particular
around the emergency pathways. It is important to the Trust that these emerging difficulties are
anticipated and look towards the development of roles such as the Emergency Physician
Assistants.
Student placements
Autumn 2014 saw changes to the team that delivers clinical placements. This involved
implementing a new model of delivery of quality placements by aligning the Practice Education
team more effectively with Divisional structures. All outcomes within the Learning and
Development Agreement were achieved. 18,698 placement days were provided, across 78
placement areas including nursing, midwifery & AHPs. This equates to 275 students. In addition
the team have supported 734 mentors/assessors to enable them to be effective in their
mentorship roles.
There has been considerable focus over the year to strengthen the partnership between
students and the Trust, as a result the Student Voice initiative was developed. This has given
students an equal opportunity to be involved in forums whereby they can contribute their ideas
to improve patient experience. The Trust has continued to actively recruit graduates who select
us as their employer of choice. The new Practice Education Team model has provided the new
recruits with continuity as they continue to be supported during their preceptorship period.
Staff engagement
The National Staff Survey results for 2014 show an improvement in performance overall with
staff engagement from 3.70 to 3.72. In the league table of acute Trust’s, based on the results,
Burton has renewed efforts in 2014 have allowed a number of opportunities for our staff to be
actively involved in improving the quality of care that the organisation provides.
Health and wellbeing
The health and wellbeing of our staff is critical to our success and though sickness rates
amongst in some staff groups have deteriorated the Trust is committed to supporting staff in the
workplace. The three year strategy has identified best practice across the whole country and the
Trust now has an annual operation delivery plan that is designed to improve the health of staff.
Pivotal to this is the development of the Occupational Health service and the Trust is currently
looking at ways that links with a number of organisations, that can help the Trust achieve its
goals, can be developed.
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Leadership
Led by the Chairman and Chief Executive, coaching programmes and leadership development
initiatives have been put in place to support and develop all board members Overall the Trust
has a very good blend of Board members and although the levels of experience are
comparatively low the Trust is confident that with the measures in place this will be mitigated.
Immediately below Board level the Trust has three clinical divisions. The three divisions each
have an Associate Director, Medical Director and a Head Nurse and all posts are currently filled.
Supporting the structure is a Leadership and Management Framework. This new framework will
give staff access to a broad range of training programmes that have been designed to add
significant value. This will incorporate both internal and externally delivered programmes and an
in house coaching programme.
The Environment
The Patient-Led Assessment of the Care Environment (PLACE) assessment has been designed
to replace the Patient Environment Action Team (PEAT) assessments which had been
undertaken from 2000-2012 inclusive.
PLACE is a self-assessment of a range of non-clinical services which contribute to the
environment in which healthcare is delivered in the both the NHS and independent/private
healthcare sector in England.
The PLACE assessment focuses on the areas which patients say matter and the involvement of
patients, public and other bodies, such as Local Health Watch, as part of the assessment team
is central to the process.
The following table provides an analysis between the 2013/14and 2014/15 results. The national
average score for 2014/15 is not available at this stage.
Site
Cleanliness %
2013
2014
Food %
% Vari
2013
2014
Privacy & Dignity %
% Vari
2013
2014
Condition & Maintenance %
% Vari
2013
2014
% Vari
QHB
94.41
96.16
1.75
79.05
84.3
5.25
87.79
85.66
-2.13
87.1
86.54
-0.56
SJH
93.78
98.84
5.06
83.08
87.5
4.42
93.81
88.55
-5.26
89.27
92.96
3.69
SRP
90.86
96.72
5.86
90.06
87.63
-2.43
82.68
82.34
-0.34
85.42
89.49
4.07
National Average
Scores 2013
95.74
Key
Improved Score
Decreased Score
84.98
88.87
88.75
Green
Red
Cleanliness
The scores for cleanliness have increased across all 3 trust sites. These scores are above the
national average score for 2013.
Food
The scores for food have increased for the Queens and Samuel Johnson Hospitals, but
decreased for Sir Robert Peel Hospital. However the cumulative score for the Trust is above the
national average based on the 2013 score.
Privacy and Dignity
The scores for Privacy and Dignity have reduced across the board. It is understood that this is
a trend that has also been seen in other trusts and the reason for this is currently being queried.
However the Trust did not score highly for the following Privacy and Dignity questions:62
1. Television access at ward level
2. Private rooms for patient conversations at ward level.
3. Sufficient space at reception desks so that conversations between staff and patients
cannot be overheard
4. Patients cannot leave consultation / counselling rooms without having to return through
the general waiting area.
Condition and Maintenance
The scores for maintenance have increased for the community hospitals but have reduced by
0.56% for the Queens Hospital. The cumulative score for the Trust is above the national
average based on the 2013 score.
There were 3 main areas that did not score highly for maintenance and condition:1. Emergency department
2. X ray
3. Outpatients B
There is an ongoing risk assessed capital programme for the Trust. Refurbishment is required in
some areas but funding will allocated dependant on risk. A number of refurbishments have
taken place over the last year, all of which have improved the patient environment:
Centralisation of Endoscope Reprocessing
To comply with ever improving JAG standards, the Trust relocated the washer disinfectors from
the current Endoscopy Suite to the centralised HSSU together with the new equipment into a
state of the art facility along with the implementation of a new contractor for the supply of
endoscopes. The new process can clean, disinfect and sterilise the scope in a 17 minute cycle
compared to the previous 40 minute cycle saving time and resources. This facility will also
future proof the opportunities of this service going forward.
Nurse call system replacement
The three year phased replacement of the hospital wide nurse call system has been completed.
This involved the replacement of the twenty year old existing system. The new system has
allowed more efficient diagnostics and analysing for maintenance use and also allowing for full
reporting of activation and response to the system aiding clinical teams.
Central corridor upgrading, floor walls ceiling heating insulation
A scheme is half way through for the refurbishment of the main circulation junction outside the
WH Smith’s shop. This includes replacement flooring and new ceiling including heating,
ventilation and lighting. The upgraded systems will help increase the efficiency of the services
within the building and lower running costs. The new décor and lighting scheme provides a
more modern feel to the circulation areas and should enhance patient experience.
Power Supplies
As part of an ongoing scheme to bring the Hospital’s engineering infrastructure up to standards
the critical services were targeted first. This involved installation of combined isolated power
supplies backed up with uninterrupted power supplies (Batteries) services to Main Theatres,
Delivery Theatre, Neo-natal and the replacement of an end of life UPS/IPS system in the
HDU/ITU Department, allowing increase resilience and safety for the patients.
Clinical Coding
As part of rationalisation of the Clinical Coding Team a refurbishment of a centralised area in
one of our administration buildings has been undertaken. This allowed the whole Clinical
Coding Team to be brought under one roof instead of being spread out around the Trust. As
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part of this move efficiencies and communications increased which allowed cost savings and
improvements in processes which have been completed.
SRP Generator
The existing standby generator at Sir Robert Peel was originally installed in the old St Editha's
Hospital in Tamworth and was relocated to the Sir Robert Peel hospital when this was built in
1996. The generator and control equipment have been causing maintenance and reliability
issues for some time and this replacement will improve the resilience and stability of the
emergency standby power supply to the site as well as contribute to efficiency targets with a
more efficient engine.
Lighting Replacement Scheme - replace T12 lighting
As part of the Trusts drive for energy efficiency and reducing the carbon emissions, the Trust is
in the process of replacing the old T12 lighting, which is over 20 years old, with new efficient
LED solutions. This has been rolled out to all areas where existing T12 solutions are present.
Alongside this there is also a replacement scheme for the external lighting giving increased light
output; improving safety for patients, visitors and staff, as well as providing energy savings
through the use of LED.
Fats Oils and Grease
The Trust has installed a of state of the art grease recovery units within the Central Production
Kitchen and restaurant finishing kitchen to remove all fats oils and grease from the food
production and food waste streams. Additionally a food waste bio-digester has been installed to
treat all food waste; reducing this to grey water. This improves the sustainability issues around
waste water and drains and should help to reduce unexpected drain blockages down steam of
the hospital.
Approach to Delivering Quality and Service Improvement
The Trust is working with partner organisations including other acute providers and GPs to
ensure clinical services remain sustainable and that, where possible, services are redesigned
across organisational boundaries.
As an example, the Medicine Division considered the service for those patients who attend
Burton Hospitals and require specialist cardiac surgery.
A multidisciplinary clinical team from Burton and Stoke met to discuss possible options of
working more collaboratively to benefit patient care.
The outcome was that Stoke now offer timely access to cardiac surgery and transfer emergency
admissions within 24/48 hours for our patients.
Stoke are also providing a surgeon to attend the multidisciplinary team meeting at Burton once
a month. At this meeting, elective cases can be discussed and patients will be allocated to
Stoke based on clinical priority/need and patient choice.
In addition following the appointment, in September 2014, of a new Interventionalist post within
Cardiology, a weekly angioplasty session has now been set up in Stoke and is being delivered
by a Burton Cardiologist for Burton patients to support continuity of care.
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A number of other developments are planned for 2015/16; improved pathways across
secondary and primary care, to which end a series of sessions have been set up between our
own consultants and our local GPs. The inaugural session was in February 2015 where a
number of pathways were discussed for improvement including respiratory, diabetes and heart
failure. Further sessions are planned for June and November 2015.
65
Annex 1: Statements from commissioners, local Healthwatch
organisations and Overview and Scrutiny Committees
Burton Hospital NHS Foundation Trust Quality Account 2014/15
Statement from East Staffordshire CCG
On behalf of all South Staffordshire CCGs, Southern Derbyshire CCG and North West
Leicestershire CCG
Review of 2014/15
The CCG acknowledges the work undertaken by the trust to fully embed their Quality Strategy.
In particular, their Ward Assurance Framework shows consistently high scores throughout the
year. The Board to Ward rounds are noted and the CCG is aware of the extensive patient
experience work undertaken by the trust as well as the efforts to improve patient feedback
across all wards. The trust is to be commended for its work on reducing hospital acquired
pressure ulcers. The work the trust has undertaken in respect of dementia care is also
acknowledged by commissioners and a particular highlight was the launch of the Dementia
strategy in late 2014.
The work carried out by the trust to embed compassion in care and 6Cs is to be commended,
particularly the ward based philosophies of care detailed in the Account.
It is noted that communication is the area that scores lowest on the Trusts’ patient’s survey and
the CCG looks forward to learning what actions the trust will be taking to improve this.
The introduction of housekeepers is a welcome addition to the workforce and will undoubtedly
contribute towards improved patient experience. The CCG looks forward to receiving updates
on their effectiveness.
Priorities for 2015/16
The trust has identified three priorities for 2015/16, all of which will impact positively on patient
care and safety.
Priority 1 is to reduce harm across the trust with a particular focus on sepsis, acute kidney
injury and catheter associated urinary tract infection. The CCG looks forward to receiving
regular reports and updates on the effectiveness of improvements in these areas.
Priority 2 is to ensure their workforce is sufficient in number and equipped to provide safe and
effective care. The CCG has previously commended the use of Staffing Boards on every ward
and welcomes further development in this area. The CCG acknowledge the work undertaken
by the Trust in terms of local, national and international recruitment of trained nurses. In
addition, the Medical Workforce Strategy is recognised and reports on appraisal, training and
revalidation of medical staff will be most informative to the CCG.
Priority 3 is to improve patient experience by developing an initiative called “Our Warm
Welcome”. This builds on the trust’s priorities for last year and is well received by
commissioners.
Quality Overview
 The trust remains in special measures following the Keogh Review originally carried out
in May 2013. The ongoing monitoring is undertaken by the Care Quality Commission
and a further visit to the trust is planned for summer 2015. It is anticipated that the CCG
will be invited to be part of this review. The CCG recognises the considerable amount of
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work undertaken by the trust to implement all actions and wish to particularly highlight
the value and learning presented by the “mock” CQC review planned for early June.
Commissioners also wish to record that positive relationships exist between the CCG
and the trust.
Commissioners are pleased to note the trust’s extensive participation in national clinical
audits as well as a number of local clinical audits. Also noted is the number of actions
taken as a result of the findings, which will improve quality of services for patients. The
CCG would be pleased to work further with the trust in respect of community based
excisions of squamous cell carcinomas and melanoma.
The trust’s involvement in research is noted and welcomed. In addition, South
Staffordshire CCGs are grateful to the trust’s research department for the arrangements
that are in place for the trust to undertake research governance permissions for local
studies on behalf of primary care.
Commissioners note and confirm the trust’s achievements against the Commissioning
for Quality and Innovation Schemes (CQUINs) for 2014/15. The considerable work
undertaken by the trust to reach this level of achievement is acknowledged. The actions
taken and planned to improve data quality are noted.
The account includes detailed reference to the Trust’s performance in respect of Core
Indicators.
However despite many of these reported as green many also show a
worsening position on the previous year and the CCG look forward to seeing continued
improvement in the coming year across all targets, not only the ones reported as red in
the quality account.
The CCG notes the introduction of the Trust’s Mortality Electronic Toolkit and look
forward to receiving more detailed information about this very important area. This has
not been provided in a comprehensive and consistent way to date.
In respect of MRSA the CCG notes that the two patients with MRSA blood stream
infections did have signs of clinical infection, however in one case it was found to be due
to a contaminant rather than a clinical infection.
Commissioners were disappointed to note that the only assessment of quality in relation
to pharmacy services is the recording of medication errors. There are national
standards for hospital pharmacy services produced by the Royal Pharmaceutical Society
and a measure of the trust’s performance against these would be a useful indicator for
future years.
The trust has introduced a falls risk assessment tool, which has been a priority area for
improvement. The CCG notes the actions taken by the trust in respect of falls however
concerns remain in respect of the number of falls that result in fractures and look forward
to continued improvement in this key patient safety area.
The CCG is aware that the trust has faced challenges in fully achieving the requirements
of the Eliminating Mixed Sex Accommodation guidelines.
However, the CCG
acknowledges that the trust is openly reporting when breaches occur and has valuable
dialogue with CCG staff where possible breaches require further consideration.
The CCG welcomes the trust’s revised approach to complaints management, which
enables complaints to be investigated locally at ward level in the first instance. The
examples given of changes made in response to complaints are laudable.
In respect of NICE guidance, the CCG is aware that the trust is investing in Blueteq, a
system for monitoring compliance with NICE criteria for certain drugs. A report on
progress would be welcome early in the implementation phase of this project..
To trust has continued to report all serious incidents in line with reporting requirements
and has worked to improve the timeliness of their reporting. The Quality Account does
not include the number of Never Events reported by the trust. During 2014/15 the trust
reported two incidents of retained foreign objects following procedures, recognised
nationally as a Never Event. In addition, one local avoidable event was reported as one
patient was discharged home with a cannula still in situ. This is noted as a considerable
67
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improvement on last year’s incidence of never events and local avoidable events,
specifically retained cannula incidents.
The trust has a robust process for investigating serious incidents. This Quality Account
would have benefitted from including a summary of lessons learned and improvements
made in respect of quality and safety and the CCGs would encourage the Trust to
consider this in future Quality Accounts.
Commissioners were pleased to note the improvements to the midwifery service and
would like to congratulate the trust on winning the CHKS Excellence in Midwifery Care
Award in May 2014.
The CCG note the areas of improvement in the Staff Survey but were disappointed that
no planned actions are included in respect of the areas either worsening or still requiring
improvement.
The Trust have faced significant difficulties in relation to the recruitment of nursing staff
and the CCG welcomes the Trust actions in respect of enhancing the workforce through
international recruitment drives. The CCG are disappointed that little reference is made
to recruiting to the medical workforce however although not including reference to
recruitment, the new medical workforce strategy is welcomed.
The CCG note the report in respect of the PLACE self-assessment. There are some
areas of improvement seen within the most recent review however for those areas
where the score has deteriorated actions are not clear. For example, despite remaining
above the national average there are no clear plans included to improve the score for
food. Similarly, for privacy and dignity the Trust have identified the issues but have not
made clear their plans to rectify the issues in these areas.
The CCG wish to state that to the best of their knowledge, the data and information
contained within the quality account is accurate.
Overall we recognise that significant improvements in quality and safety have been seen
at the Trust during a challenging period locally but also in the wider NHS. We look
forward to working together with the Trust to ensure continued improvement over the
coming year.
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Burton Hospital Foundation Trust Quality Account 2014/15
Statement from Healthwatch Derbyshire
Healthwatch Derbyshire collects real people’s experiences of health and social care services, as
told by patients, their families and carers. These experiences, as reported to Healthwatch, will
form the basis of this response.
Healthwatch Derbyshire has passed this patient feedback to the Trust during the reporting
period in the form of comments. A total of 50 comments have been received about the services
provided by the Trust, with 20 comments being positive, 15 being negative and 15 being mixed.
These comments have been regarding a wide range of Trust services, including inpatients,
outpatients, and accident and emergency.
In terms of the comments received by Healthwatch, there are many positive comments about
staff attitude, good systems and high quality care. However, negative comments have also been
received demonstrating that there is always work to do and room for improvement to improve
patient experience.
Healthwatch Derbyshire has encouraged the Trust to feedback actions and learning from these
comments, and has received assurance that experiences have been tabled at a patient
experience group for triangulation. The Trust has generally provided this feedback, and recently
has provided one response which demonstrates a specific change in system and policy as a
result of the patient feedback given. This is a useful demonstration of the Trust’s capacity to
listen to and learn from patient feedback and Healthwatch Derbyshire looks forward to working
with the Trust in 2015-16 along similar lines.
Burton Hospital Foundation Trust Quality Account 2014/15
Statement from Healthwatch Staffordshire
Healthwatch Staffordshire continue to work closely with BHFT, undertaking several projects in
the past year. These include the consultation on the proposed closure of Theatre at Sir Robert
Peel Community Hospital. Patient experience studies based on focus groups, surveys and
interview methodologies. A thematic review of the complaints service and process, and also
collating and collecting ongoing feedback from patients their relatives and carers about services.
Throughout these activities we have engaged and interacted with over 1,000 service users. A
high proportion of the experience data is very positive but issues identified include waiting times,
appointments and communication.
We are pleased that the Trust is continuing to focus on improving quality of patient care through
initiatives such as the Quality Strategy. From the feedback we have had from patients and
relatives over the past twelve months this is appreciated and having a positive impact on their
hospital experience. We also support the ongoing work that the Trust is doing in developing
and applying the Ward Assurance Framework. This is helping to address the issue of ensuring
consistency of care across the hospital. During the year, with the support of hospital staff and in
conjunction with colleagues from Healthwatch Derbyshire we have introduced regular ‘drop in’
sessions at Queens Hospital, Burton. This has helped us both to have a closer understanding of
patient experience and the issues and challenges facing the Trust in delivering services.
The three priority areas for 2015/16 – reducing avoidable harm, staffing and ‘warm welcome’
are all aimed at improving patient experience. All of these present a challenge to the Trust and
we will be engaging with hospital users over the next twelve months to understand how the
Trust’s work in each of these areas is improving the patient experience.
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Annex 2: Statement of Directors’ responsibilities for the
Quality Report
The directors are required under the Health Act 2009 and the National Health Service (Quality
Accounts) Regulations to prepare Quality Accounts for each financial year.
Monitor has issued guidance to NHS foundation trust boards on the form and content of annual
quality reports (which incorporate the above legal requirements) and on the arrangements that
NHS foundation trust boards should put in place to support the data quality for the preparation
of the Quality Report.
In preparing the Quality Report, directors are required to take steps to satisfy themselves that:

the content of the Quality Report meets the requirements set out in the NHS Foundation
Trust Annual Reporting Manual 2014/15 and supporting guidance

the content of the Quality Report is not inconsistent with internal and external sources of
information including:
o
o
o
o
o
o
o
o
o
board minutes and papers for the period April 2014 to the date of signing this statement
papers relating to Quality reported to the Board over the period April 2014 to the date of
signing this statement
feedback from commissioners dated 01/05/2015
feedback from local Healthwatch organisations dated 24/04/2015
the trust’s complaints report published under regulation 18 of the Local Authority Social
Services and NHS Complaints Regulations 2009, dated 14/04/15
the national patient survey dated 20/04/15
the 2014 national staff survey
the Head of Internal Audit’s annual opinion over the Trust’s control environment dated
May 2015
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

there are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Report, and these controls are subject to review to
confirm that they are working effectively in practice

the data underpinning the measures of performance reported in the Quality Report is robust
and reliable, conforms to specified data quality standards and prescribed definitions, is
subject to appropriate scrutiny and review and

the Quality Report has been prepared in accordance with Monitor's annual reporting
guidance (which incorporates the Quality Accounts regulations) (published at
www.monitor.gov.uk/annualreportingmanual) as well as the standards to support data
quality for the preparation of the Quality Report (available at
www.monitor.gov.uk/annualreportingmanual).
The directors confirm to the best of their knowledge and belief they have complied with the
above requirements in preparing the Quality Report.
70
By order of the board
Chris Wood
Chairman
Helen Ashley
Chief Executive
28 May 2015
71
Annex 3: Independent auditor’s limited assurance report to
the Council of Governors and Board of Directors of Burton
Hospitals NHS Foundation Trust
We have been engaged by the Board of Directors and Council of Governors of Burton Hospitals
NHS Foundation Trust to perform an independent limited assurance engagement in respect of
Burton Hospitals NHS Foundation Trust’s Quality Report for the year ended 31 March 2015 (the
‘Quality Report’) and certain performance indicators contained therein.
Scope and subject matter
The indicators for the year ended 31 March 2015 subject to limited assurance consist of the
national priority indicators as mandated by Monitor:
 percentage of incomplete pathways within 18 weeks for patients on incomplete
pathways at the end of the reporting period
 emergency re-admissions within 28 days of discharge from hospital
We refer to these national priority indicators collectively as the ‘indicators’.
Respective responsibilities of the directors and auditor
The directors are responsible for the content and the preparation of the Quality Report in
accordance with the criteria set out in the ‘NHS Foundation Trust Annual Reporting Manual’
issued by Monitor.
Our responsibility is to form a conclusion, based on limited assurance procedures, on whether
anything has come to our attention that causes us to believe that:
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the Quality Report is not prepared in all material respects in line with the criteria set
out in the ‘NHS Foundation Trust Annual Reporting Manual’
the Quality Report is not consistent in all material respects with the sources specified
in Monitor's 'Detailed guidance for external assurance on quality reports 2014/15’,
and
the indicators in the Quality Report identified as having been the subject of limited
assurance in the Quality Report are not reasonably stated in all material respects in
accordance with the ‘NHS Foundation Trust Annual Reporting Manual’ and the six
dimensions of data quality set out in the ‘Detailed guidance for external assurance
on quality reports 2014/15’.
We read the Quality Report and consider whether it addresses the content requirements of the
‘NHS Foundation Trust Annual Reporting Manual’, and consider the implications for our report if
we become aware of any material omissions.
We read the other information contained in the Quality Report and consider whether it is
materially inconsistent with:
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Board minutes for the period 1 April 2014 to 28 May 2015
papers relating to quality reported to the board over the period 1 April 2014 to 28 May
2015
feedback from Commissioners, dated 01/05/2015
feedback from local Healthwatch organisations, dated 24/04/2015
the Trust’s complaints report published under regulation 18 of the Local Authority Social
Services and NHS Complaints Regulations 2009, dated 14/4/2015
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the national patient survey, dated 20/04/2014
the 2014 national staff survey
Care Quality Commission Intelligent Monitoring Report, dated December 2014
the Head of Internal Audit’s annual opinion over the Trust’s control environment, dated
May 2015
We consider the implications for our report if we become aware of any apparent
misstatements or material inconsistencies with those documents (collectively, the
‘documents’). Our responsibilities do not extend to any other information.
We are in compliance with the applicable independence and competency requirements of
the Institute of Chartered Accountants in England and Wales (ICAEW) Code of Ethics. Our
team comprised assurance practitioners and relevant subject matter experts.
This report, including the conclusion, has been prepared solely for the Council of Governors
of Burton Hospitals NHS Foundation Trust as a body and the Board of Directors of the Trust
as a body, to assist the Board of Directors and Council of Governors in reporting Burton
Hospitals NHS Foundation Trust’s quality agenda, performance and activities. We permit the
disclosure of this report within the Annual Report for the year ended 31 March 2015, to
enable the Board of Directors and Council of Governors to demonstrate they have
discharged their governance responsibilities by commissioning an independent assurance
report in connection with the indicators. To the fullest extent permitted by law, we do not
accept or assume responsibility to anyone other than the Board of Directors as a body, the
Council of Governors as a body and Burton Hospitals NHS Foundation Trust for our work or
this report, except where terms are expressly agreed and with our prior consent in writing.
Assurance work performed
We conducted this limited assurance engagement in accordance with International Standard
on Assurance Engagements 3000 (Revised) – ‘Assurance Engagements other than Audits
or Reviews of Historical Financial Information’, issued by the International Auditing and
Assurance Standards Board (‘ISAE 3000’). Our limited assurance procedures included:
 evaluating the design and implementation of the key processes and controls for
managing and reporting the indicators
 making enquiries of management
 testing key management controls
 analytical procedures
 limited testing, on a selective basis, of the data used to calculate the indicator back to
supporting documentation
 comparing the content requirements of the ‘NHS Foundation Trust Annual Reporting
Manual’ to the categories reported in the quality report and
 reading the documents.
A limited assurance engagement is smaller in scope than a reasonable assurance engagement.
The nature, timing and extent of procedures for gathering sufficient appropriate evidence are
deliberately limited relative to a reasonable assurance engagement.
Limitations
Non-financial performance information is subject to more inherent limitations than financial
information, given the characteristics of the subject matter and the methods used for
determining such information.
73
The absence of a significant body of established practice on which to draw allows for the
selection of different, but acceptable measurement techniques which can result in materially
different measurements and can affect comparability. The precision of different measurement
techniques may also vary. Furthermore, the nature and methods used to determine such
information, as well as the measurement criteria and the precision of these criteria, may change
over time. It is important to read the Quality Report in the context of the criteria set out in the
‘NHS Foundation Trust Annual Reporting Manual’.
The scope of our assurance work has not included governance over quality or non-mandated
indicators, which have been determined locally by Burton Hospitals NHS Foundation Trust.
Conclusion
Based on the results of our procedures, nothing has come to our attention that causes us to
believe that, for the year ended 31 March 2015:
 the Quality Report is not prepared in all material respects in line with the criteria set out
in the ‘NHS Foundation Trust Annual Reporting Manual’;
 the Quality Report is not consistent in all material respects with the sources specified
above; and
 the indicators in the Quality Report subject to limited assurance have not been
reasonably stated in all material respects in accordance with the ‘NHS Foundation Trust
Annual Reporting Manual’.
Grant Thornton UK LLP
Colmore Plaza
20 Colmore Row
Birmingham
B4 6AT
28 May 2015
74
Burton Hospitals NHS Foundation Trust
Belvedere Road
Burton upon Trent
Staffordshire
DE13 0RB
Tel: 01283 566333
communications@burtonft.nhs.uk