The Mid Yorkshire Hospitals NHS Trust
Quality Accounts 2014/15
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1
Sue Hooton, Quality Accounts
Project Lead
Mrs Sally Napper, Executive
Director
Trust & external partners
V1.14
Trust Board, 4 June 2015
(FOI Lead will insert date)
June 2016
(to be appended to document)
103
Table of Contents
The Quality Account .......................................................................................................... 3
1.
Statement on quality from the Chief Executive ............................................................. 3
2.
Our priorities for improvement 2015-16 (agreed at May Quality Committee).................. 6
2.1
How we identify our priorities .................................................................................. 7
2.2
Statements of assurance from the Board ................................................................ 7
2.3
Audit & Research .................................................................................................... 8
2.4
Information on the use of the CQUIN payment framework .................................... 19
2.5
Trust TDA priority .................................................................................................. 21
2.6
Information relating to registration with the Care Quality Commission (CQC) and
periodic / special reviews ................................................................................................. 22
3.
2.7
Information on the quality of data .......................................................................... 26
2.8
Information Governance........................................................................................ 28
Patient safety, clinical effectiveness & patient experience 2014-15 Priorities ............... 29
3.1
Patient safety ........................................................................................................ 30
3.2
Clinical Effectiveness ............................................................................................ 39
3.3
Patient Experience ................................................................................................ 43
3.4
National inpatient survey 2014 .............................................................................. 50
3.5
NRLS – Organisation Patient Safety Incident Report (April to Sept 2014) .............. 57
3.6
Performance against key national priorities & operational delivery standards ....... 62
3.7
Quality Improvement Dashboard........................................................................... 67
3.8
Appraisal & Training .............................................................................................. 67
4.
Statements from Commissioners, Healthwatch and Overview and Scrutiny Committees ......
68
5.
Statement of directors’ responsibilities in respect of the quality report .................................. 78
6.
Independent Auditor’s Limited Assurance Report ............................................................. 82
Appendix ............................................................................................................................
Appendix 1 Acute Hospital Core Indicators .........................................................................
2
The Quality Account
This is an important document that informs the public about the quality and safety of the
services provided by our Trust. All NHS organisations are required to publish an annual
quality report and account that evidences the quality of services provided and demonstrates
a genuine commitment to quality improvement.
This document complies with the Trust’s statutory duties under the Health and Social Care
Act 2012 and Department of Health Guidance for Quality Accounts for 2012/13. The account
provides information on:
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Achievements over the last year 2014-15
A review of the quality of services and statements of assurance from the Board
Priorities for quality improvement in 2015/16
We hope this report provides information for local people, patients and their families,
stakeholders and our staff to enable them to be assured that our number one priority is to
provide high quality services.
1. Statement on quality from the Chief Executive
On behalf of the Board, I am pleased to introduce the Quality Account of The Mid Yorkshire
Hospitals NHS Trust. This report is intended to complement our full Annual Report and
summarises our performance against selected quality indicators.
I am grateful to the members of the Clinical Commissioning Groups, Healthwatch in
Wakefield and Kirklees, and the Overview and Scrutiny Committees who have again worked
with us, to challenge and review our performance against these quality indicators throughout
2014/15.
Mid Yorkshire Hospitals NHS Trust is committed to providing high quality care and clinical
excellence that puts patients at the centre of everything we do. We will ensure that the
programme of work we undertake will build on our successes in the last three years and
rapidly build a momentum to take Mid Yorkshire on an improvement path to becoming the
safest Trust in the country.
In accordance with our Striving for Excellence strategy we want to improve our services to
patients so that they are amongst the best in the country and the Trust has committed to a
new Quality Improvement Strategy for 2015-18.
Our new strategy aims to:
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Reduce mortality
Reduce Harm
Continually improve clinical services and practices
Improve patient experience
In order to ensure that we meet these objectives, the Trust has, over the past year, continued
to observe, monitor and demonstrate how we are performing and, most importantly, how we
are improving the experience patients receive.
3
The Trust continues to ensure that quality and patient safety is incorporated within all of its
decision making processes and is an important factor in how it plans the future direction of
the organisation.
Our Clinical Services Strategy has been formally launched and has been approved by the
Secretary of State for Health. This is an exciting development for the Trust and for the people
living in the communities that we serve. This will see around £23million worth of investment
in hospital sites across Mid Yorkshire to accommodate the changes.
Dewsbury Hospital will have a £20 million investment programme with an anticipated 14,000
more patients being cared for there by 2017. Our Clinical Services Strategy will enable us to
organise services across the Trust to meet the needs of our patients whilst keeping our
objectives of providing first class safe and harm-free services at the top of everything we do.
Exciting and innovative changes are also planned for how patients will receive care without
having to be admitted to hospital and how the Trust will work in partnership with other
organisations to create much more effective services.
We will also ensure that we deliver and significantly improve upon the outcomes of the Care
Quality Commission re-inspection following the Chief Inspector of Hospitals report in
November 2014.
We have had a very successful year as shown by some of our achievements:
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We have successfully achieved a further reduction in patients contracting clostridium
difficile
Mortality is at one of the lowest points ever recorded for the Trust
The level of ‘harm free care’ (as measured by the Safety Thermometer) has
increased over the year
We saw a 17.1% reduction of healthcare acquired pressure ulcers
We have implemented the VitalPac system to support & improve the care of patients
at risk of deterioration
We have improved overall patient satisfaction of the care they receive from the Trust
We have continued to improve the assessment of risk in elderly patients at the Trust
We have worked hard to improve the quality and experience of care for patients with
dementia by gaining a baseline study and identifying options for improvement
Unfortunately, there are still some elements of care where we still have yet to achieve full
success:
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The Trust did not achieve a ‘zero’ score in patients acquiring an MRSA bacteraemia,
and although we achieved an 86% reduction on 2013/14 figures, we finished the year
with 1 trust attributed MRSA bloodstream infection.
We did not achieve our aim to reduce by 25% the severity of harm experienced by
patients falling in hospital and the community (whilst under our care). We saw a 0.2%
increase in the severity of harm during this period.
Whilst we celebrate our achievements during this period, we will continue to work tirelessly
on the areas above to ensure continued improvement.
4
We cannot make these achievements on our own, we have worked in collaboration with our
partners and stakeholders to agree our priorities for 2015/16. We have identified these as
being a priority as they aim to improve areas we know need attention, or are areas where we
will be building upon work already completed. We know we need to work hard to sustain and
make further improvements to reduce the potential harm to our patients and to meet the
expectations of our public.
We have set out our Quality Accounts in accordance with the Department of Health’s
guidelines. The Board of Directors confirms that to the best of its knowledge this report
complies with the requirements and is satisfied that the information contained herein is
accurate.
Stephen Eames
Chief Executive
June 2015
5
2.
Our priorities for improvement 2015-16 (agreed at May Quality Committee)
The Trust has developed priorities in patient safety, experience and clinical effectiveness.
Each priority has clear measures to enable us to monitor how we are doing and what needs
to be achieved.
The Trust Board has agreed our improvement priorities for 2015/16 will include:
Domain
Outcome measure/ indicators
To reduce the prevalence of pressure ulcers
by 10% on 2014-15 baseline as measured by
the national safety thermometer.
Rationale
Sign up to Safety
CQC Action plan
(This will include a breakdown of hospital and
community acquired pressure ulcers )
Safety
Experience
To reduce the number of moderate and
severe medication incidents by 10% on
2014/15 baseline as measured by Datix
reported medication incidents.
Sign up to Safety
CQC Action plan
Ensure the five steps to safer surgery (WHO)
is embedded in theatre practice. The
measure of improvement will be based on the
4 baseline audits as below:
-Peri-operative pathway swab count
-Surgical safety checklist, observation of sign
in, time out & sign out (2 audits)
-Surgical safety team brief and debrief
Re-audits of these will be undertaken 6
months post baseline audit.
Improve the understanding of information
given to patients at discharge about the
effects of their medication as measured by
local patient survey.
Ensure delivery of dementia training for staff
in line with CQUIN as measured by training
numbers
Sign up to Safety
CQC Action plan
Improve on the 2014-15 national staff survey
where the Trust is in the bottom 20%
nationally as measured by the National staff
Survey
Increase incident reporting rates from
2014/15 baseline as measured by NRLS
Reduce proportion of harm related incidents
to 29% as measured by NRLS data.
Increase the percentage of open Serious
Incident actions completed within timescale.
Baseline to be established in the quarter 1
report
Be in the top 10% of NHS Organisations with
the lowest risk adjusted mortality as
measured by Hospital Standardised Mortality
Ratio ( HSMR)
6
Local Patient Survey
National patient survey
CQC Action plan
Quality Accounts 14-15 set
the baseline for
improvement
CQC Action plan
National Staff survey
Wakefield Healthwatch
priority
Trust QI Strategy
Sign up to Safety
Wakefield Health Watch
priority
CQC Action plan
Trust QI Strategy
Deliver Mental Capacity Act and Deprivation
of Liberty Safeguards (DoLS) training in line
with 2015/16 training trajectory as measured
by training compliance reports
Increase in number of authorised Deprivation
of liberty safeguards from 2014/15 baseline
as measured by Trust DoLS database and
Local Authority data
CQC Action Plan
The performance against the above priorities is reviewed and discussed at:
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Divisional meetings
Patient Safety Panel
Clinical Executive Group
Workforce Organisational Wellness Committee (sub-committee of the Board)
Quality Committee (sub-committee of the Board)
Meetings of the Board of Directors
Meetings with the commissioners of the Trust’s services
2.1 How we identify our priorities
The priorities have been identified through receiving regular feedback from and regular
engagement with staff, patients, the public, and commissioners of NHS services, Overview
and Scrutiny committees and other stakeholders. Progress on the planned improvements will
be reported through the Trust’s assurance committees and ultimately through to the Trust
Board.
Our success in achieving these priorities will be measured, where possible, by using
nationally benchmarked information (e.g. National Inpatient Survey results/Friends and
Family Test results, Dr Foster) and using measurement tools that are clinically recognised
(e.g. the National Safety thermometer, standardised classification tools such as those
recommended by the National Pressure Ulcer Advisory Panel (NPUAP) and European
Pressure Ulcer Advisory Panel (EPUAP)).
The processes that we use to monitor and record our progress will be audited by the Trust’s
external auditors to provide assurance on the accuracy of the data collection methods
employed.
2.2 Statements of assurance from the Board
During 2014 - 2015, the Mid Yorkshire Hospital NHS Trust provided and/or sub-contracted
twenty (20) relevant health services. These are:
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7
A&E
Non-Elective
Maternity Pathways
New OP
New OP Procedure
New OP NFTF
Review OP
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Elective Daycase
Ward Attenders
Critical Care Services
Diagnostic Services
Therapies
Pathology
Pharmacy
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Review OP Procedure
Review OP NFTF
Pre-Assessment
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Rehabilitation
Screening
Elective Inpatient
The Mid Yorkshire Hospital NHS Trust has reviewed all the data available to them on the
quality of care in twenty (20) of these relevant health services.
The income generated by the relevant health services reviewed in 2014-2015 represents
100% of the total income generated from the provision of relevant health services by the Mid
Yorkshire Hospital NHS Trust for 2014-2015.
Further information about the services the trust provides can be found at:http://www.cqc.org.uk/provider/RXF/services
2.3 Audit & Research
2.3.1
Audit
Participation in National Clinical Audits 2014-15
The national audit projects tabled below include quality account audits, National Clinical
Audit and Patient Outcome Programme (NCAPOP) and National Confidential Enquiry into
Patient Outcome and Death (NCEPOD).
During 2014-15, 35 national clinical audits and 4 national confidential enquiries covered NHS
services that the Mid Yorkshire Hospitals NHS Trust provides. Mid Yorkshire Hospitals NHS
Trust participated in 33 (94%) of the national clinical audits and 4 (100%) of the national
confidential enquiries that it was eligible to participate in.
The national clinical audits and national confidential enquiries that Mid Yorkshire Hospitals
NHS Trust was eligible to participate in during 2014-15 are included in the following table.
Quality Accounts
National Clinical Audits
Acute Care
Adult Community Acquired Pneumonia
MYHT
Participation
Yes
Adult Critical Care (Case Mix Programme)
ICNARC – CMP
Yes
Elective Surgery National PROMs
Programme:
1. Hips
2. Knees
3. Varicose Vein Surgery
4. Groin Hernia Surgery
http://www.hscic.gov.uk/catalogue/PUB16478
The majority of hip & knee patients have
been offered the PROMs questionnaire at
Dewsbury and Pontefract. Pinderfields
Yes
8
(Estimated
Trust -wide
compliance
80%).
Number included (%)
Project ongoing not due to
end until June 2015
Q1 2014-15 = 390 (100%)
Q2 2014-15 = 361 (100%)
Q3 2014-15 = 334 (100%)
Quarter 4 data not available
@ 17/2/15
Varicose Vein Surgery 11/80
Response rate 14%
Issues rate 100%
Groin Hernia Surgery 45/133
Response rate 34%
Issue rate 84%
Hips Surgery 22/86
Response rate 14%
Quality Accounts
National Clinical Audits
patients may not achieve target due to
process change and staffing issues; data has
not yet been input and verified locally.
MYHT
Participation
Issue rate 48%
Mental Health (Care in Emergency
Departments)
National Emergency Laparotomy Audit
(NELA) – NCAPOP
National Joint Registry (NJR) – NCAPOP
Yes
Non-invasive Ventilation – Adults
No
Pleural Procedures
Yes
Severe Trauma (Trauma Audit and Research
Network - TARN)
Yes
Blood and Transplant
National Comparative Audit Of Blood
Transfusion Programme:
1. Information And Consent-2014
2. Sickle Cell
Renal Replacement Therapy (Renal
Registry)
Cancer
Bowel Cancer (NBOCAP) – NCAPOP
Head and Neck Oncology (DAHNO)
- NCAPOP
Lung Cancer (NLCA) – NCAPOP
National Prostate Cancer Audit (NPCA)
Oesophago-gastric Cancer (NOGCA)
- NCAPOP
Heart
Acute Coronary Syndrome or Acute
Myocardial Infarction (MINAP) – NCAPOP
Adult Cardiac Surgery Audit – NCAPOP
Cardiac Arrhythmia (HRM) - NCAPOP
Cardiac Rhythm Management (CRM)
Congenital Heart Disease (Paediatric Cardiac
Surgery) (CHD) – NCAPOP
Coronary Angioplasty – NCAPOP
Heart Failure (HF) – NCAPOP
National Cardiac Arrest Audit (NCAA)
(ICNARC)
9
Number included (%)
Yes
Yes
Knees Surgery 28/111
Response rate 25%
Issue rate 44%
Submitted pending numbers
from national report
117/122
PGH 96%
73/73
DDH 100%
Estimate 1200 patients to be
uploaded to NJR for 2014
(final figure to be available
w/c 2/3/15). Data will be
uploaded for 95%+ of eligible
patients by 28/2/15
Removed Nat level from QA
MYH to do as a local audit
Submitted pending numbers
from national report
285 Pinderfields, 57
Dewsbury
(100%)
Yes
N/A
1. 24/24 (100%)
2. No participation limited
case
Treated at Leeds
Yes
Yes
231/231 (100%)
81/81 (100%)
Yes
Yes
Yes
476/476 (100%)
241/241 (100%)
64/64 (100%)
Yes
1347 (100%)
N/A
Yes
Treated at Leeds
Dewsbury - 147/147
Pinderfields 273/273 (100%)
Treated at Leeds
N/A
Yes
Yes
Yes
308/308 (100%) 2013 data,
2014 data collection is
ongoing
Number of Calls - 570
Cardiac Arrests - 186
Number of Patients – 176
Quality Accounts
National Clinical Audits
Pulmonary Hypertension Audit
Long-term conditions
Chronic Obstructive Pulmonary Disease
(COPD) – NCAPOP
Chronic Kidney Disease In Primary Care
Diabetes (Adult) ND(A), Includes National
Diabetes Inpatient Audit
- NCAPOP
Diabetes Paediatric (NPDA) – NCAPOP
MYHT
Participation
N/A
121/121 (100%)
N/A
Yes
Primary Care
132/132 (100%)
Yes
189 - Pinderfields
119 - Dewsbury
Total 308 (100%)
Jan 2014 to 1st 31st March
2015
100 Home based and 50 Bed
based, Total 150 (100%)
Staffing problems prevented
participation
Yes
Inflammatory Bowel Disease (IBD)
- NCAPOP
Mental Health
Mental Health Programme: National
Confidential Inquiry Into Suicide And
Homicide For People With Mental Illness
(NCISH) – NCAPOP
Prescribing Observatory For Mental Health
(POMH-UK)
No
N/A
Not undertaken by this Trust
N/A
Not undertaken by this Trust
(Phil Deady – Dir. of
Pharmacy)
N/A
Not due to start until 2015/16
Yes
Submitted pending numbers
from national report
Staffing problems prevented
participation
No
Yes
215/215 (100%)
Yes
60 (100%)
Yes
Submitted pending numbers
from national report
Obstetric figures
Pinderfields 8 Dewsbury 6
Neonatal figures 01/04/2014
to 31/01/2015 MYH – 4
618 (100%)
Maternal, Infant And Newborn Clinical
Outcome Review Programme – (MBRRACE)
NCAPOP
Yes
Neonatal Intensive And Special Care (NNAP)
– NCAPOP
Paediatric Intensive Care (PICANet)
Paediatric Pneumonia
Paediatric Asthma
Others
British Society Clinical Neurophysiology
(BSCN) Association Neurophysiological
Scientists (ANS) Standards For Ulnar
Yes
10
Primary Care
Yes
National Audit Of Intermediate Care
Older People
National Audit Of Dementia (NAD)
- NCAPOP
Older People Care In Emergency
Departments
Falls And Fragility Fractures Audit
Programme, Includes National Hip Fracture
Database (FFFAP) – NCAPOP
Sentinel Stroke National Audit Programme
(SSNAP)
Women’s & Children’s Health
Epilepsy 12 Audit (Childhood Epilepsy)
- NCAPOP
Fitting Child Care In Emergency Department
Number included (%)
N/A
N/A
Treated at Leeds / Sheffield
Withdrawn from Quality
Accounts
N/A
Not due to start until 2015/16
Quality Accounts
National Clinical Audits
Neuropathy At Elbow (UNE) Testing
National Vascular Registry, Including CIA /
Elements of NVD (NVR) – NCAPOP
Rheumatoid And Early Inflammatory Arthritis
- NCAPOP
1. Clinician/Patient Baseline
2. Clinician/Patient Follow Up
MYHT
Participation
Specialist Rehabilitation For Patients With
Complex Needs – NCAPOP
NCEPOD
Medical and Surgical Clinical Outcome
Review Programme: NCEPOD
- NCAPOP
1. Lower Limb amputation
2. Tracheostomy Care
3. Subarachnoid Haemorrhage
4. Alcohol Related Liver Disease
Other National Audits
Participated in or data
submitted during 2014-15
PASCOM (Podiatric Audit in
Clinical and Outcome
Measurement)
British Association Urology
Surgeons (BAUS) - Cancer
and non cancer
National Heavy Menstrual
Bleeding (HMB) Audit (4 year
audit) The third annual report
can be accessed on:
National Heavy Menstrual
Bleeding (HMB) Audit (4 year
audit)
National Audit of
Intermediate Care (NAIC)
2014
Number included (%)
N/A
Treated at Leeds
Yes
Baseline Clinician - 39
Baseline Patient - 37
Follow-up Clinician - 5
Follow-up Patient - 4
Not capturing follow-ups well
working with team to improve
participation
Not applicable in this
reporting period
N/A
Yes
1. MHY - 8/8(100%)
2. MYH - 11/11 (100%)
3. MYH - 3/4 (75%)
4. MYH - 8/8 (100%)
Provider
% of Cases
Society of Chiropodists and
Podiatrists
100%
British Association Urological
Surgeons
Target 100%
3rd Annual Report
September 2013
MYHT submitted 276 cases
4th Annual Report July 2014
Organisational survey
repeated in the fourth year of
the audit.
Participated for 2 years
2014/2015
3rd Annual Report November
2014
A further 56 audits in addition to those in the tables were completed during 2014/2015. A
comprehensive list of these audits, including action plans can be provided if required.
Quarterly Audit Reports for each Division are published trust wide and shared across all
clinical and management groups and includes:
 Plans for any new level 1 projects started from the Annual Audit Priority Programme
(AAPP)
 Summaries with action plans for any audit projects which have been completed
 Tracking tables by speciality for progress of audit projects identified on the AAPP
 Action tracking tables for all completed projects where actions have been identified
11
The reports of all national clinical audits were reviewed by the provider in April 2014 to
March 2015 and the MYHT intends to take the following actions to improve the quality of
healthcare provided based on the national recommendations and individual results when
available.
National audit reports are reviewed through the following mechanism within the trust:
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Divisional Governance Committee meetings
Specialty and Sub Specialty meetings
Quarterly Reports
Quality Committee
Medical Directors Office
Steering groups for example the Dementia Steering Group
Examples of National Audit Reports that have been published during March 2014 to April
2015 which the MYHT participated in are included below:
National Clinical
Audit
Use of Anti-D 2013
reported in 2014
12
Report
Actions from audit
Local Actions
• Disseminate findings to MYHTT members for
discussion at a future MYHTT
• Present summary of audit findings to MYHTC
• Present summary of audit findings to
Transfusion Link Group at their next meeting
• Disseminate audit report & findings with
Obstetricians and Midwives Trust Wide and
Obstetric Clinical Governance Committee.
Review of policy & practice:
1. Ensure patients are given an information
leaflet explaining the Rh factor and anti-D
prophylaxis and that this is documented in
patients notes.
2. Ensure patient consent for RAADP (or if
declined, reason for this) is documented in
patients notes.
3. Document dosage and date anti-D Ig
prophylaxis given following potentially sensitising
events.
4. Review mechanism to follow up patients who
do not receive/attend for RAADP at 28 – 30
weeks gestation.
5. Document dosage and date anti-D Ig
prophylaxis given following delivery.
6. Timely administration (within 72 hours) of AntiD post delivery. Should the patient be
discharged before Anti-D can be administered, a
robust plan should be in place for them to
receive anti-D and any additional dose as
indicated by the result of the Kleihauer test.
National Clinical
Audit
Cont. Use of Anti-D
2013 reported in
2014
Report
Epilepsy 12 reported
November 2014
Saving Lives,
Improving Mothers’
Care Lessons
learned to inform
future maternity care
from the UK and
Ireland
National Audit of
Intermediate Care
Beds
National
Comparative Audit
Of Blood
Transfusion
Programme:
1. Information And
Consent-2014
Confidential
Enquiries into
Maternal Deaths
and Morbidity
2009-2012
Actions from audit
7. Review methods to record the above and who
is responsible for checking this has taken place
(all points 1 - 6 above).
8. Omissions/delays in administration of Anti-D
Immunoglobulin Prophylaxis should be reported
via Datix to enable local investigation and timely
follow up of the patient.
Local Actions:
• Investigate Epilepsy CNS
• 1st assessment care pathway
• Devise clinic proforma
This local summary with extensive action plan
(see attached) was developed after publication
and local presentation.
Local Summary produced from national report
with action plan containing recommendation to
re-audit readmission rates which is on-going
currently.
Local Action
• When delivering mandatory and also bespoke
blood transfusion training e.g. at Doctors
induction raise awareness of the importance of:
1. Informed consent/information leaflet 2. “Will I need a blood
transfusion”/documentation
• Present summary of audit findings to
Transfusion Link Group, MYHTT, MYHTC
Presentation of completed audits takes place at a number of forums including the Clinical
Governance Speciality and Divisional Governance Committee meetings. Findings and key
learning for cross divisional audit such as record keeping and consent are benchmarked and
shared cross trust. Examples of changes resulting from audit projects are included below.
Action plans for each completed audit are available in the Directorate Quarterly Reports.
Examples of Actions to improve patient safety, quality and / or experience:
Critical Care: Record Keeping 2014 (Core audit and re-audit example)
The audit is part of the ICU annual audit program that aims to maintain, and improve where
possible, the standard of record keeping for critical care patients. The audit demonstrated
the majority of record keeping sections audited (73%) were completed for 90% of the cases
reviewed, improvement from previous audits. A further 3 sections had been completed in
over 79% of cases which indicated that there is room for improvement.
A single element, countersigning of deletions/alterations, was poorly completed in the cases
reviewed indicating a need for improvement, results were better than in previous years.
13
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In response to these findings the following actions were implemented;
Investigate feasibility of alteration of daily review sheet to emphasise the time of entry
and
Printing name.
Succinct email all Critical Care clinicians to share results and highlight areas where
Improvement is indicated (emphasising that re audit will be undertaken to evaluate
improvement.)
Review anaesthetic/critical care induction and include/emphasise record keeping
requirements.
Investigate feasibility of introducing name stamps for Anaesthetic doctors
Critical Care: ICU Central Line Documentation 2014 Re-audit (evidence on value of re-audit)
The placement of a central venous catheter/line (CVC) is an essential technique in the
treatment of many hospitalised patients. NICE provides guidance on the placing of CVC’s
and the Trust has a local policy which incorporates this along with guidance on managing a
line.
A previous audit identified areas for improvement in the documentation of CVC insertion. It
therefore recommended that the Trust develop central line documentation and educate
clinicians on its use and requirements. These recommendations were implemented.
This 2014 audit intended to review the effectiveness of previous recommendations and to
establish compliance with best practice in ICU documentation. The audit concluded that the
documentation of insertion of CVC using the Midyorks pathway was of a good standard
overall and highlighted where there was potential to make further improvement.
In response to these findings the following action was agreed and initiated;

Change pathway to make confirmation of placement by pressure monitoring and
venous wave form mandatory.
ENT: Re-audit of Fine Needle Aspiration Cytology for Thyroid Lumps (closed loop audit)
A patient presenting with a swelling to the thyroid may undergo an investigative procedure
called fine needle aspiration cytology (FNAC). If thyroid disease is present then treatment
may consist of medications, surgery and/or radioactive therapy which could need to be
undertaken quickly. It is therefore important to have tests undertaken and results available
expeditiously.
Three cycles of audit have now been undertaken to identify and address areas for
improvement in the process of receiving results. Through the audit process the average
reporting times for FNA samples reduced even though the volume of samples has increased.
The 2014 re-audit report (Cycle 3) demonstrated:
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14
Average days for reporting has improved > 98% compliant ( from 94% in Cycle 2)
Cycle 1 average -10 days, Cycle 2 data - 4.31 days, Cycle 3 data – 2.7 days
No difference over method of FNA (U/S or non U/S)
Overall diagnostic rate has improved since 2008 data (80%), 2011 data (86%) to
>90% (2013 data)
In response to these findings it was recommended to continue as is unless anecdotal
evidence suggests a reduction in compliance with best practice or if standards change.
Therefore no further actions are needed and the audit cycle is closed.
Anaesthetics: Awake Fibre optic Intubation (AFOI): Clinician Knowledge and Experience Reaudit 2014 (evidence on effective action planning value of re-audit)
This project was a re-audit intended to evaluate local experience and promote the delivery of
best practice within anaesthesia. It specifically related to securing the airway in situations
where difficulties with airway management are predicted. In these cases awake intubation
may be undertaken and is usually achieved using a fibre optic laryngoscope rather than by
tracheal intubation following induction of anaesthesia.
The initial audit indicated action was required to improve the education of anaesthetists in
AFOI. In response to this a local training program (based on NCEPOD guidance) was
developed and introduced. The training uses instruction, demonstration and hands-on
experience of the technique using the other course participants as awake volunteer subjects.
It is intended to promote best practice and develop anaesthetists’ skills and confidence.
The re-audit concluded that, since the introduction of the training course (completion of
previous audit action plan), not only has confidence in performing AFOI increased, but that
AFOI is being performed more frequently. This indicates a higher local skill set which
promotes best practice and supports effective risk management. Improved compliance with
NCEPOD recommendations was achieved and promoted. Recommendations: Continue to
offer the AFOI course with no further action required, audit cycle effective and closed.
Audit of Record Keeping Standards - Maternity Services
Effective communication is very important for the safe delivery of care in maternity services.
Failure to communicate information clearly and to ensure that it has been received and
understood has been highlighted as a cause of unsafe care. The Nursing and Midwifery
Council (NMC) states that records should identify any risks or problems that have arisen and
show the actions taken to deal with them. The midwife has a duty to communicate fully and
effectively with colleagues, ensuring that they have all the information they need about the
people in their care.
The rolling audit programme has allowed the maternity services to gain a good overview of
the quality of record keeping across the service and the ability to monitor ongoing
improvement in practice. Actions from the audit include:


Audit champions providing individual feedback on audit results to midwives
Dissemination of audit results through governance and supervision.
SBAR Handover of Care on Labour Ward
The World Health Organisation (2007) recommends the use of the SBAR (Situation,
Background, Assessment and Recommendation) tool to standardise handover
communications.
The tool was specifically developed and introduced to ensure a consistent approach to the
handover of care. SBAR is an easy to remember mechanism that helps to clarify what
information should be communicated between members of the team and how.
15
Audit findings show that midwives are very good at documenting the situation and
assessment of women on taking over care; two areas of concern had been identified; the
background including risk factors and documenting the handover by midwives at the end of
the shift. This audit has led to the implementation of the following actions:


Dissemination of audit findings via safety briefs and governance newsletters
The integration of SBAR questions into the rolling record keeping audit for midwifery
Consultant Obstetric Follow-up Fetal Loss Clinics
Special clinics run by senior obstetricians have been set up for over 10 years at Pinderfields
and Pontefract to provide a consultant follow-up service for women and families who have
lost a baby at any time in pregnancy. There are a number of reasons, which include:
following loss of a baby, following a termination for congenital anomaly, for specialist prepregnancy advice and for debriefing following a complicated delivery. The audit has led to
the following changes:




Set up nhs.net e-mail accounts to reduce delays in receiving PM reports from
Sheffield Children’s hospital
Create alert system re timing of follow up appointment
Job plan discussion to introduce more follow up appointment flexibility
Consideration to ways of improving provision of counselling to bereaved families
CT Response in Suspected Stroke (108)
This audit has led to the following changes in practice:



Increased scope for when stroke nurses can refer patients to include weekends and
evenings
Inform radiographers and radiologists of change in imaging targets to meet National
clinical guideline for stroke (Emergency Department patients within 1 hour the
remainder within 12 hours).
All stake-holders involved at start of stroke pathway to participate in multi-disciplinary
audit to identify potential delays to requesting CT scan and then to identify measures
to reduce these delays
Radiology and Venous Thromboembolic Disease Imaging Guidelines Audit (CT) (43)
The audit has led to the following changes in practice:



Radiology to ensure justification of requests done quicker
Radiology Guidance to be given re: management of patients with decreased renal
function
VTE committee to raise awareness of need to ensure referral made correctly
Attention deficit hyperactivity disorder (ADHD) in Community Paediatrics (22)
The audit has led to the following changes in practice:

16
Participate in the Wakefield district meeting made up of CAMHS, CCG, Education
services,



Community health, Social care and secondary care working on developing an ADHD
care pathway across the services
Raised awareness through presentation and e-mail the need to: Improve
documentation on all forms, letters notes to provide clear and accurate information in
a consist format.
Verbally and via e-mail: Remind staff to offer information to parents in the form of
verbal, leaflets, websites, ADHD groups and any available sources of information.
New-born Heart Murmur Re-Audit (141)
The audit has led to the following changes in practice:



Hold teaching session with Juniors to emphasize the need to speak and discuss with
neonatal consultants directly about making clinic appointments within or at 1 week for
babies with heart murmurs discharged from post natal wards
Appoint second Paediatrician with expertise in Cardiology
Discuss the feasibility of adding a separate section in Euroking to record pre and post
ductal saturations with IT Department.
Young Diabetes Clinic
The Young Adult Diabetes Service is especially designed to meet the needs of young people
aged 16-23 years of age, recognising that many aspects of their lives change during these
years and diabetes management often needs to reflect this. The audit has led to the
following changes in practice:







Retinal screening results sent direct to the Consultant so are available for discussion
at next clinic appointment
Retinal screening DNA’s to be monitored closely and offered another appointment to
ensure compliance with regular testing
HbaC1 analyzer available in Pontefract clinic
Implementation of transitional care pathway to improve transition between paediatric
and adult services
Annual Foot care assessments and ACR samples now undertaken in clinic
Developed service and increased support for young adults who go to university and
move away, ensuring that they have a contact and support if required when visiting
home
Education provided in clinic around sick day rules and regular ketone monitoring to
reduce DKA admissions
Vitamin D Testing at Time of Melanoma Diagnosis
Vitamin D is essential for bone health. The sources of vitamin D are diet and sunlight
exposure, with sunlight being a major source in most people. However, the ultraviolet
radiation in sunlight is the main cause of both melanoma and non-melanoma skin cancer.
Vitamin D deficiency has been associated with a poorer prognosis in melanoma patients and
therefore should be avoided. This audit resulted in the following changes being
implemented:

17
Regional policy implemented, all staff made aware and education provided

2.3.2
All patients attending clinic have vitamin D levels checked by Clinician and actioned
where appropriate
Information on participation in clinical research
The Mid Yorkshire Hospitals NHS Trust is a partner organisation in the Yorkshire & Humber
Clinical Research Network (a new regional network to support research). We have been
involved in the early stages of transition to the new network structure, and have been
involved in planning for 2015-16. This partnership working helps the Trust to support national
commitments to research, including the NHS Mandate, the NHS Operating Framework and
NHS Commissioning Guidance.
In year 2014/15, the Trust has continued to work with the YHCRN to implement the National
Institute for Health Research (NIHR) guidance for research management and governance in
support of national initiatives to improve the quality, speed and co-ordination of clinical
research by removing the barriers within the NHS, unifying systems, improving collaboration
with industry and streamlining administrative processes. The table below shows our
performance on key targets and measures related to this drive for improvement:
Objective
Performance in 2014-15
Increase in patients recruited
into NIHR portfolio studies
1247 recruits
75.3% of target
Proportion of NIHR noncommercial studies recruiting
to time and target (RTT)
8/12 studies
67%
Proportion of NIHR
commercial studies recruiting
to time and target
3/4 studies
75%
Number of NIHR studies
gaining local NHS
permission in 30 days or less
19/30 in under 15 days
(63%)
27/30 in under 30 days
(90%)
13/30 (43%)
Proportion of all NIHR
studies achieving NHS
permission to first patient first
visit within 30 days
Target / performance
comments
Full year target was 1600
recruits
4th highest recruiting Trust in
Yorkshire and Humber.
Highest recruiting acute
Trust in West Yorkshire
Area for improvement in
2015-2016
Target is 80%
League table data
unavailable.
For all studies RTT are 3rd
highest acute Trust in
Yorkshire and Humber
Target is 80%
Equal 3rd best acute Trust in
Yorkshire and Humber and
2nd best overall Trust in
West Yorkshire
Target is 80%
Target was reduced to 15
days during 14-15
Target is 70%
League table data
unavailable
Between 1st April 2014 and 31st March 2015, 257 research studies were active within the
Trust (including studies where patients are being followed up after recruitment and treatment
phases are complete). Of those, 50 studies were new and opened during 2014-15.
18
The number of patients receiving relevant health services provided or subcontracted by Mid
Yorkshire Hospitals NHS Trust in 2014/15 that were recruited during that period to participate
in research approved by a research ethics committee was 1457. This figure will increase
slightly when all end of year data are collected end June 2015. 83% (1208) of this activity is
related to research adopted onto the National Institute for Health Research portfolio of high
quality studies.
2.4 Information on the use of the CQUIN payment framework
The Commissioning for Quality and Innovation (CQUIN) framework aims to secure better
outcomes for patients and improvements in quality and innovation above the baseline
mandated in the National Contract. It does so by providing commissioners with a mechanism
through which to incentivise providers to deliver a set of core quality improvement goals as
part of the service contract. A proportion of contract income is linked to achievement of each
of the CQUIN goals; payment conditional on achieving the required quality improvements
and innovation goals agreed between the provider and commissioner as part of the
contracting process.
The financial framework for 2014/15 set the level of CQUINs at 2.5% of the total value of all
healthcare services commissioned through the Contract. The scope of the framework was
extended at the Trust in 2014/15 to include contracts held by local authority and NHS
England commissioners, in addition to the acute and community contracts held with local
Clinical Commissioning Groups. The total value of CQUINs equated to £9.6million in total for
Mid Yorkshire in 2014/15; split across 3 national goals comprising a total of 8 indicators and
a further 21 improvement goals identified locally to improve the quality of care and patient
experience.
Performance against the agreed goals is reported quarterly to commissioners. A summary of
the Trust’s performance in 2014/15 is provided in the table below. It identifies the 29 CQUIN
indicators referred to above, the value of income attached to achievement of these and the
value of income secured through the delivery of the agreed improvement targets, based on
the latest position forecast for year end.
Of the total £9.6million available, the Trust has delivered the required quality and innovation
improvements to secure £8.93million (93.0%) of the income available in 2014/15. This is an
improvement from 90.2% of CQUIN funding secured in 2013/14.
In 3 of the 4 cases in which the CQUIN requirements were not delivered in full in 2014/15,
partial achievement was reported and a proportion of the associated CQUIN finance
secured. This included the national NHS Safety Thermometer CQUIN goal and the DNACPR
CQUIN scheme agreed locally with commissioners.
The requirements of the national NHS Safety Thermometer goal set out 95% of an agreed
20% reduction in pressure ulcer prevalence as measured through the NHS Safety
Thermometer to be achieved. The Trust delivered 89.9% of the agreed 20% reduction target
based on the 5 data points from November 2014 to March 2015.
The aim of the local DNACPR CQUIN was to deliver improvement in the Trust’s DNACPR
documentation processes; performance assessed based on delivery of an agreed action
plan for improvement and the results of snapshot audits completed on the Trust’s elderly
care wards in Q4. The Trust delivered the required improvement against 3 of the 4 audit
19
indicators with targets attached in Q4, and improvement from the baseline was demonstrated
in all cases.
CQUIN
CQUIN
Income
Income
% of CQUIN
Available
Secured Income Var
Income
Full Yr (£K) Full Yr (£K) Full Yr (£K)
Secured
£168.2
£168.2
£0.0
100.0%
CQUIN Indicator
Implementation of Staff FFT
Type
National
Early Implementation
National
£169.2
£169.2
£0.0
100.0%
Increased or Maintained Response Rates
National
£169.2
£169.2
£0.0
100.0%
Increased Response Rate
National
£169.2
£169.2
£0.0
100.0%
NHS Safety Thermometer - Pressure Ulcers
National
£616.1
£246.5
-£369.7
40.0%
Find, Assess, Investigate and Refer (FAIR)
National
£370.0
£370.0
£0.0
100.0%
Clinical Leadership
National
£62.0
£62.0
£0.0
100.0%
Supporting Carers
National
£185.0
£185.0
£0.0
100.0%
Recording EDMF for Acute Inpatients
Local
£591.0
£591.0
£0.0
100.0%
Medication Safety
Local
£590.1
£590.1
£0.0
100.0%
Reducing cancellations
Local
£591.0
£591.0
£0.0
100.0%
Timely Review of Electronic Referrals
Local
£590.1
£516.4
-£73.8
87.5%
Optimisation of SystmOne
Local
£1,182.0
£1,182.0
£0.0
100.0%
Deteriorating Patient - NEWs and VitalPAC
Local
£591.0
£517.1
-£73.9
87.5%
DNACPR
Local
£590.1
£553.2
-£36.9
93.8%
Care of the Elderly - Assessment
Local
£591.0
£591.0
£0.0
100.0%
Care of the Elderly - Handover
Local
£591.0
£591.0
£0.0
100.0%
Information at Discharge
Local
£394.3
£394.3
£0.0
100.0%
Forget-Me-Not Questionnaire
Local
£393.4
£393.4
£0.0
100.0%
Care Environment
Local
£393.4
£393.4
£0.0
100.0%
Quality Dashboards
Local
£37.2
£37.2
£0.0
100.0%
Retinopathy of Prematurity
Local
£85.4
£85.4
£0.0
100.0%
TPN for Preterm Infants
Local
£85.4
£85.4
£0.0
100.0%
Acute Spinal Cord Injury (SCIC) Outreach
Local
£85.4
£85.4
£0.0
100.0%
Diabetic Eye Screening Programme
Local
£58.9
£58.9
£0.0
100.0%
Reporting Requirements
Local
£117.8
£0.0
-£117.8
0.0%
Building Community Capacity
Local
£58.9
£58.9
£0.0
100.0%
Substance misuse 15-24 years
Local
£43.0
£43.0
£0.0
100.0%
Partner notification for chlamydia diagnosis
Local
£36.7
£36.7
£0.0
100.0%
£9,606.5
£8,934.5
-£672.0
93.0%
Total
Further details of the agreed CQUIN goals for 2014-2015 and for the following 12-month
period are available on request.
20
2.5 Trust Development Authority priority
2.5.1
To improve outpatient scheduling, bookings and communications with patients
Throughout 2014/15 the Trust had an Outpatient Improvement programme which aimed to
address the issues of appointments, letters, cancellations and patient experience whilst
accessing our outpatient services. The main issue was that the Trust had a waiting list of
overdue follow up patients of 20,000 in April 2014, this was reduced to 2,800 by April 2015
(this cohort were not the same group that were present in April 2014) as a result of the
recovery actions put in place. The action plan progress was monitored by Trust Board and
below are the headline achievements:










2.5.2
Revision of standard operating procedures, escalation policies and competencies of
staff within the call centre, appointment centre, reception areas and rescheduling
team.
Cross skilling of staff to support pressure areas
Review of clinic utilization, scheduling and names
Improvement of information and support provided to Specialty Control Towers
Realignment of functional booking teams to specialty based teams, managed by
Patient Access Team leaders who were transferred from Specialty teams to reduce
duplication and hand overs
Continued focus on competency checks and performance management
Maintained the Call Centre performance, meeting the target of 95% of calls answered
within 3 minutes.
Increased the use of InTouch electronic booking system
Improvement in outpatient areas – toys in paediatric waiting areas, replaced chairs in
consulting rooms
Improved communication, regular team meetings and development sessions
Patient Administration System (PAS) Replacement
The Trust has replaced its patient administration system (PAS) over the last two years. This
has been a significant undertaking. The Trust migrated 1.4 million patient records, 3.8
million historical patient contacts 64,329 appointments and manually entered 2,300 in-patient
transactions. Whilst there was robust planning in place for this implementation, it did result
in a number of operational issues that had an impact on our outpatient performance.
The issues that occurred following the PAS replacement were dealt with throughout the year
as described above.
2.5.3
Cancellation and rescheduling of clinics
This is one of the areas we have targeted for improvement. The PAS replacement
unfortunately identified a number of challenges that resulted in the Trust not having as
efficient a service as we would have wanted. Further work was required to rebuild our
systems. All this had to be undertaken on the live system and again meant that some
patients were booked inappropriately.
We have been working with our PAS supplier to develop a bespoke module to resolve some
of these issues throughout 2014/15.
21
Reducing cancellations of outpatient appointments was a CQUIN for 2014/15 which the
Trust met, as well as being a Trust priority. With the actions undertaken in the Outpatient
Improvement programme the performance against this measure has improved, as shown
below:
% of Cancellations of Outpatient Appointments within 42 days of the appointment date
5.0%
7.3%
8.2%
6.6%
6.2%
5.7%
6.3%
6.0%
6.8%
7.0%
7.3%
8.0%
8.4%
8.5%
9.0%
7.9%
9.5%
10.0%
4.0%
3.0%
2.0%
1.0%
0.0%
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
The above graph shows the improvements made but indicates that work needs to be
continued to ensure continued improvement in cancellation of appointments throughout
2015-16.
2.6 Information relating to registration with the Care Quality Commission (CQC) and
periodic / special reviews
In July 2014 of last year the Trust underwent a Chief Inspector of Hospitals inspection. This
involved over 60 inspectors visiting all of our hospital sites, intermediate care and community
nursing services. The purpose of the inspection is to understand how patients view our
services and their experience when accessing our services. They inspected 8 core services:








Urgent and emergency services
Medical care
Surgery
Critical Care
Maternity and Gynaecology
Services for children and young people
End of life care
Outpatients
During their visit they talked to staff to understand what it is like to work in Mid Yorkshire
Hospitals and also patients and carers of their experiences when using our services. The
focus of the inspection was based around 5 key questions: Are services safe? Are services
effective? Are services caring? Are services responsive to patients needs and are services
well led?
22
The CQC allocated ratings for each for the core services and overall ratings for the Trust as
a whole. The table below demonstrates the overall ratings and the Trust were advised that
overall the Trust requires improvement.
http://www.cqc.org.uk/provider/RXF/inspection-summary
The publication of the report resulted in the development of an improvement plan to ensure
all identified actions from the report are completed, performance measures identified so that
assurance can be given and that there are systems in place to ensure continual
improvement and sustainability. Executive Leads and Lead Officers were identified for each
action and progress continues to be monitored by the weekly Driving Clinical Standards
Group and monthly to the Quality Committee.
A full reporting structure was set up to monitor progress and performance against the action
plans. The structure is illustrated below.
2014 CQC
Action Plan
• Actions
• Milestones
• Clear Outcomes
2014 CQC
Driving Clinical
Standards Group
2014 CQC
Action Plan
Steering Group
•
•
•
•
• MYHT Chief
Executive
• NHS Wakefield
CCG and NHS
North Kirklees CCG
Chief Officers
• MYHT Chief Nurse
Chief Nurse
Medical Director
Operations Director
Other Clinical
Practice and
improvement leads
The table below sets out the recommendations within the Chief Inspector of Hospitals report
and covers recommendations which must and should be implemented.
23
Ref Recommendation
No
Reporting Period 1st-31st March 2015
ACTIONS THE TRUST MUST TAKE TO IMPROVE
Risk Management & Board Assurance
1
Ensure that the reporting of performance, risk and unsafe care and treatment is robust and
timely to the Trust Board so that appropriate decisions can be made and actions taken to
address or mitigate risk to patient safety.
2
Ensure recommendations from serious incidents and never events are monitored to ensure
changes to practice are implemented and sustained in the long term
Staffing Levels & Skill Mix
3
Ensure there are always sufficient numbers of suitably qualified, skilled and experienced staff to
deliver safe care in a timely manner.
4a
Review the skills and experience of staff working with children in the: a) A&E departments,
4b
Review the skills and experience of staff working with children in the: b) special care baby unit
and children’s outpatients clinics to meet national and best practice recommendations
Outpatients
5
Address the backlog of outpatient appointments, including follow-ups, to ensure patients are
not waiting considerable amounts of time for assessment and/or treatment.
6
Ensure clinical deteriorations in the patient’s condition are monitored and acted upon for
patients who are in the backlog of outpatient appointments.
7
Review the ‘did not attend’ in outpatients clinics and put in steps to address issues identified
DNAR CPR
8
Ensure the procedures for documenting the involvement of patients and relatives in ‘Do Not
Attempt Cardiopulmonary Resuscitation (DNA CPR) are in accordance with best practice at all
times.
Ensure staff follow policy best practice on DNAR CPR when the patient condition changes or
on the transfer of medical responsibility
Safeguarding
9
Ensure staff are aware of the Deprivation of Liberty Safeguards and apply them in practice
where appropriate.
10
Ensure staff are clear about which procedures to follow in relation to assessing capacity and
consent for patient who may have variable mental capacity. This would ensure staff act in the
best interest of the patient in accordance with the MCA 2005 and this is recorded appropriately.
11
Ensure all staff attend and complete mandatory training and role specific training, particularly
for safeguarding and resuscitation
12
Ensure all staff working in urgent care settings undertake where appropriate level 3
safeguarding training.
Education &Training
13
Ensure staff receive training on caring for patients living with dementia in clinical areas where
patients living with dementia access services
14
Ensure staff are trained on the End of Life care plan booklet and updated on the Trust’s new
policy
Medical Equipment
15
Ensure pathology equipment is fit for purpose to reduce the risk of delayed diagnosis and
potential spurious results which could lead to misdiagnosis.
16
Ensure equipment in A+E department is appropriately cleaned and labelled and stored in an
appropriate environment.
17
Ensure all anaesthetic equipment in theatres and resuscitation equipment in clinical areas are
checked in accordance with best practice guidelines
24
Medicines Management
18
Ensure the pharmacy department is able to deliver an adequate clinical pharmacy service to all
wards.
19
Ensure staff are trained and competent with medication storage, handling and administration.
20
Ensure controlled drugs are administered, stored and disposed of in accordance with Trust
policy, national guidance and legislation.
21
Ensure all clinical areas minimum and maximum fridge temperatures are recorded to ensure
medications are stored within the correct temperature range and remain safe and effective to
use.
Theatres
22
Ensure the 5 steps to safer surgery (WHO) is embedded in theatre practice
23
Review the access and provision of sterile equipment and trays in theatres to ensure that they
are delivered in good time
Surgical care & patient flow
24
Ensure there are improvements in the number of Fractured Neck of Femur patients being
admitted to orthopaedic care within 4 hours and surgery within 48 hours
25
Review and make improvements in the access and flow of patients receiving surgical care.
26
Ensure ambulance handover target times are achieved to lessen the detrimental impact on
patients. (recovery plan in place)
27
Ensure there are improvements in referral to treatment times to meet national standards.
(recovery plan in place)
Medical care
28
Review the arrangements over the oversight of Gate 20 acute respiratory care unit to ensure
there is appropriate critical care medical oversight in accordance with the Critical Care Core
Standards (2013).
Infection Control
29
Ensure staff in ward areas follow the correct procedures in identifying infection control concerns
in deceased patients to protect staff in the mortuary against the risks of infection.
Mortuary
30
Ensure the recommendations from the mortuary review are implemented and monitored to
ensure compliance.
31
Ensure actions are taken to address the poor decorative state of the mortuary to ensure
effective and thorough cleaning can be undertaken (Dewsbury)
Clinical administration & communication
32a Ensure improvements are made in reducing the backlog of clinical dictation and discharge
letters to GPs and other departments.
32b Ensure improvements are made in the clinical discharge letters to GP’s
Harm Free Care
33
Ensure the high prevalence of pressure ulcers is reviewed and understood and appropriate
actions are implemented to address the issue.
Patient Identification
34
Ensure staff follow the correct procedures to make sure the patient is correctly identified at all
times, including when deceased.
ACTIONS THE TRUST SHOULD TAKE TO IMPROVE
Patient Flow
35
The trust should review the service to improve in the number admissions following an elective
surgery admission
36
The provider should take steps to ensure the community inpatient facilities referral criteria are
applied consistently.
Staffing
37
The Trust should review their Lone working policy and its implementation as well as their
anticipatory planning for major events.
25
Consent
38
The Trust should review the recording of consent in community children’s services
Communications
39
Ensure information leaflets for relatives and carers of dying patients are updated following the
withdrawal of the Liverpool care pathway
Staff engagement
40
The Trust should improve staff engagement between frontline staff, team leaders, middle
management and the Board.
41
The Trust should ensure at Board Level there is an identified lead with the responsibility for
service for children and young people
Appraisal and Clinical Supervision
52
Improve systems to make sure that all staff have access to regular appraisals and clinical
supervision
53
The provider should review interim management appointments to minimise the effect on
stability and sustainability of improvements.
In addition to the report the Trust received two enforcement actions, the purpose of
enforcement is:


To protect people who use regulated services from harm and the risk of harm
To hold providers and individuals to account for failures in how service is provided
The two enforcement actions received were related to:


Against the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards
(DoLS). It was CQC’s view MYHT are failing to protect service users against the risks
of inappropriate or unsafe care and treatment. This is because CQC identified that
MYHT was failing to improve the understanding, training and awareness of nursing,
medical and support staff in relation to the MCA and DoLS requirements. CQC’s view
was it was reasonable to expect that the Trust should have improved overall
compliance in these areas since their inspection in July 2014 however MYHT failed to
demonstrate that the required improvements have been made, and:
Medicines Management and failure to protect services against the risks associated
with the unsafe use and management of medicines. CQC identified across both the
Pinderfields and Dewsbury sites that controlled drugs were not always correctly
stored or disposed of in accordance with Trust policy and the number of patients
medicines reconciled within 24 hours of admission had deteriorated from January
2014.
Both warning notices were subject to comprehensive action plans and significant
improvement has now been made. In March 2015 CQC were formally informed of the Trust’s
compliance with the required standards and the evidence to support was submitted.
2.7 Information on the quality of data
The Trust accepts responsibility for providing good quality information to underpin effective
patient care, and has monitored standards of data quality throughout the year at the
management board chaired by the Chief Executive.
There are documented procedures in place for all statutory returns produced from within the
Trust and reports are validated by the relevant managers in the Divisions prior to submission.
26
The Trust is continually promoting the use of the summary care records (SCR) to trace and
confirm patient demographic information. It uses the demographic batch service (DBS) for
batch tracing to trace patients prior to submission of Commissioning Data Sets (CDS) to
ensure optimum accuracy of demographic information, in particular patient NHS numbers.
The Trust continues to promote the use of centrally produced data quality dashboards and
key performance indicators (KPIs) to monitor the Trust’s progress towards the collection of
key demographic data items.
This data is shared externally with Clinical Commissioning Groups (CCGs) and other
external organisations. This is the principal method of data quality assurance used
throughout the Trust so that the Trust can assure itself against regional and national
standards and targets.
The Trust confirms that it submits returns to the Secondary Uses Service (SUS). In the
context of monitoring NHS number usage and validity of General Medical Practice codes,
Mid Yorkshire submitted records during April 2014 to January 2015 for inclusion in Hospital
Episode Statistics that are included in the latest published data. The percentage of records in
the published data with valid NHS numbers and valid General Medical Practice codes are as
follows:
Valid NHS number
Patient type
Admitted patient care
Outpatient care
Accident and emergency care
Valid General Medical Practice code
Admitted patient care
Outpatient care
Accident and emergency care
Mid
Yorkshire
2013/14
99.7%
99.8%
98.4%
Mid
Yorkshire
2013/14
99.9%
100%
99.7%
2013/14
Target
99%
99%
95%
2013/14
Target
99%
99%
99%
Mid
Yorkshire
2014/15
99.8%
99.9%
99.0%
Mid
Yorkshire
2014/15
100%
100%
99.9%
2014/15
Target
99%
99%
95%
2014/15
Target
99%
99%
99%
The Mid Yorkshire Hospitals NHS Trust was subject to a Payment and Tariff assurance
framework audit at the end of 2014/15 which included a clinical coding audit. There is only a
draft audit report available at present but initial results indicate that the Clinical Coding
accuracy was good, with 93.5% of primary diagnosis codes correct and 94.4% of primary
procedure codes correct.
The Trust appointed a Clinical Coding Auditor during 2014/15. The Coding Auditor has
developed a rolling programme of internal coding audits to give assurance on the quality of
the clinical coding and identify any areas where improvement is needed. The Auditor will
work with the Coding Trainer to identify any coder training requirements that are identified as
a result of the audits to ensure the coders maintain and improve their standards of coding.
A dedicated Data Quality team is being established within Information Services to ensure
that the electronic data stored in the Trust’s Patient Information systems is recorded
accurately and in a timely manner to support the Trust’s clinical and business requirements.
They will be responsible for promoting data quality, identifying data quality issues and
27
producing a rolling improvement plan to ensure compliance with National and Local
standards and definitions.
2.8 Information Governance
The Trust has an Information Governance and Security Management Group that the
Caldicott Guardian* attends and influences. In accordance with the Caldicott Guardian
Manual, this is a position held by a senior clinician.
Information quality and records management is assessed using the Information Governance
Toolkit that provides an overall assessment of the quality of data systems, standards and
processes. The toolkit is completed by specialists advising the Information Governance and
Security Management Group and validated by commissioners before submission. Secondary
use assurance achieved a score of 91%, an improvement on the previous year’s score of
87%.
The Mid Yorkshire Hospitals NHS Trust Information Governance Assessment report overall
score for 2014/15 was 87% and was graded GREEN.
*A Caldicott Guardian is a senior person responsible for protecting the confidentiality of
patient and service user information and enabling appropriate information-sharing.
Each NHS organisation is required to have a Caldicott Guardian; this was mandated for the
NHS by Health Service Circular: HSC 1999/012. The mandate covers all organisations that
have access to patient records, so it includes acute trusts, ambulance trusts, mental health
trusts, primary care trusts, strategic health authorities, and special health authorities.
28
3. Patient safety, clinical effectiveness & patient experience 2014-15
Priorities
Priorities for improving patient safety, clinical effectiveness and patient experience for 20142015 were set out in the Trust’s Quality Account 2013/14. Throughout the year, a dashboard
of performance against each of the agreed targets for improvement has been presented to
the Trust Board (and the wider committee groups) to provide assurance on progress and
improvements made in the areas of patient safety, clinical effectiveness and patient
experience.
This information is also shared with our commissioners to demonstrate how care for patients
is delivered and sustained improvements are maintained.
The information is collated from, whenever possible, sources which could be benchmarked
with other organisations in order to indicate the Trust’s performance in relation to others. As
such, Dr Foster is used wherever relevant. Other sources of data collection come from inhouse sources (audit, survey, point prevalence studies, incident reporting, complaints and
observation).
The overall purpose of this information is to inform the organisation of its effectiveness and
performance and to lead it in a direction of improvement by indicating specific issues/areas
that need to be developed.
The Trust priorities for 2014-15 were:
Area for
Improvement
Improvement Priorities for 2014/15
Infection
Control
A zero tolerance target for MRSA bacteraemia
To have fewer than 42 cases of healthcare acquired Clostridium difficile
To reduce the severity of harm experienced by patients by falling in
hospital and the community (whilst under our care) by 25%
Patient
Safety
To reduce the prevalence of healthcare acquired pressure ulcers (as
measured by the Safety Thermometer) by 20%
Clinical
To maintain mortality rates below the national average and improve upon
Effectiveness the 2013/14 outcomes
To support and improve the care of patients at risk of deteriorating by
introducing the VitalPac system
Patient
Experience
Improve overall patient satisfaction of the care they receive from the
Trust
To improve the assessment of risk in elderly patients at the Trust and to
improve their safety and experience.
To improve the quality and experience of care for patients with dementia
by implementing a baseline study and identifying options for
improvement.
29
3.1 Patient safety
3.1.1
Infection Control priorities 2014-15


A zero tolerance target for MRSA bacteraemia
To have fewer than 42 cases of healthcare acquired Clostridium difficile
Infection Prevention and Control
We are pleased to report our progress in our fight against infections in our hospitals and
community settings. We have worked in close partnership with all our colleagues in health
and social care as well as our patients and visitors.
In 2014/15, we had one case of MRSA bloodstream infection.
Our objective was to have a zero tolerance to avoidable MRSA infections in 2014/15.
Although this was an 86% reduction on the previous reporting year (2013/14) we
failed to achieve this priority.
Our plan for 2015/16 is to continue to have a zero tolerance of avoidable MRSA
bloodstream infections.
Although it is disappointing that we had one case of MRSA bloodstream infection, we are
pleased to report the improvement we have made and our efforts intensify to make sure we
bring this down to zero in 2015/16.
30
C Difficile Indicator Scope
C Difficile - the rate per 100,000 bed days
of Trust apportioned cases of C Difficile
infection that have occurred in the Trust
amongst patients over 2 years or over
during the reporting period
MYHT Rate per 10,000 bed days
National Average
Lowest (best) Trust Rate
Highest (Worst) Trust Rate
Data Source
Previous
Period
Latest
Period
Apr12 Mar13
Apr13 Mar14
11.8
13.2
17.4
14.7
0
0
31.2
37.1
HSCIC
HSCIC
In 2014/15, we had 33 cases of Clostridium difficile infections.
Our objective was to have no more than 42 cases of Clostridium difficile infections in
2014/15.
We had 33 Trust attributable cases of Clostridium difficile infections and therefore we
achieved our goal. This was a 23% reduction on the previous reporting year.
Our plan for 2015/16 is to have no more than 27 cases of Clostridium difficile
infections.
31
In 2014/15 we had 15 cases of methicillin sensitive staphylococcus aureus (MSSA) blood
stream infections.
In 2014/15 our objective was to have a zero tolerance to avoidable infections. This was a
35% reduction on the previous reporting year.
Our plan for 2015/16 is to continue to have a zero tolerance of avoidable MSSA bloodstream
infections.
Clostridium
difficile (Trust
attributable)
rates
per 10,000
bed days
32
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Target
0.93%
0.93%
0.93%
1.23%
0.93%
0.93%
1.23%
1.23%
1.23%
1.23%
0.93%
Actual
0.63%
0.65%
0.33%
0.32%
0.95%
0.62%
0.32%
0.56%
1.78%
1.67%
1.52%
The base data was as follows:



33
Occupied bed days Apr14-Mar15 (quarterly KH03 returns): 317,441
Cases of Trust attributable C. diff cases in 2014/15: 33
Rate per 100,000 bed days: 10.4
Some of the steps we have taken to strengthen infection prevention and control have
included:
















34
Approval of the Trust 5 year antimicrobial resistance strategy which is monitored
through the Trust Antimicrobial Stewardship Group. The work of this group has
been commended by the Chief Pharmacist for the Trust Development Authority
commenting that the Trust has ‘a highly commendable and well organised approach
to antimicrobial stewardship’
Antibiotic Management in the mandatory medicines management training and
education in the Trust.
The Chief Pharmacist for the Trust Development Authority (TDA) commended the
work of the Trust Antimicrobial Stewardship team
Agreeing a process with the Clinical Commissioning Group Medicines Management
Teams on ensuring key messages from post infection reviews (PIRs) are
disseminated.
Improved infection prevention and control data that clinical colleagues receive at
divisional level.
Increased visibility of the IPC team in the clinical area and developed close
relationships with front-line clinical colleagues to facilitate the development of
bespoke infection prevention guidance to meet the needs of the service e.g.
Admissions Units and Elderly Care services.
Supporting colleagues at divisional, ward and department level to embed infection
prevention practice into every day practice
Recognising opportunities to deliver ad hoc training at clinical level
Introducing an Infection Prevention and Control ‘message of the month’
Supported clinical areas in delivering Aseptic non touch technique (ANTT) training
and competency assessment
Reducing our blood culture contamination rate
Providing catheter care training and education to care home staff
A review of the cleaning standards to deliver a revised version of the 2007 and PAS
2011 risk assessed standards
Mobilisation of the new service model for environmental cleaning of patient facing
areas at Pinderfields and Pontefract Hospitals led by the General manager of
Facilities, our PFI partners, Cofely, continue to provide environmental cleaning in
departments, outpatients, theatres and circulation areas.
A review of the environmental cleaning monitoring system to create a uniform
standard for monitoring across the Trust and developed a process for clinical staff to
assist in environment monitoring audits.
Reviewing our cases of Clostridium Difficile Infection (CDI) with health economy
colleagues where CDI cases are presented to ensure learning is shared across the
health economy.
Patient Safety Priorities 2014-15


To reduce the severity of harm experienced by patients due to falling in
hospital and the community (whilst under our care) by 25%
To reduce the prevalence of healthcare acquired pressure ulcers (as
measured by the Safety Thermometer) by 20%
Two areas that have been a priory for the Trust over the last year are: reducing the number
of patients falls on the wards and reducing the number of pressure ulcers that patients can
develop whilst in hospital or being looked after in the community.
3.1.2
Falls
The Trust recognises that there is a need to support vulnerable patients and prevent them
from enduring harm from falls sustained whilst in our care.
The Trust’s aim has been to reduce the incidence of falls that result in lasting (temporary or
permanent) harm to patients. Therefore, we use the classifications established by the
National Patient Safety Agency to determine what level of harm we are talking about when a
patient falls.
Falls are reported onto the Trust’s incident reporting system and then forwarded to the
National Reporting and Learning System (NRLS) so a greater learning is achieved across all
health communities.
Term
No Harm
Low harm
Moderate Harm
Severe Harm
35
NPSA definition adapted to
falls
Where no harm came to the
patient.
Examples from reports to the NRLS*
“No complaints of pain, no visible
bruising.”
Where the fall resulted in harm
that required first aid, minor
treatment, extra observation or
medication.
“Patient says he has a sore
bottom…”
Where the fall resulted in harm
that was likely to require
outpatient treatment,
admission to hospital, surgery
or a longer stay in hospital.
“Sustained fracture to left wrist.”
Where permanent harm, such
as brain damage or disability,
was likely to result from the
fall.
“….following an x-ray, a fractured
neck of femur was confirmed.”
“Shaken and upset.”
“…one inch laceration over left
eye, taken to A&E for suturing.”
Death
Where death was the direct
result of the fall.
“Patient heard to fall from
commode hitting her head on the
floor as she fell, bleeding from
back of head... fully responsive but
computerised tomography (CT)
scan requested together with 15
minute neuro observations.”
"Gradually Glasgow Coma Scale
lowered ...patient intubated and
sedated and transferred to
intensive care unit (ICU) following
scan. Patient died later the same
day.”
*these are reports that the NRLS use for illustrative purposes and are not reflective of reports
from Mid Yorkshire Hospitals NHS Trust.
These charts show the degree of harm suffered by patients who have fallen in our services:
In 2012/13 we had 87 incidents of patients falling whilst in our care (both as
inpatients and in the community) and experiencing moderate to severe harm/death.
In 2013/14 our goal was to have a 25% reduction in moderate to severe harms/death
as a result of falls. We had 57 incidents of patients falling whilst in our care (both as
inpatients and in the community) and experiencing moderate to severe harm/death.
This is a reduction in harm from falls of 34.4% and therefore we achieved our goal.
Our plan for 2014/15 was to have a further 25% reduction in the number of falls
resulting in moderate to severe harm/death to patients. There was a 0.2% increase in
moderate & severe harm and 1 death due to falls. We did not achieve our goal.
36
Incident Reporting
Incidents are recorded on the Trust’s incident reporting system and are given an initial grade
of the severity of harm suffered by the patient. This grade is subsequently validated when the
consequence to the patient is fully understood.
Inpatient and Community (Adult Nursing)
13/14 Total Number of
Falls
14/15 Total Number
of Falls
Moderate (Short term harm caused)
Severe
Death
Total
Modified against activity levels
54
1
2
57
71
4
1
76
0.02% increase
Total Falls by Severity and Year
80
70
60
50
40
30
20
10
0
13/14
Total Number of Falls
14/15
Total Number of Falls
Moderate (Short
term harm
caused)
Severe
Death
Elderly patients and falls
A number of patients who are on the wards due to the nature of their health can be at risk of
falling during their stay and a working group was established at the beginning of the year to
look at how the Trust can reduce the number of patients who fall whilst in hospital. Elderly
patients now get an early medication review which can help prevent the patient from falling
and a falling star symbol is being used above patient beds when they are identified as being
at risk of falling.
The Trust has now started using Safety Guardians who support patients who may be
confused and
may wander around the ward. The Safety Guardians use distraction
techniques and provide one to one support whilst the patient needs this level of supervision.
In addition the Trust has purchased new sensor mats for beds and chairs to alert staff to
when a patient tries to climb out of bed and putting themselves at risk of falling.
Please see section 3.3 for the performance against last year’s patient experience priority to
improve elderly care in the Trust.
37
3.1.3
Pressure Ulcers
In 2012/13 we had 461 cases of avoidable healthcare acquired pressure ulcers.
In 2013/14 our goal was to have no more than 392 cases of avoidable healthcare
acquired pressure ulcers. In 2013/14 we had 341 cases of avoidable pressure
ulcers. We have achieved our goal.
In 2013/14 our goal was to have no more than 18 cases of category 3 & 4 avoidable
healthcare acquired pressure ulcers
In 2013/14, we had 78 cases of avoidable healthcare acquired pressure ulcers
category 3 & 4. We did not achieve our goal.
Our goal for 2014/15 was to have a reduction of 20% of healthcare acquired
pressure ulcers as measured against the ‘point prevalence’ study of the Safety
Thermometer (rather than as an overall calculation of the number of incidents)
In 2014/15, we saw a17.1% reduction of healthcare acquired pressure ulcers
achieved. We have partially achieved our goal
The information above is collected using an internationally recognised pressure ulcergrading tool devised by National Pressure Ulcer Advisory Panel (NPUAP) and European
Pressure Ulcer Advisory Panel (EPUAP).
The Trust has developed an organisation-wide approach to reviewing the circumstances of
every healthcare acquired pressure ulcer at category 3 and 4 to determine whether they
were avoidable*.
This approach is enabling the Trust to develop further improvement initiatives and to learn
valuable lessons of how to reduce harm to patients.
The Trust is also working with its partners in the local community to help identify ways of
reducing the numbers of patients coming into hospital with pressure ulcers being acquired at
home or in nursing homes. We intend to develop further our improvements in the coming
year to continue to reduce the numbers of pressure ulcers.
* Not all pressure ulcers are avoidable; there are situations that render pressure ulcer
development unavoidable, including hemodynamic instability that is worsened with
physical movement and inability to maintain nutrition and hydration status and the
presence of an advanced directive prohibiting artificial nutrition/hydration.
The focus of the work for reducing the amount of pressure ulcers over the year includes
looking at new ways of working that will include the use of cameras to improve the speed of
sourcing specialist advice from the Tissue Viability specialist nurses when this may been
required. Others actions include in depth investigation using a technique called root cause
analysis that allows the exploration of all the factors that could have led to the development
of the pressure sore. This is allowing learning to be identified and addressed.
38
Reducing patient falls and reducing the number of pressure ulcers remain a key priority area
for the next year and further work is being progressed to reduce patient harm in both these
areas.
3.2 Clinical Effectiveness
3.2.1
Mortality
The measure of mortality is an important part of assessing the safety of a hospital and there
are a number of different ways that this can be achieved. To compare actual death rates
between hospitals is challenging as the severity of illness and types of cases can vary. A
number of measures have been developed to compensate for these types of differences.
The two best known of these are the Summary Hospital Level Mortality Indicator (SHMI)
produced by the Department of Health and the Hospital Standardised Mortality Rate (HSMR)
produced by Dr Foster.
The Hospital Standardised Mortality Ratio is an indicator of healthcare quality that measures
whether the mortality rate at a hospital is higher or lower than you would expect. It is limited
to 56 diagnosis groups that are the reason for about 80% of all deaths in hospital. The
Summary Hospital Level Mortality Indicator does not allow for palliative care coding and
includes all deaths.
For the Hospital Standardised Mortality Ratio a ratio of 100 equates to the number of deaths
that would be expected.


A number below 100 indicates fewer deaths than would be expected.
A number above 100 means more deaths than would be expected.
Each year the HSMR data is recalculated (called rebasing) and therefore a year-on-year
comparator of HSMR figures isn’t appropriate.
For the period April 2014 to December 2014 our HSMR score for all hospital admissions has
been modelled internally to be 91.9. A position calculated via the Dr Foster tool hasn’t been
able to be identified due to difficulties with data following a switch in the source of data used
by Dr Foster.
The Trust’s long term aim is for their HSMR to be within the Top 10% of trusts within
England.
The Trust Mortality Review Steering Group has developed a three-year action plan to
support the achievement of this target and this is kept under regular review. The key
areas of work in the current plan include:
 Development and implementation of ward round safety check lists
 Development of 7 day working for acute inpatient care
 Implementation of 24/7 emergency department consultant cover
 Implementation of Root Cause Analysis on hospital acquired Venous ThromboEmbolisms(VTEs)
 Development of new models to improve elderly acute assessment
 Development of increased access to elderly care consultants across a wider range of
orthopaedic fractures.
39

Implementation of electronic systems of taking observations and escalating
deteriorating patients (Vital PAC).
The Trust’s HSMR for April 2013 to January 2014 was 86 which was rebased to 91.9.
The Trust achieved its goal for the reduction of the HSMR to be below that of the
national average.
In 2014/15 the Trust again maintained mortality rates below the national average
The proposed 2015-16 priority is: ‘to be in the top 10% of NHS Organisations with the
lowest risk adjusted mortality’.
3.2.2
Safety Thermometer - reducing harm
The NHS Safety Thermometer is a local improvement tool for measuring, monitoring, and
analysing patient harms and ‘harm free’ care. The tool measures four high-volume patient
safety issues:
1. Pressure ulcers
2. Falls whilst in care
3. Urinary infection (in patients with a urinary catheter)
4. Treatment for venous thromboembolism (VTE)
The NHS Safety Thermometer is a tool that the Trust uses to proactively measure the rate of
harm from the four harms referenced above; it is essentially a prevalence survey that is
carried out on a given day every month.
The tool looks at the complete patient pathway and as such, captures harm that occurred
before the patient was admitted to our services (in the case of pressure ulcers, UTI & VTE)
as well as harm acquired whilst receiving care from our services.
The data can now demonstrate an overview of the whole organisation, team by team, to
show the improvement (or otherwise) in achieving a reduction in harm to patients over a
period of months. This gives the Trust the opportunity to share the good practice in areas
that are successfully meeting the challenge whilst supporting those that have difficulty in
making the demonstrable improvement.
Wards and adult community nursing teams audit their areas on a predetermined date against
the four harms. This information is submitted to the ‘National Safety Thermometer’ and also
used to inform the monthly divisional dashboards.
The results in the dashboards are split in to overall harm free care, meaning the percentage
of patients who experienced no harms and new harms meaning the percentage of harms
that only occurred when the patient was on the ward/being cared for by the community team.
40
Safety Thermometer ‘Harm Free Care’ figures from April 2014 – March 2015 (Summary)
Harm free care has steadily risen over the past 12 months, 91.86% in April 2014
and stands at 93.76% in March 2015. However, this is very close to the national
average for harm free care. The Trust Development Authority set a national
target of >95% for harm free care. We have partially achieved our goal
In 2015/16 we aim to a harm free position equal, if not better, than the national
average.
3.2.3 PROMS (hip and knee replacements)
PROMS (Patient Recorded Outcome Measures) data is recorded as an appendix as part of
the national core indicator set for all acute Trusts. This will be in relation to:i. groin hernia surgery
ii. varicose vein surgery
iii. hip replacement surgery
iv. knee replacement surgery
Indicator Scope and Measure
Patient Reported
Outcome Measures
(PROMS) - Adjusted
Health Gain
Groin hernia
Hip Replacement
(Primary)
41
Measure
EQ-5D
Index
EQ-VAS
EQ-5D
Index
Previous Period: Apr13 Mar14 (Provisional)
Latest Period: Apr14 Dec14 (Provisional)
MYHT
National Av.
MYHT
National
Av.
0.058
0.085
0.061
0.084
-3.164
-1.0
-3.657
-0.5
0.402
0.436
0.415
0.449
Knee Replacement
(Primary)
Varicose vein
EQ-VAS
Oxford Hip
Score
EQ-5D
Index
EQ-VAS
Oxford
Knee Score
EQ-5D
Index
8.6
11.5
9.1
12.1
20.5
21.4
19.9
21.9
0.318
0.323
0.34
0.319
5.5
5.6
4.7
5.8
16.3
16.3
15.5
16.3
0.093
0.133
0.102
No
modelled
records
-0.2
EQ-VAS
-0.5
-1.4
-0.2
Aberdeen
-13.3
-8.7
-12.2
-8.8
Score
- Higher scores are better with the exception of Aberdeen Varicose Vein Questionnaire
scores (Data Source: HSCIC)
- Indicates negative (95%) outlier
- Indicates positive (95%) outlier
42
3.3 Patient Experience
Our patient experience goals for 2014/15
Patient
Improve overall patient satisfaction of the care they receive from the
Experience Trust
To improve the assessment of risk in elderly patients at the Trust and
to improve their safety and experience.
To improve the quality and experience of care for patients with
dementia by implementing a baseline study and identifying options for
improvement.
Priority: To improve overall satisfaction of the care patients receive from the Trust
The Trust participated in the National Annual Inpatient Survey in summer 2014. The results
of this survey were published in early 2015.
Within the survey there is a rating question which asks respondents to rate their overall
experience of the care they have received on a scale of 0 to 10 (0 being rated as ‘very poor’
and 10 as ‘very good’).
Patients reported that their experience of care improved since 2013 with 78% of patients
rating their overall experience of care as 7 or more out of 10 in 2014 compared to 76% in
2013.
To ensure that no trust appears better or worse than another because of its respondent
profile, results are standardised by the age, sex and method of admission then converted
into scores on a scale from 0 -10. A score of 10 represents the best possible response and a
score of 0 the worst. The following table shows the 2014 scores compared with the 2013 for
the ‘Overall how would you rate your experience’ question.
CQC scores: Inpatient services - Overall rating of experience of care
2013
2014
Mid Yorkshire
Score
7.6
7.8
Lowest trust
score achieved
7.1
7.2
Highest trust score
achieved
9.1
9.2
Improvements in patient experience – Accident and Emergency Survey 2014
Within the CQC national Accident and Emergency Survey there is a similar overall rating
question asking respondents to rate their overall experience of the care they have received
on a scale of 0 to 10 (0 being rated as ‘very poor’ and 10 as ‘very good’).
Results for 2014 show that 84% of patients rated their overall experience of care as 7 or
more out of 10 compared to 83% in 2012 (there was no national survey in 2013).
The following table shows the 2014 CQC scores compared with the 2012 for the ‘Overall
how would you rate your experience’ question.
43
CQC scores: Accident and Emergency - Overall rating of experience of care
2012
2014
Mid Yorkshire
Score
8.1
8.1
Lowest trust score
achieved
6.9
6.6
Highest trust score
achieved
8.3
8.5
Note: The percentages are taken from the unweighted scores in the Picker Institute Europe
report. The ‘statistically significant’ scores are taken from the CQC Benchmark report.
These survey results help us identify priorities for improvement in patient experience.
Progress against actions identified for improvement is monitored by several Trust forums
and overseen by the Quality Committee.
Priority: To improve the assessment of risk in elderly patients at the Trust and to improve
their safety and experience
The priority was to form a multi-disciplinary task force, to develop an annual project
plan and present six monthly reports to Trust board.
The objectives were: Monitor the ongoing development and roll out of dementia awareness training
across staff groups
 Participate in, and evaluate, the NHS Benchmarking on elderly care services
in 2014
 Develop the Elderly Care Champion role
 Monitor the AEC ongoing roll out and extended opening from September
2014
 Monitor the Liaison Psychiatry Contract from April 2014 and the further roll
out to Community Services
 Monitor the progress of the Hip Fracture Pathway and links to Frailty service
 Monitor Single Assessment documentation pilots and consider IM&T
implications
 Monitor the development and implementation of the Frailty Service
 Monitor and consider the evaluation of the Care Closer to Home Proof of
Concept Pilots
 Monitor and evaluate the Gateway to Care and Single Point of Contact
initiatives
These objectives have been met
During 2013-14 the Trust completed a major piece of work to improve discharge from
hospital.
The measures of success of the discharge programme were to achieve a reduction in length
of stay in hospital, improve the quality of discharge and reduce the number of assessments
undertaken in the acute setting.
44
This piece of work was carried forward into the 2014-15 Quality Accounts. The programme
was subsumed into the Elderly Care Taskforce and the programme was remapped against
the ‘Silver Book’ standards for elderly care provision. In addition, a number of new initiatives
and work streams were added to the programme as a result of this mapping, changing the
scope and focus of the initial objectives. This priority was reported via the Elderly Care
Taskforce to Trust board.
Defined assessment service for older people
Our Trust’s pioneering Older People’s Assessment Service has been chosen to be part of
the Royal College of Physicians’ (RCP) prestigious Future Hospital Programme.
A successful pilot project last winter was headed by two consultants working out of the Acute
Medical Unit. Their expertise led to quicker assessment and discharge of elderly patients
and an ability to quickly tackle often complex care needs.
We have worked towards remodelling of facilities to allow a multi-faceted ‘front door’
assessment service for older people.
We have worked on a range of factors to improve our home care liaison along with improved
systems for transitions and handovers of care.
We have also worked hard to reduce falls in elderly care settings. There are a number of
patients on the wards, who due to the nature of their health can be at risk of falling during
their stay. A working group was established at the beginning of 2015 to look at how we can
reduce the number of patients who fall whilst in hospital. Elderly patients now get an early
medication review which can help prevent the patient from falls. A falling star symbol is
placed above patient beds when they are identified as being at risk.
We have implemented a frailty rating system to identify older people most at risk during their
admission.
We used NHS Change Day to promote better provision of literature on our elderly care
wards, using posters to provide essential information both physically and electronically.
45
Priority: To improve the quality and experience of care for patients with dementia by
implementing a baseline study and identifying options for improvement
We have completed our baseline study for patients with dementia which we will build
upon for our 2015-16 priorities. This baseline reflects the national standards for inpatients with dementia







We have improved our dementia training statistics
We have invested in a lead dementia nurse
We have improved the ‘Forget me Not’ patient identification scheme
We have recruited over 30 new volunteers
We have integrated dementia screening into the VitalPac record system
All patients over 75 are screened
Patient information has been improved with the ‘Forget me Not’ carers
passport
We have met our 2014-15 priority to baseline against the national dementia
standards.
This dementia priority has been reported to the Quality Committee.
We have secured investment in a lead dementia nurse from the Charitable Funds Committee
to support improving our care for patients living with dementia and enhancement of our
facilities at Pinderfields Hospital for our patients.
During 2014 we continued to expand the dementia ‘Forget Me Not’ volunteers with over 30
new volunteers being recruited. These volunteers are making a real difference with patients
with memory problems who are being cared for on the elderly care wards.
Dementia screening has been boosted after the roll-out of a system known as VitalPAC
which is used to for the recording and monitoring of observations, cannula care and NEW
score calculations. VitalPAC is a set of medical applications used with an iPad which
replaces paper notes. All nursing observations across our hospital sites are now paperless
as the VitalPAC rollout continues apace
All patients over the age of 75 are being screened for dementia with a three stage process
involving finding, assessment and referral. A dashboard application helps the team track
their progress which shows that over 99 per cent of suitable patients are now being screened
and receiving suitable interventions for their needs.
Our campaign to improve care for patients living with dementia continues to make progress
with the introduction of a ‘Forget Me Not Carers Passport’.
A credit-card sized passport is being given to the patient’s nearest relative or primary carer.
The passport enables the holder to visit outside normal visiting hours (provided they inform
ward staff) to provide assistance with personal cares, provide assistance at mealtimes, be
actively involved in discussions about their loved one’s care, treatment and discharge and
provide support to the patient when having investigations in hospital – for example, attending
x-rays or giving blood samples.
46
3.3.1
Patient Advice and Liaison Service (PALS)
Our Patient Advice and Liaison Service (PALS) is available for our patients, relatives and
carers so that they have someone to turn to for on-the-spot help, advice and information.
The main role of the PALS team is to:




Advise and support our patients, their families and carers.
Provide information on NHS services.
Listen to concerns, suggestions or queries.
Help sort out problems quickly on behalf of our patients, carers and relatives.
PALS operates across our Trust and in January 2014 the Patient Liaison Team was
reconfigured in response to the Clwyd/Hart report “Putting Patients Back in the Picture”, so
that there is a clear delineation between the management of formal and informal complaints.
The PALS team relocated to level C within Pinderfields Hospital to make the service easily
and clearly accessible to patients, relatives and carers so they can obtain advice and
assistance quickly.
A drop in service is provided 10am-4pm Monday-Friday and telephone advice continues to
be available 8.30am-5pm Monday- Friday.
The service has been very well received by the public, who have valued greatly the personal,
‘real time’ assistance and support provided by the team.
The Trust also benefits, as the intelligence collated by the team enables targeted, timely
action to be taken in response to problems identified and helps to prevent issues escalating
into formal complaint situations.
Plans have been put in place to develop the service in 2015/16 to provide a physical
presence on the Dewsbury and Pontefract sites upon recruitment to vacant posts.
More information on our PALS team can be found on our website at:
http://www.midyorks.nhs.uk
3.3.2
Patient Liaison Team
If there are concerns that cannot be resolved by our services then patients, relatives, carers
and visitors can get in touch with a member of our Patient Liaison Team, which is the central
point of contact for PALS. The team works to get the best resolution for a complaint or
concern and aims to provide a listening ear in order to find the most appropriate way forward.
3.3.3
Formal Complaints
We always aim to provide the best possible care for our patients but occasionally things can
go wrong, which is why we take complaints very seriously and investigate them fully. If there
are issues identified, we work with the patient and their family to address them and learn
from them for the future.
We would like to know when things go wrong so we can quickly put them right and improve
our services. If our patients feel unable to discuss their concerns directly with our staff and
47
wish to complain formally, they can do this by contacting our Patient Liaison Team at Trust
Headquarters on the Pinderfields site. More information on formal complaints can be found
on our website at:
http://www.midyorks.nhs.uk
During 2014/15, we received 3,400 PALS enquiries to our Patient Liaison Team from
patients, relatives and carers contacting us for practical and emotional support for their
issues or concerns. Working with staff across our Trust, the team also worked hard to
support individuals through the process of making a formal complaint and ensuring that it
was dealt with as quickly as possible.
In 2012/13 we stated one of our Improvement Priorities was to improve performance,
satisfaction and learning from complaints.
In 2013/14 we improved both the acknowledgement of the complaint and the
response to the complaint within the agreed timeframes. We achieved our goal.
Our plan for 2014/15 was to secure a further improvement in the performance of
managing formal complaints and set a 95% response rate (within agreed time
periods) for all formal complaints. The target was either met or exceeded each month
during 2014/15. We achieved our goal.
2013/14
2014/15
Number of formal complaints received
1,407
1,428
% acknowledged within three working days
100%
100%
% responded to within the agreed timeframe
79%
98%
Number of PALS enquiries
3,100
3,400
Number of complaints received 2014/15 in
comparison with 2013/14 and 2012/13
numbers received
200
150
100
50
0
Apr May Jun July Aug Sept Oct Nov Dec Jan Feb Mar
2012/13 139 122 114 125 110
75
103 124
92
150 173 150
2013/14 104 118 126 132 124 134 151 111 102 146 132 123
2014/15 104 118 126 132 124 134 151 111
48
87
96
109 135
The most frequent issues raised within formal complaints to the Trust have been:





Delay in treatment - outpatient and inpatient care
Poor medical/nursing care
Cancellation /rescheduling/access to appointments
Co-ordination of treatment
Delay in diagnosis
During 2014/15, because of feedback from our patients, carers and relatives, we made some
key changes including:





Development of a training package for nursing staff on the identification and
treatment of delirium. The package was initially piloted and then rolled out across the
Trust. Pathways, guidelines and interventions are now available for all staff to access
via the Trust Intranet.
Introduction of new sensory pads to reduce/mitigate the risk of patient falls.
Processes in place on Gate 40 (Day Surgery) at Pinderfields have been improved to
reduce waiting and to streamline the arrival procedure of patients. The environment
has also been improved.
The ‘intentional rounding’ system has been reviewed and improved to ensure that the
needs of the patient are being met.
Nurse staffing levels across the Trust have been reviewed and improved.
Recruitment methods have been innovative and encompassed securing qualified
nurses from Spain during the year.
Throughout the year, the Patient Liaison Team had a particular focus on resolving as many
concerns as possible on an informal basis in order to try to respond more quickly (as formal
complaints can take longer). Much effort was concentrated on supporting patients in
arranging timely outpatient appointments in those specialities which were experiencing
capacity issues during the year.
The team has established a GP liaison service, with secure email address, to support
colleagues in primary care requiring advice and help in relation to Trust services. A review of
the uptake of the service during the year indicates that GP colleagues in North Kirklees, in
particular, appreciate the swift help/ intervention provided by the team.
The service provided by the Patient Liaison Team is valued by both the Trust and the
community we serve, as demonstrated in a recent email received from a patient, who said:
“Thank you so much for your prompt response. Appointment now fixed. Have a
good weekend” (E. S.)
The drop in service has also proved extremely popular, with contacts increasing over the
year by 10%.
More information on our PALS team can be found on our website at:
http://www.midyorks.nhs.uk
49
Our philosophy for handling complaints
The Trust policy on dealing with formal and informal complaints was reviewed in
2014. The policy outlines our philosophy for handling complaints and describes how
this is underpinned by the Ombudsman’s ‘Principles of Good Administration’,
‘Principles for Remedy’ and ‘Principles for Good Complaint Handling’.
A particular focus for our Trust is the application of the principles:
 Getting it right
 Being customer focused
 Being open and accountable
 Acting fairly and proportionately
 Putting things right
 Seeking continuous improvement
3.4 National inpatient survey 2014
The Trust participated in the annual Inpatient Survey in summer 2014. The results of this
survey were published in early 2015. Patients reported that their overall experience of care
improved since 2013 with 78% of patients rating their care as 7 or more out of 10 in 2014
compared to 74% in 2013.
Compared to 2013 our results were better, and statistically different, compared to other
Trusts in England in the following areas:


Waiting a long time to get a bed on a ward
Enough nurses on duty to care for patients
Compared to the 2013 our results were worse, and statistically different, compared with other
trusts in England in the following areas:


Bothered by noise at night from staff
Cleanliness of the hospital room or ward
The Trust was worse, and significantly different, compared with other trusts in England in the
following areas:


Discharge: not given any written/ printed information about what patients should or
should not do after leaving hospital
Discharge: not given completely clear written/ printed information about medicines
The following table shows the position of the Trust compared to other Trusts.
50
CQC Patient survey Report 2014 - survey of adult patients at MYHT
These survey results have helped us identify new priorities for improvement in patient
experience for 2015-16 and will become improvement priorities for the Trust.
Progress against actions identified for improvement is monitored by several Trust forums
and overseen by the Quality Committee.
3.4.1
The National Friends and Family Test (Patient questions)
The NHS Friends and Family Test (FFT) is a survey assessing patient experiences of NHS
services. It uses a simple question which asks how likely, on a scale ranging from extremely
unlikely to extremely likely, a person is to recommend the service to a friend or family if they
needed similar treatment. Data is reported and published on a monthly basis. The feedback
is used to highlight and promote areas of good practice and identify areas for improvement.
Inpatient areas
Inpatient areas achieved a FFT response rate of 48% in March 2015 which was well above
the national target of 40%.
The Trust achieved all national CQUIN targets for FFT Inpatient response rates:
 Q1 = 25%
 Q4 = 30%
 March 2015 = 40%
Broken down into each month our Inpatient % response rates compared against the national
rates are as follows.
51
Inpatient monthly percentage response rates
MYHT
Apr
2014
May
June
July
Aug
Sep
Oct
Nov
Dec
Jan
2015
Feb
Mar
32%
34%
33%
34%
31%
28%
28%
26%
23%
37%
44%
48%
38%
37%
34%
36%
40%
45%
National
35%
36%
38%
38%
36%
37%
average
% scores are rounded to the nearest whole number
The responses to the FFT question are used to produce a score for the percentage of people
that would recommend the service. The average monthly percentage of patients that would
‘recommend’ our Inpatient services was 95% which is in line with the national average
(national average results for March 2015 = 95%).
The ‘Recommend Score’ replaces the previously used ‘Net Promoter Score’ which was
changed in September 2014 following a national review of FFT.
The following chart shows the Trust’s monthly FFT Net Promoter Score for Inpatient areas
compared against the National monthly average FFT Net Promoter Scores for Inpatient
areas.
Inpatient monthly FFT Net Promoter Scores (April - August 2014)
Apr 14
May
June
July
August
MYHT
76
74
74
73
71
National average
73
73
73
73
73
The following chart shows the Trust’s monthly % of patients ‘extremely likely’ or ‘likely’ to
recommend the service for Inpatient areas compared against the National monthly average
% of patients ‘extremely likely’ or ‘likely’ to recommend scores for Inpatient areas.
Inpatient monthly FFT ‘Recommend scores’ (Sept 2014 - March 2015)
Sep 14
Oct
Nov
Dec
Jan 15
Feb
March
MYHT
95%
94%
97%
95%
92%
93%
93%
National average
94%
94%
95%
95%
94%
95%
95%
Accident and Emergency Assessment Areas
(This includes Medical Assessment Unit, Acute Assessment Unit, and Surgical Assessment Unit).
Accident and Emergency assessment areas achieved a FFT response rate of 29% in March
2015 which was above the national target of 20%.
The Trust achieved all the national CQUIN targets for FFT A&E response rates:
 Q1 = 15%
 Q4 = 20%
Broken down into each month our % response rates compared against the national rates are
as follows:
52
Accident and Emergency monthly percentage response rates
April
2014
May
June
July
August
Sept
Oct
Nov
Dec
Jan
2015
Feb
March
MYHT
25%
26%
25%
24%
23%
21%
21%
24%
24%
26%
24%
29%
National
19%
19%
21%
20%
20%
20%
20%
19%
18%
20%
21%
23%
The average monthly percentage of patients that would ‘recommend’ our Accident and
Emergency Assessment Areas was 94% which is above the national average (national
average results March 2015 = 87%).
The following chart shows the Trust’s monthly FFT Net Promoter Score for Accident and
Emergency assessment areas compared against the National monthly average FFT Net
Promoter Score for Accident and Emergency assessment areas.
Accident and Emergency monthly FFT Net Promoter Scores (April - August 2014)
April
May
June
July
August
MYHT
64
67
65
64
64
National
55
54
53
53
57
The following chart shows the Trust’s monthly % of patients ‘extremely likely’ or ‘likely’ to
recommend the service for Accident and Emergency areas compared against the National
monthly average % of patients ‘extremely likely’ or ‘likely’ to recommend scores for Accident
and Emergency areas.
Accident and Emergency monthly FFT ‘Recommend scores’ (Sept 2014 - March 2015)
Sept
Oct
Nov
Dec
Jan
Feb
March
MYHT
95%
94%
93%
93%
95%
94%
93%
National
86%
87%
87%
86%
88%
88%
87%
Maternity services achieved an overall FFT response rate of 22% in March 2015 (national
rates not available). The average monthly percentage of patients that would ‘recommend’
our Maternity services was 97%.
National targets were also set for extending FFT to all our patient services which the Trust
implemented ahead of the national timescales.
This has enabled us to gain valuable
feedback from patients on their experience of care. Results for March 2015 show that the
majority of our patients would recommend the service they received from our Day Care
(99%) Outpatient (96%) and Community services (97%).
We have increased accessibility of the FFT for our patients by developing an ‘Easy read’
version of the card as well as offering access to a Freephone language line for those whose
first language is not English. Patients are also able to offer their feedback via the website if
they wish.
All the comments from patients and users of our services are collated and priorities for
improvement identified. The majority of positive comments are focussed around the quality
of care and staff being friendly and helpful. The highest number of suggestions for
improvement relate to waiting times, food and staffing levels.
53
A number of changes have been implemented including TVs and iPads for patient use (Gate
29) regular verbal updates and display of waiting times in Antenatal outpatients, relocation of
triage to Labour ward to improve waiting times, redesign of patient dining room to make more
homely environment (G41), changes to menu options trust wide.
The Trust will continue to regularly review, via the Trust Patient Experience Strategy Group,
the data collection methods available in light of costs, resources and technical
capability. The group will make appropriate decisions regarding modifications or changes
according to the consensus of the group, in line with national guidance, aiming to achieve a
balance between consistency of collection and making the FFT accessible to all within the
available resources.
3.4.2
The National Friends and Family Test (Staff questions)
From 1st April 2014 all organisations providing acute, community, ambulance and mental
health services were required to implement the Staff Friends and Family test each quarter,
giving all staff the opportunity to feedback their views at least once a year.
The Staff FFT consists of two questions:
“How likely are you to recommend Mid Yorkshire Hospitals to friends and family if
they needed care or treatment?”
“How likely are you to recommend Mid Yorkshire Hospitals to friends and family as a
place to work?”
Each question has a comments box for staff to provide more information to understand why
staff chose a particular answer. In addition, the Trust was able to ask additional questions. In
quarters 1 and 4, all staff were invited to take part, in quarter 2 a selection of staff groups
were involved and in quarter 3 the NHS Staff Survey covers the required questions.
Approximately 2,000 staff took part during quarters 1 and 4 when all staff were invited to
respond. In both quarters, 52% would recommend the Trust to friends and family if they
needed care or treatment and 40% would recommend the Trust to friends and family as a
place to work. 75% in quarter 4 would recommend their own ward or unit as a place for
friends and family to receive care and treatment.
What are the areas of good practice?
Areas where staff identified good practice are:




quality of care
attitude
choice
benefits
Where do we need to improve?
Areas which staff identified as needing improvement are:


54
staffing levels
communication


quality of care
systems and culture
Some of the comments made were as follows:
“I have used the service myself and have been happy with the care received”
“We deliver excellent care in my opinion despite the pressure in the system. I have
confidence in the clinical teams who treat patients.”
“Staffing is still an issue within the Trust and this has a direct effect on patient care”
“Staff are very friendly but there are not enough of them to cope with patient workload
safely in my opinion”
“Excellent place to work and some good benefits including pension, NHS Discounts
and car scheme”
“This is a friendly Trust with modern facilities. My colleagues are great to work with
and I find every day a challenge but hugely enjoyable”
“At times too much pressure and not enough resources causing stress on dedicated
colleagues”
“Staffing levels are a big issue in all areas and morale amongst staff is low”
Feedback from the Staff FFT highlights similar issues as the NHS Staff Survey results with
staffing levels being the main area identified as requiring improvement. The Trust has
invested in strategies to address this area and continues to do so including international
recruitment and development of training and support packages for particular groups of staff
to improve staff retention and career development.
3.4.3
Staff Recommendation (from the national staff survey)
The National NHS Staff Survey for 2014 asked staff the question of how likely they would be
to recommend the Trust. The responses remain below the national average. A reinforced
programme of improvement initiatives will be delivered over the year to build upon the 201415 staff engagement programmes.
Staff Recommendation
"If a friend or relative needed
treatment, I would be happy with
the standard of care provided by
this organisation"
This Trust
2012
This Trust
2013
This Trust
2014
National
Average
41%
40%
45%
65%
Although there is some improvement in our 2014 Trust score, this is clearly an area that we
wish to improve upon. We have therefore included it as a key improvement priority for 201516.
During 2014-15 we have worked on staff engagement and support in the following ways:
55








We have worked hard to improve our staffing levels with significant investment in
recruitment during 2014-15
We have held a large successful international recruitment campaign which has
reached as far as Spain and India
We have held the ‘big conversations’ with staff as part of the first year of the
‘Listening into Action’ programme
This encourages staff to say what can be improved for them and their patients and
they are then supported to make the suggested improvements locally
This has resulted in improvements for patients with regards to medicines
management, dementia care and provision of cancer services.
We have also seen improvements in the provision of elderly care services as a result
of the ‘Listening in Action’ campaign
We have run a ward development programme which approximately 90 ward
managers have completed
We are now investing in leadership development for our staff and have developed a
new programme with Manchester Business School
Freedom to Speak Up
The Trust is committed to meeting the Freedom to Speak Up principles.
This is an important initiative designed to address cases of poor treatment and care where
there is a lack of awareness by an organisation’s leadership of the existence or scale of
problems known to the frontline.



Principle 1 – Culture of safety: Every organisation involved in providing NHS
healthcare should actively foster a culture of safety and learning in which all staff feel
safe to raise concerns
Principle 4: Culture of visible leadership: All employers of NHS staff should
demonstrate, through visible leadership at all levels in the organisation that they
welcome and encourage the raising of concerns by staff
Principle 13: Transparency: All NHS organisations should be transparent in the way
they exercise their responsibilities in relation to the raising of concerns, including the
use of settlement agreements
The Francis report found that in many cases staff felt unable to speak up, or were not
listened to when they did. The leadership ambitions outlined in these Quality Accounts
particularly address the above principles. A more detailed picture of the 2015-16 Freedom to
Speak Up initiative will be included in next year’s Quality Accounts.
56
3.5 NRLS – Organisation Patient Safety Incident Report (April to Sept 2014)
It is a requirement that each Trust uploads reported incidents on to the National Reporting
and Learning System (NRLS). This information is used to generate bi -annual reports for
Trusts covering the periods April to September 2014.
The report focuses on the following areas:



Volume of incidents reported as compared to 140 other large acute NHS
organizations
How quickly MYHT reports incidents to the NRLS
What type of incidents we report
There is evidence organizations that report more incidents usually have a better and more
effective safety culture. You can't learn and improve if you don't know what the problems are.
Actions taken to improve Trust NRLS position
At the end of 2012/13 into 2013/14 the Trust put in place an action plan to improve the Trusts
incident reporting performance. This has involved the implementation of the following
changes and improvements to the Trusts incident reporting processes.
System review and staff support and training
The Trust undertook a review of the Datix Incident reporting system and had amended it to
simplify the reporting process. Update training has been provided to Trust staff along with the
provision of ‘Datix easy guides’ to encourage reporting.
The Trust also reviewed the Risk team’s processes on how and when we upload data to
NRLS.
Duty of Candour
The Trust has raised awareness of the requirements of employees in relation to Duty of
Candour and produced mechanisms to capture compliance and report on performance.
Performance manage incident reporting and closure
Working with the clinical divisions the Trust has implemented a series of dashboard and
performance reports that have raised the profile of incident reporting and timeliness of
investigation within the Trust. Performance against these dashboards is monitored weekly
through the Patient Safety Panel and Clinical Executive Group. The impact of this has been
a significant reduction in the volume of incidents past their completion deadline.
Incident feedback
Systems have been put in place to ensure that feedback is provided to the incident reporter
via the Datix system. Generic learning from incidents and incident themes are now cascaded
via the weekly Patient Safety Bulletin and Risky Business newsletter.
57
Incident trigger list
The Trust has been really encouraged by the significant increase in reporting, the next step
for improving our safety culture is understanding about incidents that are occurring frequently
that are not causing harm to help our organisation learn and improve, but to also build a 'risk
profile' for the Trust, to predict potential future problems and take early steps to prevent
them.
To help encourage staff to report incidents the Trust developed a trigger list reportable
incidents based on the global trigger tool from the Institute for Healthcare Improvement. The
Trust is also encouraging Specialities/Divisions to create ‘local’ incident trigger lists specific
and relevant to their speciality/service.
Staff survey results
The MYHT Staff Survey results (2014) have demonstrated a big improvement in relation to
how staff feel about the fairness and effectiveness of the Trust’s incident reporting
procedures. In particular the Trust scored well above average in relation to how well
informed staff feel about errors and incidents and the feedback received.
NRLS Summary
As can be seen from the table below MYHT is currently in the upper 25% of large acute
Trusts for incident reporting. MYHT reported 41.17 incidents per 1,000 bed days, the median
reporting rate for this cluster is 35.1.
2 years ago MYHT was in the bottom 3 of the 39 large acute Trusts for incident reporting, so
it is very encouraging that the actions implemented have started to make a positive impact
on the incident reporting culture.
58
59
What type of incidents we report
The table above highlights the types of incidents MYHT is reporting and the degree of harm.
60
It would appear that we are not applying the degrees of harm correctly when reporting
incidents. The key issue is the differentiation between ‘no harm’ and ‘low harm’. This was
also flagged as an issue in the CQC intelligence monitoring report. In 2014/15 the Trust put
in place an action plan to improve the proportion of incidents that are harmful performance
which has been reported to Trust Board monthly.
In April 2014 the number of incidents reported resulting in harm was 57%, the figure at the
end of March 2015 is 36.0%. Work will continue in 2015/16 to aim for the performance
trajectory of ≤29%, set by the CQC, activity around this target is monitored by the local
Intelligent Monitoring process.
Key factors relating to this improvement were identified:
1. The Risk Management team have taken an active role in working with clinical staff
to challenge grading of incidents based on the 'actual' harm; not the 'potential'
harm. Audit has demonstrated that staff do not always grade accurately.
2. The Trust is proactively encouraging the reporting of No Harm and Near Misses
incidents.
3. ‘Near Miss’ has been incorporated into the ‘No Harm category’ on Datix to
encourage reporting.
Summary
The significant improvements in incident reporting, combined with the reduction in proportion
of harm and improvements in the staff survey results around incidents/risk, provides sound
assurance that there has been a positive step change in patient safety culture at MYHT.
61
3.6 Performance against key national priorities & operational delivery standards
The Trust has an agreed Performance Framework in place which sets out the robust
processes and systems in place to ensure the sustainable delivery of mandatory and locally
agreed performance targets, strategic and corporate objectives.
In line with the Framework, the following approach to RAG rating of performance and
escalation has been adopted at the Trust to facilitate performance management of delivery
against the specified nationally mandated and locally identified standards.
RAG Status
Performance Description
Green
Achieved – the required standard has been met for
this indicator
lmAmber
Not Achieved – the required standard has not been
met by a narrow margin and performance is within an
agreed tolerance
Red
Not Achieved – the required standard has not been
met and performance is not within an agreed
tolerance
For the purpose of reporting, indicators are grouped in to the five domains of quality (caring,
safe, effective, responsive and well led) identified by the CQC and mirrored in the TDA
Accountability Framework for 2014/15.
Performance in each of the domains in 2014/15 is summarised below, based on the year end
position reported to the Trust Board in the March 2015 Performance Report, or the latest
information available. A full breakdown of performance against each indicator can be found
in Appendix 1.
62
Caring
The Trust achieved the zero tolerance standard mandated nationally for single sex
accommodation breaches in 2014/15. This is a reduction from 3 cases in 2013/14 and 4
cases in 2012/13.
Safe
In 2014/15, the Trust achieved the required standard against 6 of the 11 (54.5%) indicators
included within the safe domain of quality in the Trust Board scorecard. Areas of
underperformance related to:





MRSA Incidence – the Trust reported 1 case of hospital attributed MRSA infection in
2014/15 against the zero tolerance standard mandated nationally. This occurred in
June 2014. Performance in 2014/15 represents an 85.7% reduction in MRSA
incidence from 7 cases in 2013/14.
Never events – 1 never event occurred at the Trust in 2014/15 against the zero
tolerance standard mandated nationally. This occurred in September 2014.
Performance in 2014/15 represents a significant 75.0% reduction from 4 cases last
year.
Medication errors resulting in serious harm – there were 2 medication errors that
resulted in serious harm reported at the Trust in 2014/15. Both occurred in December
2014.
Harm Free Care (NHS Safety Thermometer) – a harm free care rate, as measured
through the NHS Safety Thermometer, of 93.8% was achieved against the 95%
target at the Trust in March 2015. This took the 2014/15 position to 92.9%. Although
performance remained below the 95% target in 2014/15, the current position shows
an increase in the proportion of patients receiving harm free care at the Trust in
2014/15 compared to the previous year; performance of 90.4% reported in March
2014.
Proportion of reported patient safety incidents that are harmful – this was a new
indicator for 2014/15. In March 2015, 36.5% of the reported patient safety incidents at
the Trust were categorised as harmful, against the 29% target. This took the year to
date position to 43.1%. Although performance remains below the required target,
analysis of performance by quarter shows the Trust delivered:
i) an increase in the number of patient safety incidents reported monthly;
from an average of 959 per month in Q1 to an average of 1,135 per month
in Q4 (a higher number of incidents reported recognised to be reflective of
a safety culture),
ii) a reduction in the proportion of reported patient safety incidents that are
harmful; from 53.7% in Q1 to 37.5% in Q4 (performance of 36.7%
achieved in Q3).
Effective
The Trust achieved the required standard against 4 of the 5 (80.0%) indicators included
within the effective domain of quality, as reported in the Trust Board scorecard, based on
cumulative performance in 2014/15 or the latest data available against the mortality
indicators.
63

The reported underperformance relates to underperformance against the weekend
HSMR indicator in March to May 2014 and September to December 2014; December
2014 the latest data available for performance against the HSMR mortality indicators.
Although above the <100 target, performance remained within the national
benchmark.
Responsive
In 2014/15, the Trust achieved the required standard based on cumulative performance
reported at the end of March 2015 against 13 of the 21 (61.9 %) indicators included within
the responsive domain of quality, as reported in the Trust Board scorecard. Areas of
underperformance related to:






64
A&E waiting times – 94.1% of patients attending A&E departments across the Trust in
2014/15 were admitted, transferred or discharged within 4 hours against the 95%
standard mandated nationally. Of 225,798 patients attending A&E at Mid Yorkshire
Hospitals in 2014/15, 13,327 waited over 4 hours to be admitted, transferred or
discharged. Benchmarking of monthly performance shows the Trust continues to
perform well compared to peers nationally for Type 1 A&E performance; ranked 37th
out of 146 reporting organisations across 2014/15 and performing above the national
average of 90.4%.
18 Weeks RTT – the Trust achieved the required performance against the 92%
standard for incomplete pathways and the 90% standard for completed admitted
pathways within 18 weeks in March 2015. Underperformance against the completed
non-admitted standard reflects planned underperformance against this indicator at
the Trust in 2014/15 as part of an agreed recovery plan to achieve sustainable
delivery of the incomplete standard, in addition to the standards for completed
pathways moving forwards.
Incomplete RTT pathways over 52 weeks at month end – a total of 33 RTT pathways
over 52 weeks and incomplete at month end were reported across the Trust in
2014/15. The majority of these pathways were identified as part of the Trust’s
strategy to improve data quality through validation of the waiting list position.
Delayed transfers of care – in 2014/15, the Trust did not achieve the ≤7.5% target for
delayed transfers of care from community beds based on cumulative performance
over the 12 month period of 10.6%. However, performance of 6.66% was achieved in
the month of March 2015; reflecting the improvement delivered by a recovery plan
implemented at the request of the Trust Board. The Trust delivered the ≤3.5% target
for delayed transfers of care from acute/sub-acute beds in March 2015 (2.89%);
however performance was assigned an amber RAG rating based on cumulative
performance of 3.78% in 2014/15. A review of monthly performance for acute
delayed transfers of care shows an improvement from 4.1% in Q1 and Q2 combined,
to 3.5% across Q3 and Q4.
Cancelled operations not re-booked within 28 days – 4 breaches of the 28 day
standard were identified at the Trust in 2014/15; 2 in December 2014 and 2 in
January 2015. This is an increase from 1 case in 2013/14.
Ambulance handovers – 1,327 ambulance handovers took place over 30 minutes
from arrival at A&E across the Trust in 2014/15. This equates to 2.86% of total
handovers completed in the period. Of the 1,327 handovers over 30 minutes, 146
took place more than 60 minutes from arrival at the Trust. This equates to 0.32% of
total handovers completed in the period. The Trust has continued to perform above
the regional average for the proportion of handovers completed within 30 minutes
and 60 minutes respectively. The Trust has reported no handovers taking place more
than 120 minutes from arrival in 2014/15.
Well-led
The Trust achieved the required standard based on cumulative performance reported at the
end of March 2015 against 5 of the 12 (41.7%) indicators included within the well-led domain
of quality, as reported in the Trust Board scorecard. Areas of underperformance related to:




65
Turnover rate – a turnover rate of 10.8% was reported against the <8.0% target for
2014/15 at the end of March 2015. This is an increase from 10.6% in 2013/14.
Sickness absence – for the rolling 12 month period ending February 2015, sickness
absence of 4.84% was reported across the Trust against the 4% target. This is an
increase from 4.49% across 2013/14.
Non-medical appraisal rates – at the end of March 2015, for the rolling 12 month
period, 75.0% of non-medical staff had an annual appraisal completed against the
80% target. Although performance remained below the required target, the
performance improved from 72.0% across 2013/14 and Q1 2014/15.
Medical appraisal rates – at the end of March 2015, for the rolling 12 month period,
89.5% of consultant medical staff and 89.7% of non-consultant medical staff had an
annual appraisal completed against the 90% target. Both targets were achieved
across Q3 and in January and February 2015.
Performance Indicator
Standard
2014/15
0
0
0
1
≤3 (42)
33
≥95%
95.8%
Publication of Formulary
Y
Y
Duty of Candour
0
0
No. of never events: occurred
0
1
Medication errors causing serious harm
0
2
Harm Free Care - NHS Safety Thermometer
≥95%
92.94%
0
0
≤29%
43.1%
0
0
Summary Hospital Mortality Indicator (SHMI)
≤100
87.60*
Hospital Standardised Mortality Ratio (HSMR) - remodelled
≤100
91.91*
HSMR - weekend (non-elective emergency)
≤100
109.14*
HSMR - weekday (non-elective emergency)
≤100
90.84*
Emergency readmission within 30 days following an elective spell at the Trust
≤3.5%
3.5%
≤12.6%
12.1%
≥95%
94.1%
0
0
RTT Waiting Times - Incomplete Pathways within 18 Weeks
≥92%
92.0%
RTT Waiting Times - Completed Admitted Pathways within 18 Weeks
≥90%
91.4%
RTT Waiting Times - Completed Non Admitted within 18 Weeks
≥95%
94.3%
0
33
≤1%
0.54%
Delayed Transfers of Care - Acute Beds
≤3.5%
3.78%
Delayed Transfers of Care - Community Beds
≤7.5%
10.6%
Cancer 2 Week Wait - for 1st OP from urgent GP referral
≥93%
95.4%
Cancer 2 Week Wait - for 1st OP from urgent referral - breast symptoms
≥93%
97.8%
Cancer 31 Day Wait - diagnosis to 1st definitive treatment
≥96%
99.0%
Cancer 31 Day Wait - subsequent treatment (surgery)
≥94%
96.4%
Cancer 31 Day Wait - subsequent treatment (drug regimen)
≥98%
100.0%
Cancer 62 Day Wait - from urgent GP referral to 1st definitive treatment
≥85%
86.5%
Cancer 62 Day Wait - from screening referral to 1st definitive treatment
≥90%
≤13.5
annual
92.4%
Caring
Sleeping Accommodation Breach
Safe
Zero tolerance MRSA
Minimise rates of Clostridium difficile
VTE risk assessment: all inpatients risk assessed for VTE
Maternal deaths
Proportion of reported patient safety incidents that are harmful
Overdue CAS alerts
Effective
Emergency readmission within 30 days following an emergency spell at the Trust
Responsive
A&E Waiting Times - admitted, transferred or discharged within 4 hours
Trolley waits in A&E longer than 12 hours
Zero tolerance RTT waits over 52 weeks for incomplete pathways
Diagnostic Test Waiting Times - >6 weeks from referral
Cancer 62 Day Wait - following consultant upgrade (breaches)
66
8.5
3.7 Quality Improvement Dashboard
Mid Yorkshire is committed to delivering healthcare in a safe and effective environment for
our patients. An unrelenting focus on patient safety and quality is essential for this to be
achieved. The Trust has therefore further developed its Patient Safety Dashboard to
incorporate wider quality priorities and to ensure robust monitoring of the CQC Action plan.
This will ensure we are operating to the high standards that are set for us both nationally and
that we set ourselves.
The Quality Improvement Dashboard report details the Trust’s performance against the key
measures of quality and safety mandated nationally as part of the National Standard
Contract and NHS Trust Development Authority (TDA) Accountability Framework for
2014/15. In addition locally identified key outcome and process measures are included.
The dashboard was revised in January 2015 to remove outdated priorities and include
actions detailed in the CQC Improvement Plan in order to demonstrate delivery of on-going
sustainability against the actions, ensuring monitoring and assurance.
The Quality Improvement Dashboard is reviewed monthly at the Quality Committee.
3.8 Appraisal & Training
The Trust has worked hard this year to ensure that our staff are compliant with their
mandatory training requirements. This applies to all staff from the Executive team to our
frontline staff.
Our training and appraisal figures are monitored regularly. They are reviewed:




67
weekly at divisional management team meetings
monthly at divisional governance committee
monthly at the workforce committee
included in the Trust board performance dashboard
Non Medical Appraisal % Compliance for by Division & Directorate April 2014 to April 2015
Departmental
Compliance Non Medical
Appraisal
Finance & Corp Serv
Division of Surgery
Clinical Support Serv
Women’s & Children’s
Care Closer to Home
Division of Medicine
Access, B’king & Choice
Planning & Partnerships
Staff & Patient Engm’t
Site Services
BBW
Grand Total
68
Apr
2014
May
2014
Jun
2014
Jul
2014
Aug
2014
Sept
2014
Oct
2014
Nov
2014
Dec
2014
Jan
2015
Feb
2015
Mar
2015
87%
55%
76%
66%
80%
54%
N/A
N/A
N/A
99%
69%
70%
85%
62%
79%
62%
84%
56%
64%
N/A
79%
98%
88%
72%
73%
67%
87%
59%
83%
65%
69%
N/A
75%
94%
73%
70%
87%
66%
80%
67%
79%
66%
60%
N/A
56%
92%
85%
74%
70%
71%
81%
68%
72%
64%
63%
N/A
67%
91%
79%
73%
63%
63%
81%
73%
69%
63%
82%
N/A
69%
92%
79%
72%
65%
63%
83%
74%
67%
60%
87%
33%
73%
88%
69%
71%
77%
61%
86%
77%
67%
62%
85%
33%
81%
91%
91%
73%
80%
63%
82%
76%
69%
74%
83%
33%
88%
94%
88%
76%
77%
64%
79%
77%
73%
74%
55%
60%
83%
96%
90%
75%
73%
63%
81%
80%
75%
70%
50%
50%
77%
96%
87%
75%
76%
66%
83%
81%
74%
68%
44%
43%
80%
94%
91%
75%
Non-Medical Appraisal Compliance Statistics as of 1st April 2015
Service Group
Finance & Corporate Services
Division of Surgery
Clinical Support Services
Women’s & Children’s
Care Closer to Home
Division of Medicine
Planning and Partnership
Company Secretary
Access, Booking and Choice
Staff & Patient Engagement
Chief Nurse
Medical Director
Site Services
Cofely
Grand Total
69
Total Number in Target
No Appraisal Compliance
% Compliance 1 April 2015
249
1059
649
955
763
1457
7
8
301
25
68
80
793
187
6601
188
701
536
777
564
992
3
7
133
20
35
58
749
171
4934
76%
66%
83%
81%
74%
68%
43%
88%
44%
80%
51%
73%
94%
91%
75%
Trust Board Report – April 2015 Core Mandatory Training Compliance Statistics as of 1st April 2015
Access,
Booking &
Choice
Cofely GDF
Suez
(ROE Staff)
Chief
Nurse
Clinical
Support
Services
Care
Closer to
Home
Company
Secretary
Div of
Medicine
Div of
Surgery
Finance &
Corporate
Services
Medical
Director
Planning &
Partnership
Site
Services
Staff &
Patient
Engagement
Women’s
&
Children’s
Overall %
Compliance
Total Staff
= 310
Total Staff
= 187
Total
Staff
= 72
Total
Staff
= 721
Total
Staff
= 802
Total
Staff
= 22
Total
Staff
= 1625
Total
Staff
= 1271
Total Staff
= 262
Total
Staff
= 87
Total Staff
=7
Total
Staff
= 796
Total Staff
= 27
Total
Staff
= 1017
Total
Staff
= 7206
Diversity
Awareness
98%
303 of 310
Staff
97%
181 of 187
Staff
97%
70 of 72
Staff
98%
709 of
721
Staff
99%
795 of
802
Staff
100%
22 of 22
Staff
96%
1555 of
1625
Staff
98%
1243 of
1271
Staff
99%
259 of 262
Staff
99%
86 of 87
Staff
100%
7 of 7
Staff
99%
791 of
796
Staff
96%
26 of 27
Staff
99%
1011 of
1017
Staff
98%
7058 of
7206
Staff
Fire Safety
83%
256 of 310
Staff
80%
149 of 187
Staff
81%
58 of 72
Staff
87%
627 of
721
Staff
88%
703 of
802
Staff
82%
18 of 22
Staff
69%
1129 of
1625
Staff
74%
942 of
1271
Staff
90%
235 of 262
Staff
94%
82 of 87
Staff
71%
5 of 7
Staff
96%
768 of
796
Staff
93%
25 of 27
Staff
82%
834 of
1017
Staff
81%
5831 of
7206
Staff
Health &
Safety
100%
310 of 310
Staff
100%
187 of 187
Staff
100%
72 of 72
Staff
100%
721 of
721
Staff
100%
802 of
802
Staff
100%
22 of 22
Staff
100%
1625 of
1625
Staff
100%
1271 of
1271
Staff
100%
262 of 262
Staff
100%
87 of 87
Staff
100%
7 of 7
Staff
100%
796 of
796
Staff
100%
27 of 27
Staff
100%
1017 of
1017
Staff
100%
7206 of
7206
Staff
Infection
Control
81%
252 of 310
Staff
43%
80 of 187
Staff
68%
49 of 72
Staff
83%
598 of
721
Staff
86%
691 of
802
Staff
82%
18 of 22
Staff
75%
1226 of
1625
Staff
73%
925 of
1271
Staff
88%
230 of 262
Staff
91%
79 of 87
Staff
71%
5 of 7
Staff
93%
743 of
796
Staff
96%
26 of 27
Staff
79%
800 of
1017
Staff
79%
5722 of
7206
Staff
Information
Governance
77%
238 of 310
Staff
68%
127 of 187
Staff
75%
54 of 72
Staff
87%
628 of
721
Staff
87%
694 of
802
Staff
86%
19 of 22
Staff
71%
1149 of
1625
Staff
76%
970 of
1271
Staff
89%
234 of 262
Staff
94%
82 of 87
Staff
14%
1 of 7
Staff
96%
762 of
796
Staff
93%
25 of 27
Staff
80%
818 of
1017
Staff
81%
5801 of
7206
Staff
Manual
Handling
(L1)
100%
310 of 310
Staff
100%
187 of 187
Staff
100%
72 of 72
Staff
100%
721 of
721
Staff
100%
802 of
802
Staff
100%
22 of 22
Staff
100%
1625 of
1625
Staff
100%
1271 of
1271
Staff
100%
262 of 262
Staff
100%
87 of 87
Staff
100%
7 of 7
Staff
100%
796 of
796
Staff
100%
27 of 27
Staff
100%
1017 of
1017
Staff
100%
7206 of
7206
Staff
Safeguarding
Adults (L1)
100%
310 of 310
Staff
100%
187 of 187
Staff
100%
72 of 72
Staff
100%
721 of
721
Staff
100%
802 of
802
Staff
100%
22 of 22
Staff
100%
1625 of
1625
Staff
100%
1271 of
1271
Staff
100%
262 of 262
Staff
100%
87 of 87
Staff
100%
7 of 7
Staff
100%
796 of
796
Staff
100%
27 of 27
Staff
100%
1017 of
1017
Staff
100%
7206 of
7206
Staff
Safeguarding
Children (L1)
100%
310 of 310
Staff
100%
187 of 187
Staff
100%
72 of 72
Staff
100%
721 of
721
Staff
100%
802 of
802
Staff
100%
22 of 22
Staff
100%
1625 of
1625
Staff
100%
1271 of
1271
Staff
100%
262 of 262
Staff
100%
87 of 87
Staff
100%
7 of 7
Staff
100%
796 of
796
Staff
100%
27 of 27
Staff
100%
1017 of
1017
Staff
100%
7206 of
7206
Staff
Topic
70
Core Mandatory Training Compliance Progression Statistics – April 2014 to 1st April 2015
Compliance
of each Service Group
Access, Booking & Choice
Cofely GDF Suez (ROE
Staff)
Clinical Support Services
Care Closer to Home
Company Secretary
Div of Medicine
Division of Surgery
Finance & Corporate
Services
Planning & Partnership
Site Services
Staff & Patient Engagement
Women’s & Children’s
Overall Percentage
71
Apr
2014
May
2014
Jun
2014
Jul
2014
Aug
2014
Sep
2014
Oct
2014
Nov
2014
Dec
2014
Jan
2015
Feb
2015
Mar
2015
N/A
95%
96%
96%
97%
96%
95%
95%
97%
96%
93%
95%
93%
95%
96%
95%
92%
93%
92%
88%
92%
84%
92%
86%
N/A
N/A
N/A
92%
94%
98%
96%
96%
98%
91%
93%
97%
95%
95%
95%
91%
92%
96%
95%
95%
93%
90%
91%
96%
95%
95%
94%
91%
92%
97%
94%
94%
92%
89%
91%
95%
93%
92%
90%
88%
89%
95%
95%
94%
94%
89%
91%
96%
93%
93%
95%
88%
89%
96%
93%
93%
93%
88%
89%
96%
93%
94%
91%
88%
89%
95%
94%
95%
94%
89%
90%
96%
N/A
99%
N/A
N/A
95%
N/A
99%
93%
95%
94%
N/A
98%
94%
93%
93%
N/A
99%
100%
92%
93%
N/A
99%
100%
92%
94%
N/A
99%
96%
92%
92%
92%
99%
94%
92%
92%
92%
98%
96%
93%
93%
91%
98%
94%
92%
96%
90%
98%
95%
92%
96%
91%
97%
95%
92%
96%
82%
98%
97%
93%
96%
4. Statements from Commissioners, Healthwatch and Overview and
Scrutiny Committees
All statements published within this section have been reproduced verbatim.
Statement from Wakefield Council’s Adults and Health Overview and Scrutiny
Committee (29.05.2015)
Through the Quality Accounts process the Adults and Health Overview and Scrutiny
Committee have engaged with the Trust to review and identify quality themes and the Trust
has sought the views of the Overview and Scrutiny Committee with the opportunity to
provide pertinent feedback and comments.
This has included discussions on progress against the areas for improvement identified in
the 2013/14 Quality Account. This allowed consideration of any potential issues that may
have been of concern and has helped the OSC build up a picture of the Trust’s performance
in relation to the Quality Account.
Overall the Committee would like to see a more challenging approach to the setting of
priority areas for improvement. Members note the references to the Care Quality
Commission inspection and support the actions the Trust has taken to address the concerns
raised.
The Committee notes the inclusion of medicines management and the Deprivation of Liberty
Safeguards as priority areas for improvement. Both these areas were the subject of CQC
warning notices which resulted in comprehensive action plans being developed.
The Committee welcomes the statement in the Quality Account that significant improvement
has now been made in these two areas, and in March 2015 the CQC were formally informed
of the Trust’s compliance with the required standards and the evidence to support was
submitted.
The Committee supports the continuum of improvement by identifying these two areas as
priority areas for improvement but would suggest more challenging outcome measures
would support the Trust’s ambition in setting priorities for patient safety, experience and
clinical effectiveness.
The Committee notes the Trust’s commitment to providing high quality care and clinical
excellence and supports arrangements to observe, monitor and demonstrate progress in
meeting the objectives as set out in the Quality Account.
The Committee recognises the momentum of improvement, particularly in relation to key
performance targets, such as further reductions in patients contracting clostridium difficile,
the increase in harm free care (as measured by the Safety Thermometer), and the
improvement in the mortality rate, which demonstrates that the Trust has made progress in
providing assurance to patients and the public about the safety and quality of services.
However, it’s disappointing to note that despite continued emphasis some elements of care
have not shown the desired level of improvement including zero cases of MSRA bacteremia,
the reduction in the severity of pressure ulcers, and the severity of harm experienced by
patients falling in hospital and in the community. Indeed, despite renewed emphasis on
improvement, pressure ulcers and patient falls actually increased over the last year.
72
The Committee is particularly disappointed regarding the increase in pressure ulcers. From
a patient’s perspective, pressure damage to the skin in traumatic and painful. Members
firmly believe that pressure ulcer prevention is a fundamental part of ensuring high quality
patient care, promotion of patient safety and health service efficiency.
In November 2014, the Committee considered the actions by the Trust to reduce the
prevalence of pressure ulcers. The Committee indicated that they would like to see a more
ambitious target in relation to the reduction of pressure ulcers and the Trust at that time
accepted the Committee’s arguments and indicated that the issues raised would be taken
into account, as part of the preparation of the Quality Account. It is therefore disappointing
that the target appears to have been revised down for 2015/16.
In February 2015, the Committee reviewed hospital care for frail older people and agrees
that the Trust has continued to improve the assessment of risk in elderly patients at the
Trust. Service developments will help meet the continuum of people’s needs from prevention
of hospital admission, specialist inpatient care, timely discharge from hospital and then care
in the community closer to home.
Ambulance handover times remain a concern at Pinderfields hospital which has consistently
missed the target over the last year. Feedback from member constituents highlights a poor
experience of care in these circumstances, particularly for frail elderly patients.
Feedback from member constituents continues to support the need to improve the
scheduling of outpatient appointments, reduce cancellations and improve communication
with patients. Although there is some improvement problems still persist resulting in
continuing public frustration regarding rescheduling outpatient appointments and the
negative impact these have on patient experience and the quality of care.
Members firmly believe that listening to and acting on patient feedback is an effective means
by which to improve services. The Committee therefore supports the development of real
time feedback through the Patient Advice and Liaison Service (PALS) for capturing and
acting on patient experience.
The Committee has focussed on staff engagement as part of its current work programme
and members note the results of the 2014 national staff survey. The Committee welcomes
the decision to include staff engagement as a key improvement priority for 2015-16. There
is compelling evidence that highly engaged employees have fewer accidents, make better
use of resources and deliver better financial performance. In addition, highly engaged
employees are more likely to deliver high-quality care, are healthier and happier, with lower
sickness rates and lower staff turnover – all of which will effectively contribute to the Trust’s
quality goals.
The Committee’s work on dementia care has highlighted the need for a concerted effort on
behalf of the health community to provide significant improvements in the quality of care.
Members therefore welcome the continued emphasis on staff training on caring for patients
living with dementia in clinical areas.
The Committee is grateful for the opportunity to comment on the Quality Account and looks
forward to working with the Trust in reviewing performance against the quality indicators over
the coming year.
73
Statement from Wakefield Healthwatch (11th June,2015)
Re: Quality Account 2014 /15
Healthwatch Wakefield would like to thank Mid Yorkshire NHS Trust (the Trust) for the
opportunity to comment on their draft Quality Account for 2014 2015.
In order to provide these comments Healthwatch Wakefield formed a Task Group of
volunteers, including lay people and retired health professionals, to collect the information
and intelligence regarding the quality of services provided by the Trust.
The Task Group was also provided with details of the feedback from the public which had
been received by the Healthwatch during the previous 4-6 months. The Task Group had
access to the finding of the Enter and View reports conducted by Healthwatch Wakefield
over the year. These were visits to Gate 43 (elderly care), Gate 12 (Acute Assessment
Unit), Queen Elizabeth House (Intermediate Care Ward) and the Emergency Department.
The Task Group had very informative and open meetings with Trust representatives on 8th
May and 28th May 2015 for which we are grateful to the Trust.
In the first meeting on the 8th May we discussed the following items:
1. National staff surveys for the last two years
2. NHS litigation authority payments on behalf of the Trust
3. Waiting times and capacity issues at mid Yorkshire
On the meeting on 28th May the following items were discussed:
1. The Trust’s current standardised motility ratio and summary hospital level mortality
indicator
2. Patient safety incidents, incident reporting and learning per 1000 bed days
3. Annual staff surveys
4. Annual staff mandatory and statutory training
5. Revalidation of fully registered medical staff
6. Nurse patient ratios, ratio of trained nursing staff to Healthcare assistants
7. Hospital acquired infection rates
8. Incidents of pressure sore and ulcers
9. Falls, their risk assessment and prevention
10. Staff sickness levels
11. Staff friends and family test
12. Trust policies in relation to handover of clinical care between specialities,
departments and clinical teams
13. Policies regarding handover of duties amongst junior medical staff
14. Ratio of permanent and temporary staff
15. Duty of Candour, any breaches during the last year
16. The number of never events
17. Venous thrombo-embolism risk assessment and prevention
18. Midwife to birth ratios
19. Access to services, both outpatients, inpatients and A&E
20. Ambulance handover times
74
Based on discussions with the Trust representatives and the information gathered from the
sources above we would like to make the following comments:
75

We feel that the Trust continues to provide satisfactory, safe and effective services.
Their appointment system both for new patients and review patients has improved
significantly over the last 2-3 years. The cancellation rates and waiting times have
improved significantly. However Autism spectrum disorder and Attention deficit
hyperactive disorder (ADHD) assessment pathways are not meeting the current
NICE guidance with regard to time wait for Multidisciplinary team assessment and
co-ordination of care. Both Clinical Commissioning Managers and the Trust
representatives accept this weakness and steps are being taken to improve the
situation. The Task Group will keep a close watch on the situation.

Reporting and learning from patient safety incidents is improving. The Trust is now
amongst the top 25% of the reporters. The Trust assures us that root cause analysis
and creating systems to prevent and avoid safety incidents is improving and this is
one of the priorities for improvements for the forthcoming year. The Task Group will
monitor the progress in the forthcoming months.

We had a full and frank discussion on the national staff survey reports of the last two
years. The Trust assures us that steps have been taken to improve the staff
engagement and again this is the priority for the forthcoming year and the Task
Group will monitor the situation in the coming months.

There was one never event in 2014/15 and not two as wrongly suggested by our
intelligence. The never event in 2014/15 was ‘Inappropriate administration of daily
oral methotrexate’. Wrong sided dentistry occurred in January 2014 therefore was
counted in the year 2013/14.

The Trust has achieved six of their improvement priorities for the year 2014 2015 but
has narrowly missed three priorities, (Zero tolerance target of MRSA bacteraemia,
falls and pressure ulcers). They will continue to work on these on the forthcoming
year.

We felt assured that the Trust has a good system of audits, learning from them and
changing clinical practice if indicated by the audits. Quality audit reports of each
division are published Trust wide and shared across all clinical management groups.

We were surprised to learn that the Trust does not have Trust wide policies regarding
handover of clinical care, between specialties, departments and clinical teams and
also policies regarding handover of duties amongst the junior medical staff. But we
were told that there are policies within each department and specialties. We hope
that the Trust will soon have Trust wide policies on these important issues. We
endorse the priorities for improvement in the forthcoming year and it is agreed that
we will have quarterly review of success in achieving these priorities.

We think that the draft Quality Accounts for the year 2014/15 are well written, easy to
read and understand.
Commentary from NHS Wakefield Clinical Commissioning Group (12 th June 2015)
MYHT Quality Account 2014/15
Commissioning CCG Written Statement
The following statement is presented on behalf of the commissioning partners of Wakefield
and North Kirklees Clinical Commissioning Groups (CCGs). Commissioners welcome the
opportunity to comment on the 2014/15 Quality Account and the quality of care provided by
the Mid Yorkshire Hospitals NHS Trust. Both MYHT and commissioners have access to a
high level of information on the quality and safety of patient care. This is carefully assessed
by the MYHT and CCG Boards, informs regular discussions with the Trust, and is used to
identify areas for development and improvement. We are therefore confident that the
Quality Account provides an accurate and balanced summary of the quality of care provided
by MYHT.
The Trust has continued to undertake significant work throughout the year in preventing
healthcare acquired infections. As a result, the Trust has continued to reduce the number of
patients contracting Clostridium difficile infections and MRSA. We share the Trust’s
disappointment that the Trust did not achieve the zero target for MRSA, having 1 identified
case in 2014/15.
MYHT has successfully maintained mortality rates below the national average, experiencing
fewer deaths than would be expected. The Trust has completed the first phase of
implementing VitalPAC, new technology which supports the early identification of patients at
risk of deterioration. This is already having an impact on patient care, helping promote
timely and accurate observations electronically. The Trust is committed to extending the use
of this technology which will be used to automatically alert doctors to significant changes in a
patient’s condition.
The Trust has also achieved significant improvements in the care of patients with dementia
and increased support available for their families and carers. The Trust has invested in a
lead Dementia Nurse to drive improvements including further staff training, creation of a
reminiscence room and dementia friendly wards, Carer’s Passport (which enables families to
visit and support their relatives outside of normal visiting hours) and improved information at
patient discharge.
Unfortunately, MYHT remains below the national average for the level of ‘harm free care’. It
is disappointing that the number of patients experiencing a healthcare acquired pressure
ulcer, or a fall resulting in moderate to severe harm, has not significantly reduced. The Trust
has comprehensive improvement workstreams in place to address these areas, and is
working closely with external partners to improve the prevention of patient falls. We are
committed to supporting the Trust to achieve a reduction in the prevalence of pressure
ulcers and falls throughout the coming months.
The Trust has been candid about the challenges it faces relating to staffing levels,
communication with senior management, and the systems and culture within the
organisation.
Staffing levels and morale have been frequently highlighted during
commissioner led Patient Safety Walkabouts. The National Staff Survey and Friends and
Family Staff Surveys have also highlighted a number of concerns including whether staff
would recommend the Trust as a place to work and receive treatment, senior management
communication with staff, staff morale, job satisfaction and work related stress. Hospitals
throughout the country have experienced increased patient demand over recent months.
76
This has been coupled with difficulties in obtaining sufficient qualified nurses to work on
hospital wards in some areas.
However, MYHT is undertaking significant work to safeguard nurse staffing levels and
improve staff morale. The Trust has adopted a new Safer Staffing Tool with regular detailed
reporting to the Board, is undertaking recruitment drives to improve nurse staffing levels and
implementing initiatives to help retain staff. We would have liked to have seen more
discussion about the work the Trust is undertaking to recruit and retain high quality staff
within the Quality Account. We recognise that changing the culture of an organisation takes
time and considerable focus. However, we are confident that the Trust is committed to
achieving it’s ambitions and look forward to seeing these realised.
The Trust has faced a number of challenges throughout the year, including two Warning
Notices following the CQC inspection in July. These related to the Mental Capacity Act and
Deprivation of Liberty standards and to medicines management. However, the Trust’s
prompt response to ensure full compliance with required standards shows that there is a
clear commitment to improve the quality of care provided to patients.
The Trust has carefully selected improvement priorities for 2015/16 which accurately reflect
the ongoing quality challenges within the organisation. Some of these areas are included in
the Trust’s Commissioning for Quality Improvement and Innovation (CQUIN) scheme, for
example, medicines management and patient safety. We look forward to seeing progress in
these areas throughout the year.
We fully support the Trust’s ambition to become one of the safest in the country and deliver
services that are amongst the best nationally. We are committed to working with the Trust to
deliver improvements in the quality of care, and believe that these are achievable with
committed leadership and strengthening relationships with commissioners.
Response from Principal Governance & Democratic Engagement Officer
Governance & Democratic Services, Kirklees Council (22.06.15)
Discussion with Kirklees Council around the Quality Accounts commentary commenced on
22 April, 2015. Unfortunately the responsible officer was subsequently away from work due
to illness. The Council have provided an apology for not providing a commentary with the
following explanation:‘Firstly sorry for the delay in getting back to you but unfortunately I have only just returned
from work due to being off with ill-health.
Unfortunately the Panel will struggle to provide any meaningful comment for the Mid Yorks
Quality Accounts 2014/15. Following annual council there has been a change of
membership which has included the appointment of members who are new to Health
Scrutiny. At the same time we have lost the service of two experienced co-opted members
which we are currently looking to replace.
This issue will however be picked up by Cllr xxxxx and we will be looking to review our
procedures in an attempt to avoid a repetition of this matter next year’.
77
5. Statement of Directors’ responsibilities in respect of the quality report
The Directors are required under the Health Act 2009 and the National Health Service
Quality Accounts Regulations to prepare quality accounts for each financial year.
Monitor has issued guidance to NHS foundation trust boards on the form and content of
annual quality reports (which incorporate the above legal requirements) and on the
arrangements that NHS foundation trust boards should put in place to support 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 Account report meets the requirements set out in the NHS
Foundation Trust Annual Reporting Manual 2014/15; the content of the quality report is
not inconsistent with internal and external sources of information including:





o board minutes and papers for the period April 2014 to June 2015
o papers relating to quality reported to the Board over the period April 2014 to June
2015
o feedback from commissioners
o feedback from local Healthwatch organisations
o feedback from the Overview and Scrutiny Committee
o the trust’s complaints report published under regulation 18 of the Local Authority
o Social Services and NHS Complaints Regulations 2009,
o [latest] national patient survey
o [latest] national staff survey
o the Head of Internal Audit’s annual opinion over the trust’s control environment
dated [27 June 2015]
o CQC inspections & quality reports.
the quality report presents a balanced picture of the (NHS foundation) trust’s
performance over the period covered;
the performance information 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 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) as well as the
standards to support data quality for the preparation of the quality report.
The Directors confirm to the best of their knowledge and belief they have complied with
the above requirements in preparing the quality report. By order of the Board
26 June 2015.........Date…....
26 June 2015.........Date….....
78
……. Chairman
..... Chief Executive
Auditor guidelines for the ‘Core indicators to be included in the Quality Accounts’ (2014-15)
(grey shaded indicators = acute services)
12. The data made available to the trust by the Information Centre with
regard to
(a) the value and banding of the summary hospital-level mortality
indicator (“SHMI”) for the trust for the reporting period; and
(b) the percentage of patient deaths with palliative care coded at either
diagnosis or specialty level for the trust for the reporting period.
13. The data made available to the National Health Service trust or NHS
foundation trust by the Health and Social Care Information Centre with
regard to the percentage of patients on Care Programme Approach
Mental
Health
Trusts only
14. The data made available to the trust by the Information Centre with
regard to the percentage of Category A telephone calls (Red 1 and Red
2 calls) resulting in an emergency response by the trust at the scene of
the emergency within 8 minutes of receipt of that call during the
reporting period.
Ambulance
services
14. The data made available to the trust by the Information Centre with
regard to the percentage of Category A telephone calls resulting in an
ambulance response by the trust at the scene of the emergency
within 19 minutes of receipt of that call during the reporting period
15. The data made available to the trust by the Information Centre with
regard to the percentage of patients with a pre-existing diagnosis of
suspected ST elevation myocardial infarction who received an
appropriate care bundle from the trust during the reporting period.
16. The data made available to the trust by the Information Centre with
regard to the percentage of patients with suspected stroke assessed
face to face who received an appropriate care bundle from the trust
during the reporting period.
17. The data made available to the trust by the Information Centre with
regard to the percentage of admissions to acute wards for which the
Crisis Resolution Home Treatment Team acted as a gatekeeper
during the reporting period.
18. The data made available to the trust by the Information Centre with
regard to the trust’s patient reported outcome measures scores for
(i) groin hernia surgery, (ii) varicose vein surgery,
(iii) hip replacement surgery, and
(iv) knee replacement surgery, during the reporting period.
Ambulance
services
19. The data made available to the trust by the Information Centre with
regard to the percentage of patients aged
Acute
Trusts
(i) 0 to 14; and
(ii) 15 or over,
readmitted to a hospital which forms part of the trust within 28 days of
being discharged from a hospital which forms part of the trust during the
reporting period.
20. The data made available to the trust by the Information Centre with
regard to the trust’s responsiveness to the personal needs of its patients
during the reporting period.
79
Acute trusts
Ambulance
services
Ambulance
services
Mental
Health
trusts
Acute
Trusts
Acute trusts
80
21. The data made available to the trust by the Information Centre with
regard to the percentage of staff employed by, or under contract to, the
trust during the reporting period who would recommend the trust as a
provider of care to their family or friends.
Acute
Trusts
21.1 Friends and Family Test – Patient. The data made available by
National Health Service Trust or NHS Foundation Trust by the Health
and Social Care Information Centre for all acute providers of adult NHS
funded care, covering services for inpatients and patients discharged
from A&E (types 1 and 2)
Acute
Trusts
22. The data made available to the trust by the Information Centre with
regard to the trust’s “Patient experience of community mental health
services” indicator score with regard to a patient’s experience of contact
with a health or social care worker during the reporting period.
Mental
Health
23. The data made available to the trust by the Information Centre with
regard to the percentage of patients who were admitted to hospital and
who were risk assessed for venous thromboembolism during the
reporting period.
Acute
Trusts
24. The data made available to the trust by the Information Centre with
regard to the rate per 100,000 bed days of cases of C.difficile infection
reported within the trust amongst patients aged 2 or over during the
reporting period.
Acute
Trusts
25. The data made available to the trust by the Information Centre with
regard to the number and, where available, rate of patient safety
incidents reported within the trust during the reporting period, and the
number and percentage of such patient safety incidents that resulted in
severe harm or death.
Acute
Trusts
6. Independent Auditor’s Limited Assurance Report
Independent Auditor's Limited Assurance Report to the Directors of
The Mid Yorkshire Hospitals NHS Trust on the Annual Quality
Account
We are required to perform an independent assurance engagement in respect of The Mid Yorkshire
Hospitals NHS Trust’s Quality Account for the year ended 31 March 2015 (“the Quality Account”) and
certain performance indicators contained therein as part of our work. NHS trusts are required by section
8 of the Health Act 2009 to publish a quality account which must include prescribed information set out
in The National Health Service (Quality Account) Regulations 2010, the National Health Service (Quality
Account) Amendment Regulations 2011 and the National Health Service (Quality Account) Amendment
Regulations 2012 (“the Regulations”).
Scope and subject matter
The indicators for the year ended 31 March 2015 subject to limited assurance consist of the following
indicators:


Rate of clostridium difficile infections; and
Friends & Family Test (FFT) patient element score.
We refer to these two indicators collectively as “the indicators”.
Respective responsibilities of directors and auditors
The directors are required under the Health Act 2009 to prepare a Quality Account for each financial
year. The Department of Health has issued guidance on the form and content of annual Quality Accounts
(which incorporates the legal requirements in the Health Act 2009 and the Regulations).
In preparing the Quality Account, the directors are required to take steps to satisfy themselves that:
 the Quality Account presents a balanced picture of the Trust’s performance over the period
covered;
 the performance information reported in the Quality Account is reliable and accurate;
 there are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Account, 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 Account is robust
and reliable, conforms to specified data quality standards and prescribed definitions, and is
subject to appropriate scrutiny and review; and
 the Quality Account has been prepared in accordance with Department of Health guidance.
The Directors are required to confirm compliance with these requirements in a statement of directors’
responsibilities within the Quality Account.
81
Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything
has come to our attention that causes us to believe that:
 the Quality Account is not prepared in all material respects in line with the criteria set out in the
Regulations;
 the Quality Account is not consistent in all material respects with the sources specified in the
NHS Quality Accounts Auditor Guidance 2014-15 issued by DH in March 2015 (“the
Guidance”); and
 the indicators in the Quality Account identified as having been the subject of limited assurance in
the Quality Account are not reasonably stated in all material respects in accordance with the
Regulations and the six dimensions of data quality set out in the Guidance.
We read the Quality Account and conclude whether it is consistent with the requirements of the
Regulations and to consider the implications for our report if we become aware of any material
omissions.
We read the other information contained in the Quality Account and consider whether it is materially
inconsistent with:
 Board minutes for the period April 2014 to May 2015;
 papers relating to quality reported to the Board over the period April 2014 to May 2015;
 feedback from the Commissioners dated June 2015;
 feedback from Local Healthwatch dated June 2015;
 the Trust’s complaints report published under regulation 18 of the Local Authority, Social
Services and NHS Complaints (England) Regulations 2009, dated 2015;
 the latest national inpatient survey (2014) dated February 2014;
 the national staff survey 2014;
 the Head of Internal Audit’s annual opinion over the trust’s control environment dated May
2015;
 the annual governance statement dated May 2015; and
 the Care Quality Commission’s Intelligent Monitoring Report dated July 2014, December 2014 &
May 2015
We consider the implications for our report if we become aware of any apparent misstatements or
material inconsistencies with these documents (collectively the “documents”). Our responsibilities do not
extend to any other information.
This report, including the conclusion, is made solely to the Board of Directors of The Mid Yorkshire
Hospitals NHS Trust.
We permit the disclosure of this report to enable the Board of Directors to demonstrate that they have
discharged their governance responsibilities by commissioning an independent assurance report in
connection with the indicators. To the fullest extent permissible by law, we do not accept or assume
responsibility to anyone other than the Board of Directors as a body and The Mid Yorkshire Hospitals
NHS Trust for our work or this report save where terms are expressly agreed and with our prior consent
in writing.
82
Assurance work performed
We conducted this limited assurance engagement under the terms of the guidance. 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 of the Quality Account to the requirements of the Regulations; and
 reading the documents.
A limited assurance engagement is narrower in scope than a reasonable assurance engagement. The
nature, timing and extent of procedures for gathering sufficient appropriate evidence are deliberately
limited relative to a reasonable assurance engagement.
Limitations
Non-financial performance information is subject to more inherent limitations than financial information,
given the characteristics of the subject matter and the methods used for determining such information.
The absence of a significant body of established practice on which to draw allows for the selection of
different but acceptable measurement techniques which can result in materially different measurements
and can impact comparability. The precision of different measurement techniques may also vary.
Furthermore, the nature and methods used to determine such information, as well as the measurement
criteria and the precision thereof, may change over time. It is important to read the Quality Account in
the context of the criteria set out in the Regulations.
The nature, form and content required of Quality Accounts are determined by the Department of Health.
This may result in the omission of information relevant to other users, for example for the purpose of
comparing the results of different NHS organisations.
In addition, the scope of our assurance work has not included governance over quality or non-mandated
indicators which have been determined locally by The Mid Yorkshire Hospitals NHS 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 Account is not prepared in all material respects in line with the criteria set out in the
Regulations;


the Quality Account is not consistent in all material respects with the sources specified in the
Guidance; and
the indicators in the Quality Account subject to limited assurance have not been reasonably
stated in all material respects in accordance with the Regulations and the six dimensions of data
quality set out in the Guidance.
Grant Thornton UK LLP
No1 Whitehall Riverside
Leeds
LS1 4BN
25 June 2015
83
Appendix
Appendix 1
MYHT 14-15 performance against the acute hospitals core indicators
12. The data made available to the trust by the Information Centre with regard to
(a) the value and banding of the summary hospital-level mortality indicator (“SHMI”)
for the trust for the reporting period; and
(b) the percentage of patient deaths with palliative care coded at either diagnosis or
specialty level for the trust for the reporting period
Apr13 Mar14
Jul13 Jun14
Latest
Period
Oct13 Sep14
0.911
0.905
0.876
"As
expected"
"As
expected"
"Lower than
expected"
National Average
1.00
1.00
1.00
Lowest (best) Trust Value
0.539
0.541
0.597
Highest (worst) Trust Value
1.197
1.198
1.198
Palliative Care Coding - % of patient
deaths with palliative care coded at either
diagnosis or specialty level
Apr13 Mar14
Jul13 Jun14
Oct13 Sep14
MYHT Value
23.4%
23.7%
23.6%
National Average
23.6%
24.6%
25.3%
Highest (best) Trust Value
48.5%
49.0%
49.4%
Lowest (worst) Trust Value
0.0%
0.0%
0.0%
HSCIC
HSCIC
HSCIC
Indicator Scope
Summary Hospital-Level Mortality
Indicator (SHMI)
MYHT Value
MYHT Banding
Data Source
84
Previous Period
18. The data made available to the trust by the Information Centre with regard to the trust’s
patient reported outcome measures scores for
(i) groin hernia surgery, (ii) varicose vein surgery,
(iii) hip replacement surgery, and
(iv) knee replacement surgery, during the reporting period.
Indicator Scope and Measure
Patient Reported
Outcome Measures
(PROMS) - Adjusted
Health Gain
Groin hernia
Hip Replacement
(Primary)
Knee Replacement
(Primary)
Varicose vein
Measure
EQ-5D
Index
EQ-VAS
EQ-5D
Index
EQ-VAS
Oxford Hip
Score
EQ-5D
Index
EQ-VAS
Oxford
Knee Score
EQ-5D
Index
EQ-VAS
Aberdeen
Score
Previous Period: Apr13 Mar14 (Provisional)
Latest Period: Apr14 Dec14 (Provisional)
MYHT
National Av.
MYHT
National
Av.
0.058
0.085
0.061
0.084
-3.164
-1.0
-3.657
-0.5
0.402
0.436
0.415
0.449
8.6
11.5
9.1
12.1
20.5
21.4
19.9
21.9
0.318
0.323
0.34
0.319
5.5
5.6
4.7
5.8
16.3
16.3
15.5
16.3
0.093
0.133
0.102
-0.5
-1.4
-0.2
-8.7
-12.2
-8.8
No
modelled
records
-0.2
-13.3
- Higher scores are better with the exception of Aberdeen Varicose Vein Questionnaire
scores (Data Source: HSCIC)
- Indicates negative (95%) outlier
- Indicates positive (95%) outlier
85
19. The data made available to the trust by the Information Centre with regard to the
percentage of patients aged:
(i) 0 to 14; and
(ii) 15 or over,
readmitted to a hospital which forms part of the trust within 28 days of being discharged from
a hospital which forms part of the trust during the reporting period.
Previous
Period
Latest
Period
2010/11
2011/12
2010/11
2011/12
MYHT % readmitted within 28 days
9.18%
9.59%
National Average (Large Acute Trust)
10.31%
10.11%
Lowest (best) Trust Rate (Large Acute)
6.41%
6.40%
Highest (worst) Trust Rate (Large Acute)
14.11%
14.94%
Over 16 years
2010/11
2011/12
MYHT % readmitted within 28 days
11.84%
11.58%
National Average (Large Acute Trust)
11.55%
11.56%
Lowest (best) Trust Rate (Large Acute)
9.20%
9.34%
Highest (worst) Trust Rate (Large Acute)
14.06%
13.80%
Data Source
HSCIC
HSCIC
Indicator Scope
Readmissions within 28 days - % of
patients readmitted to a hospital which
forms part of the Trust within 28 days of
being discharged from a hospital which
forms part of the Trust
0 - 15 years
20. The data made available to the trust by the Information Centre with regard to the trust’s
responsiveness to the personal needs of its patients during the reporting period.
Indicator Scope
Responsiveness to the personal needs of
patients - overall score for
responsiveness to inpatient needs
MYHT
National Average
Highest (best) Trust Score
Lowest (worst) Trust Score
Data Source
86
Previous
Period
Latest
Period
2012/13
2013/14
66.5
68.1
84.4
57.4
HSCIC
63.8
68.7
84.2
54.4
HSCIC
21. The data made available to the trust by the Information Centre with regard to the
percentage of staff employed by, or under contract to, the trust during the reporting period
who would recommend the trust as a provider of care to their family or friends.
Indicator Scope
Previous
Period
Latest
Period
2013
2014
39.6%
44.8%
64.5%
64.7%
88.5%
89.3%
39.6%
38.2%
HSCIC
HSCIC
National Staff Survey - % of staff
employed by, or under contract to, the
trust who would recommend the trust as
a proivder of care to their family/friends
(responded agree or strongly agree)
MYHT - % recommend
National Average (acute, non-spec
trusts)
Highest (best) Trust Rate (acute, non
spec)
Lowest (worst) Trust Rate (acute, non
spec)
Data Source
21.1 Friends and Family Test – Patient. The data made available by National Health Service
Trust or NHS Foundation Trust by the Health and Social Care Information Centre for all
acute providers of adult NHS funded care, covering services for inpatients and patients
discharged from A&E (types 1 and 2) (3.4.1 of report).
Indicator Scope
Patient Friends and Family Test
Inpatient
Latest Period
Mar-15
Response
Rate
Likely to
Recommend
Not Likely to
Recommend
MYHT
48.1%
93.3%
2.1%
National Average
44.9%
94.7%
1.6%
Highest (best) Trust Rate (NHS trusts)
94.1%
100.0%
0.0%
Lowest (worst) Trust Rate (NHS trusts)
20.8%
78.2%
9.7%
Response
Rate
Likely to
Recommend
Not Likely to
Recommend
MYHT
28.7%
92.5%
2.5%
National Average
22.9%
87.0%
6.5%
Highest (best) Trust Rate (NHS trusts)
53.8%
98.6%
0.5%
Lowest (worst) Trust Rate (NHS trusts)
1.8%
57.8%
24.4%
HSCIC
HSCIC
HSCIC
A&E
Data Source
87
23. The data made available to the trust by the Information Centre with regard to the
percentage of patients who were admitted to hospital and who were risk assessed for
venous thromboembolism during the reporting period.
Indicator Scope
VTE Risk Assessment - % of patients
who were admitted to hospital and who
were risk-assessed for venous
thromboembolism
MYHT - % of patients risk-assessed
Latest
Period
Previous Period
Apr14 Jun14
Jul14 Sep14
Oct14 Dec14
96.4%
96.4%
96.1%
National Average
96.1%
96.1%
95.4%
Highest (best) Trust Rate (NHS trusts)
100%
100%
100%
Lowest (Worst) Trust Rate (NHS trusts)
87.2%
86.4%
81.2%
Data Source
HSCIC
HSCIC
HSCIC
24. The data made available to the trust by the Information Centre with regard to the rate per
100,000 bed days of cases of C.difficile infection reported within the trust amongst patients
aged 2 or over during the reporting period.
Indicator Scope
C Difficile - the rate per 100,000 bed days
of Trust apportioned cases of C Difficile
infection that have occurred in the Trust
amongst patients over 2 years or over
during the reporting period
MYHT Rate per 100,00 bed days
National Average
Lowest (best) Trust Rate
Highest (Worst) Trust Rate
Data Source
88
Previous
Period
Latest
Period
Apr12 Mar13
Apr13 Mar14
11.8
13.2
17.4
14.7
0
0
31.2
37.1
HSCIC
HSCIC
25 The data made available to the trust by the Information Centre with regard to the number
and, where available, rate of patient safety incidents reported within the trust during the
reporting period, and the number and percentage of such patient safety incidents that
resulted in severe harm or death. (3.5 of report shows reporting rates benchmarked with
other trusts)
Previous
Period
Latest
Period
Oct13 Mar14
Apr14 Sep14
MYHT - No. of incidents reported
5,354
6,269
MYHT Rate per 1,000 bed days
33.0
41.17
Highest Trust Score (acute trust, non-spec)
12.46
74.96
Lowest Trust Score (acute trusts, non-spec)
1.72
0.24
Patient Safety Incidents - number reported
that resulted in severe harm or death
Oct13 Mar14
Apr14 Sep14
Indicator Scope
Patient Safety Incidents - rate of patient
safety incidents reported within the Trust
(Rate per 1,000 bed days)
MYHT - No. of incidents resulting in severe
harm/death
Highest Trust Score (acute trust, non-spec)
20
36
103
97
Lowest Trust Score (acute trusts, non-spec)
1
0
Oct13 Mar14
Apr14 Sep14
0.4%
0.6%
Highest Trust Score (acute trust, non-spec)
2.6%
82.9%
Lowest Trust Score (acute trusts, non-spec)
0.0%
0.0%
HSCIC
HSCIC
Patient Safety Incidents - % reported that
resulted in severe harm or death
% resulting in Severe Harm or Death
Data Source
89
Report on the 2014-15 Quality Account
The Mid Yorkshire Hospitals NHS Trust
Year ended 31 March 2015
23 June 2015
Paul Dossett
Engagement Lead
T 0207 728 3180
E paul.dossett@uk.gt.com
Gareth Mills
Engagement Manager
T 0113 200 2535
E gareth.mills@uk.gt.com
Thomas Mulloy
Engagement In-Charge
E thomas.mulloy@uk.gt.com
© 2015 Grant Thornton UK LLP | Quality Account 2014-15 | The Mid Yorkshire Hospitals NHS Trust
Contents
Section
Introduction to our review
2
Our conclusion
4
Compliance with regulations
5
Consistency of information
6
Data quality of reported performance indicators
7
Fees
9
Appendices
A - Action Plan
10
B - Proposed 'limited assurance' audit opinion
11
The contents of this report relate only to the matters which have come to our attention,
which we believe need to be reported to you as part of our audit process. It is not a
comprehensive record of all the relevant matters, which may be subject to change, and in
particular we cannot be held responsible to you for reporting all of the risks which may affect
the Trust or any weaknesses in your internal controls. This report has been prepared solely
for your benefit and should not be quoted in whole or in part without our prior written
consent. We do not accept any responsibility for any loss occasioned to any third party acting,
or refraining from acting on the basis of the content of this report, as this report was not
prepared for, nor intended for, any other purpose.
© 2015 Grant Thornton UK LLP | Quality Account 2014-15 | The Mid Yorkshire Hospitals NHS Trust
1
Introduction to our review
The Quality Account
• the data underpinning the measures of performance reported in the
Quality Account is robust and reliable, conforms to specified data
quality standards and prescribed definitions, and is subject to
appropriate scrutiny and review
• the Quality Account has been prepared in accordance with
Department of Health guidance.
The Directors are required to confirm compliance with these
requirements in a statement of Directors’ responsibilities within the
Quality Account.
The Quality Account is an annual report to the public from providers of
NHS healthcare about the quality of services they deliver. The primary
purpose of the Quality Account is to encourage boards and leaders of
healthcare organisations to assess quality across all the healthcare services
they offer. It allows leaders, clinicians, governors and staff to show their
commitment to continuous, evidence-based quality improvement, and to
explain progress to the public.
The Trust's responsibilities
The auditor's responsibilities
All providers of NHS healthcare services in England are required by
section 8 of the Health Act 2009 to publish a Quality Account for each
financial year. The Quality Account must include prescribed information
set out in the NHS (Quality Account) Regulations 2010, the NHS (Quality
Account) Amendment Regulations 2011 and the NHS (Quality Account)
Amendment Regulations 2012 (collectively referred to as “the Regulations”).
The Department of Health has issued guidance on the form and content
of annual Quality Accounts (which incorporates the legal requirements in
the Health Act 2009 and the Regulations).
In preparing the Quality Account, the Directors are required to take steps
to satisfy themselves that:
• the Quality Account presents a balanced picture of the Trust’s
performance over the period covered
• the performance information reported in the Quality Account is
reliable and accurate
• there are proper internal controls over the collection and reporting of
the measures of performance included in the Quality Account, and
these controls are subject to review to confirm that they are working
effectively in practice
© 2015 Grant Thornton UK LLP | Quality Account 2014-15 | The Mid Yorkshire Hospitals NHS Trust
We are required by the Department of Health to perform an independent
assurance engagement in respect of the Quality Account for the year
ended 31 March 2015 and certain performance indicators contained
therein. This work is classified as audit related services.
Our responsibility is to form a conclusion, based on limited assurance
procedures, on whether anything has come to our attention that causes us
to believe that:
• the Quality Account is not prepared in all material respects in line with
the criteria set out in the Regulations
• the Quality Account is not consistent in all material respects with the
sources specified in the NHS Quality Accounts Auditor Guidance 2014/15
issued by the Department of Health (“the Guidance”)
• the indicators in the Quality Account identified as having been the
subject of limited assurance, are not reasonably stated in all material
respects in accordance with the Regulations and the six dimensions of
data quality set out in the Guidance.
2
Introduction to our review (continued)
Assurance work performed
We read the Quality Account and conclude whether it is consistent with
the requirements of the Regulations and consider the implications for our
report if we become aware of any material omissions.
We conducted this limited assurance engagement in accordance with the
Guidance. Our limited assurance procedures included:
• evaluating the design and implementation of the key processes and
controls for managing and reporting the indicators
• making enquiries of management
• limited testing, on a selective basis, of the data used to calculate the
chosen indicators back to supporting documentation
• comparing the content of the Quality Account to the requirements of
the Regulations
• reading the documents.
We read the other information contained in the Quality Account and
consider whether it is materially inconsistent with the documents specified
in the Regulations.
We consider the implications for our report if we become aware of any
apparent misstatements or material inconsistencies with these documents.
Our responsibilities do not extend to any other information.
This report to the Board summarises the results of this independent
assurance engagement including testing performance indicators and is
provided in conjunction with our signed limited assurance report, which is
published with the Trust's Quality Account and enables the Board of
Directors to demonstrate that they have discharged their governance
responsibilities by commissioning an independent assurance report.
Limitations
Non-financial performance information is subject to more inherent
limitations than financial information, given the characteristics of the
subject matter and the methods used for determining such information.
The absence of a significant body of established practice on which to
draw allows for the selection of different but acceptable measurement
techniques which can result in materially different measurements and can
impact comparability. The precision of different measurement techniques
may also vary. Furthermore, the nature and methods used to determine
such information, as well as the measurement criteria and the precision
thereof, may change over time. It is important to read the Quality
Account in the context of the criteria set out in the Regulations.
The scope of our assurance work has not included governance over
quality or non-mandated indicators which have been determined locally by
the Trust.
To the fullest extent permissible by law, we do not accept or assume
responsibility to anyone other than the Board of Directors as a body and
the Trust for our work or this report save where terms are expressly
agreed and with our prior consent in writing.
© 2015 Grant Thornton UK LLP | Quality Account 2014-15 | The Mid Yorkshire Hospitals NHS Trust
3
Unqualified Conclusion
Our limited assurance opinion
Key messages
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 Account is not prepared in all material respects in line with
the criteria set out in the Regulations
• the Quality Account is not consistent in all material respects with the
sources specified in the Guidance
• the indicators in the Quality Account subject to limited assurance have
not been reasonably stated in all material respects in accordance with
the Regulations and the six dimensions of data quality set out in the
Guidance.
We would like to highlight the following key messages arising from our
review:
• we anticipate issuing an unqualified conclusion based on our limited
assurance procedures
• the Trust has produced a good draft report that presents information
in a well structured and accessible style
• as part of the audit, we made a small number of suggestions for
improving the presentation and clarity of the Quality Account, which
we understand the Trust will action in the final revised Quality
Account.
Our recommendations are set out in the Action Plan at Appendix A.
Acknowledgements
We would like to thank the Trust staff for their co-operation in
completing this review, specifically the members of the Quality Account
team for their work on agreeing the content of the Quality Account, and
Internal Audit for their work on the two performance indicators selected
for review.
© 2015 Grant Thornton UK LLP | Quality Account 2014-15 | The Mid Yorkshire Hospitals NHS Trust
4
Compliance with regulations
We checked that the Quality Account had been prepared in line with the requirements set out in the Regulations.
Requirement
Work performed
Conclusion
Compliance with regulations
We reviewed the content of the Quality Account against the
requirements of 'the Regulations’ set by the Secretary of State, as
described in:
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 Account is not prepared in all
material respects in line with the criteria set out in the
Regulations.
•
the National Health Service (Quality Accounts) Regulations 2010
•
the National Health Service (Quality Accounts) Amendment
Regulations 2011
•
the National Health Service (Quality Accounts) Amendment
Regulations 2012.
© 2015 Grant Thornton UK LLP | Quality Account 2014-15 | The Mid Yorkshire Hospitals NHS Trust
5
Consistency of information
We checked that the Quality Account is consistent in all material respects with the sources specified in the Department of Health guidance.
Requirement
Work performed
Conclusion
Consistency with other sources of
information
We reviewed the content of the Quality Account for consistency with
specified documentation, set out in the auditor's guidance provided
by the Department of Health. This includes the board minutes for the
year, feedback from commissioners, and survey results from staff
and patients.
In our review we noted that the draft Quality Account was
awaiting formal feedback from certain stakeholders. At the time
of this report, we have noted that some of the stakeholders
have sent their feedback to the Trust for inclusion in the
updated Quality Account.
Subject to receipt and appropriate inclusion of key stakeholder
comments in the revised Quality Account, nothing has come to
our attention that causes us to believe that, for the year ended
31 March 2015, the Quality Account is not consistent in all
material respects with the sources specified in the Guidance.
Other checks
We also checked the Quality Account:
• to check the consistency of indicator commentary with the
reported outcomes
• to check that Directors' Assertions on controls are consistent with
disclosures in the Annual Governance Statement.
In the initial draft, the Trust used March 2015 figure for the
Friends & Family Test indicator. It was suggested to the Trust
that they should disclose the performance under the original
method up to October 2014 and the performance for the
remaining period using the revised method as per issued
guidance. The Trust has taken this on board.
Overall, we concluded that:
• the indicator commentary was consistent with the reported
outcomes
• Directors' Assertions on controls are consistent with
disclosures in the Annual Governance Statement.
© 2015 Grant Thornton UK LLP | Quality Account 2014-15 | The Mid Yorkshire Hospitals NHS Trust
6
Data quality of reported performance indicators
We undertook substantive testing on two indicators in the Quality Account to report on whether there is evidence to suggest that they have not
been reasonably stated in all material respects in accordance with the Regulations and the six dimensions of data quality set out in the Department
of Health guidance.
Selecting performance indicators for review
The Trust is required to obtain assurance from its auditors over two indicators applicable to an Acute Trust.
The Department of Health requires that two indicators should be selected from a subset of four mandated indicators deemed suitable for audit.
In line with the auditor guidance, and agreement with the Trust, we reviewed the following two indicators:
• Rate of clostridium difficile infection (CDI)
• Friends & Family Test (FFT) patient element score.
© 2015 Grant Thornton UK LLP | Quality Account 2014-15 | The Mid Yorkshire Hospitals NHS Trust
7
Data quality of reported performance indicators (continued)
Indicator & Definition
Work performed
Conclusion
We reviewed the work of Internal Audit on the
process used to collect data for the indicator. We
re-performed a sample of Internal Audit's testing, in
order to ascertain the accuracy, completeness,
timeliness, validity, relevance and reliability of the
data, and whether the calculation is in accordance
with the definition. We also checked that the
indicator presented in the Quality Account
reconciled to the underlying data.
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 indicator has not
been reasonably stated in all
material respects.
Work performed
Conclusion
We reviewed the work of Internal Audit on the
process used to collect data for the indicator. We
re-performed a sample of Internal Audit's testing, in
order to ascertain the accuracy, completeness,
timeliness, validity, relevance and reliability of the
data, and whether the calculation is in accordance
with the definition. We also checked that the
indicator presented in the Quality Account
reconciled to the underlying data.
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 indicator has not
been reasonably stated in all
material respects.
Indicator outcome
Rate of clostridium difficile infection ("CDIs")
Numerator: 33 (the target set
by the Trust is at or under 42)
Rate of CDIs per 100,000 bed days for patients
aged two or more on the date the specimen was
taken during the reporting period
Denominator: 3.17441
(317,441 when undivided)
•
Numerator: The number of CDIs identified
within a trust during the reporting period.
Rate: 10.4 CDIs per 100,000
bed days
•
Denominator: The number of bed days
(divided by 100,000) reported by a trust during
the reporting period.
Indicator & Definition
Indicator outcome
FFT patient element score
The friends and family test (patient element)
score for the reporting period.
93.3%
(National Ave. 94.7%)
All inpatients and patients discharged from A&E
should be asked to complete the friends and
family survey.
© 2015 Grant Thornton UK LLP | Quality Account 2014-15 | The Mid Yorkshire Hospitals NHS Trust
8
However, we have raised a
recommendation in the Action Plan
to further enhance the reporting
procedures for this indicator. [Rec 1]
Fees
Fees for the audit of the Quality Account
Service
Fees £
For the audit of the Quality Account 2014-15
£10,000
Our fee was agreed with in the Trust as part of our signed letter of engagement in April 2015.
The fee is exclusive of VAT.
© 2015 Grant Thornton UK LLP | Quality Account 2014-15 | The Mid Yorkshire Hospitals NHS Trust
9
Appendix A - Action Plan
Rec
Issue and risk
Recommendations
Priority
Management response and implementation details
1
For FFT, we note the Trust has
relied on a paper format for the
inpatients to record their opinion.
There is a risk the Trust is not
maximising their resources to
increase participation of this
particular indicator.
The Trust should consider using
various methods to record the FFT
results. Examples include text
messages, online surveys and emails.
This could result in an increased
participation and in turn help enhance
the value of the indicator result. We
are aware that other trusts are already
employing these methods.
Medium
The Trust will continue to regularly review, via the Trust Patient Experience
Strategy Group, the data collection methods available in light of costs,
resources and technical capability. The group will make appropriate decisions
regarding modifications or changes according to the consensus of the group,
in line with national guidance, aiming to achieve a balance between
consistency of collection and making the FFT accessible to all within the
available resources.
© 2015 Grant Thornton UK LLP | Quality Account 2014-15 | The Mid Yorkshire Hospitals NHS Trust
10
Appendix B - Proposed 'limited assurance' audit opinion
Independent Auditor's Limited Assurance Report to the Directors of The Mid Yorkshire Hospitals
NHS Trust on the Annual Quality Account
The Directors are required to confirm compliance with these requirements in a statement of directors’
responsibilities within the Quality Account.
We are required to perform an independent assurance engagement in respect of The Mid Yorkshire
Hospitals NHS Trust’s Quality Account for the year ended 31 March 2015 (“the Quality Account”) and
certain performance indicators contained therein as part of our work. NHS trusts are required by section 8 of
the Health Act 2009 to publish a quality account which must include prescribed information set out in The
National Health Service (Quality Account) Regulations 2010, the National Health Service (Quality Account)
Amendment Regulations 2011 and the National Health Service (Quality Account) Amendment Regulations
2012 (“the Regulations”).
Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything has
come to our attention that causes us to believe that:
• the Quality Account is not prepared in all material respects in line with the criteria set out in the
Regulations;
• the Quality Account is not consistent in all material respects with the sources specified in the NHS
Quality Accounts Auditor Guidance 2014-15 issued by DH in March 2015 (“the Guidance”); and
• the indicators in the Quality Account identified as having been the subject of limited assurance in the
Quality Account are not reasonably stated in all material respects in accordance with the Regulations and
the six dimensions of data quality set out in the Guidance.
Scope and subject matter
The indicators for the year ended 31 March 2015 subject to limited assurance consist of the following
indicators:
•
•
We read the Quality Account and conclude whether it is consistent with the requirements of the Regulations
and to consider the implications for our report if we become aware of any material omissions.
Rate of clostridium difficile infections; and
Friends & Family Test (FFT) patient element score.
We read the other information contained in the Quality Account and consider whether it is materially
inconsistent with:
We refer to these two indicators collectively as “the indicators”.
•
•
•
•
•
Respective responsibilities of directors and auditors
The directors are required under the Health Act 2009 to prepare a Quality Account for each financial year.
The Department of Health has issued guidance on the form and content of annual Quality Accounts (which
incorporates the legal requirements in the Health Act 2009 and the Regulations).
•
•
•
•
•
In preparing the Quality Account, the directors are required to take steps to satisfy themselves that:
• the Quality Account presents a balanced picture of the Trust’s performance over the period covered;
• the performance information reported in the Quality Account is reliable and accurate;
• there are proper internal controls over the collection and reporting of the measures of performance
included in the Quality Account, 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 Account is robust and
reliable, conforms to specified data quality standards and prescribed definitions, and is subject to
appropriate scrutiny and review; and
• the Quality Account has been prepared in accordance with Department of Health guidance.
© 2015 Grant Thornton UK LLP | Quality Account 2014-15 | The Mid Yorkshire Hospitals NHS Trust
Board minutes for the period April 2014 to May 2015;
papers relating to quality reported to the Board over the period April 2014 to May 2015;
feedback from the Commissioners dated June 2015;
feedback from Local Healthwatch dated June 2015;
the Trust’s complaints report published under regulation 18 of the Local Authority, Social Services and
NHS Complaints (England) Regulations 2009, dated 2015;
the latest national inpatient survey (2013) dated February 2014;
the national staff survey 2014;
the Head of Internal Audit’s annual opinion over the trust’s control environment dated May 2015;
the annual governance statement dated May 2015; and
the Care Quality Commission’s Intelligent Monitoring Reports dated July 2014, December 2014 & May
2015.
We consider the implications for our report if we become aware of any apparent misstatements or material
inconsistencies with these documents (collectively the “documents”). Our responsibilities do not extend to
any other information.
11
Appendix B - Proposed 'limited assurance' audit opinion
This report, including the conclusion, is made solely to the Board of Directors of The Mid Yorkshire
Hospitals NHS Trust.
The nature, form and content required of Quality Accounts are determined by the Department of Health.
This may result in the omission of information relevant to other users, for example for the purpose of
comparing the results of different NHS organisations.
We permit the disclosure of this report to enable the Board of Directors to demonstrate that they have
discharged their governance responsibilities by commissioning an independent assurance report in
connection with the indicators. To the fullest extent permissible by law, we do not accept or assume
responsibility to anyone other than the Board of Directors as a body and The Mid Yorkshire Hospitals NHS
Trust for our work or this report save where terms are expressly agreed and with our prior consent in
writing.
Assurance work performed
We conducted this limited assurance engagement under the terms of the guidance. Our limited assurance
procedures included:
In addition, the scope of our assurance work has not included governance over quality or non-mandated
indicators which have been determined locally by The Mid Yorkshire Hospitals NHS 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
•
•
•
•
•
•
•
•
•
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 of the Quality Account to the requirements of the Regulations; and
reading the documents.
•
the Quality Account is not prepared in all material respects in line with the criteria set out in the
Regulations;
the Quality Account is not consistent in all material respects with the sources specified in the Guidance;
and
the indicators in the Quality Account subject to limited assurance have not been reasonably stated in all
material respects in accordance with the Regulations and the six dimensions of data quality set out in the
Guidance.
Grant Thornton UK LLP
No1 Whitehall Riverside
Leeds
LS1 4BN
A limited assurance engagement is narrower 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.
XX June 2015
Limitations
Non-financial performance information is subject to more inherent limitations than financial information,
given the characteristics of the subject matter and the methods used for determining such information.
The absence of a significant body of established practice on which to draw allows for the selection of
different but acceptable measurement techniques which can result in materially different measurements and
can impact comparability. The precision of different measurement techniques may also vary. Furthermore,
the nature and methods used to determine such information, as well as the measurement criteria and the
precision thereof, may change over time. It is important to read the Quality Account in the context of the
criteria set out in the Regulations.
© 2015 Grant Thornton UK LLP | Quality Account 2014-15 | The Mid Yorkshire Hospitals NHS Trust
12
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