Bedford Hospital NHS Trust
Quality Account
2014/15
Contents
Part 1: Statement on Quality from the Chief Executive ......................................................................... 4
Part 2: Quality Improvement priorities ................................................................................................... 6
1: Patient safety priority 2014/15: Improve care for patients whose condition is deteriorating.. 7
2: Patient experience priority 2014/15: Treat our patients with dignity and respect and improve
the way we communicate with our patients ............................................................................... 10
3: Clinical effectiveness priority 2014/15: Reduce the number of patients who need to be
readmitted to hospital ................................................................................................................. 14
Quality improvement priorities for 2015/16 .................................................................................... 16
1: Patient safety improvement priority 2015/16: Continue to reduce incidents of avoidable
harm ............................................................................................................................................. 17
2: Patient experience improvement priority 2015/16: Improve the information provided to
patients and relatives at the point of discharge .......................................................................... 20
3: Clinical effectiveness improvement priority 2015/16: Introduce a ‘hospital at home’ service
...................................................................................................................................................... 22
Statements of assurance from the board......................................................................................... 24
Review of services provided by Bedford Hospital NHS Trust ....................................................... 24
Participation in clinical audits ...................................................................................................... 25
National Confidential Enquiries.................................................................................................... 33
Participation in clinical research .................................................................................................. 34
CQUIN Framework ....................................................................................................................... 35
Care Quality Commission registration and compliance ............................................................... 37
Data Quality.................................................................................................................................. 38
Information Governance Toolkit .................................................................................................. 38
Clinical Coding Accuracy ............................................................................................................... 38
Part 3: Overview of the quality of our care in 2014/15 ........................................................................ 39
Our performance against 2014/15 quality indicators ...................................................................... 40
Summary Hospital-Level Mortality Indicator (SHMI) ................................................................... 41
Patient Reported Outcome Measures ......................................................................................... 43
Emergency readmissions to the hospital within 28 days of discharge ........................................ 48
Responsiveness to the personal needs of patients ...................................................................... 49
Percentage of staff who would recommend the Trust to friends or family needing care........... 50
Percentage of admitted patients who were risk assessed for venous thromboembolism ......... 51
Rate of Clostridium difficile infections ........................................................................................ 53
Rate of patient safety incidents and the percentage resulting in severe harm or death ............ 55
Summary of 2014/15 ........................................................................................................................ 58
Bedfordshire and Milton Keynes Healthcare Review................................................................... 58
Breast cancer waiting times ......................................................................................................... 60
Maternity Services........................................................................................................................ 62
Summary of Serious Incidents and Never Events in 2014/15 ...................................................... 64
Reducing the number and severity of pressure ulcers ................................................................ 69
Complaints, Patient Advice and Liaison Service and Complements ............................................ 71
“Hello, my name is…” ................................................................................................................... 77
Improving services for patients with learning disabilities............................................................ 78
Patient Transportation ................................................................................................................. 79
Nursing and Midwifery Revalidation ............................................................................................ 80
Annex 1: Services provided by Bedford Hospital NHS Trust in 2014/15 .............................................. 81
Annex 2: Statement from commissioners, healthwatch and overview and scrutiny committees ....... 82
Bedfordshire Clinical Commissioning Group ................................................................................ 82
Bedford Borough Council Adult Services and Health Overview and Scrutiny Committee .......... 84
2
Healthwatch Bedford Borough .................................................................................................... 86
Annex 3: Statement of directors’ responsibilities................................................................................. 87
Annex 4: External audit limited assurance report ................................................................................ 89
Annex 5: acronyms and abbreviations.................................................................................................. 93
3
PART 1: STATEMENT ON QUALITY FROM THE CHIEF
EXECUTIVE
Safe, effective and caring – these are the
essential elements that contribute to the
delivery of high quality care at Bedford
Hospital, and form the basis of everything we
do.
meet future demand, whilst also improving
the experience for our patients.
Additionally, our Maternity service achieved
the highly-prestigious Baby Friendly (infant
feeding) accreditation from UNICEF and the
World Health Organisation, which means we
are currently the only hospital in
Bedfordshire, Hertfordshire and
Buckinghamshire to have achieved the Level 3
Baby Friendly Award.
I am very proud of the quality of care we
provide at Bedford Hospital to the many
thousands patients who use our services day
in, day out.
We have achieved a great deal in 2014/15;
notably with our initiatives to improve more
collaborative working to support patients who
are fit for discharge and continuing to reduce
infection rates. During the year we celebrated
150 days without an avoidable grade three
pressure ulcer for the first time. This is in
addition to no grade 4 pressure ulcers for a
number of years and is testament to the
ongoing commitment of our nurses and care
workers in preventing our patients from
experiencing a pressure ulcer.
We also met national standards relating to 18
week wait for referral to treatment and A&E
access times. In respect of the latter we
provided some of the best performance in the
country at times, often under difficult
circumstances, to ensure patients had the
best possible experience.
In August 2014 we received an unannounced
inspection from the CQC and we were pleased
to receive confirmation that we are meeting
all essential standards. This is a significant
achievement following the challenges
identified in the previous year and a
testament to the effort to improve the
services and also our systems to support
clinical governance.
Our continued drive to improve the quality of
care we provide for patients with dementia
saw the refurbishment of two of our wards Harpur and Elizabeth - as part of a £1million
joint bid with Bedford Borough Council for
Department of Health funding to create
specialist environments to support dementia
care.
Ensuring we provide consistently good care is
now truly at the heart of our governance and
decision-making processes as part of our
commitment to getting it right for every
patient, every time.
During the year, significant improvements in
clinical quality, patient experience, workforce
and training in our Endoscopy Unit were
recognised by the Joint Advisory Group (JAG)
on Gastrointestinal Endoscopy at an
accreditation inspection. This came mid-way
through our £3.3 million investment
programme, which will ensure the service can
We have continued our regime of quality
assessment and inspection, inviting our
partners, including Bedfordshire Clinical
Commissioning Group, Local Authorities,
4
Healthwatch, local councillors and Patient
Council members to form joint quality review
teams to assess our care provision. This
external scrutiny helps us to make sure our
facilities and staff are meeting patients’
needs, and particularly the needs of the most
vulnerable in our care.
We have refreshed our organisational
objectives for 2015/16; they reflect our
strategic aims and are also mapped to the
CQC domains of well led, safe, caring,
effective and responsive. Our objectives are
all based on our commitment to continuous
quality improvement and our commitment to
provide excellent care to the people of
Bedfordshire.
We have adopted the recommendations in Sir
Robert Francis QC’s report following the Mid
Staffordshire University Hospitals NHS
Foundation Trust public inquiry, and the
government’s response: ‘Hard truths, the
journey to putting patients first’; including
increasing the number of nurses working on
our wards and committing to publishing our
nurse-to-patient ratios every day. We
continue to recruit our local student nurses
upon graduation and have a strategy to
reduce the reliance on bank and agency by
recruiting additional nurses from overseas
including Spain and India.
Next year will bring with it more opportunities
to make the care we provide better and more
efficient to meet the needs of local people. It
will be undertaken though in a more
challenging financial environment and the
trust will need to work closely with its
partners to redesign the models of care to
continue to provide the highest standards in a
more cost effective way.
While I am proud of the standards we
maintain and this report highlights many of
our achievements, I am not complacent.
There is more work to be done. Health care
has to be right for every individual and we will
continue to strive to improve the patient
experience. In doing this, I look forward to
continuing to work alongside patients, carers,
stakeholders and staff to listen, learn and
grow as a hospital providing great care for the
people of Bedfordshire.
We have a robust quality governance process
from board to bedside, with a clear reporting
and escalation structure from wards and
departments to clinical business units;
through to our executive quality and risk
boards; non-executive quality and clinical risk
committee and the trust board. This enables
the effective ongoing management
monitoring and independent scrutiny of the
quality of care we provide, and ensures that
issues are identified, acted upon and
escalated.
To the best of my knowledge and belief, the
information contained in this document is
accurate.
Stephen Conroy
Chief Executive
24th June 2015
5
PART 2: QUALITY IMPROVEMENT PRIORITIES
In the 2013/14 Quality Account the Trust identified three quality improvement priorities for
2014/15:
1. The patient safety improvement priority was to improve the care the Trust provides to
patients whose condition is deteriorating
2. The patient experience improvement priority was to increase our patients’ experience of
dignity, respect and communication whilst in our care
3. The clinical effectiveness improvement priority was to reduce the number of patients
requiring readmission
The Trust’s progress in achieving these improvement priorities is presented in pages 7 to 14.
6
1: Patient safety priority 2014/15: Improve care for patients whose
condition is deteriorating
Aim
The Trust’s aim for 2014/15 is to further improve the care we provide to patients whose condition is
deteriorating
Targets for 2014/15
In order to achieve this aim, the Trust set the following target:

Reduce the number of avoidable cardiac arrests
Progress made in 2014/15
The Trust met its target to reduce the number of avoidable cardiac arrests in 2014/15.
The number of cardiac arrests in 2014/15 across the Trust (excluding the Accident and Emergency
Department) was 82, of which 17 were unavoidable. In 2013/14, there were 87 cardiac arrests, of
which 15 were unavoidable (Figure 1). The change, year on year, represents a reduction of avoidable
cardiac arrests in 2014/15 of ten percent. This represents a significant success for the Trust as not
only has the total number of cardiac arrests declined, but the proportion of cardiac arrests that
could have been avoided has also declined (Figure 2).
Figure 1: Avoidable and unavoidable cardiac arrests in 2013/14 and 2014/15
Number of
cardiac
arrests
100
90
80
70
60
50
40
30
20
10
0
15
17
72
65
2013/14
2014/15
Avoidable cardiac arrests
Unavoidable cardiac arrests
7
Figure 2: Avoidable and unavoidable cardiac arrests in 2013/14 and 2014/15 as % of all cardiac
arrests
% of
cardiac
arrests
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
17.24
20.73
82.76
79.27
2013/14
2014/15
Avoidable cardiac arrests
Unavoidable cardiac arrests
At the same time, the number of peri-arrest alerts made to the Critical Care Outreach Team
increased from 44 in 2013/14 to 78 in 2014/15 (an increase of 55 percent), indicating greater
awareness of our staff of when a patient is deteriorating and is in need of additional support.
In order to achieve the reduction in avoidable cardiac arrest in 2014/15 the Trust implemented the
following measures:
 The Trust rolled-out the use of Treatment Escalation Plans across the hospital. The Trust is
currently reviewing the TEP form with the plan to merge it with the DNACPR (Do Not
Attempt Cardiopulmonary Resuscitation) form. The NHS End of Life Care Strategy stipulates
that all people approaching the end of their lives need to have their needs assessed, their
wishes and preferences discussed and an agreed set of actions reflecting the choices they
make about their care recorded in a care plan. Treatment and care towards the end of life
requires good practice in decision making and acknowledges that the most difficult and
sensitive decisions in end of life care are often those around starting, stopping, potentially
life-prolonging treatment such as CPR. Such decision making should be recorded as part of
advance care planning. The TEP would help guide any DNACPR decision.
 The Trust aimed to make Acute Life Threatening Events Recognition and Treatment (ALERT)
1
training mandatory for all clinical staff and Bedside Emergency Assessment Course for
1
ALERT™ is a multi-professional course to train staff in recognising patient deterioration and act appropriately
in treating the acutely unwell. In practice, ALERT uses a structured and prioritised system of patient
assessment and management to enable a pre-emptive approach to critical illness. It instructs staff in the
8
Healthcare Assistants (BEACH)2 mandatory for all clinical support workers. Although both
courses have been completed by a high proportion of staff, these courses are not yet
mandatory.
 Immediate Life Support training is now available to all qualified nurses. In addition, the
Cardiac Arrest Prevention Team developed a Maternal Immediate Life Support course
designed specifically for midwives in September 2013. Since its introduction, 62 midwives
successfully completed the course.
 The Trust implemented the National Early Warning Scoring system (NEWS), which
incorporates a traffic light system to identify patients at risk of cardiac arrest. The Trust is
revising its standard observation chart in 2015/16 and will include the NEWS score on the
revised chart.
 The Trust continued its “ward a week” programme . The ‘ward a week’ initially focused on
3
areas identified as having an education need in recognising the deteriorating patient and
then rolled out to all other areas. This project will continue in 2015/16.
recognition of impending clinical deterioration, the management of disordered physiology and other aspects
of the delivery of acute care.
2
BEACH is designed to equip Health Care Assistants and Clinical Support Workers with the skills and
techniques required to recognise and escalate a deteriorating patient.
3
The “ward a week” programme is led by the Critical Care Outreach Team and the Cardia Arrest prevention
team. The teams work intensively with a ward for one week to increase knowledge and understanding of how
to identify patient whose condition is deteriorating and when to refer these patients to the Critical Care
Outreach Team.
9
2: Patient experience priority 2014/15: Treat our patients with
dignity and respect and improve the way we communicate with our
patients
Aim
The Trust’s aim for 2014/15 was to improve the reported patient experience scores in relation to:

Ensuring our patients have privacy and are treated with dignity and respect

Making sure our patients feel involved and fully understand their care and treatment

Improving the information we give patients undergoing surgical procedures
Targets for 2014/15
Achieve a two point improvement in the Picker Institute Inpatient Survey scores for questions
relating to:

Patients feel they have enough privacy when discussing their conditions and treatment

Patients feel they receive enough emotional support from our staff

Staff respond to call bells within five minutes

Patients feel more involved in decisions

Patients feel their questions have been fully answered

Patients are told how to expect to feel after an operation/procedure

Patients are told what would be done during an operations/procedure
Progress made in 2014/15
The Trust exceeded its patient experience improvement target in relation to providing patients with
enough privacy and dignity when discussing their conditions and treatment. There was no change in
the Trust’s score in relation to patients feeling involved in decisions about their care and treatment.
The remaining targets were not met (see Table 1 for further details). The Trust remains committed
to improving these areas for patients, carers and relatives and the Trust will use the results of the
patient survey to focus on specific areas for improvement.
10
Table 1: Comparison of Picker Institute Inpatient Survey Scores in 2013 and 2014
Bedford
Question
Patients always had enough privacy
2013
England
average
2013
Bedford
2014
England
average
2014
Change
2013 to
2014
Bedford
68%
75%
72%
76%
+ 4%
52%
57%
52%
57%
0
53%
58%
51%
59%
- 2%
74%
83%
71%
82%
- 3%
51%
57%
46%
58%
- 5%
76%
79%
69%
78%
- 5%
73%
77%
64%
76%
- 9%
when discussing condition or
treatment
Patients felt involved in decisions
about their care and treatment
Patients were told how to expect to
feel after an operation/procedure
Staff responded to call bells within 5
minutes
Patients always received enough
emotional support from hospital staff
Patients’ questions were fully
answered before an
operation/procedure
Patients were told what would be done
during an operation/procedure
Sources: Picker Institute Europe (2015) Inpatient Survey Results 2014: Bedford Hospital NHS Trust final Report;
Picker Institute Europe (2014) Inpatient Survey 2013: Bedford Hospital NHS Trust. A total of 850 patients were
sent a questionnaire, of which were 361 returned (response rate of 44 percent compared to national average
of 46 percent).
Patient experience improvements and achievements in 2014/15
Improving Feedback
 A patient experience event for stakeholders (e.g. CCG, Patient Council, Healthwatch and
staff) presented the results of the Inpatient Survey. The result of this event was jointly
agreed actions and innovations for continuous improvement of patient experience.
 In July 2014 the Trust held a public listening event inviting service users to provide feedback
on their experiences of care and treatment at Bedford Hospital directly to the Executive
team.
11
 During 2014/15, the Trust’s Complaints Department received nine letters expressing
gratitude for the way in which the Trust managed and resolved the issues raised by service
users.
Improving Learning
 A programme for clinical staff raised awareness of the importance of offering inpatients the
opportunity to discuss their condition or treatment in private. Wards also now have signage
for patients and carers informing them that facilities for private conversations are available.
 The Picker Institute Inpatient Survey results were provided to all clinical areas and each area
was provided with a service-level report including areas for improvement that were of
highest importance to patients.
 The Trust developed an log of actions and service improvements that have been introduced
following a complaint. This is monitored by the Complaints Department and monthly
feedback is provided to each Clinical Business Unit.
 The Trust continued its commitment to shared learning by including of patient
representatives on key committees and assessments.
 The Trust used audit data from carers of inpatients living with dementia to provide weekly
feedback for staff on the quality of care for this patient group and their carers.
Improving Services
 New facilities were finished on the fourth floor as part of the Dementia Challenge. This will
allow the Trust to deliver outstanding care to patients living with dementia, their families and
their carers within a specifically designed environment.
 The Trust undertook a trial of resources designed to help patients living with dementia enjoy
activities that are meaningful to them, such as art and reminiscence activities. These
resources will now be provided to every adult ward.
 The Trust introduced a new communication service for patients with hearing impairment. A
designated email address is checked every thirty minutes and questions or concerns are
forwarded to the appropriate department or ward. Initial feedback from patients using this
service has been positive.
 The Trust invested in ‘personal pagers’ for patients for use in outpatient areas. These alert
patients (using flashing lights, sound and vibration) exactly when their appointment will take
place. This allows patients to leave the department should they wish to do so while awaiting
an appointment. The Trust has made further bids to charities to extend this scheme to more
of our outpatient departments, including audiology following suggestions from the Trust’s
deaf service users.
12
 New nurse-led services were introduced to improve the experience of patients requiring
long-term venous access for various conditions. Feedback from patients indicates that the
new service has greatly improved their experience of requiring long-term intravenous
therapy. Further benefits include the reduction of waiting times for vascular access and the
reduction of cannulae required by individual patients.
 The presentation of information given to patients undergoing surgical procedures was
improved.
 The Trust introduced a “one-stop” outpatient and pre-operative assessment process for
patient convenience.
13
3: Clinical effectiveness priority 2014/15: Reduce the number of
patients who need to be readmitted to hospital
Aim
Our aim for 2014/15 is to reduce the number of patients who need to be readmitted to hospital
following a stay in hospital.
Targets for 2014/15
Our targets in relation to the reduction of readmissions were:


Reduce the number of readmissions within seven days of discharge by 10 percent
Reduce the number of readmissions within 28 days of discharge by 20 percent
Progress made in 2014/15
The Trust did not meet the clinical effectiveness targets for 2014/15. Table 2 presents the
readmission rate at seven days and 28 days following discharge in 2013/14 and 2014/15 as
percentages of the total number of admissions to the Trust in each year.
Table 2: Seven-day and 28-day readmissions in 2013/14 and 2014/15
2013/14
2014/15
% change
7-day readmissions
5.18%
5.19%
0.01% increase
28-day readmissions
12.31%
12.70%
0.39% increase
The increase in readmissions at the 7-day and 28-day point after discharge should be viewed in the
context of a 4 percent increase in emergency demand for services in 2014/15 compared with
2013/14.
14
The Trust implemented the following measures in 2014/15 to reduce readmission rates and remains
committed to achieving a reduction in readmission rates in the future:
 In 2014/15 the Trust implemented a Standard Operating Procedure to support the
standardisation of ward and board rounds. This has facilitated information sharing across
multidisciplinary teams to ensure effective care planning is in place for all patients.
 The Trust has increased the services provided by the Clinical Support Business Unit to
facilitate seven-day working. For example, the working hours of the Pharmacy Department
have been extended and there is now increased provision of therapies such as
physiotherapy, occupational therapy and dietetics out of normal working hours.
 The Trust has completed the Seven Day Services Self-Assessment to provide a baseline of
4
the provision of services available seven days per week. Following sign off by the Trust’s
Executive team a comprehensive action plan will be developed alongside the Trust’s
Commissioners to further increase the provision of services seven days a week.
 During 2014/15 the Trust established a multi-agency weekly meeting with providers of
Community Services and the Local Authority the review of all patients who are medically fit
for discharge. This has resulted in a decrease in the number of patients staying in hospital
for more than ten days.
4
The Seven Days a Week standards were developed by NHS England and consist of ten clinical standards to
ensure patients receive the best possible care and treatment every day of the week. The standards include:
appropriately involving patients, their families and carers, in decisions about treatment; all emergency
admissions should be seen by an appropriate consultant within 14 hours of admission; and, patients must have
seven-day a week access to diagnostic tests such as x-ray and endoscopy (with varying time-related targets
according to the need of the patient).
15
Q UALITY IMPROVEMENT PRIORITIES FOR 2015/16
The Trust consulted a wide range of our stakeholders, including patients, staff, commissioners, local
authorities, Healthwatch and the wider public, to identify the three quality improvement priorities
for the coming year. A total of 124 stakeholders took part in the survey and ranked the following
improvement priorities as the highest priorities for inclusion in the Quality Account:
1. Patient safety improvement priority: Continue to reduce incidents of avoidable harm (e.g.
pressure ulcers, falls, venous thromboembolic disease and infection)
2. Patient experience improvement priority: Improve the information provided to patients and
relatives at the point of discharge
3. Clinical effectiveness improvement priority: Introduce a ‘Hospital at Home’ service as an
alternative for patients who do not need to stay in hospital for their care and treatment (to
help avoid admissions or reduce the length of stay)
Further details of the 2014/15 quality improvement priorities are presented in pages 17 to 23.
16
1: Patient safety improvement priority 2015/16: Continue to reduce
incidents of avoidable harm
Aim
To continue to reduce the incidents of avoidable harm experienced by our patients whilst receiving
care and treatment at Bedford Hospital NHS Trust
Target for 2015/16

Reduce the number of MRSA blood infections to zero

Reduce the number of hospital-apportioned Clostridium difficile infections to below 10 cases
per year

Reduce the maximum ceiling for hospital acquired avoidable grade 2 pressure ulcers by 50
percent (35 in 2014/15 to 17 in 2015/16) and hospital acquired avoidable grade 3 pressure
ulcers by 25 percent (12 in 2014/15 to 9 in 2015/16) and not exceed either ceiling

Achieve 95 percent venous thromboembolism (VTE) assessment rate
Improvements made in 2014/15
The Trust has worked hard in 2014/15 to educate staff about the ways in which harm-free care can
be achieved.
The Trust secured £900,000 from the Nursing Technology Fund to support the implementation of
electronic vital signs, risk assessment and care plans.
The Trust piloted a package of safety measures including:
 The introduction of the SAFE Chart – a chart to monitor the risk to a patient of skin care, at
risk patients (of deterioration), falls, eating and drinking
 Frequent safety huddles when all relevant members of staff on a ward group together to
discuss high-risk patients and allocate resources accordingly
 Additional harm free care monitoring through the use of a ‘Safety Cross’ (a RAG rating
system to identify the incidence of various harms on a ward on a daily basis).
A new scheme has also been introduced to help reduce the risk of patients acquiring an infection as
a result of a catheter. The Catheter Passport is a patient-held record of the patient’s catheter care.
17
This programme has been developed and introduced by the Integrated Patient Safety Meeting that
is held with local partners and the Trust.
The Trust will introduce mandatory review panels for all hospital acquired pressure ulcers. The
review panels is hosted by a senior nurse and a clinical leader with the objective of identifying and
disseminating learning from each incident of hospital-acquired patient harm.
In response to the implementation of the national “Sign up to
Safety” campaign in June 2014 the Trust launched its Patient
Safety Programme in autumn 2014. The Patient Safety
Programme consists of fourteen patient safety streams, each
with a dedicated lead who is driving improvement work across
the Trust:

Care Bundle Development

Sepsis

Acute Kidney Injury

Handover and Patient Flow

Warfarin

Handover communication

Medication Errors (critical medication)

Medication Errors (medication omissions)

VTE

Falls

Deteriorating Patients

Nutrition and Hydration

Embedding learning from Serious incidents and Severe Harms

Measurement and Monitoring of the Patient Safety Culture
The patient safety stream leads participated in a training programme provided by the University of
Bedfordshire designed to support the leads in their work streams.
Trustwide quality improvement capability was also reviewed and the first cohort of clinicians
attended a patient safety leadership program designed to support clinicians to lead and manage
patient safety improvement work locally.
In wards and departments, the Trust recruited Patient Safety Improvement Champions. The
Champions play a vital role in leading patient safety improvements on the wards.
18
Planned improvements for 2015/16
The Trust plans to implement the following improvement activities in 2015/16:

Reinstate the VTE Committee to engage clinicians identifying improvement actions to ensure
more than 95 percent of patients are VTE assessed.

The Trust will further roll-out mandatory review panels for falls resulting in severe harm. The
review panels will be hosted by a senior nurse and a clinical leader with the objective of
identifying and disseminating learning from each incident of hospital-acquired patient harm.

The Trust will review its serious incident reporting process in line with recently issued
guidance.

Commence a programme of reviews of falls assessments, pressure prevention and infection
risk assessments and care plans to identify areas in need of further education and training.

Implement electronic risk assessments and care plans for key patient risks including
infection, falls, pressure prevention and nutrition providing real time effectiveness data.

Review education programmes for staff and patients in relation to preventative measures
for harm-free care.

We will develop Trustwide quality improvement capability approach that supports teams to
lead and manage their own improvement work with focus on coaching in quality
improvement methodology.

Developing a Patient Safety brief to encourage involvement and understanding of our safety
work.

Ensure on-going improvement in the quality and safety of patient care through our Clinical
Quality Strategy.

Continue to deliver root cause analysis investigation training to middle and senior managers.

The Trust will pilot customer care training for front line staff.
How we will measure, monitor and report on our progress

The Trust will present a quarterly patient safety report to Quality and Clinical Risk
Committee.

Levels of harms will continue to be reported to the Trust Board on a monthly basis.

The Trust will publish its safety plans on the Trust website to ensure transparency with plans
for improvement.

Ongoing monthly data collection and validation in relation to each quality improvement
target.
19
2: Patient experience improvement priority 2015/16: Improve the
information provided to patients and relatives at the point of
discharge
Aim
To improve the information we provide to patients and their relatives when they leave hospital
Target for 2015/16
To implement two measures to improve patients’ experiences before, during and after discharge
from hospital:

Introduce a “Helping You Plan to Leave Hospital” information booklet, mandatory for all
inpatients

Develop and provide a discharge information pack (the Place of Discharge Toolkit) for people
with complex discharge needs (e.g. patients requiring discharge to a new place of residence
such as nursing/residential home)
Improvements made in 2014/15
In 2014/15 the Trust established a Discharge Improvement Group to oversee the improvements
planned for 2015/16.
The Group developed and trialled a new Nursing Transfer Letter on one of the Trust’s wards that
treats elderly frail patients. Upon discharge of a patient to a nursing or residential home, the Nursing
Transfer Letter provides the home with detailed information on the patient such as any medication
given to the patient that day, a full skin integrity assessment, food and drink consumed on the day of
discharge and details of any catheters in place. The Trust has received positive feedback from
nursing and residential homes in relation to the Nursing Transfer Letter and the working group is
planning a further roll out of the practice across the Trust in 2015/16.
Planned improvements for 2015/16
In addition to the roll out of the Nursing Transfer Letter, the Trust plans to undertake the following
in 2015/16:
20

Implementation of the “Helping You Plan to Leave Hospital” information booklet for all
inpatients. This information booklet will be completed by nursing staff with all inpatients (or
their carers/relative if a patient lacks capacity). The booklet will include an estimated date of
discharge, a checklist for patients regarding the practicalities of leaving hospital (e.g.
identification of how a patient will get home, the name of a friend, family member or carer
and how they can help, medications that need to go home with the patient, a reminder for
the patient/carer to ensure they can access their home).

The booklet will also contain information for the patient outlining what might happen on
their day of discharge. For example, if they are leaving hospital before 10am they will usually
leave directly from the ward. However if a patient needs to stay beyond 11am they may
remain on the ward or be transferred to the discharge lounge where they will be cared for
until a suitable time for discharge.

Further information such as useful contacts for organisations that can help newly discharged
patients (such as Age UK, British Red Cross Home form Hospital Service) will be included in
the information booklet alongside a guide of what a patient should expect from community
care teams.

A discharge information pack (the Place of Discharge Toolkit) tailored to meet the needs of
patients with more complex discharge requirements will be implemented across the Trust.
This will be aimed at the small number of patients who arrive in hospital from their own
homes but have been assessed as requiring discharge to a nursing or residential home. The
information pack will include details of all local authority approved nursing and residential
homes in the area and supporting information from Age UK. The Trust’s dedicated discharge
planners will discuss the information with the patient or their carer/relatives if they lack
capacity.

The discharge planners will offer to accompany carers or relatives to any suitable nursing or
residential homes to look around and view the facilities and meet with staff. This will be
particularly helpful for relatives and carers who need support and guidance through what
can be a difficult and stressful time. Following the visits, the discharge planners will arrange
for the management from any chosen nursing or residential home to come and visit the
patient in hospital to answer their questions and provide any further support in anticipation
of the patient’s discharge.
How we will measure, monitor and report on our progress
The Helping You Plan to Leave Hospital booklet and Place of Discharge Toolkit will be developed with
patients and fully implemented in 2015/16. Progress will be monitored as part of the Quality
Strategy 2015-18 monitoring process and regular updates will be provided to the Trust’s Quality
Board.
21
3: Clinical effectiveness improvement priority 2015/16: Introduce a
‘hospital at home’ service
Aim
To introduce the Hospital at Home service to help reduce the length of stay of patients who do not
need to be in hospital to receive their care and treatment
Target for 2015/16
To increase the provision of the Hospital at Home service to 15 ‘virtual’ beds
Improvements made in 2014/15
The Trust’s Hospital at Home service is an innovative programme that was introduced in March
2015. The aim of the service is to facilitate early supported discharge for patients who may benefit
from receiving their care and treatment at home. Between March 2015 and early May 2015, 20
patients have received the service and the team has helped to avoid four hospital inpatient
admissions through treating patients in their place of residence or on the Trust’s day unit.
The service is led by a Matron with expertise in complex discharges, a Band 7 nurse manager and 3.5
whole time equivalents (WTE) Band 6 nurses. The service is provided between 7am and 8pm, seven
days a week.
The team manage a ‘virtual’ ward of up to eight patients who have been assessed as meeting the
criteria for the Hospital at Home service. Usually, this means the patient is asymptomatic yet still
requires treatment that would ordinarily be provided as an inpatient (for example, the patient
requires intravenous antibiotics). The Hospital at Home team assess potential patients to determine
their suitability for the service and obtain support from the patient’s consultant. The patient,
consultant and the Hospital at Home team must be in agreement that the Hospital at Home service
is appropriate for the patient. Prior to leaving hospital the team develop a care plan including the
frequency of visits to meet the care and treatment needs of the patient.
Once the patient has left hospital and is in their usual place of residence (including nursing and
residential homes and prisons) a member of the team will visit them at the agreed frequency to
provide the care and treatment required. This may include administering intravenous medication,
dressing wounds and providing pain relief. During the home visits the team take routine
observations of the patient (e.g. blood pressure, temperature, heart rate). If the nurse has any
22
concerns they immediately contact the patient’s consultant who advises on the best course of
action. This may result in the patient returning to hospital as an inpatient or as a day case to the day
treatment unit.
Patients are provided with the contact details for the members of the Hospital at Home team and
asked to contact the team if at any point they have concerns about their condition.
The benefits to a patient of the Hospital at Home service are significant. Once in their own home or
usual place of residence, a patient is at much lower risk of contracting hospital acquired infections
and other avoidable harms. Initial feedback from patients has been very positive. The service has
enabled patients with cancer who are asymptomatic to receive treatment for the side effects of
chemotherapy at home. This has been particularly beneficial for patients with young children or
family member with their own health issues.
Planned improvements for 2015/16
In order to achieve the target of increasing the virtual ward from eight beds to 15 the Trust plans to
recruit two whole time equivalent (WTE) Band 6 nurses to the team in 2015/16.
How we will measure, monitor and report on our progress
The team report any operational issues on a weekly basis to the Trust’s patient flow meeting.
23
S TATEMENTS OF ASSURANCE FROM THE BOARD
Review of services provided by Bedford Hospital NHS Trust
During 2014/15, Bedford Hospital NHS Trust provided 42 relevant health services and subcontracted 12 relevant health services. A list of all services provided by the Trust is located in Annex
1.
Bedford Hospital NHS Trust has reviewed all the data available to it on the quality of care in 100
percent of these relevant health services.
The income generated by the relevant health services reviewed in 2014/15 represents 100 percent
of the total income generated from the provision of relevant health services by Bedford Hospital
NHS Trust for 2014/15.
24
Participation in clinical audits
Clinical audit is a quality improvement process that seeks to improve patient care and outcomes
through systematic review of care against explicit criteria and the implementation of change.
National clinical audit is designed to improve patient outcomes across a wide range of health
conditions. Its purpose is to engage all healthcare professionals across England and Wales in
systematic evaluation of their clinical practice against standards and to support and encourage
improvement in the quality of treatment and care. It also allows hospitals of similar size the
opportunity to benchmark their practice with that of other hospitals.
During 2014/15, 55 national clinical audits covered relevant health services that Bedford Hospital
NHS Trust provides.
During 2014/15 Bedford Hospital NHS Trust participated in 75 percent (41/55) of national clinical
audits. Although 3 were postponed by the British Thoracic Society so this changes the denominator
from 55 to 52 changing the percentage to 79 percent (41/52) completion.
The national clinical audits and national confidential enquiries that Bedford Hospital NHS Trust was
eligible to participate in during 2014/15 are as follows:



















Acute coronary syndrome or Acute myocardial infarction (MINAP)
Adult Bronchiectasis
Adult community acquired pneumonia
Adult critical care (ICNARC)
Bowel Cancer (NBOCAP)
Cardiac Arrhythmia
Chronic obstructive pulmonary disease (COPD) (Pulmonary rehab) BTS
Chronic obstructive pulmonary disease (COPD) (Secondary Care) BTS
Coronary angioplasty
National Diabetes audit (four separate audits including the main National Diabetes Audit
itself and the three listed below)
NADIA National Diabetes inpatient audit
NPID Pregnancy in Diabetes audit
NDFA: National Diabetes Foot Care Audit
Elective surgery (National PROMs programme)
Epilepsy 12 audit (Childhood Epilepsy)
National hip fracture database (NHFD), includes Falls and Fragility Fractures audit (FFAP)
Fitting Child (Care in emergency departments)
Head and Neck oncology (DAHNO)
National audit of dementia
25




































National audit of intermediate care
National cardiac arrest audit
National comparative audit of blood transfusion programme
National emergency laparotomy audit (NELA)
National joint registry (NJR)
National vascular registry
Non-invasive ventilation (adults)
Older people (Care in emergency departments)
Inflammatory Bowel Disease (IBD)
Sentinel Stroke National Audit Programme (SSNAP)
Severe trauma (Trauma Audit and Research Network, TARN)
National Lung Cancer Audit
Multicentre Non accidental injuries audit
National audit of cardiac rehabilitation
National care of the dying audit
National neonatal audit programme
National oesophago-gastric cancer audit
National heart failure audit
Endoscopy audits (GRS requirements, 38 in total)
National pulmonary hypertension audit
Percutaneous nephrolithotomy (PCNL) audit
Rheumatoid and early inflammatory arthritis audit
National audit of seizure management (NASH)
National Psoriasis audit
Neonatal intensive and special care
Emergency readmissions
Patient blood management in scheduled surgery
Bedfordshire diabetic eye screening programme
Paediatric pneumonia
Stress urinary incontinence audit
National Cancer Patient Survey (Outpatients)
National Cancer Patient Survey (Inpatients)
Paediatric Diabetes Audit
National Parkinson’s audit
National Chemotherapy patient survey
National comparative audit of patient information and consent
The national clinical audits that Bedford Hospital NHS Trust participated in, and for which data
collection was completed during 2014/15, are listed in Table 3.
26
Table 3: Bedford Hospital NHS Trust participation in national clinical audits
National audit
Fitting child (care in emergency department)
Older people (care in emergency department)
Inflammatory Bowel Disease Audit
Care of the dying audit
National COPD audit (BTS) Secondary care
Paediatric diabetes audit
Epilepsy 12 (Childhood epilepsy)
Neonatal intensive and special care
Emergency readmissions – Payment by results
Patient Blood Management in Scheduled
Surgery – NCA pilot 2015
British Association of Urological Surgeons
(BAUS) Stress Urinary Incontinence Audit
Head and Neck Oncology Audit (DAHNO)
Multicentre Non accidental injuries audit
Severe Trauma (Trauma Audit and Research
Network)
Bedfordshire diabetic eye screening
programme
Cardiac Arrest (National Cardiac Arrest Audit)
Sentinel Stroke National Audit Programme
(SSNAP)
Percentage participation
Completed
Completed
Completed
Up to 50 requested. Bedford Hospital submitted 8
100% (50/50) Completed
Completed
Data collection completed
100% (16/16) Completed
Completed
Review Completed
Pilot completed
Completed
Completed
Data collection completed
Data collected continually and sent to Trauma
Network Site for benchmarking
Ongoing
Ongoing
Ongoing
National audit of dementia
Coronary angioplasty (NICOR Adult Cardiac
Interventions Audit)
Acute Myocardial Infarction and other ACS
(MINAP)
Heart failure (National heart failure audit)
Cardiac Arrhythmia
Cardiac Rehab (NACR)
Community acquired pneumonia
COPD Audit (BTS) Pulmonary rehab
Lung cancer (National lung cancer audit)
National emergency laparotomy audit
Elective surgery (National PROMS
programme)
ICNARC – Adult critical care
National vascular disease
Bowel Cancer (National Bowel cancer audit
programme)
National cancer patient survey (Outpatients)
National joint registry
National hip fractures database including falls
Ongoing
Ongoing
Ongoing
Ongoing
Ongoing
Ongoing
Ongoing
Ongoing
Ongoing
Ongoing
Ongoing
Ongoing
Ongoing
Ongoing
Ongoing
Ongoing
Ongoing
27
National audit
and fragility fractures
Endoscopy (GRS requirement – 38 in total)
NDA National diabetes audit
NADIA National diabetes inpatient audit
NPID National Pregnancy in diabetes audit
NDFA: National Diabetes Foot Care Audit
Percentage participation
Ongoing
Ongoing
Ongoing
Ongoing
Ongoing
In 2014/15 Bedford Hospital NHS Trust did not participate in 3 national audits for the following
specific reason, identified in Table 4.
Table 4: Bedford Hospital NHS Trust non-participation in national clinical audits
Audit
National non-invasive (NIV) audit
Adult Bronchiectasis
Paediatric pneumonia
Reason
British Thoracic Society postponed audit. Future
dates to be confirmed.
British Thoracic Society postponed audit. Future
dates to be confirmed.
British Thoracic Society postponed audit. Future
dates to be confirmed.
The reports of 42 local clinical audits were reviewed by the Bedford Hospital NHS Trust in 2014/15
and the Trust intends to take the following actions to improve the quality of healthcare provided
(Table 5).
Table 5: Local clinical audits and associated actions
Local Clinical Audit
Pharmacy
Antibiotic treatment – point
prevalence audit
Antibiotic – switching IV back to
oral
Actions
The recommendation from this audit was to improve
antimicrobial stewardship - the antimicrobial stewardship group
met for the first time in February 2015
Since February 2015 indications for antimicrobials are mandatory
on medication charts
Clinical review required for on MEDChart for IV antimicrobials
continuing beyond 48 hours since February 2015
Clinical review required for on MEDChart for IV antimicrobials
continuing beyond 48 hours since February 2015Trial an
intravenous antimicrobial review form / sticker that is placed in
the medical notes by pharmacy staff
Review of antimicrobial guidelines to include a more detailed
section on recommendations for intravenous to oral switch
Education of medical and nursing staff on the importance and
patient safety benefits of a timely intravenous to oral switch
28
Local Clinical Audit
IV paracetamol switching back
to oral
Specialty Medicine
Management of hyperosmolar
hypoglycaemic state (HHS)
Oxygen prescription
Review of cases with a
discharge diagnosis or
exacerbation of infective
exacerbation of COPD
Home oxygen service – patient
experience survey
Acute respiratory assessment –
patient experience survey
Early supported discharge –
patient experience survey
Re audit of the use of BNP as a
diagnostic tool in patients with
suspected heart failures
Management of community
acquired pneumonia
Ear, Nose and Throat Surgery
Two week wait neck lump clinic
– 3rd cycle
ENT patient satisfaction survey
Final ultrasound guided fine
Actions
Review of medicines management policy to state whether we
should allow more than one route to be prescribed
Prescribers should review intravenous paracetamol prescriptions
on a regular basis and consider other formulations rather than IV
where appropriate
Pharmacy should advise staff of costs involved of different
formulations
Snapshot audit completed - full audit to be undertaken in 2015/16
New guideline finalised and undergoing final consultant review
No update on actions available
No update on actions available
Findings reported back to the Respiratory Team at Bedford
hospital, Specialty Medicine Clinical Business Unit, Commissioners
of Home Oxygen Service, BOC Healthcare and Respiratory
Networks. No further actions as results were positive.
Findings reported back to the Respiratory Team at Bedford
hospital, Specialty Medicine Clinical Business Unit, Commissioners
of Home Oxygen Service, BOC Healthcare and Respiratory
Networks. No further actions as results were positive.
Findings reported back to the Respiratory Team at Bedford
hospital, Specialty Medicine Clinical Business Unit, Commissioners
of Home Oxygen Service, BOC Healthcare and Respiratory
Networks. No further actions as results were positive.
Local Guidelines for chronic heart failure revised and distributed
in primary care
Education and Meetings organised with local GPs to increase the
use of NT pro BNP test according to NICE guidelines for chronic
Heart failure
Procedure amended to give IV antibiotics immediately
Improved documentation
Improved accuracy of death certification
Audit has completed three cycles spanning 5 years
Most patients are seen in a timely manner as referral are faxed by
GPs and emailed for triage, ensuring patients seen within two
weeks of referral
Majority of neck lumps were benign and were diagnosed clinically
Majority of suspicious neck lumps were diagnosed within 31days,
and then promptly referred on for treatment
Low non-attendance rate for clinic
There were no negative comments
The findings were presented at the June 2014 ENT audit meeting
Findings presented at November 2014 ENT audit meeting
29
Local Clinical Audit
needle aspiration audit
Thyroid audit
General Surgery
Emergency surgery –
Assessment of risk
Antibiotic prophylaxis audit
Audit of emergency AAA
Audit of standard of vascular
Post-take ward rounds (PTWR)
documentation
Laparoscopic Cholecystectomy
Trauma and Orthopaedics
Audit of documentation of
neurovascular status in the
emergency department
Completion of mental state
competency score for fractured
neck of femur patients
Deep wound infection
Maternity
Breastfeeding drop off rate
audit
Ectopic pregnancy audit
Fresh eyes CTG monitoring re
audit
Postnatal discharges record
Actions
Findings presented at September 2014 ENT audit meeting
Findings were also published nationally
This was presented at the September 2014 surgery audit meeting
and there was no action
Audit in relation to NICE Quality Standard 49 (People having
surgery for which antibiotic prophylaxis is indicated receive this in
accordance with the local antibiotic formulary)
Trust does not currently meet this recommended standard
Action plan under development
Presented at the June 2014 surgery audit meeting
Creation of a formalised PTWR proforma
Plans for re-audit to assess improvements
Presented at April 2015 General Surgery audit meeting
Teaching session in A&E to take place
Neck of Femur Pathway Protocol Form to be prepared
Plan to audit Consent Form 4 in 2015/16.
Education of orthopaedic SHOs about the perioperative antibiotic
policy at induction
Reiteration of checks that appropriate antibiotics have been given
before starting surgery (currently forms part of the WHO surgical
checklist)
Recording reasons for deviating from local antimicrobial policy in
patients’ notes
Reiteration of the importance of recording the administration of
perioperative antibiotics
Completed as part of MSc study
Women and Children’s’ Clinical Business Unit is exploring how to
implement recommendations
Components of the audit are repeated three monthly as part of
Baby Friendly Initiative reaccreditation
Monthly dashboard for the quality of care presented at the
quality meeting every month
Plan to audit the management of miscarriages in 2015/16 by the
new intake doctors
Team Managers and Supervisors of Midwives to remind midwives
to undertake CTG assessments hourly
Midwives and Obstetricians to formulate action plans where
improvements are needed
Incorporate CTG training into mandatory update weeks/CTG
master classes (multi-professional)
Presented at January 2015 Obstetrics and Gynaecology audit
30
Local Clinical Audit
keeping
Audit of management of
perineal trauma repair/Third
and fourth degree tear
Medical management of
miscarriage
Genito-urinary medicine
Sexual health clinic survey
Paediatrics
Child attending Children’s
Assessment Unit (CAU) care
plan
Feverish illness in children
Rejected requests for group
and save/blood transfusion
Coeliac disease re-audit
Actions
meeting
Patient information leaflet created
Sticker has been created that reminds midwives to refer patients
for physiotherapy and consultant clinic
Provision of appointments for these patients within 7 days
Provision of contraception on discharge
Offer HIV screening to all patients
In general the patients who completed these forms were very
happy with the care they received
Some comments on the opening times of the clinic - patients said
it would be beneficial if the clinic could be open at weekends
(particularly on Saturdays), have more evening appointment times
available and be open longer
Pathways for patients with abdominal pain and undergoing
emergency surgery
Child mental health assessment
Review of children awaiting placement
Pathways have been developed to reduce the length of stay on
CAU
Use of fever care pathway for assessing children presenting with
fever
Redesign clerking proforma to include all the assessments as part
of the proforma to improve triaging of patients
Improve documentation of care at home advice and safety netting
through a parent advice leaflet
Blood management requires improvement as evidence that
blood/blood components are being requested by clinicians and
not being used
By having 2 patient group & save on all patients will mean blood
can be requested with a crossmatch sample and be ready in 20-15
minutes
All children with coeliac disease should be under the care of one
consultant paediatrician with an interest in coeliac disease and be
streamed into coeliac specific clinics
Re-audit every 2 years to ensure it is effective in achieving the
guidelines
Anaesthetics
Pain Scoring and Inpatient
Satisfaction with Pain Control
(July-August 2014)
Re-audit to determine hospital at night and progress of MEDChart
are improving patient satisfaction in relation to pain control
Results to be analysed and presented at June 2015 audit meeting
Pain Scoring and Inpatient
Satisfaction with Pain Control
re audit (February – March
2014)
Enhanced recovery surgery for
lower limb primary joint
Standardise management
Proposal for re-audit
31
Local Clinical Audit
replacements (joint with T&O)
Perioperative hypothermia
Post-operative pulmonary
complications (PPC) - A
predictive index for patients
undergoing surgery
Peri-operative use of
Antithrombotic and antiplatelet drugs
Malignant hyperthermia in
Anaesthesia
Actions
Consider use of concomitant laxatives to reduce incidence of
constipation
Recognise early on risk factors associated with increased length of
stay
Fluids to be stored in warming cupboard
Consider routine use of Bair-Hugger
Check temperature as per NICE guidelines, using the appropriate
thermometers
Total duration of anaesthesia and surgery directly correlated to
the incidence of PPC
Findings with surgical teams
Guidelines to be updated
Excellent results, no cause for concern
32
National Confidential Enquiries
The national confidential enquiries that Bedford Hospital NHS Trust was eligible to participate in
during 2014/15 are as follows:





Sepsis
Gastrointestinal Haemorrhage
Lower Limb Amputation
Tracheostomy Care
Acute Pancreatitis
The national clinical audits and national confidential enquiries that Bedford Hospital participated in,
and for which data collection was completed during 2014/15, are listed below. Alongside the audit
title are the numbers of cases submitted for each audit or enquiry as a percentage of the number of
registered cases required by the terms of that audit or enquiry (see Table 6)
Table 6: Bedford Hospital NHS Trust participation in national confidential enquiries
National Confidential Enquiry
Sepsis
Gastrointestinal Haemorrhage
Lower Limb Amputation
Tracheostomy Care
Acute Pancreatitis (Organisational data)
Percentage participation
80%
0%*
71%
100%
100%
*The Trust did not participate in the Gastrointestinal Haemorrhage National Confidential Enquiry as
there were no eligible cases during the reporting period.
33
Participation in clinical research
The number of patients receiving health services provided or sub-contracted by Bedford Hospital
NHS Trust in 2014/2015 that were recruited during that period to participate in research approved
by a research ethics committee was 614. This includes both portfolio and non-portfolio studies. In
addition to the above there are 217 patients in follow up process.
Participation in clinical research demonstrates Bedford Hospital’s commitment to improving the
quality of care we offer and to making our contribution to wider health improvement. Our clinical
staff stay abreast of the latest possible treatment possibilities and active participation in research
leads to successful patient outcomes.
Bedford Hospital NHS Trust was involved in conducting 37 clinical research studies in Oncology,
Cardiology, Stroke, Ophthalmology, Surgery, Neurology, Emergency Medicine, Critical care, Oral and
Maxillofacial Surgery, Gastroenterology, Dermatology, Respiratory Medicine, Diabetes, GUM,
Rheumatology and Haematology 2014/2015.
The improvement in patient health outcomes in Bedford Hospital NHS Trust demonstrates that a
commitment to clinical research leads to better treatments for patients.
There were over 100 of clinical staff participating in research approved by a research ethics
committee at Bedford Hospital NHS Trust during 2014/15. These staff participated in research
covering 16 medical specialties.
As well, in the last three years, 128 publications have resulted from our involvement in National
Institute for Health Research (NIHR), which shows our commitment to transparency and desire to
improve patient outcomes and experience across the NHS.
Our engagement with clinical research also demonstrates Bedford Hospital NHS Trust commitment
to testing and offering the latest medical treatments and techniques.
The Trust staff are also involved in number of research projects leading to postgraduate degrees
including MSc and PhDs in collaboration with various academic institutions including Cranfield ,
Hertfordshire and Bedfordshire universities. The Trust has a memorandum of understanding with
Cranfield University. This had provided significant research activity and number of patents. In
October 2014, Bedford Hospital and Cranfield University received a joint award from Oxfordshire
Biosciences Network (OBN) into treating bone disease. The Trust is also involved in making research
grant applications in collaboration with Cranfield University.
34
CQUIN Framework
A proportion of Bedford Hospital NHS Trust income in 2014/15 was conditional upon achieving
quality improvement and innovation goals agreed between Bedford Hospital NHS Trust and any
person or body they entered into a contract, agreement or arrangement with for the provision of
relevant health services, through the Commissioning for Quality and Innovation payment
framework. Further details of the agreed goals for 2014/15 and for the following 12 month period
are available online at: https://www.innovation.nhs.uk/pg/cv_blog/content/view/40573/network
In 2014/15 eight CQUINs applied to the Trust (listed in Table 7).
Three were mandated nationally (highlighted in blue in Table 7):



Patient Experience (1.1, 1.2, 1.3 and 1.4)
NHS Safety Thermometer (2.1)
Aware and diagnosis for dementia (3.1, 3.2 and 3.3)
The remaining five were negotiated locally with Bedfordshire Clinical Commissioning Group:





End of treatment summaries for Cancer patients
Treatment Escalation Plans (TEP)
Acute Kidney Injury (AKI) – implement a care bundle
Seven day services – time to Consultant first review
Medicines Optimisation – Care Plans
35
Table 7: Bedford Hospital NHS Trust achievement against 2014/15 CQUINs
Indicator
identifier
Description
1.1
1.2
1.3
1.4
2.1
Staff Friends and Family Test
Early Implementation in outpatients/Day case areas
Increased response rate
Increased response rate March 2015
NHS Safety Thermometer:
Reduction in Pressure Ulcers
Dementia:
Find, Assess, Investigate & Refer 90 percent of eligible
inpatients
Dementia:
Clinical leadership & staff training
Dementia:
Supporting Carer’s of People with Dementia through a
Carer’s Audit
End of Treatment Summaries for cancer patients after an
acute phase of treatment
Treatment Escalation Plans aims to improve informed
decision making of patients nearing end of life
Acute Kidney Injury – Implementation of a care bundle for
patients admitted with a raised creatinine indicating AKI
Seven Day Services – time to first consultant review within
14 hours of admission
Medicines Management – Implementation of a medicine
care plan for patients over the age of 85 discharged to their
own home with no care package.
3.1
3.2
3.3
4.1
5.1
6.1
7.
8.
Overall Achievement of
target (%) for 2014/15
100%
0%
100%
100%
100%
100%
100%
100%
100%
75%
50%
100%
50%
Note (1.2 early implementation in outpatient and day case areas): The Friends and Family Test
survey was implemented throughout the Trust in all outpatient and day case areas within the time
frame. However, the CQUIN was not achieved due to a delay in reporting of evidence to
Bedfordshire Clinical Commissioning Group.
36
Care Quality Commission registration and compliance
Bedford Hospital NHS Trust is required to register with Care Quality Commission and its current
registration status is with no conditions.
Care Quality Commission has not taken enforcement action against Bedford Hospital NHS Trust
during 2014/15.
Bedford Hospital NHS Trust has not participated in any special reviews or investigations by the Care
Quality Commission during the reporting period.
CQC conducted an unannounced inspection of Bedford Hospital NHS Trust in August 2014. This
inspection was carried out to check whether Bedford Hospital NHS Trust had taken action to meet
the following essential standards:

Care and welfare of people who use services

Cooperating with other providers

Assessing and monitoring the quality of service provision

Complaints
CQC found that the Trust was compliant with the four standards assessed and the Trust was not
required to take further action.
37
Data Quality
Bedford Hospital NHS Trust submitted records during 2014/15 to the Secondary Uses Service for
inclusion in the Hospital Episode Statistics which are included in the latest published data. The
percentage of records in the published data:
Which included the patient's valid NHS Number was:



99.5 percent for admitted patient care;
99.8 percent for outpatient care; and
98.9 percent for accident and emergency care.
Which included the patient's valid General Practitioner Registration Code was:

100 percent for admitted patient care;

100 percent for outpatient care; and

100 percent for accident and emergency care.
Information Governance Toolkit
Bedford Hospital NHS Trust Information Governance Assessment Report overall score for 2014/15
was 69 percent and was graded Green (Achieved Attainment Level 2 or above) on all requirements.
Clinical Coding Accuracy
Bedford Hospital NHS Trust was not subject to the Payment by Results clinical coding audit during
the reporting period by the Audit Commission.
Bedford Hospital NHS Trust will be taking the following actions to improve data quality:

Introduction of Data Quality Training

Expansion of Data Quality Team to support the Trusts Data Flows

Better Reporting to Monitor and predict Data Issues.

Mortality Peer Review process to be improved by use of electronic reporting

Quality Group to continue to act as key drive for improvement in clinical / management Data
Quality

Continue to improve the clinical coded data by interaction with Clinical Teams across the
trust
38
PART 3: OVERVIEW OF THE QUALITY OF OUR CARE IN
2014/15
Part 3 of the Quality Account presents data relating to national quality indicators. A quality indicator
is a measure that can help inform providers of health care, patients and other stakeholders about
the quality of services provided compared to the national average, the best performing trust and the
worst performing trust. The indicators are also used by the Secretary of State to track progress
across the whole of the NHS in meeting the targets that make up the NHS Outcomes Framework.
The NHS Outcomes Framework identifies five ‘domains’ relating to clinical effectiveness, patient
experience and safety. Progress in each domain is measured using many indicators, some of which
must be included in a trust’s annual Quality Account. The five domains are presented in Figure 3.
Figure 3: The five Domains of the NHS Outcomes Framework
Domain 1
Preventing people from dying prematurely
Domain 2
Enhancing quality of life for people with long-term
conditions
Domain 3
Helping people to recover for episodes of ill health or
following injury
Domain 4
Ensuring that people have a positive experience of care
Patient experience
Domain 5
Treating and caring for people in a safe environment
and protecting them from avoidable harm
Safety
Source: The NHS Outcomes Framework 2011/12
39
Clinical effectiveness
O UR PERFORMANCE AGAINST 2014/15 QUALITY INDICATORS
Eight Quality Account indicators apply to Bedford Hospital NHS Trust in 2014/15:

Summary Hospital-Level Mortality Indicator (SHMI) including SHMI banding and percentage
of patient deaths with palliative care coded at either diagnosis or specialty level

Patient Reported Outcome Measures (PROMs) for:
o
Groin hernia surgery
o
Varicose vein surgery
o
Hip replacement surgery
o
Knee replacement surgery

Emergency readmissions to the hospital within 28 days of discharge

Responsiveness to the personal needs of our patients

Percentage of staff who would recommend the Trust to friends or family needing care

Percentage of admitted patients who were risk assessed for venous thromboembolism (VTE)

Rate of Clostridium difficile infections

Rate of patient safety incidents and the percentage resulting in severe harm or death
40
Summary Hospital-Level Mortality Indicator (SHMI)
The Summary Hospital-level Mortality Indicator (SHMI) is an indicator which reports on mortality at
trust level across the NHS in England using a standard and transparent methodology. It is produced
and published quarterly as an official statistic by the Health and Social Care Information Centre
(HSCIC) with the first publication in October 2011.
The SHMI is the ratio between the actual number of patients who die following hospitalisation at the
trust and the number that would be expected to die on the basis of average England figures, given
the characteristics of the patients treated there.
The Summary Hospital-Level Mortality indicator relates to two NHS Outcomes Framework Domains:
1. preventing people from dying prematurely; and 2. enhancing the quality of life for people with
long-term conditions.
Bedford Hospital NHS
Trust
England average
Best performing Trust
Worst performing
Trust
2012/13
110.03
Band 2
‘As expected’
21.4% Palliative Care
100.00
65.23
Band 3
‘Lower than expected’
10.5% Palliative Care
116.97
Band 1
‘Higher than expected
12.5% Palliative Care’
2013/14
110.07
Band 2
‘As expected’
21.8% Palliative Care
100.00
62.59
Band 3
‘Lower than expected’
6.1% Palliative Care
115.53
Band 1
‘Higher than expected’
12.9% Palliative Care
2014/15
108.7
Band 2
‘As expected’
23.0% Palliative Care
100.00
59.7
Band 3
‘Lower than expected’
0% Palliative Care
119.8
Band 1
‘Higher than expected’
32.2% Palliative Care
Source: Health and Social Care Information Centre (https://indicators.ic.nhs.uk/webview )
Notes:
2012/13 data = April 2012 to March 2013 (published October 2013)
2013/14 data = July 2012 to June 2013 (published January 2014)
2014/15 data = October 2013 to September 2014 (published April 2015)
Bedford Hospital NHS Trust considers that this data is as described for the following reason:

Processes are in place to review all deaths and lessons are learnt through the review process
41
Bedford Hospital NHS Trust has taken the following actions to improve the number, and so the
quality of its services, by:

The Trust will continue to review patient deaths via the Mortality Review Group.
42
Patient Reported Outcome Measures
Patient Reported Outcome Measures (PROMs) collect information on the effectiveness of care
delivered to NHS patients as perceived by the patients themselves. The data adds to the wealth of
information available on the care delivered to NHS-funded patients to complement existing
information on the quality of services.
Since 1 April 2009, hospitals providing four key elective surgeries for the English NHS have been
inviting patients to complete questionnaires before and after their surgery. The PROMs programme
covers four common elective surgical procedures: groin hernia operations, hip replacements, knee
replacements and varicose vein operations.
Patient Reported Outcome Measures for groin hernia surgery, varicose vein surgery, hip
replacement surgery and knee replacement surgery relate to NHS Outcomes Framework Domain 3:
helping people to recover from episodes of ill health or following injury.
Groin hernia surgery
The scores patients having undergone groin hernia surgery are based the responses to a standard
measure of health questionnaire. This questionnaire covers five areas: mobility, self-care, usual
activities, pain/discomfort and anxiety/depression. Patients indicate whether they experience no
problems, some problems or severe problems in relation to each of the five areas in question. A
higher overall score indicates better reported overall health following groin hernia surgery.
Bedford Hospital NHS
Trust
England average
Best performing NHS
Trust
Worst performing NHS
Trust
2012/13
2013/14
2014/15
0.093
0.087
0.044
0.085
0.085
0.084
0.120
0.132
0.144
0.021
0.039
0.009
Source: Health and Social Care Information Centre ( http://www.hscic.gov.uk/proms)
Notes: Adjusted average health gain data to allow for case-mix (EQ-5D)
2012/13 = Final data (published August 2014) for period April 2012 to March 2013
2013/14 = Provisional data (published May 2015) for period April 2013 to March 2014
2014/15 = Provisional data (published May 2015) for period April 2014 to December 2014
Bedford Hospital NHS Trust considers that this data is as described for the following reason:
43

The figures for 2014/15 are based on a low number of patient outcome questionnaires. In
the second half of 2014/15 the Trust carried out 114 groin hernia procedures.
Questionnaires were sent to 68 of these patients of which 21 were returned.
Bedford Hospital NHS Trust has taken the following actions to improve the number, and so the
quality of its services, by:

The Trust has identified the need to increase the distribution of post-operative
questionnaires and improve the response. The Trust is working with its survey contractor to
improve data capture in 2015/16.
44
Varicose vein surgery
The Aberdeen Varicose Veins Questionnaire (Aberdeen Questionnaire) is a condition-specific
questionnaire that measures health status for patients with varicose veins. The questionnaire
consists of 13 questions relating to key aspects of the problem of varicose veins. The questionnaire
has a section in which the patients can indicate diagrammatically the distribution of their varicose
veins. There are questions relating to the amount of pain experienced; ankle swelling; use of support
stockings; interference with social and domestic activities and the cosmetic aspects of varicose veins.
A lower negative score indicates better reported outcomes by the patient.
Bedford Hospital NHS
Trust
England average
Best performing NHS
Trust
Worst performing NHS
Trust
2012/13
2013/14
2014/15
No score
-7.53
No score
-8.43
-8.70
-8.82
-16.19
-14.62
-15.27
5.17
11.23
7.57
Source: Health and Social Care Information Centre ( http://www.hscic.gov.uk/proms)
Notes: Adjusted average health gain data (Aberdeen Varicose Vein Score; a negative score indicates
improvement)
2012/13 = Final data (published August 2014) for period April 2012 to March 2013
2013/14 = Provisional data (published May 2015) for period April 2013 to March 2014
2014/15 = Provisional data (published May 2015) for period April 2014 to December 2014
Bedford Hospital NHS Trust considers that this data is as described for the following reason;

The Trust did not receive PROM score for varicose vein surgery between April 2014 and
December 2014 because there were too few records to model (17 records)
Bedford Hospital NHS Trust has taken the following actions to improve the number, and so the
quality of its services, by:

The Trust has identified the need to increase the distribution of post-operative
questionnaires and improve the response. The Trust is working with its survey contractor to
improve data capture in 2015/16.

Furthermore, most patients attending the Trust for treatment of varicose veins are treated
with radiofrequency ablation or ultrasound-guided foam sclerotherapy. In 2015/15, the
Trust will also capture the patient reported outcome for patients undergoing these
treatments.
45
Hip replacement surgery
The Oxford hip and knee scores are joint-specific outcome measure tools designed to assess
symptoms and function in patients undergoing joint replacement surgery. The scores comprise of
twelve multiple choice questions relating to the patient’s experience of pain, ease of joint
movement and ease of undertaking normal domestic activities such as walking or climbing stairs.
Each of the 12 questions on the Oxford Hip Score and Oxford Knee Score are scored in the same way
with the score decreasing as the reported symptoms increase, i.e. become worse. All questions are
laid out similarly with response categories denoting least (or no) symptoms scoring four and those
representing greatest severity scoring zero.
The individual scores are then added together to provide a single score with 0 indicating the worst
possible and 48 indicating the highest possible score.
Bedford Hospital NHS
Trust
England average
Best performing NHS
Trust
Worst performing NHS
Trust
2012/13
2013/14
2014/15
21.62
20.25
21.79
21.62
21.38
21.87
24.25
24.14
25.17
17.21
17.58
18.99
Source: Health and Social Care Information Centre ( http://www.hscic.gov.uk/proms)
Notes: Adjusted average health gain data (Oxford Hip Score)
2012/13 = Final data (published August 2014) for period April 2012 to March 2013
2013/14 = Provisional data (published May 2015) for period April 2013 to March 2014
2014/15 = Provisional data (published May 2015) for period April 2014 to December 2014
Bedford Hospital NHS Trust considers that this data is as described for the following reason;

Oxford Hip Score outcomes are on a par with NHS England average.
Bedford Hospital NHS Trust has taken the following actions to improve the number, and so the
quality of its services, by:

Focus on enhanced recovery; however clinical outcomes according to National Joint Registry
are excellent.
46
Knee replacement surgery
In relation to the reported outcome of knee replacement surgery, individual scores on patient
questionnaires are added together to provide a single score with 0 indicating the worst possible and
48 indicating the highest possible score.
Bedford Hospital NHS
Trust
England average
Best performing NHS
Trust
Worst performing NHS
Trust
2012/13
2013/14
2014/15
16.45
15.59
14.62
15.99
16.27
16.31
18.98
19.20
19.83
12.46
12.33
12.83
Source: Health and Social Care Information Centre ( http://www.hscic.gov.uk/proms)
Notes: Adjusted average health gain data (Oxford Knee Score)
2012/13 = Provisional data (published May 2014) for period April 2012 to March 2013
2013/14 = Provisional data (published May 2015) for period April 2013 to March 2014
2014/15 = Provisional data (published May 2015) for period April 2014 to December 2014
Bedford Hospital NHS Trust considers that this data is as described for the following reason:

The data for 2014/15 is modelled on 68 records from a nine-month period (April to
December), compared with 261 primary knee replacement procedures taking place during
the complete financial year.
Bedford Hospital NHS Trust has taken the following actions to improve the number, and so the
quality of its services, by:

The Trust has identified the need to increase the distribution of post-operative
questionnaires and improve the response. The Trust is working with its survey contractor to
improve data capture in 2015/16.
47
Emergency readmissions to the hospital within 28 days of discharge
Emergency readmissions to the hospital within 28 days of discharge relates to NHS Outcomes
Framework Domain 3: helping people to recover from episodes of ill health or following injury.
0 to 15 years of age
16 years and over
2012/13
9.65%
10.75%
2013/14
9.25%
11.14%
2014/15
Not available
Not available
Source: Health and Social Care Information Centre (https://indicators.ic.nhs.uk/webview )
Notes:
2012/13 data = April 2012 to March 2013 (published October 2013)
2013/14 data = July 2012 to June 2013 (published January 2014)
2014/15 data = Expected to be published in early 2016
Bedford Hospital NHS Trust considers that this data is as described for the following reason:

The Trust awaits the publication of 2014/15 data in early 2016
Bedford Hospital NHS Trust intends to take the following actions to improve the percentage, and so
the quality of its services, by:

The Trust awaits the publication of 2014/15 data in early 2016 to understand what
improvements need to be made.
48
Responsiveness to the personal needs of patients
Responsiveness to the personal needs of patients relates to NHS Outcome Framework Domain 4:
ensuring people have a positive care experience.
Bedford Hospital NHS
Trust
National average
Best performing Trust
Worst performing
Trust
2012/13
2013/14
2014/15
64.2%
67.4%
Not available
68.1%
84.4%
68.7%
84.2%
Not available
Not available
57.4%
54.4%
Not available
Source: Health and Social Care Information Centre (https://indicators.ic.nhs.uk/webview )
Note: Figures for 2012/13 differ from the data included in the 2013/14 Quality Account following the
publication of the complete dataset covering years 2003/04 to 2013/14 in May 2014. Dataset is
available to download via HSCIC.
Bedford Hospital NHS Trust considers that this data is as described for the following reason:

Data for 2014/15 is expected to be published in August 2015.
Bedford Hospital NHS Trust intends to take the following actions to improve the percentage, and so
the quality of its services, by:

The Trust awaits publication of data for 2014/15 to understand where to focus its
improvements.
49
Percentage of staff who would recommend the Trust to friends or
family needing care
The percentage of staff who would recommend the Trust to friends or family needing care related to
NHS Outcomes Framework Domain 4: ensuring that people have a positive care experience.
Bedford Hospital NHS
Trust
National average
Best performing Trust
Worst performing
Trust
2012
2013
2014
63%
63%
75%
62%
86%
64%
89%
67%
89%
35%
40%
38%
Source: Picker Institute Staff Survey (http://www.nhsstaffsurveys.com/Page/1006/LatestResults/2014-Results/ )
Bedford Hospital NHS Trust considers that this data is as described for the following reason:

The score has increased by 12 percent since 2013, placing the Trust in the top 20 percent of
similar trusts. This reflects the Trust’s various projects to improve staff engagement, training
opportunities and appraisals.
Bedford Hospital NHS Trust intends to take the following actions to improve the score, and so the
quality of its services, by:

Continuing to provide staff opportunities to feedback their experience of working at the
Trust to enable Trust leadership to be more responsive to staff needs and concerns.
50
Percentage of admitted patients who were risk assessed for venous
thromboembolism
The percentage of admitted patient who were risk assessed for venous thromboembolism related to
NHS Outcomes Framework Domain 5: treating and caring for people in a safe environment and
protecting them from avoidable harm
The scope of the indicator includes all adults (those aged 18 at the time of admission) who are
admitted to hospital as inpatients including:

surgical inpatients;

in-patients with acute medical illness (for example, myocardial infarction, stroke, spinal cord
injury, severe infection or exacerbation of chronic obstructive pulmonary disease);

trauma inpatients;

patients admitted to intensive care units;

cancer inpatients;

people undergoing long-term rehabilitation in hospital;

patients admitted to a hospital bed for day-case medical or surgical procedures; and

private patients attending an NHS hospital.
The following patients are excluded from the indicator:

people under the age of 18 at the time of admission;

people attending hospital as outpatients;

people attending emergency departments who are not admitted to hospital; and

people who are admitted to hospital because they have a diagnosis or signs and symptoms
of deep vein thrombosis (DVT) or pulmonary embolism.
Bedford Hospital NHS
Trust
National average
Best performing Trust
Worst performing
Trust
2012/13
2013/14
2014/15
95.7%
95.9%
95.19%
93.87%
100%
95.7%
100%
95.99%
100%
69.8%
90.8%
88.46%
Source: NHS England (http://www.england.nhs.uk/statistics/statistical-work-areas/vte/ )
Bedford Hospital NHS Trust considers that this data is as described for the following reasons:
51

The Trust has maintained its performance in relation to the 95 percent assessment target
due to a range of measures in place. This includes a patient safety programme dealing
specifically with VTE and the introduction of e-Prescribing and Medicines Management
(ePMA) that requires a VTE assessment before prescribing can commence.
Bedford Hospital NHS Trust has taken the following actions to improve the percentage, and so the
quality of its services, by:

In early 2015/16 the Trust established a VTE committee to provide further direction and to
drive improvement work in relation to VTE assessment and prevention.
52
Rate of Clostridium difficile infections
The rate of Clostridium difficile infections relates to NHS Outcomes Framework Domain 5: treating
and caring for people in a safe environment and protecting them from avoidable harm
The rate per 100,000 bed days of cases of Clostridium difficile infections that have occurred within
the trust amongst patients aged 2 or over during the reporting period.
The scope of the indicator includes all cases where the patient shows clinical symptoms of
Clostridium difficile infection, and has a positive laboratory test result. A Clostridium difficile
infection episode lasts for 28 days, with day one being the date the first positive specimen was
collected. A second positive result for the same patient, if collected more than 28 days after the first
positive specimen, should be reported as a separate case, irrespective of the number of specimens
taken in the intervening period, or where they were taken. Specimens taken from deceased patients
are included.
The following cases are excluded from the indicator:


people under the age of two at the date the sample of taken; and
where the sample was taken before the fourth day of an admission to the trust (where the
day of admission is day one).
Bedford Hospital NHS
Trust
National average
Best performing Trust
Worst performing
Trust
2012/13
2013/14
2014/15
13.5
9.1
17.4
0
14.7
0
Not available
Not available
31.2
37.1
Not available
11.11
Bedford Hospital NHS Trust considers that this data is as described for the following reason:

Since 2012/13, the Trust has maintained Clostridium difficile infection rates below the
England average and, despite a slight increase in 2014/15 in cases per 100,000 bed days, the
Trust’s performance was below the ceiling set by the Department of Health.
Bedford Hospital NHS Trust has taken the following actions to improve the rate, and so the quality of
its services, by:
53

In 2015/16, the Trust has set an ambitious target to reduce the total number of hospital
apportioned Clostridium difficile cases to below 10 per year. When applied to the 2014/15
bed occupancy rate, this would equate to 7.5 cases per 100,000 bed days. It should be noted
that this figure is a guide to allow comparison with the Trust’s performance in 2014/15.
54
Rate of patient safety incidents and the percentage resulting in
severe harm or death
The rate of patient safety incidents and the percentage resulting in severe harm or death relates to
NHS Outcomes Framework Domain 5: treating and caring for people in a safe environment and
protecting them from avoidable harm.
Bedford
Hospital NHS
Trust
2012/13
5.09 Incidents reported
per 100 admissions
2013/14
25.8 incidents reported
per 1000 bed days
0.012 Involving severe
harm or death per 100
admissions
2014/15
34.21 incidents reported
per 1000 bed days
0.32% resulting in severe
harm
0.50% resulting in death
National
average
7.13 Incidents reported
per 100 admissions
33.3 incidents per 1000
bed days
0.046 Involving severe
harm or death per 100
admissions
Best performing
Trust
2.47 Incidents reported
per 100 admissions
0.92% resulting in severe
harm
5.8 incidents reported
per 1000 bed days
0.083 Involving severe
harm or death per 100
admissions
Worst
performing
Trust
27.76 Incidents reported
per 100 admissions
35.9 incidents reported
per 1000 bed days
0.18% resulting in death
21.88 incidents reported
per 1000 bed days
0% resulting in severe
harm
74.9 incidents reported
per 1000 bed days
0 Involving severe harm
or death per 100
admissions
0.2% resulting in death
35.3 incidents reported
per 1000 bed days
2.3% resulting in severe
harm
0.8% resulting in death
Source: National Reporting and Learning System (NRLS) (http://www.nrls.npsa.nhs.uk/resources/ )
Notes:
55
2013/14 data covers period October 2013 – March 2014. These data were recalculated (previously
reported as number of incidents per 100 admissions) and published in April 2015.
2014/15 data covers period April 2014 – September 2014
According to the Trust’s local incident reporting system, there were a total of 2306 patient safety
incidents reported between April 2014 and September 2014 compared with 2192 uploaded to the
NRLS in the same timeframe. Furthermore, there is a discrepancy between the number of incidents
resulting in severe harm or death. According to the Trust’s local reporting system (Datix), Bedford
Hospital NHS Trust reported the following between April 2014 and September 2014:

Severe harm = 6 (0.26% of reported patient safety incidents) compared with NRLS = 7 (0.32%
of reported patient safety incidents) resulting in 0.06% difference between the two data sets

Death = 15 (0.65% of reported patient safety incidents) compared with NRLS = 11 (0.50% of
reported patient safety incidents) resulting in 0.15% difference between the two data sets
This discrepancy is due to the fact that following upload to the NRLS these incidents were
investigated and the grading amended, however this re-grading had not been re-uploaded to the
NRLS. Three of the incidents were the subject to Serious Incident (SI) investigations and have been
investigated thoroughly. Detail is as follows:

Two incidents were initially submitted to the NRLS as resulting in minor harm. These
incidents were both subsequently upgraded to the death of a patient following investigation.
One incident related to a cardiac arrest where the patient died. This was the subject of an SI
investigation. The other incident was a patient death that came to light following a mortality
review. Both incidents were graded incorrectly in terms of outcome/harm to the patient.

One incident was submitted to the NRLS as resulting in moderate harm. This incident
resulted in a patient death and was the subject of an SI investigation. This incident was
incorrectly graded when first uploaded to the NRLS.
One incident was submitted to the NRLS as resulting in severe harm. This patient sadly died and the
incident was upgraded to a patient death following completion of the serious incident investigation
According to our local reporting system, in the period October 2014 to March 2015, Bedford Hospital
NHS Trust reported:

Total number of incidents = 2479

Incidents resulting in severe harm =8 (0.32% or reported incidents)

Incidents resulting in death = 16 (0.65% of reported incidents)
56
National data for this period is not yet available.
Bedford Hospital NHS Trust considers that this data is as described for the following reason:

The Trust’s performance is lower than the national average for the number of incidents per
1000 bed days and the percentage of incidents resulting in severe harm. In 2014/15 the
Trust launched its Patient Safety campaign and appointed patient safety champions to raise
awareness of patient safety incidents and how to avoid patient harm.
Bedford Hospital NHS Trust has taken the following actions to improve the number, and so the
quality of its services, by:

The Trust will continue to review patient deaths through its mortality review group.

The Trust has a robust incident investigation process. It is anticipated that the
implementation of various patient safety programmes in 2014/15 and planned
improvements in 2015/16 will lead to further reduction in the rate of patient safety
incidents resulting in severe harm or death in 2015/16.
57
S UMMARY OF 2014/15
Bedfordshire and Milton Keynes Healthcare Review
In 2014, the Bedfordshire and Milton Keynes health
economies were subject to a strategic review
commissioned by NHS England and the two national
regulators – Monitor and the Trust Development
Authority (TDA), and involving the Clinical
Commissioning Groups for Milton Keynes and
Bedfordshire. In October 2014, the review published
a progress report which set out the work undertaken
during the review’s ‘study phase’ and made recommendations for developing robust options for
local health services.
Following a process of evaluation and elimination drawing on clinical expertise and public and
patient feedback, two options emerged which focused on the creation of a major emergency centre
and Integrated Care Centre on the two hospital sites. However the report noted that there still
remained significant concerns about financial sustainability and accessibility of care within these two
options
The recommendations and next steps of the progress report were therefore to:

Develop plans to offer more care closer to home via multi-disciplinary teams, involving
primary care, community health services and social care.

Carry out further detailed work on the preferred options for the future provision of hospital
services.

Develop a detailed plan outlining the practical steps that need to be taken to prepare for
public consultation.

Keep clinical, public and patient engagement at the heart of the review, using the best
practice tools and practices that the CCGs have developed.
The Trust, Bedfordshire Clinical Commissioning Group, local GPs and partners obtained feedback
from the public, patients and clinicians and have further assessed the scenarios for local
applicability. This has been developed through the North Bedfordshire Primary and Acute Care
Programme.
This programme of work has focused on developing the following:
58

A clear strategy and contractual framework for care closer to home, underpinned by quality
standards and robust clinical pathways.

A model for a vertically integrated hospital and community system, enabling local services to
better support vulnerable people to be cared for outside hospital and deliver swifter
assessment, diagnosis, treatment and discharge from hospital.

Defining core hospital services and networking of hyperacute services to develop sustainable
and modern district general hospital services that can meet the clinical standards of the
future.
The Strategic Outline Case will be presented to regulators in June 2015.
59
Breast cancer waiting times
Under the NHS Constitution, patients with suspected cancer must be seen by a consultant within 14
days of referral from a GP. At Bedford Hospital patients with suspected breast cancer are normally
provided with a one-stop clinic service. This means a patient is seen by a specialist breast radiologist
and a breast surgeon on the same day at the same clinic. The Trust believes this offers the best
possible service to patients as it not only reduces the number of visits to the hospital for
appointments it has also been shown that one-stop clinics improve the diagnosis of breast cancer. 5
From the end of May to the end of August, the Trust was unable to provide a one-stop clinic service
to all patients referred to the Trust with suspected breast cancer. The situation arose following the
retirement of two specialist breast radiologists and the difficulty the Trust had in recruiting to these
posts, which included attempts to recruit internationally. This was largely due to a national shortage
of radiologists, and particularly specialist breast radiologists, which had been evident for some time.
This meant the Trust had only one substantive radiologist in post. Further to the reduced number of
breast radiologists, one of the Trust’s breast surgeons was unexpectedly unavailable due to ill
health.
Under normal operating conditions the Trust meets the two week cancer referral target for all
patients. However, during the summer months of 2014, as a result of the reduced size of the surgical
and radiological teams, the Trust was unable to offer all patients referred for breast services an
appointment at a one-stop clinic within two weeks and in a number of cases patients were not seen
within the required two weeks.
The Trust provided its principal commissioner, Bedfordshire Clinical Commissioning Group, with
weekly situation reports identifying the number of patient referrals received, the number of patients
seen within 14 days at one-stop clinics, the number of patients seen within 14 days at split clinics,
the number of patients seen within 21 days and the number of patients seen beyond 21 days after
referral. The Trust also noted the number of patients who were seen beyond 21 days after referral
because in many cases this was a result of patient choice or previous non-attendance at an earlier
appointment.
To provide appointments to patients as soon as possible after referral, the Trust employed the
services of a locum radiologist and a neighbouring trust provided additional radiologist support.
5
Britton, P., Duffy, S., Sinnatamby, R., Wallis, M., Barter, S., Gaskarth, M., O'Neill, A., Caldas, C., Brenton, J.,
Forouhi, P., & Wishart, G. (2009). One-stop diagnostic breast clinics: how often are breast cancers missed?
British Journal of Cancer, 100 (12), 1873-1878 DOI: 10.1038/sj.bjc.6605082(link is external)
60
Existing Trust staff, including the substantive radiologist, breast surgeons and service managers,
worked tirelessly to ensure patients were seen as quickly as possible following referral.
The Trust recorded no patient safety issues during this challenging time. There were no adverse
clinical outcomes for patients and all patients requiring treatment received their treatment within
the mandatory 62 days. Furthermore, the Trust did not receive any formal complaints from patients
as a result of the difficulties in meeting the two week wait target.
By the end of August 2014, the Trust’s breast surgeon had returned to work, a new radiologist had
been appointed and all patients referred to the Trust for breast services were seen within two weeks
at a one-stop clinic, and the Trust has maintained this performance to date.
61
Maternity Services
2014/15 has been a highly successful year for our Maternity Unit, with the Trust’s midwives going
above and beyond the call of duty to provide the best possible service to expectant parents and
new-born babies in Bedford.
In early October 2014 the Trust held an open
day on the Maternity Unit. The open day was
designed to give expectant parents the
opportunity to explore our maternity facilities.
Our midwives and neonatal nurses produced
information stands covering antenatal
ultrasound, early pregnancy, health promotion
(including smoking cessation services and
healthy eating in pregnancy), infant feeding,
parent education and our services within the
neonatal unit. Around 70 expectant parents
attended the open day and the event was
Amanda Pachulkski (Clinical Midwife Manager), Naomi
Gallagher (Head of Midwifery, Matron - Neonatal) and Oonagh
Purdy (Clinical Midwife Manager) at the Maternity Open Day
highly praised.
Later the same month, the Trust’s dedicated Bereavement Team held its first ‘Butterflies and
Balloons’ event. The Bereavement Team is a group of midwives who provide support to new parents
during times of bereavement. The Butterflies and Balloons event gave families an opportunity to
come together to remember their babies who were stillborn or died shortly after birth. The
ceremony involved personal readings, poems and music chosen by parents. After the ceremony
parents were given the opportunity to plant daffodil bulbs outside the Cygnet Wing (the Trust’s
Women and Children’s unit) and release biodegradable balloons with personal messages for their
babies.
The Trust’s approach to bereavement care including the facilities provided for bereaved families is
well respected by our peer hospitals. The Trust regularly provides advice and support, including visits
to our bereavement suite, to other trusts seeking to improve their care of bereaved parents.
The Trust is planning to hold further Maternity open days and Butterflies and Balloons events in
2015/16 given the success of the events last year.
62
In early 2015 the Maternity Unit achieved full UNICEF Baby
Friendly Accreditation. The UNICEF Baby Friendly awards are
based on a set of interlinking evidence-based standards for
maternity, health visiting, neonatal and children’s centres
services. The standards are designed to provide parents with the
best possible care to build close and loving relationships with their baby and to feed their baby in
ways which will support optimum health and development. Maternity units implement the
standards in stages over a number of years. At each stage units are externally assessed by UNICEF
UK. When all the stages are passed they are fully accredited as Baby Friendly.
Following the assessment in February 2015, the Trust’s Maternity Unit, Neonatal Unit and
Paediatrics department were highly commended by the UK Director of UNICEF Baby Friendly
initiative for the positive leadership and supportive management that was witnessed during the
inspection visit: “A culture of kindness and support prevails throughout the maternity unit, where
staff and mothers feel cared for, supported and empowered. As we walked about the unit we were
inspired by the obvious passion from everyone to do their best, work as a team and we really felt that
this would be a lovely place to work. This supportive caring culture is what is needed to enable the
mothers to receive the best care. When speaking to the mothers, 95% of the mothers we spoke to
said they were very satisfied with the care they had received”.
The Trust’s care for women with high-risk pregnancies, including women wishing to have a Vaginal
Birth After Caesarean (VBAC), has seen significant improvements in 2014/15 and was recognised by
the Royal College of Midwives (RCM). The Maternity Unit was selected as a finalist at the RCM
Innovations Awards for the introduction of a pathway for the use of birthing pools for VBAC and
high-risk women (VBAC in Water Pathway). The financial award for improving the birth environment
from the Department of Health was used to purchase and install a birthing pool in one of the Trust’s
obstetrician-led delivery rooms. This provides women with an additional choice and the opportunity
to benefit from the use of a birthing pool during labour whilst still being under care of an
obstetrician-led team. Two of the Trust’s Supervisor of Midwives presented the success of the VBAC
in Water Pathway at the East of England Supervisor of Midwives Conference.
The Trust’s Neonatal Unit (NNU) also had a successful year. Following a review of neonatal care in
the East of England, the Neonatal Unit now provides care to babies born from 30 weeks’ gestation.
The NNU hosted the East of England Network Medical Skills Day for Paediatricians and the Unit
attained the British Association of Perinatal medical staffing levels. The Unit also successfully
completed the initial stages of the BLISS Neonatal toolkit. This resulted in an award of £10,000 which
funded the purchase of breast pumps, DVD players for parents and reclining chairs to improve the
clinical environment for the parents of babies on the Unit.
63
Summary of Serious Incidents and Never Events in 2014/15
Serious Incidents in healthcare are relatively uncommon but when they occur, the NHS organisation
have a responsibility to ensure there are systematic measures in place for safeguarding people,
property, NHS resources and reputation. This includes the responsibility to learn from these
incidents to minimise the risk of them happening again.
‘Never events’ are a particular type of serious incident that are wholly preventable, where guidance
or safety recommendations that provide strong systemic barriers are available at a national level and
should have been implemented by all healthcare providers. Each never event has the potential to
cause serious patient harm or death (Never Events Framework April 2015).
Bedford Hospital NHS Trust takes this responsibility seriously and is continually strengthening its
safety culture to ensure that serious incidents are reported and investigated thoroughly. The Trust
reports all serious incidents and never events to Bedfordshire Clinical Commissioning Group and
must provide investigation report, outlining the root causes of the incident, lessons learnt and action
plans to prevent recurrence of the incident, within 60 days.
Serious Incidents declared in 2014/15
During the financial year 2014/15, the Trust declared a total of 71 Serious Incidents compared with
58 in 2013/14. A monthly breakdown of Serious Incidents is provided in Table 8.
Table 8: Serious Incidents by Month 2014/15
Month
April 2014
May 2014
June 2014
July 2014
August 2014
September 2014
October 2014
November 2014
December 2014
January 2015
February 2015
March 2015
Total 2014/15
Number of Serious Incidents
4
2
14
5
7
13
5
6
7
2
2
4
71
64
A breakdown of the categories of Serious Incidents that occurred in 2014/15 is presented in Table 9.
Table 9: Categories of Serious Incidents in 2014/15
Type of incident
Pressure Ulcers
Falls resulting in serious injury
The deteriorating patient
Incorrect insertion of lens (IOL) Moorfields
Neonatal death
Failure to act on blood test results
Delayed diagnosis
Intra-uterine death (IUD)
Management of a baby with perinatally acquired HIV infection
Colposcopy Screening
Never Event: Gynaecology
Mal-administration insulin
Failure to monitor hypoglycaemia
Plaster of Paris applied to incorrect limb
Removal of POP and tension button
NG tube not x-rayed
Insertion of a percutaneous tracheostomy
Treatment of sickle cell crisis
Failure to obtain consent
Death following Pulmonary Embolism
Patient death during an Interventional Radiology Procedure
Medica CT scan transmission failure
Acute Kidney Injury
CPE Outbreak
Norovirus Outbreak
Delayed referral to tertiary centre
Telecommunications failure
Research Governance
Total
65
Number of Serious incidents
20
12
8
3
3
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
71
Pressure Ulcers
In 2014/15, there were 20 grade three pressure ulcers declared as serious incidents, which is a
significant improvement in performance compared to 27 in 2013/14. Of the 20 pressure ulcers
declared, 11 were deemed to be ‘unavoidable’ and nine ‘avoidable’ (compared to 19 ‘unavoidable’
and eight ‘avoidable’ in the previous financial year). Two of the avoidable pressure ulcers that were
declared in 2014/15 occurred at the end of 2013/14 but were declared following the turn of the new
financial year.
As a result of these Serious Incidents, the Trust undertook the following:
 Daily quality and safety rounds by Matrons and ward managers have been established;
 The Trust has reinforced the use of repositioning charts, particularly within surgical
specialties for all dependent and lower limb vascular patients;
 All patients with vascular complications must be positioned on pressure relieving
mattresses;
 The Tissue Viability Team provide ward-based training for staff;
 The Trust reiterated the importance of completing risk assessments, including the use of
the SSKIN Bundle;
 Staffing levels and skill mixes were reviewed; and
 The Link Nurse Study Day in October 2014 reinforced correct classification and use of
SSKIN Bundle.
Serious injury as a result of Patient Falls
There were 12 serious incidents reported relating to patients sustaining severe harm following a fall.
This compares to six incidents in financial year 2013/14. Of the 12 incidents, nine incidents related to
patients sustaining a fractured neck of femur. One fall related to a patient with a hip prosthesis
sustaining a peri-prosthetic fracture. There were a further two falls resulting in the death of a
patient; one death was due to natural causes where the patient suffered a stroke prior to the fall
and the other case is currently under investigation.
As a result of these Serious Incidents, the Trust will undertake the following:
 Ensuring that risk assessments, care planning and evaluation are undertaken to identify
high risk patients and ensure that care is appropriate;
 Patients at high risk of falls to be in an observable area on the ward close to the nurses’
station;
66
 High risk patients are identified in daily quality meetings and escalated for review by the
matron or falls lead. Staffing levels are also reviewed at these meetings and nurse
resources allocated to the areas at increased risk;
 For patients at high risk of falls, increased observation including one-to-one nursing
provided where appropriate;
 Spot check nursing care documentation by senior nursing staff to ensure high standards
maintained; and
 Patient safety champion in post and patient safety programme underway which includes
a falls prevention project.
Deteriorating patient incidents
In 2014/15 the Trust reported eight serious incidents relating to deteriorating patients compared to
five 2013/14. The cardiac arrest prevention team continue to audit all cardiac arrests and any areas
of concern are reported through the Datix Incidents reporting system.
As a result of these Serious Incidents, the Trust will undertake the following:
 Sepsis 6 stickers introduced to acute admission areas;
 Purchasing of sepsis trolleys for the Emergency Department & Acute Assessment Unit;
 Ward areas will have a sepsis box;
 Mandatory annual cardiac arrest prevention training incorporates training on sepsis;
 Implementation of National Early Warning Score (NEWS) and new observation chart. A
trial will be undertaken on Howard ward before Trust-wide roll out. The new
observation chart will incorporate urinary output and includes a prompt on recognition
of sepsis and sepsis care bundle;
 Ongoing training of staff; Immediate Life Support (ILS) course for qualified staff and
BEACH training course for clinical support workers. ILS and Advanced Life Support (ALS)
training courses all include teaching and assessment on the recognition and treatment
of sepsis;
 Technology Fund bid successful for the purchase of a track and trigger system;
 ‘Ward a week’ training implemented by Cardiac Arrest Prevention Team to target high
risk areas for training (recognition of deteriorating Patient/ Sepsis/ PAR or BLS if
required);
 Implementation of Hospital at Night and subsequent improved out of hours response for
urgent access;
 Introduction of Treatment Escalation Plan in all areas since 2014. There is currently a
draft of a combined Decision tool on TEP and DNACPR under development; and
67
 Currently exploring a system to review all blood results daily by a Sepsis Nurse to
identify those patients at risk of sepsis.
Never Event
In 2014/15 the Trust reported one Never Event which occurred in June 2014. The Never Event
involved the removal of a fallopian tube of a patient without following the correct process. This case
was subject to a thorough external investigation and a series of recommendations have been
implemented as a result:
 The introduction of a standard consent form for patients experiencing an ectopic
pregnancy;
 Introduction of a ‘team pause’ if a discrepancy occurs between ultrasound and operative
findings;
 Improved documentation of all operative findings on the operation sheet and
countersigned by the consultant; and
 Photographs at all laparoscopies for possible ectopic pregnancies are to be taken,
particularly when findings conflict with ultrasound.
68
Reducing the number and severity of pressure ulcers
Prevention of pressure damage continues to be a top safety priority at Bedford Hospital. Education,
training and vigilance of the Tissue Viability Team are at the fore front of our success. We continually
review our processes and education to ensure they remain in line with the most up to date
guidelines. We have been collaborating closely with the provider of community services in Bedford
(South Essex Partnership Trust) to reduce the prevalence of pressure ulcers in the community.
Monthly meetings as part of the CQUIN framework ensures continuing communication between
acute and community settings.
On World Wide Stop the Pressure Day our dedicated Tissue Viability Team held an awareness raising
event at a local supermarket. The team spoke to members of the public about the signs and
symptoms of pressure ulcers and pressure ulcer prevention.
Jocelyn Crawford (Dressings Representative, Bedford
Hospital NHS Trust), Tesco Community Champion,
Anna Taylor (Patient Safety Project Nurse,
Bedfordshire Clinical Commissioning Group) and
Sharon Clarke (Senior Tissue Viability Nurse, Bedford
Hospital NHS Trust)
During 2014/15 the Trust began investigating all grade 2 hospital acquired pressure ulcers as Critical
Internal Incidents to ensure the causes and lessons to be learned are identified using our Pressure
Ulcer Root Cause Analysis (RCA) process. As part of each Pressure Ulcer RCA process we hold review
meetings to capture essential learning in the early stages of investigation and we ensure a range of
staff are invited to attend these reviews in an effort to instil further learning in investigation process
and documentation.
69
Over the course of the year we invested in equipment to allow all of our electric pressure relieving
mattresses to be extended to accommodate our taller patients. We have also invested in a variety of
pressure reliving devises for the heel area.
All of these measures combined have ensured that the Trust has celebrated a significant reduction in
avoidable pressure ulcers during 2014/15.
70
Complaints, Patient Advice and Liaison Service and Complements
The Trust has a statutory obligation for the handling and consideration of complaints to ensure that
complaints are dealt with efficiently and are properly investigated and action is taken if necessary.
Supporting the formal elements of complaints, the Trust has a Patient Advice and Liaison Service
(PALS) which works with patients, relatives and carers to try and resolve their concerns informally
and at local level.
A formal complaint involves a thorough investigation and the Chief Executive responds directly to
the complainant. When investigating a complaint we are guided by national requirements, we have
a local target of 45 working days in which to complete an investigation and respond to the
complainant.
The Trust offers complainants the opportunity have access an independent advocacy service free of
charge should they wish support through the complaints process.
The Trust endeavours to always provide a timely and satisfactory response to every complaint it
receives. However, there are occasions when a complainant may not be satisfied with the initial
response provided by the Trust. If the Trust’s further efforts to resolve the issues (which may
include, for example, a further letter of response and offer a meeting for the complainant and the
clinicians involved) are unsatisfactory to the complainant, the complainant is advised they can refer
their complaint to the Parliamentary and Health Services Ombudsman (PHSO). The PHSO will review
the case using information we provide and consider further investigation and recommendations.
In 2014/15, the Trust received 303 complaints compared with 286 in 2013/14.
Complaints to the Trust encompass a range of issues and complaints can affect a number of
departments. In most cases, a complaint deals with more than one issue. The Trust’s complaints
team logs every complaint and identifies the themes raised (see Table 10 for detailed breakdown of
categories and the frequency these categories feature in complaints). The largest complaint category
relates to all aspects of the clinical treatment experienced by a patient. This broad category can
include patient dissatisfaction with the outcome of a procedure or treatment, or patient
dissatisfaction with the treatment options offered. The second most frequent cause for complaint is
poor communication, which may include issues such as staff failing to introduce themselves to
patients or a failure to adequately communicate the prognosis of a condition or a patient’s discharge
arrangements.
71
Subjects by which complaints have been categorised have been updated in line with national
reporting, it is therefore not possible to fully compare the complaint subjects from 2013/14 and
2014/15.
Table 10: Complaint categories 2013/14 and 2014/15
Category
All Aspects of Clinical Treatment
Communication/information
Attitude of Staff
Admissions, discharge and transfer arrangements
Appointments, delay/cancellation (out-patient)
Personal records (including Medical and/or Complaints)
Privacy and Dignity
Appointments, delay/cancellation (in-patient)
Policy and commercial decisions of trusts
Patients' property and expenses
Hotel Services (Including Food)
Aids and appliances, equipment, premises (including access)
Other
Consent to treatment
Independent sector services commissioned by Health Authorities
Patient's status, discrimination (e.g. racial, gender, age)
Mortuary and post mortem arrangements
2013/14
158
76
62
38
30
7
9
8
3
5
5
0
9
0
0
0
0
2014/15
268
111
66
47
25
15
10
9
9
3
3
2
2
1
1
1
1
Patient Advice and Liaison Service
The Trust’s PALS offers patients and their families or carers a point of contact for any concern, query
or other feedback. It can facilitate communication between a patient and clinical areas. At times, a
PALS issue may be escalated to a formal complaint either as a result of the Trust’s process for
managing complex issues or at the patient’s request to ensure a detailed investigation.
72
In 2014/15, the Trust recorded 766 formal PALS contacts (Figure 4 shows the top five categories for
PALS contacts). These categories are largely consistent with previous years, although there were far
fewer contacts in relation to treatment and care.
Figure 4: Themes of formal PALS contacts in 2013/14 and 2014/15
140
115
120
100
95
120
99
98
85
80
70
60
43
40
25
30
20
0
General Enquiry
Appointments
Communication
Apr 13 to Mar 14
Attitude of Staff
Concern Re:
Treatment/Care
Apr 14 to Mar 15
In addition to formal PALS contacts, the Trust received 1,005 informal contacts that are resolved
immediately by the PALS team, such as provision of contact details for departments and
‘signposting’ for patients who are unsure of how to access or communicate with certain services.
Compliments
The Trust is fortunate to receive a significant number of compliments, gifts and donations every year
(figures for 2014/15 are provided in Table 11). These kind gestures from patients are provided at
ward and service levels and include acknowledgements of individual members of staff and of
services as a whole. Individuals and teams named in compliments are included in the weekly staff
newsletter as part of our drive to celebrate achievements and successes. The donations category
includes both monetary donations to the Trust and donations of equipment. Small gifts, such as
sweets and chocolates, are given frequently by patients to staff and are always gratefully received.
Any larger gift items are declared to the Trust Board secretary. The Trust aims acknowledge each
compliment and formally records them on the Datix system.
73
The general themes of compliments include:
 The professionalism of Trust staff
 Staff are pleasant, friendly and approachable
 Excellent care delivered with compassion
 Caring attitude of staff whatever the pressures
 The quality of food
Table 11: Cards, donations and gifts received during 2014/15
April 2014
May 2014
June 2014
July 2014
August 2014
September 2014
October 2015
November 2014
December 2014
January 2015
February 2015
March 2015
Total
Cards
108
134
103
116
107
99
111
83
80
35
163
145
1284
Donations
9
6
7
7
4
8
3
3
72
5
1
1
126
Gifts
94
112
81
104
74
81
83
84
4
0
0
25
742
Bedford Hospital’s response to Complaints Matter by the Care Quality Commission (CQC)
In December 2014, CQC published Complaints Matters outlining its findings of an investigation in to
how complaints are dealt with by hospitals. The report also detailed how complaints and a trust’s
response to complaints fit within its new regulatory model. Under the new inspection model, CQC
review complaints and concerns with two aims:

To improve how Trust use the intelligence from concerns and complaints to better
understand the quality of care provided; and

To consider how well providers manage complaints and concerns to encourage
improvement.
CQC concluded there is too much poor practice in NHS providers’ responsiveness and treatment of
people who make complaints and that, while most providers have complaints processes in place,
peoples’ experiences of complaining are not consistently good.
74
CQC will continue to work closely with partners so that everyone – regulators, providers,
professionals and commissioners – makes the shift to a listening culture that encourages and
embraces complaints and concerns as opportunities to improve the quality of care.
Since the publication of Complaints Matter the Trust has developed an action plan has been
developed to ensure CQC’s recommendations are consistently met. The anticipated completion date
for these actions is June 2015.
In addition, the Trust has hosted a series of ‘listening events’. The most recent listening event was
held in April 2015. This event was advertised in the local press and internally to encourage patients,
past and present, to come forward and discuss their experiences with members of staff, including
the Chief Executive, Medical Director, Director of Nursing, senior clinical staff and manages along
with members of the complaints, PALS team, the hospital chaplain and carers lounge staff. Actions
from the event were fed back to staff and patients and will help to shape the trusts quality strategy,
future events and service improvements.
Learning from complaints and PALS
During 2014/15 the Trust introduced a clearer process to identify learning to the complainant and
staff. Responses from the chief executive inform the complainant where we have changed our
practices as a result of their complaint.
Examples of changes made in 2014/15 as a result of complaints are:
 All ward and department areas display information for patients and public regarding who
they can discuss any concerns with
 Increased availability of senior clinicians out of usual working hours
 Display notices asking staff and patients to be quiet in areas that previously experienced
unsatisfactory noise levels
 Audit of discharges from accident and emergency over night to ensure all discharges were
appropriate
 Introduction of teaching sessions for junior doctors to include; care and treatment of dog
bites; the importance of listening to parents’ concerns; and, the importance of listening to
the patient when they describe how they feel
 Administrative staff have been reminded of the importance of telephoning patients as well
as sending letters when appointments have been changed
 Case studies presented to clinical teams
 PALS and complaints are now part of mandatory Trust induction
75
 Introduction of the Hello my name is…. campaign
Next steps
In April 2015 the Trust introduced complaints satisfaction surveys to monitor the complainant’s
experience of the complaints process in line with the CQC Complaints Matter report. The Trust has
also appointed a non-executive director to champion the patient experience agenda.
76
“Hello, my name is…”
In October 2014, Medical Director Colette
Marshall launched the Hello My Name Is
campaign across the Trust.
The Hello My Name Is campaign aims to
encourage staff to introduce themselves so that patients know who is caring for them. It all starts
with a simple introduction – “Hello my name is….” - which can make a significant difference for our
patients.
Kate Granger, the campaign’s
founder, is a doctor who is
terminally ill. During a stay in
hospital last year, Dr Granger made
a stark observation that many of
the staff looking after her did not
introduce themselves before
delivering her care. Following this
experience, Dr Granger set up the
Hello My Name is campaign to
encourage staff to introduce
themselves to their patients,
something she believes to be vital
to establishing a human connection
and delivering compassionate care.
Bedford Hospital’s Medical Director Colette Marshall (top right) also feels strongly that the message
of the “Hello my name is” campaign represents a cornerstone of relationships between staff and
patients and has led the introduction of the campaign at the Trust.
Members of staff have been having their photos taken with the #hellomynameis poster, displaying
their name and job title. To help support the campaign staff have been asked to make a special
effort to introduce themselves to patients, whether they are medical, nursing, administrative or
support staff.
77
Improving services for patients with learning disabilities
This year the Bedford Hospital Learning Disability Forum has continued to be well attended by
patients, their families and carers. Staff from different departments have attended and discussed
how reasonable adjustments are put in place to meet the needs of people with learning disabilities.
There have been discussions led by staff from the Accident and Emergency Department, Ambulance
Service and the Radiology Department.
Other departments have agreed to
support future forums. The members of
the forum have found the opportunity to
discuss their needs valuable.
A member of the Bedford Hospital Learning Disability Forum
takes a tour of an ambulance
78
Patient Transportation
In July 2014, the Trust conducted a survey of 200 patients who had used the Trust’s patient
Transport Service. Forty-six percent patients responded to the survey, providing feedback on nine
aspects of the service (Figure 5). The feedback from patients was extremely positive and several
respondents praised the care and courtesy displayed by the transport drivers.
Figure 5: Results of July 2014 Patient Transport Service survey
100%
90%
80%
70%
Responses (%)
60%
50%
40%
30%
20%
10%
0%
Excellent or Very good
Good or Average
79
Poor or Very poor
Nursing and Midwifery Revalidation
The Nursing & Midwifery Council (NMC) are changing the requirements that the nurses and
midwives must meet when they renew their registration every three years. Revalidation will replace
the Post-Registration Education and Practice (PREP) standards from 31 December 2015.
The revised Code includes a duty of candour that requires nurses and midwives to speak up when
things go wrong and to uphold the reputation of the profession at all times, for example, when using
social media and networking sites.
Under revalidation nurses and midwives will be required to declare that they have:

met the requirements for practice hours and continuing professional development (CPD)

reflected on their practice based on the requirements of the Code, using feedback from
service users, patients, relatives, colleagues and others; and

received confirmation from a third party that their declaration is reliable in accordance with
the NMC’s revised Code (published in March 2015)
In order to meet the new requirements, the Trust has plans in place to link annual staff appraisals
with NMC revalidation.
80
ANNEX 1: SERVICES PROVIDED BY BEDFORD HOSPITAL
NHS TRUST IN 2014/15
Service Description
Accident and Emergency
Blood Transfusion
Breast Surgery
Cardiology
Chemical Pathology *
Critical Care Medicine (ITU)
Dermatology
Diabetic Medicine
Ear Nose and Throat (ENT)
Elderly Care
Endocrinology
Gastroenterology
General Medicine
General Pathology *
General Surgery
Genito-Urinary Medicine/Sexual Health
Gynaecology
Haematology *
Histopathology *
Immunopathology *
Lower Gastro-intestinal
Medical Oncology
Microbiology *
Midwifery
Neonatal
Nephrology**
Neurology
Obstetrics
Ophthalmology***
Oral Maxillofacial
Orthodontics
Paediatrics
Pain Management
Plastic Surgery
Podiatry (Diabetic Outpatients)****
Radiology (includes MRI/CT/Ultrasound)
Rheumatology
Thoracic Medicine*****
Trauma and Orthopaedics
Tunable Dye Laser Treatment
Upper Gastro-intestinal
Urology
Vascular
Speciality Support Services
Audiology
Dietetics
Occupational Therapy
Orthotics*****
Retinal Screening
Service Departments
Occupational Therapy
Pharmacy
Physiotherapy
Speech and Language Therapy****
Theatres
Acute Admissions Unit
* indicates a laboratory service provided by viapath
** indicates a service provided by Lister Hospital - East and North Hertfordshire NHS Trust
*** indicates a service provided by Moorfields Eye Hospital NHS Foundation Trust
**** indicates a service provided by South Essex Partnership Trust (SEPT)
***** indicates a service provided by Papworth Hospital NHS Foundation Trust
****** indicates a service provided by Patterson Healthcare
81
ANNEX 2: STATEMENT FROM COMMISSIONERS,
HEALTHWATCH AND OVERVIEW AND SCRUTINY
COMMITTEES
Bedfordshire Clinical Commissioning Group
82
83
Bedford Borough Council Adult Services and Health Overview and
Scrutiny Committee
84
85
Healthwatch Bedford Borough
Throughout the year Healthwatch Bedford Borough has worked in partnership to improve and
develop the patient experience at the hospital being involved in a number of quality initiatives.
Healthwatch Bedford Borough looked at the quality accounts and was pleased to see the
improvements that had been made against a number of the areas and the action points that were
outlined in terms of the improvements that had been made were clear and understandable. The
format which uses a combination of information and "case histories" makes the document much less
dry and highlight some of the individual areas such as the maternity work and the launch of the" my
name is initiative" where real progress and inclusion have been demonstrated
However whilst accepting that this is a draft document for comment at this stage it is quite
difficult to comment on the areas which are incomplete or highlighted in yellow on the draft
document, in particular the information about responsiveness to the personal needs of patients
would have been of interest.
The lack of improvement against the scores in the Picker survey under the areas of patient
experience was disappointing but as an organisation we are aware and have been involved in the
work to progress this important area.
It was pleasing to see the planned actions to improve and develop the discharge process; however
the increase in readmissions within 28 days seems to be high even when considered against the
overall increase in admissions.
The list of clinical audits is extensive. How many of these audits had patient or carer involvement?
The listed priorities for the next years’ work plans pick up the areas we would hope to see develop.
86
ANNEX 3: STATEMENT OF DIRECTORS’
RESPONSIBILITIES
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 National Health
Service (Quality Accounts) Regulations 2010 (as amended by the National Health Service (Quality
Accounts) Amendment Regulations 2011 and the National Health Service (Quality Accounts)
Amendment Regulations 2012)).
In preparing the Quality Account, directors are required to take steps to satisfy themselves that:

the Quality Accounts 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.
PwC has qualified its limited assurance report in relation to patient safety incident data as outlined
on pages 55 to 57 of the Quality Account.
The directors are satisfied that the Trust’s disclosure of the discrepancy between its internal incident
reporting system and data held by the National Reporting and Learning System (NRLS) has been
clearly identified, quantified and disclosed within the Quality Accounts.
The directors are satisfied that the future reliability and accuracy of patient safety incident data held
by the Trust and submitted to NRLS will be maintained as a result of:

Strengthened corporate risk management and patient safety team;

Increased education and training on incident grading;

Implementation of tighter processes for quality checking grading of incidents by introducing
weekly grading review meetings between the corporate and divisional teams; and
87

Agreed plans to strengthen the divisional governance structure to include accountabilities
for clinical governance.
The directors confirm to the best of their knowledge and belief they have complied with the above
requirements in preparing the Quality Account.
By order of the Board
Chair:
Date:
Chief Executive:
Date:
88
ANNEX 4: EXTERNAL AUDIT LIMITED ASSURANCE
REPORT
INDEPENDENT AUDITORS’ LIMITED ASSURANCE REPORT TO THE DIRECTORS
BEDFORD HOSPITAL NHS TRUST ON THE ANNUAL QUALITY ACCOUNT
We have been engaged by the Board of Directors of Bedford Hospital NHS Trust to perform an
independent assurance engagement in respect of Bedford Hospital NHS Trust’s Quality Account for
the year ended 31 March 2015 (“the Quality Account”) and specified performance indicators contained
therein.
In accordance with section 8 of the Health Act 2009 (“the Health Act”) and the National Health
Service (Quality Accounts) Regulations 2010 and subsequent amendments thereto (the
“Regulations”), the Trust is required to prepare a Quality Account annually.
NHS Quality Accounts Auditor Guidance 2014/15 (the “Auditor Guidance”), published in March 2015
by NHS England, sets out the requirements for our limited assurance work, including the choice of
indicators.
Scope and subject matter
The indicators for the year ended 31 March 2015 subject to limited assurance (the “specified
indicators”); marked with the symbol
as mandated by NHS England:
in the Quality Account, consist of the following indicators
Specified Indicators
Specified indicators criteria
Rate of clostridium difficile infections
page 53-54
Percentage of reported patient safety
incidents resulting in severe harm or death
page 55-57
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.
89
The Directors are required to confirm compliance with these requirements in a statement of directors’
responsibilities within the Quality Account.
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 has not been prepared in line with the requirements set out in the
Regulations;

the Quality Account is not consistent in all material respects with the sources specified in
Auditor Guidance, issued by NHS England on March 2015 and specified below; and

the specified indicators in the Quality Account identified as having been the subject of limited
assurance in the Quality Account have not been prepared in all material respects in
accordance with the Regulations and the six dimensions of data quality set out in the Auditor
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 financial year, April 2014 and up to the date of signing this limited
assurance report;

papers relating to the Quality Account reported to the Board over the period April 2014 to the
date of signing this limited assurance report;

feedback from Bedfordshire Clinical Commissioning Group received 03/06/2015;

feedback from Overview and Scrutiny Committee dated 09/06/2015;

feedback from Healthwatch Bedford Borough dated 12/06/2015;

the Trust’s complaints report published under regulation 18 of the Local Authority, Social
Services and NHS Complaints (England) Regulations 2009, dated April 2015;

the 2014 national patient survey dated February 2015;

the 2014 national staff survey dated May 2015;

the Head of Internal Audit’s annual opinion over the Trust’s control environment dated
28/05/2015;

the annual governance statement dated 03/06/2015;

Care Quality Commission Intelligent Monitoring Report dated May 2015.
90
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 Bedford Hospital
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 Bedford
Hospital NHS Trust for our work or this report save where terms are expressly agreed and with our
prior consent in writing.
We are in compliance with the applicable independence and competency requirements of the Institute
of Chartered Accountants in England and Wales (“ICAEW”) Code of Ethics. Our team comprised
assurance practitioners and relevant subject matter experts.
Assurance work performed
We conducted this limited assurance engagement in accordance with International Standard on
Assurance Engagements 3000 ‘Assurance Engagements other than Audits or Reviews of Historical
Financial Information’ issued by the International Auditing and Assurance Standards Board (‘ISAE
3000’) and the Auditor Guidance. Our limited assurance procedures included:








reviewing the content of the Quality Account against the requirements of the Regulations;
reviewing the Quality Account for consistency against the documents specified above;
obtaining an understanding of the design and operation of the controls in place in relation to
the collation and reporting of the specified indicators, including controls over third party
information (if applicable) and performing walkthroughs to confirm our understanding;
based on our understanding, assessing the risks that the performance against the specified
indicators may be materially misstated and determining the nature, timing and extent of
further procedures;
making enquiries of relevant management, personnel and, where relevant, third parties;
considering significant judgements made by the management in preparation of the specified
indicators;
performing limited testing, on a selective basis of evidence supporting the reported
performance indicators, and assessing the related disclosures; 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.
91
In addition, the scope of our assurance work has not included governance over quality or nonmandated indicators which have been determined locally by Bedford Hospital NHS Trust.
Basis for qualified conclusion
The NHS Quality Accounts Auditor Guidance 2014/15 states that the Trust is required to report the
percentage of reported patient safety incidents resulting in severe harm or death during the reporting
period in line with the following definitions:


Numerator: Number of reported patient safety incidents resulting in severe harm or death at a
trust reported through the National Reporting and Learning Service (NRLS) during the
reporting period.
Denominator: Number of reported patient safety incidents at a trust reported through the
NRLS during the reporting period.
During reconciliation of patient safety incident data between the Trust’s internal reporting system
Datix and the data reported nationally on NRLS, we identified that the Trust had underreported to
NRLS on severe harm and death incidents during the year ended 31 March 2015. The overall impact
upon the reported indicator is as follows:

Severe harm = 6 (0.26% of reported patient safety incidents) compared with NRLS = 7 (0.32%
of reported patient safety incidents); and
 Death = 15 (0.65% of reported patient safety incidents) compared with NRLS = 11 (0.50% of
reported patient safety incidents).
The discrepancies have been fully investigated and disclosed by the Trust in the Quality Report on
page 56.
Conclusion
Based on the results of our procedures, except for the matters described in the basis for qualified
conclusion paragraph above, 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 above;
and

the indicators in the Quality Account subject to limited assurance have not been prepared in
all material respects in accordance with the Regulations and the six dimensions of data quality
set out in the Auditor Guidance.
PricewaterhouseCoopers LLP
10, Bricket Road, St Albans, Herts, AL1 3JX.
Note: The maintenance and integrity of the Bedford Hospital NHS Trust’s website is the responsibility of the
directors; the work carried out by the assurance providers does not involve consideration of these matters and,
accordingly, the assurance providers accept no responsibility for any changes that may have occurred to the
reported performance indicators or criteria since they were initially presented on the website.
92
ANNEX 5: ACRONYMS AND ABBREVIATIONS
A&E
AAU
AKI
ALERT
ALS
BEACH
BLS
BNP
BTS
CAP
CAU
CCG
COPD
CPD
CQC
CQUIN
CTG
DAHNO
DNACPR
DVT
ED
ENT
FFT
GMC
GP
GRS
GUM
HHS
HPA
HSCIC
HSE
HSMR
IBD
ICNARC
ILS
ISO
JAG
MHRA
MINAP
MRSA
NACR
NASH
NBOCAP
NCDAH
NCEPOD
NCRN
NELA
Accident and Emergency
Acute Assessment Unit
acute kidney injury
Acute Life Threatening Events Recognition and Treatment
Advanced Life Support
Bedside Emergency Assessment Course for Healthcare Assistants
Basic Life Support
B-type natriuretic peptide
British Thoracic Society
community acquired pneumonia
Children’s Assessment Unit
Clinical Commissioning Group
chronic obstructive pulmonary disease
Continuing Professional Development
Care Quality Commission
Commissioning for Quality and Innovation payment framework
cardiotacography
Data for Head and Neck Oncology
Do Not Attempt Cardio Pulmonary Resuscitation
deep vein thrombosis
Emergency Department
ear, nose and throat
Friends and Family Test
General Medical Council
General Practitioner
Global Rating Scale
genitourinary medicine
Hyperosmolar Hyperglycaemic State
Health Protection Agency
Health and Social Care Information Centre
Health and Safety Executive
Hospital Standardised Mortality Ratio
inflammatory bowel disease
Intensive Care National Audit & Research Centre
Immediate Life Support
International Organisation for Standardization
Joint Advisory Group
Medicines and Healthcare Products Regulatory Agency (MHRA)
Myocardial Ischaemia National Audit Project
methicillin-resistant Staphylococcus aureus
National Audit for Cardiac Rehabilitation
National Audit of Seizure Management
National bowel cancer audit programme
National Care of the Dying
National Confidential Enquiry into Patient Outcomes and Death
National Cancer Research Network
National Emergency Laparotomy Audit
93
NEWS
NHFD
NHS
NICE
NIHR
NIV
NJR
NMC
NNU
NRLS
NT
OBN
PACC
PALS
PAR
PCNL
PHSO
PLACE
PPC
PREP
PROM
PTWR
QRS
RAG
RAM
RCA
SHMI
SHO
SSNAP
TARN
TDA
TEP
UNICEF
VBAC
VTE
WHO
WTE
National Early Warning System
National Hip Fracture Database
National Health Service
National Institute for Health and Care Excellence
National Institute for Health Research
non-invasive ventilation
National Joint Registry
Nursing and Midwifery Council
Neonatal Unit
National Reporting and Learning System
neural tube
Oxfordshire Biosciences Network
Professional Association of Clinical Coders
Patients’ Advice and Liaison Service
patient at risk
percutaneous nephrolithotomy
Parliamentary and Health Service Ombudsman
Patient Led Assessment of Care Environments
post-operative pulmonary complications
Post-Registration Education and Practice
Patient Reported Outcome Measure
Post-Take Ward Round
Quality Review Scheme
Red, Amber, Green
risk adjusted mortality
Root Cause Analysis
Summary Hospital-level Mortality Indicator
Senior House Officer
Sentinel Stroke National Audit Programme
Trauma Audit and Research Network
Trust Development Authority
Treatment Escalation Plan
United Nations Children’s Fund
vaginal birth after caesarean
venous thromboembolism
World Health Organisation
whole time equivalent
94