Quality
Account
2014-15
QUALITY ACCOUNT 2014-2015
Contents
Page
Part One
Statement on quality from the Chief Executive of the Trust
3
Part Two
Priorities for improvement and statements of assurance from the Board
6
Patient Safety
Patient Experience
Clinical Effectiveness
Mandatory declarations and assurances
Review of services
Participation in clinical audits
Participation in National Confidential Enquiries
Local initiatives in clinical audit
Participation in clinical research
Goals agreed with the Commissioners
25
25
27
29
31
32
33
What others say about us:
The Care Quality Commission (CQC)
Data Quality
Information Governance Toolkit attainment level
Clinical Coding error rate
Department of Health Core Quality Indicators
37
39
39
39
40
Part Three
Other information
48
How we performed on Quality in 2014/15
The Intensive Care Audit
Nursing Technology Fund
Midwifery
Urogynaecology Unit
Top 100 Places to Work
Queen Mary’s Hospital
Patient Led Assessment of the Care Environment
Kent, Surrey and Sussex Safety Collaborative
Falls
Pressure Ulcers
Complaints
NICE Standards compliance
Workforce
‘Our Behaviours’
Statements from other organisations
Dartford Gravesham and Swanley Clinical Commissioning Group
Medway Healthwatch
Kent County Council Overview and Scrutiny Committee (HOSC)
Trust response to comments from other organisations.
48
49
50
50
51
52
53
55
56
58
60
61
62
63
2) Statement of directors’ responsibilities in respect of the Quality Account
64
3) Independent auditors testing of indicators
4) Independent auditors opinion
65
66
How you can comment on this Quality Account
By email – glyn.oakley@dvh.nhs.uk
By letter – Susan Acott, Chief Executive, Darent Valley Hospital, Dartford, Kent DA2 8DA
DGT 2014/15 Quality Account – final
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Part One
Statement on quality from the Chief Executive of the Trust
I am pleased to be writing the introduction to the 2014/15 Quality Account which gives me an opportunity to tell
you how we have concluded the year with strong performance in all of Trust’s key areas of responsibility.
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The Trust has finished with a small surplus of £235k.
The key access target on the 18 weeks maximum waiting time was achieved at 92.4% and achievement of
the A&E 4 hour wait was just below target, at 94.7%.
The very demanding target for health acquired infections measured on C-difficile has been met (17 cases);
and the Trust has had just one MRSA case in 14 months.
81% of patients admitted with a fractured neck of femur (hip) were operated on within 36 hours which is
good, leading to better outcomes for this frail group of patients
The ‘Our Behaviours’ standards which form the basis of the culture of our organisation have been updated
with the values work completed by staff this year.
The Trust’s Hospitalised Standard Mortality Ratio (HSMR) is 89 which is better than average. There are no
issues demonstrated with weekend mortality rates.
The year, 2014/15 has been another busy year for this organisation and for the NHS in general. We, along with
our health and social care partners managed the winter better than most and this was due to better whole
systems working as well as developments around integrated discharge planning and ambulatory care.
There has been much debate and comment in the health media about the new NHS England Chief Executive,
Simon Stephens’ early views on the role of smaller hospitals like ours. I was invited to speak at an event hosted
by the Nuffield Trust on this same subject. I was delighted to take part as I think smaller hospitals have a huge
amount to offer. Hospitals like ours often have a strong culture, are very friendly, have great commitment
amongst the staff and are accessible for the local population. We will have to change over the next few years
however and ensure we have a strategy which is relevant – and I think the clinical strategy which we have is
strong and also flexible.
We also needed to agree a five year strategy and as part of this we have asked staff to become involved to
develop our new vision and values. Many staff have participated in small workshops to tell us what is important
to them and what they think our hospital should stand for. This has proved an important contribution to guide our
overall strategy and plans.
The five year strategy also considers the developments that have taken place in the local area. I attended the
first meeting regarding the new Ebbsfleet housing development and heard first hand that there is already
planning consent for 6,000 houses. Whilst the whole ‘Garden City’ will take several years to deliver in full, I was
surprised to see that building work has already started on the first houses.
I, and other health colleagues, made the point that the design for the Ebbsfleet space needs to be based on
healthy architecture and healthy living space as the most fundamental contribution to the residents’ long-term
health and wellbeing.
We confirmed that the current health infrastructure could not cope with the development and there would need to
be appropriate investment in primary, community and hospital infrastructure. Lastly, we and all of the other
people present expressed concerns regarding the wider infrastructure requirements around roads, rail, schools
and policing. Overall there was wide support for both Ebbsfleet and the Paramount London development as both
were likely to make the whole area more vibrant and attractive, bringing new employment, housing and leisure
opportunities.
In part two of this Quality Account you will find the priorities set by the Trust Board for the year, 2015/16,
together with the results and achievements in respect of the 2014/15 priorities. For 2015/16 there are three
priorities set in each of these areas – Patient Safety, Patient Experience and Clinical Effectiveness.
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For Patient Safety the priorities will be (a) achieving a reduction in the number of inpatient falls which result in
harm; (b) improving the reporting of medication errors within the Trust; and (c) increasing awareness, detection
and treatment of acute kidney injury.
For Patient Experience our priorities will be (a) improving the organisation of care for the population we serve;
(b) reducing the elective Caesarean Section rate; and (c) achieving better patient representation and
engagement in the services provided by the Trust.
For Clinical Effectiveness we will (a) continue to work for improvement in the care of patients who have had a
stroke; (b) develop the Sepsis Six pathways across the Trust; and (c) work at developing care pathways
between primary and secondary care for patients who have frequent admissions to hospital as a result of a long
term condition.
We have also reported on the outcomes and achievements of the last year and the priorities we set ourselves for
2014/15. We have achieved the priorities set for the use of the Safety Thermometer to measure avoidable harms
on the wards; and the national C-difficile target. We have achieved an improvement in the documentation of fluid
balance in patients’ clinical records. In addition, we have partly achieved the patient experience priorities with an
improvement in the scores for treating patients with dignity and respect and, against a background of increased
planned surgical activity; we have achieved a reduction in the number of complaints about cancelled procedures.
The management of pain for children attending our Emergency Department is much better, and there is also
better supervision for junior doctors undertaking emergency gynaecological procedures.
We have done less well in improving the experience of patients being discharged from hospital and in getting a
therapist to see every patient who has a stroke within 24 hours. We have ensured that almost every stroke
patient is seen and assessed by a therapist within 72 hours of admission but the 24 hour target remains
challenging because we are not able to provide a 7 day therapy service for stroke patients.
I fully recognise that this is a standard that we should be able to achieve. So, we are looking at practical ways to
achieve a 7-day service and we have kept this priority for the coming year to ensure that we are accountable for
doing so.
I would also like to tell you about some of the new initiatives and services we have launched this year and you
will find more information about these in Part Three of this report.
The Trust has scored highly in a survey about support provided to the families of patients in our Intensive Care
Unit. This is an area where patients are not able to provide feedback and their family members are in a
particularly stressful situation. It is reassuring to know that our staff recognise and know how to support these
family members in a caring, sensitive and well-informed manner.
Our Midwifery Department has had another successful year with several Midwives gaining awards and
nominations and the service has been awarded the stage 2 Baby Friendly Initiative accreditation. We also
th
delivered the 50,000 baby to be born at Darent Valley Hospital this year.
The Trust has been recognised by the Nursing Technology Fund and awarded funding to complete a real-time
patient tracking solution for the wards. This will better support bed management whilst being compliant with
Information Governance requirements and maintaining the dignity of patients.
th
Dartford and Gravesham NHS Trust has become only the 11 trust in the UK to have a Urogynaecology Unit
accredited with the British Society of Urogynaecology for high standards of patient care. The Urogynaecology
Unit team provide services both at Queen Mary’s Hospital, Sidcup and at Darent Valley Hospital.
This Quality Account also includes the results of the annual NHS national staff survey which was published by
the Care Quality Commission in April 2014. The survey showed that overall staff engagement with this
organisation is in the highest 20% of all Trusts in the country. Our staff said they were able to contribute towards
improvements at work, and that they would recommend the Trust as a place to work or receive treatment.
DGT 2014/15 Quality Account – final
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I share the sense of pride held by staff about the Trust and was pleased to see this acknowledged when the
Trust was rated by the Health Service Journal as one of the top 100 places to work.
In conclusion, this Quality Account includes the mandatory criteria that we are required to report by NHS
England but will also tell you about the services we provide, improvements we have made this year and the
plans we have for the future. It is my responsibility, as Chief Executive, to ensure that we present an honest and
accurate account of the work done at the Trust. I hope that, as you read, you will understand why I am proud of
the achievements of the staff who work here.
I would like to thank all the Trust’s staff, whichever role they fulfil, for delivering care to more patients than ever,
with skill, kindness, intellect and compassion. Staff are resourceful and dedicated and it is to their credit that our
hospital is held in high regard by our local population.
To the best of my knowledge the information in this report is accurate.
Susan Acott
Chief Executive
Dartford and Gravesham NHS Trust
DGT 2014/15 Quality Account – final
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Part Two
Priorities for improvement and statements of assurance from the Trust Board for the
2014/15 Quality Account
In the previous Quality Account the priorities were set for 2014/15 on the basis of feedback
from staff, Governors, patients and commissioners.
The themes decided by the Board were:
 Patient safety
 Patient experience
 Clinical effectiveness
These were linked to the Commissioning for Quality and Innovation (CQUIN) payment
framework and other contractual quality mechanisms the priority being to ensure that no
patient suffers avoidable harm or complications whilst in our care.
The 2014/15 priorities were selected by the Trust Board having reviewed information from
many sources for example; incidents reported by staff, letters and complaints from patients
and/or their carers, comments placed by service users on the NHS Choices website and other
social media, internal audit outcomes and data published by the Health and Social Care
Information Centre.
Summary of results and achievements for the 2014/15 Quality Account
priorities
Patient Safety
Continued use of Safety Thermometer to measure falls,
Priority 1 pressure ulcers, urinary tract infections and VTE assessment
(venous thromboembolism).
To achieve or better the nationally set Trust target for Hospital
Priority 2 Acquired Infections in respect of Methicillin-resistant
Staphylococcus aureus (MRSA) and C-difficile.
Priority 3
To improve the documentation of fluid balance in each patient’s
clinical records as part of clear nursing documentation.
Achieved/Notachieved
Fully achieved
Partially achieved
Fully achieved
Patient Experience
Priority 1
Improve patient experience in respect of privacy and dignity in
different areas in the Trust.
To improve the patient experience of discharge planning
following an inpatient episode of care.
Improve the processes of scheduling elective admissions and
patient contacts to minimise cancellation or rescheduling of
Priority 3
procedures by the Trust aiming to reduce hospital cancellations
by 20%.
Clinical Effectiveness
To improve aspects of care given to patients admitted following
Priority 1 stroke in respect of admission; swallow assessment and
assessment by therapists.
To improve the management of pain in paediatric patients in the
Priority 2
Emergency Department in line with NICE Guidance.
Priority 2
Priority 3
To improve supervision of junior doctors undertaking
emergency gynaecological procedures.
DGT 2014/15 Quality Account – final
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Partially achieved
Not achieved
Partially achieved
Partially achieved
Fully achieved
Fully achieved
Results and achievements for the 2014/15 Quality Account priorities
A) PATIENT SAFETY
Priority 1: We will continue the use of Safety Thermometer to measure falls, pressure
ulcers, urinary tract infections and VTE assessment (venous thromboembolism).
Background
The NHS Safety Thermometer (ST) has been
designed to be used by frontline healthcare
professionals. It measures a snapshot of harms
once a month from pressure ulcers, falls, urinary
infection in patients with catheters and treatments
for VTE.
The NHS Safety Thermometer provides a
‘temperature check’ on harm and can be used
alongside other measures of harm to measure local
and system progress. In April 2012, the Safety
Thermometer became a monthly tool under the National Operating Framework.
The tool was designed to measure local improvement over time and should not be used to
compare organisations. Important considerations are:
 Demographics and case mix of patients surveyed.
 Not all harm is avoidable.
 Operational definitions can be interpreted by data collectors.
 Causation can occur both in and out of hospital.
 The national standard was originally set at 95% in 2010 however this has since
changed so that Trusts are expected to show year on year improvement goals. In
December 2014 the rate was 94.1%.
Why was this a priority?
We looked at the NHS Safety Thermometer as one of a number of vehicles in engaging staff
in the promotion of a safety culture.
What was our aim?
The Trust aimed to achieve the national standard by the end of 2014 and continue this
improvement theme in 2015.
Did we achieve this priority?
This standard (94.1%) was not reached in December 2014 but was achieved in January
2015.
DGT 2014/15 Quality Account – final
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Safety Thermometer results
Month
Trust September 2013
(baseline)
Harm Free (%)
93.67%
Old Harms (%)
3.17%
New Harms (%)
3.17%
Trust April 2014
91.25%
6.25%
2.71%
Trust January 2015
95.64%
3.27%
1.09%
National dataset Jan 2015
93.9%
3.7%
2.4%
Source: NHS Safety Thermometer database
How have we improved our performance?
The improved performance is focussed on achieving successful data collection together with
an overall improvement in harm-free care since 2012. The Trust will continue to focus on
reducing harm in all four categories - in particular pressure area damage.
How did we measure and monitor our improvement?
Through monthly submissions to the NHS Safety Thermometer database which feeds into the
Health and Social Care Information Centre.
How was progress reported?
The Trust Quality and Safety Committee receives a six monthly report on the NHS Safety
Thermometer performance.
Our key achievements:
 100% data collection in all inpatient bed areas on a monthly basis.
 Monthly data validation with ward sisters from the collection team on the same day
collection.
 Increased awareness of Safety Thermometer among ward staff, ward sisters and
Matrons.
 Review of all falls occurring in the Trust by the Falls Steering Group which is chaired by
the Director of Nursing and Quality.
 Harm Free Care is a monthly agenda item at the Clinical Nurse and Midwifery Board.
 Safety Thermometer results published monthly in Board Papers.
 Root Cause Analysis of all Grade 3 and 4 Pressure ulcers - led by the Director of
Nursing and Quality
The Executive Lead for Safety Thermometer is the Director of Nursing and Quality.
Priority 2: To achieve or better the nationally set Trust target for Hospital Acquired
Infections in respect of Methicillin-resistant Staphylococcus aureus (MRSA) and Cdifficile.
Why was this a priority?
The Trust is maintaining a focus on infection prevention and control initiatives to continue
reduction of hospital acquired infections.
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What was our aim?
The aim was to have sufficiently robust systems in place so as to be able to meet the
nationally set standard.
Did we achieve this priority?
This priority was achieved for C-difficile.
However there was one MRSA case assigned to the Trust in March which was disappointing
as it was the first case for 14 months.
Period
Trust C-difficile cases
MRSA cases
National target 2014/15
17
0
Trust cases 2014/15
17
1
Source: GOV.UK - Clostridium difficile infection: annual data (10/07/2014)
How have we improved our performance?
 The introduction and embedding of a new drug chart within the Trust which has
separate pages for antimicrobial prescribing and allows only 7-day prescribing. This
ensures a review after 7 days. The chart also includes a very obvious field (in red)
recording the patient’s MRSA status.
 Increased use of the electronic Pharmacy data collection system to allow close
monitoring of prescribing, and prompt intervention when necessary.
 Monthly reporting of the Hospital Antimicrobial Prudent Prescribing Indicator (HAPPI
audit) which is part of the antimicrobial stewardship guidance for hospitals issued by
the NHS England. The audit is a spot check on each ward that, for all patients on
antibiotics, the medication has been administered as prescribed for the correct number
of days and changed from intravenous to oral antibiotics when appropriate.
 The internal Trust standard to achieve a ‘green’ rating in the HAPPI audit was raised
during the year to make it harder for clinical areas to score ‘green’.
How did we measure and monitor our improvement?
Progress to achieve this priority was measured and monitored by submissions to the Public
Health England database and by reports to the Trust Quality and Safety Committee on the
Quality Account priorities.
How was progress reported?
Progress was reported to the Trust Quality and Safety Committee and Trust Board. In
Submissions to the Public Health England and data published by the Health and Social Care
Information Centre (HSCIC).
The Executive Lead for the prevention and control of infection is the Medical Director.
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Priority 3: To improve the documentation of fluid balance in each patient’s clinical
records as part of clear nursing documentation.
Why was this a priority?
A review of the clinical documentation of deteriorating patients who are the subject of a
Medical Emergency Team (MET) call shows that fluid balance is often poorly documented or
interpreted.
What was our aim?
To demonstrate by clinical audit an improvement on the baseline internal audit ‘Observations
and Fluids Audit’ completed in quarter two, November 2014. This is an annual audit carried
out by the Outreach Nurses to establish Trust compliance with NICE CG50 and local policy.
Did we achieve this priority?
This priority was achieved.
Results of fluid balance audit
2013
2014
Recording of patient demographics
82%
92%
Full date and current ward
documented?
88%
88%
Fluid Balance – Input:
38%
49%
Fluid Balance – Output:
34%
41%
Total fluid balance
18%
21%
Previous 24hr balance
20%
17%
Source: Trust information system.
How have we improved our performance?
By creating a robust clinical audit and having a good pathway of accountability as follows:
 This local audit is registered with the Clinical Audit Department and uses a
standardised audit form, making it easily repeatable for on-going monitoring.
 Local audit results are presented at the Nursing and Midwifery Board and the Ward
Sisters meeting so that collective learning can take place.
 The Matrons and the Ward Sisters meet with the Director of Nursing and Quality to
discuss the outcomes and progress for each ward.
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How did we measure and monitor our improvement?
Progress to achieve this priority was monitored and measured by re-audit following
implementation of the new documentation and by reports to the Trust Quality and Safety
Committee on the Quality Account priorities.
How was progress reported?
Progress was reported to the Audit Leads Committee and the Trust Quality and Safety
Committee.
The Executive Lead for clinical services is the Medical Director.
B) PATIENT EXPERIENCE
Priority 1: Improve patient experience in respect of privacy and dignity in different
areas in the Trust.
Why was this a priority?
The CQC Inpatient survey is one of a number of ways used as part of the programme to
engage staff in promoting improved patient experience.
What was our aim?
To improve the responses to the following questions in the CQC 2014 Inpatient survey:
 Q11 Did you share a sleeping area with patients of the opposite sex?
 Q14 Did you use the same bathroom or shower area as patients of the opposite sex?
 Q37 Were you given enough privacy when discussing your condition or treatment?
 Q38 Were you given enough privacy when being examined or treated?
 Q66 Overall, did you feel you were treated with respect and dignity in hospital?
Did we achieve this priority?
This priority was partly achieved.
2013 result
(out of 10)
2014 result
(out of 10)
Q11 Did you share a sleeping area with patients
of the opposite sex?
7.8
8.4
worse
Q14 Did you use the same bathroom or shower
area as patients of the opposite sex?
7.7
7.5
better
Q37 Were you given enough privacy when
discussing your condition or treatment?
8.3
8.2
same
Q38 Were you given enough privacy when
being examined or treated?
9.4
9.4
same
Q66 Overall, did you feel you were treated with
respect and dignity in hospital?
8.7
8.8
same
Question
Source: CQC Inpatient Survey 2014
DGT 2014/15 Quality Account – final
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Better / Worse or
the same
How have we improved our performance?
 Patient experience is regularly discussed at the Ward Sisters meeting.
 The Director of Nursing and Quality has reviewed the terms of reference for the Patient
Experience Group and chairs the meetings.
 The 2014 CQC Inpatient Survey indicates that scores are similar or improved on the
results of the 2013 survey.
 The response to Q11 is less good reflecting the pressures of increased activity in the
Trust and the imbalance between admissions and discharges.
How did we measure and monitor our improvement?
Progress to achieve this priority was measured using the CQC inpatient survey and monitored
by reporting on the above questions in the CQC 2014 Inpatient Survey to the Trust Quality
and Safety Committee.
How was progress reported?
Reporting to the Trust Quality and Safety Committee, which is a sub-committee of the Trust
Board.
The Executive Lead for patient experience is the Director of Nursing and Quality.
Priority 2: To improve the patient experience of discharge planning following an
inpatient episode of care.
Why was this a priority?
The CQC Inpatient survey is one of a number of ways used as part of the programme to
engage staff in promoting improved patient experience.
What was our aim?
To improve responses to the following questions in the CQC 2014 Inpatient survey:





Q49 Did you feel you were involved in decisions about your discharge from hospital?
Q50 Were you given enough notice about when you were going to be discharged?
Q60 Did hospital staff take your family or home situation into account when planning
your discharge?
Q61 Did the doctors or nurses give your family or someone close to you all the
information they needed to care for you?
Q62 Did hospital staff tell you who to contact if you were worried about your condition
or treatment after you left hospital?
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Did we achieve this priority?
An improvement in this priority has not been achieved.
2013 result
(out of 10)
2014 result
(out of 10)
Q50 Did you feel you were involved in decisions
about your discharge from hospital?
6.6
6.7
same
Q51 Were you given enough notice about when
you were going to be discharged?
6.7
6.4
worse
7.2
6.7
worse
5.7
5.8
same
7.7
7.6
same
Question
Q61 Did hospital staff take your family or home
situation into account when planning your
discharge?
Q62 Did the doctors or nurses give your family
or someone close to you all the information they
needed to care for you?
Q63 Did hospital staff tell you who to contact if
you were worried about your condition or
treatment after you left hospital?
Better / Worse or
the same
Source: CQC Inpatient Survey 2014
How have we improved our performance?
The CQC guidance on the interpretation of the report advises that the small variations in the
scores are not statistically significant so the conclusion should be that whilst the results
statistically are no worse they do not demonstrate a measurable improvement.
How did we measure and monitor our improvement?
Progress to achieve this priority was measured using the CQC inpatient survey and monitored
by reporting on the above questions in the CQC 2014 Inpatient Survey to the Trust Quality
and Safety Committee.
How was progress reported?
By reporting to the Trust Quality and Safety Committee, which is a sub-committee of the Trust
Board.
The Executive Lead for patient experience is the Director of Nursing and Quality.
Priority 3: Improve the processes of scheduling elective admissions and patient
contacts to minimise cancellation or rescheduling of procedures by the Trust aiming to
reduce hospital cancellations by 20%.
Why was this a priority?
A number of complaints have been received concerning the inconvenience of cancellation or
rescheduling of appointments.
Complaints may be received as a formal, written complaint or via the Patient Advice and
Liaison Service (PALS) which offers confidential advice, support and information on healthrelated matters. PALS provides a point of contact for patients, their families and their carers.
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What was our aim?
The Trust received a number of written complaints reflecting similar concerns associated with
the inconvenience of cancelled appointments and having these rebooked by the Trust. The
aim was to improve the experience of patients using Trust services by reducing the number of
occasions when this occurred and so improving the experience of patients and service users.
Any improvement would be reflected in the number of written and PALS complaints received.
Complaints received about scheduling elective admissions or rescheduling of procedures
Formal written and PALS
complaints received
Complaints per 1,000 bed
days
Number of procedures
2013/14
2014/15
25
29
1.8
2
26,156
31,485
Percentage change
13.8%
10%
increased
increased
20.4% increased
Source: Trust information systems
This priority did not improve and the Trust recorded a 10% increase in the number of
complaints received but this should be considered against the increased activity and a
20.4% increase in the number of procedures carried out.
The Trust did achieve the 20% reduction in cancelled operations target.
Cancelled operations 2013/14 and 2014/15 reduced by 20%
Cancelled operations rate by
monthly submissions of
**HES/SUS CCS Group
2013/14
2014/15
Percentage
change
256
194
24.2% decreased
Source: Monthly submissions national reporting
** Hospital Episode Statistics, Secondary User Statistics Clinical Classification System
Did we achieve this priority?
This priority was partly achieved as although there was an increase in the number of formal
complaints received the number of operation cancelled was reduced.
How did we measure and monitor our improvement?
This priority was measured and monitored using data reported into Trust information systems
on the number of formal and informal complaints received and the reported activity targets to
NHS England.
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How was progress reported?
Progress was reported to the Trust Quality and Safety Committee as part of reporting on the
Quality Account priorities.
The Executive Lead for patient experience is the Director of Nursing and Quality.
C) CLINICAL EFFECTIVENESS
Priority 1: Improvements in the care of patients who have had a stroke. Continuing the
work of 2013/14 we will ensure that;
 75% of patients admitted following a stroke are admitted directly to the Stroke
Unit (national average is 73%).
 65% of patients have a swallow assessment completed within 4 hours of
admission (national average is 56%).
 60% of stroke patients are assessed by a Physiotherapist within 24 hours
(national average is 48%).
 45% of stroke patients are assessed by an Occupational Therapist within 24
hours (national average 37%).
 80% of eligible stroke patients are assessed by a Speech and Language
Therapist for communication impairment within the first 24 hours (national
average is 16%).
Baseline: Current data on achievement of the Sentinel Stroke National Audit Programme
(SSNAP) survey indicators as shown in the table below.
Why was this priority?
A direct admission to a Stroke Unit is seen as the most important marker in improving the
quality of stroke care. Recent research and clinical audit reviews have shown that access to a
high quality Stroke Unit with access to each speciality of Therapist is associated with reduced
mortality and improved outcomes for the patient.
What was our aim?
To achieve an outcome equal to, or better than, the national average for acute trusts in
respect of the SSNAP survey indicators.
Sentinel Stroke National Audit Programme (SSNAP) Organisational data results for the
reporting period to October 2014
Table to show SSNAP data for 2013/14 and latest published DGT performance (Oct-Dec 2014)
First ward of admission = stroke unit
National average
as of 31/03/14
DGT Jan to
Mar 2014
DGT Oct to
Dec 2014
National average
as of 31/12/14
73%
64%
77% ↑ better
76%
56%
59%
72% ↑better
69%
48%
35%
49% ↑ better
56%
Swallow screening within 4 hours
Assessed by Physiotherapist within
24 hours
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Assessed by OT* within 24 hours
Assessed by SALT** within 24 hours
(note: 50% of patients admitted to
DGT had no deficit requiring SALT
assessment for communication).
37%
10%
41% ↑ better
47%
16%
19%
25% ↑ better
38%
* OT = Occupational Therapist
**SALT = Speech and Language Therapist
Source: Sentinel Stroke National Audit Programme (SSNAP) data
Did we achieve this priority?
Priority
Admission to
ward
Swallow
screening
Physiotherapist
Occupational
Therapist
Speech and
Language
Therapist
Source: Sentinel Stroke National Audit Programme (SSNAP) data
How have we improved our performance?
 The Executive Board have agreed in principle to keep a ring-fenced bed for available
for acute stroke admissions. This principle is adhered to, however, it is jeopardised
when there are extreme bed pressures throughout the hospital.
 All of the indicators have shown an improvement compared to the Jan – Mar 2014
results, but not sufficiently improved to achieve the target.
How did we measure and monitor our improvement?
Progress to achieve this priority was monitored and measured in reports to the Trust Quality
and Safety Committee on the Quality Account priorities and the results of the National
Sentinel Stroke Audit.
How was progress reported?
Progress was reported to the Trust Quality and Safety Committee as part of reporting on the
Quality Account priorities.
The Executive Lead for clinical services is the Medical Director.
Priority 2: To improve the management of pain in paediatric patients in the Emergency
Department in line with NICE Guidance.
Why was this a priority?
The CQC inspection in December 2013 highlighted a need for improvement in pain
management for child patients attending the Emergency Department.
DGT 2014/15 Quality Account – final
16
What was our aim?
The aim was to improve the assessment of child patients and the management of their pain
whilst they were patients in the Emergency Department.
Did we achieve this priority?
There has been a steady improvement in the documentation of initial pain scores in the notes
of child patients presenting at the Paediatric Emergency Department. The documentation of
the review pain score, which is necessary to see if the medication has been effective, is less
good and has not shown a significant improvement.
Initial pain score
completed
Review of pain score
documented
Baseline
April 2014
47%
4%
Quarter 4
Jan-Mar 2015
96%
9%
Source: Paediatric Emergency Department audit data.
Pain Score Documented
120%
100%
80%
60%
Pain Score Documented
40%
20%
APR
MAR
FEB
JAN
DEC
NOV
OCT
SEP
AUG
JUL
JUN
MAY
APR
0%
Source: Paediatric Emergency Department audit data.
How have we improved our performance?
 A Paediatric sub-group has been established as part of the Emergency Care Redesign
project and has commenced a review of paediatric pathways.
 Senior paediatric nurses consistently monitor triages during their shift and support
colleagues to correct omissions.
 Time agreed for referral to paediatrics is now agreed as being a maximum of 30
minutes after triage.
 Level of paediatric nursing cover in the Paediatric ED increased to 24 hour cover.
How did we measure and monitor our improvement?
This priority was monitored and measured in reporting of the Paediatric audit outcomes to the
Trust Quality and Safety Committee.
DGT 2014/15 Quality Account – final
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How was progress reported?
Progress to achieve this priority was monitored by reports to the Trust Quality and Safety
Committee as part of reporting on the Quality Account priorities.
The Executive Lead for clinical services is the Medical Director.
Priority 3: To improve supervision of junior doctors undertaking emergency
gynaecological surgical procedures.
Baseline: Consultant cover for the number of emergency operations during 2013/14 done by
junior doctors. Procedures to be counted identified from OPCS codes.
Why was this a priority?
The Trust is responding to a concern raised by junior doctors regarding the supervision
arrangements for junior doctors undertaking emergency procedures in gynaecology.
Did we achieve this priority?
This priority was achieved. The number of procedures has increased which reflects good
training opportunities for junior doctors. It is still the case that a Consultant is not in theatre for
every procedure but the Directorate scored well in the 2014 survey of the opinions of junior
doctors training in Gynaecology in the national survey carried out by the General Medical
Council (GMC)
Number of surgical procedures carried out by junior doctors in 2013/14 and 2014/15
2013/14
Number of emergency
gynaecological operations
carried out by junior doctors
29
2014/15
38
Source: Trust information systems (correct to Dec 2014)
Outcome indicator scores for junior doctor trainees in Obstetrics and Gynaecology
from the 2014 General Medical Council national survey 2014
Indicator score for:
DGT mean 2014
National mean 2014
Clinical supervision
89.9 ↑ better
87.4
Induction
88.0 ↑ better
84.9
Adequate experience
89.0 ↑ better
78.8
Overall satisfaction
86.0 ↑ better
78.6
Source: General Medical Council (GMC) National Trainee Survey 2014
DGT 2014/15 Quality Account – final
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How have we improved our performance?
 Consultants now review all emergency admissions within 24 hours of admission.
 Phone calls from the Emergency Department are now taken by the Registrar level
doctor not the Senior House Officer.
 Clinical Director reports that trainees do not operate unsupervised or beyond level
of their expertise. This requires most cases to be supervised by a Consultant.
How did we measure and monitor our improvement?
Monitoring of the number of emergency gynaecological operations carried out by junior
doctors in 2014/15. Progress to achieve this priority will be monitored and measured in
quarterly reports to the Trust Quality and Safety Committee.
How was progress reported?
Progress was reported to the Trust Quality and Safety Committee as part of reporting on the
Quality Account priorities.
The Executive Lead for clinical services is the Medical Director.
Introduction to the 2015/16 priorities for improvement
The next section describes our priorities for quality improvement in the coming year
2015/16 and provides the required statements of assurance from the Board with regard
to services, clinical audit, research, clinical quality goals, CQC registration and data
quality, the priority being to ensure that no patient suffers avoidable harm or
complications whilst in our care.
Qualitative information from a number of sources including patient surveys, staff surveys and
complaints has helped inform the Trust’s priorities for 2015/16.
The themes decided by the Board were:
 Patient safety
 Patient experience
 Clinical effectiveness
These priorities have been agreed by the Trust Board and each priority has an identified
Executive Director lead. Progress towards achieving these priorities will be recorded in the
Trust internal data management systems and submissions to the external reporting bodies
e.g. Public Health England, the National Patient Safety Agency and the Health and Social
Care Information Centre as per the reporting schedule. Progress and interim results will be
reported to the Trust Patient Safety Committee and the Trust Quality and Safety Committee,
the latter being a sub-committee of the Trust Board. The minutes of the Trust Board are
published on the Trust website.
Some of the schemes presented here also form part of the Commissioning for Quality
Improvement (CQUIN) programme, agreed with our local lead commissioners, Dartford
Gravesham and Swanley Clinical Commissioning Group (CCG).
The following priorities under the headings of Patient Safety; Patient Experience; and Clinical
DGT 2014/15 Quality Account – final
19
Effectiveness were selected by the Trust Board having reviewed information from incidents
reported by staff, letters and complaints from patients and/or their carers, comments placed
by service users on the NHS Choices website and other social media and internal audit
outcomes.
A) PATIENT SAFETY
Priority 1: To achieve a reduction in the number of falls sustained by patients in the
inpatients setting together with a reduction in the number of fractures resulting from
an inpatient fall.
Why is this a priority?
Falls are serious at any age, and breaking a bone after a fall becomes more likely as a person
ages. The fracture may require surgery which has associated risks and the person’s
independence and activities are limited whilst recovering. Preventing falls in hospital is
important because the recovery period can add to the time spent in hospital and is a serious
consequence to a person who is already unwell.
Baseline: Trust performance in 2014/15, the number of falls resulting in a fracture or other
significant harm.
Measurement: Progress to achieve this priority will be monitored and measured by incidents
reported by staff to the Datix incident reporting system and monitored by the Trust falls group.
How will progress be reported?
Progress will be reported to the Trust Quality and Safety Committee which is a sub-committee
of the Trust Board, on the Quality Account priorities.
Priority 2: To improve the reporting of medication errors within the Trust and reduce
the number of inappropriate omissions of doses of medication.
Why is this a priority?
Medication incidents are the second most commonly reported incident to the National
Reporting and Learning System (NRLS). These may be ‘near misses’ where the potential
injury is avoided or incidents resulting in actual harm. The Trust can improve patient safety if
there is understanding of the circumstances and mechanisms by which mistakes occur and
this will happen if staff are encouraged and supported to report incidents. Only when the
causes are understood will patient safety improve.
Baseline: Medication incidents reported to the NRLS by the Trust in 2014/15.
Measurement: Progress to achieve this priority will be monitored by submissions to the
National Reporting and Learning System database and by reports to the Trust Medicines
Management Committee.
DGT 2014/15 Quality Account – final
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How will progress be reported?
Progress will be reported to the Trust Quality and Safety Committee which is a sub-committee
of the Trust Board, on the Quality Account priorities.
Priority 3: To increase the awareness of the prevention, detection and treatment of
acute kidney injury to support the prevention of avoidable harm related to AKI in all
care settings.
Why is this a priority?
This priority is high profile nationally with increasing numbers of frail elderly people in hospital
and is also a possible complication of some medications likely to be prescribed for this group
of patients. It is therefore a significant issue for safer patient care and has been designated a
national priority within the Commissioning for Quality Improvement (CQUIN) agenda.
Baseline: A local audit to show the number of patients in the Trust with deteriorating renal
function in a two week period in quarter one of 2015/16.
Measurement: Progress to achieve this priority will be monitored with a re-audit of the above
to measure the number of patients in the Trust with deteriorating renal function in a two week
period in quarter four of 2016.
How will progress be reported?
Progress will be reported to the Trust Quality and Safety Committee which is a sub-committee
of the Trust Board, on the Quality Account priorities.
B) PATIENT EXPERIENCE
Priority 1: To improve patient experience by improving the organisation of care for the
population we serve.
Why is this a priority?
The Trust values all communications, written and verbal, formal and informal, received from
patients and people who have contact with our services. A number of formal complaints have
been received which include communication by Trust staff within the complaint. The Trust
Board views poor communication seriously and has designated this as a priority for
improvement across the organisation.
Baseline: The number of formal complaints received which include a complaint about the
communication standards of a staff member as an element of the complaint.
Measurement: The number of complaints recorded is monitored each month and progress to
achieve this priority will be shown in patient experience reports to the Trust Quality and Safety
Committee.
DGT 2014/15 Quality Account – final
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How will progress be reported?
Progress will be reported to the Trust Quality and Safety Committee which is a sub-committee
of the Trust Board, on the Quality Account priorities.
Priority 2: To reduce the elective Caesarean Section rate at the Trust
Why is this a priority?
The Trust rate for elective Caesarean Section is higher than the peer average and has been
the subject of an alert from the Care Quality Commission (CQC).
Baseline: The Trust rate for Caesarean in 2014/15.
Measurement: Progress to achieve this priority will be measured and monitored via the
Midwifery dashboard reflected in the Directorate report to the Trust Quality and Safety
Committee.
How will progress be reported?
Progress will be reported to the Trust Quality and Safety Committee which is a sub-committee
of the Trust Board, on the Quality Account priorities.
Priority 3: To achieve better patient representation and engagement in the services
provided by the Trust.
Why is this a priority?
The Trust Board recognises that involvement of people and organisations external to the
organisation is needed at different levels to get real time feedback which can be used to
improve services provided by the Trust.
Baseline: The number of Trust committees or groups with lay membership in 2014/15,
currently three; the Research and Development Sub-committee, the Maternity Services
Liaison Committee and the Patient Experience Committee.
Measurement: Progress to achieve this priority will be monitored and measured when
revisions of the terms of reference for Trust committees are received.
How will progress be reported?
Progress will be reported to the Trust Quality and Safety Committee which is a sub-committee
of the Trust Board, on the Quality Account priorities.
DGT 2014/15 Quality Account – final
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C) CLINICAL EFFECTIVENESS
Priority 1: Priority 1: Improvements in the care of patients who have had a stroke.
Continuing the work in 2014/15 we will ensure that;
 More than 76% of patients admitted following a stroke are admitted directly to
the Stroke Unit (national average is 76%).
 More than 69% of patients have a swallow assessment completed within 4 hours
of admission (national average is 69%).
 More than 56% of stroke patients are assessed by a Physiotherapist within 24
hours (national average is 56%).
 More than 47% of stroke patients are assessed by an Occupational Therapist
within 24 hours (national average 47%)
 More than 38% of stroke patients are assessed by a Speech and Language
Therapist for communication impairment within the first 24 hours (national
average is 38%).
Baseline: The SSNAP audit percentages for each of the above achieved between October
and December 2014 which is the current report.
Why was this a priority?
Achievement of the metrics used in the SSNAP audit is recognised as best practice in the
provision of care and rehabilitation for patients suffering a stroke. The Trust does better in
achieving some indicators than others and has a continued aspiration to improve care for
patients suffering a stroke in 2015/16.
Measurement: Progress to achieve this priority will be monitored and measured in reports to
the Trust Quality and Safety Committee which include the results of the National Sentinel
Stroke Audit.
How will progress be reported?
Progress will be reported to the Trust Quality and Safety Committee which is a sub-committee
of the Trust Board, on the Quality Account priorities.
Priority 2: To maintain and progress improvements made in the care of patients
presenting with, or developing, sepsis by the trust-wide implementation of the metrics
used in the Sepsis Six pathway.
Why was this a priority?
This is a priority because ensuring that these six actions are taken within the first hour after
diagnosis can double the patient’s chances of survival. With each hour of delay the mortality
rate increases. The Sepsis Six are:
 Administer of high flow oxygen.
 Take blood cultures.
 Give broad spectrum antibiotics.
 Give intravenous fluid challenges.
 Measure serum lactate and haemoglobin
DGT 2014/15 Quality Account – final
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
Measure accurate hourly urine output.
Baseline: A local audit of Emergency Department admission cards against the Sepsis Six
metrics, 20 cards in quarter one of 2015/16 and repeated for 20 cards in quarter four of
2015/16.
Measurement: Progress to achieve this priority will be monitored and measured by the
Mortality Working Group reporting to the Patient Safety Committee.
How will progress be reported?
Progress will be reported to the Trust Quality and Safety Committee which is a sub-committee
of the Trust Board, on the Quality Account priorities.
Priority 3: To develop care pathways between primary and secondary care for patients
who have frequent admissions to an acute bed as a result of failure, or inability, to
manage an exacerbation of a pre-existing long-term condition.
Why was this a priority?
The Trust sees a number of patients with long term conditions admitted and readmitted due to
a worsening of their condition that is not managed outside the hospital when they are at
home. Sometimes this may be due to the patient not having sufficient knowledge to become
successfully self-caring, and sometimes it may be because there is insufficient service
provision in the community to provide support.
Baseline: The number of clinical care pathways between primary and secondary care which
existed in the Dartford and Bexley area in 2014/15
Measurement: Progress to achieve this priority will be monitored and measured by recording
the pathways in quarter one of 2014/15 and recording each additional pathway until the end
of quarter four in 2016.
How will progress be reported?
Progress will be reported to the Trust Quality and Safety Committee which is a sub-committee
of the Trust Board, on the Quality Account priorities.
DGT 2014/15 Quality Account – final
24
Mandatory declarations and assurances
The information on the following pages contains mandatory text that all NHS trusts must
include in their Quality Account. We have added some explanations of key terms.
The requirement for all NHS trusts to produce Quality Accounts is included in Chapter 2 of the
Health Act 2009. Subsequent to the Act guidance may be issued annually by the Secretary of
State for Health relating to the content and form of trust Quality Accounts. Dartford and
Gravesham NHS Trust receives this guidance in notification by letter(s) issued by the NHS
England and the implementation of the guidance is overseen by a designated Executive
Director.
Statements of assurance
Review of Services
During 2014/15 the Dartford and Gravesham NHS Trust provided and/or sub-contracted
twelve relevant health services.
The Dartford and Gravesham NHS Trust has reviewed all the data available to them on the
quality of care in twelve of these relevant health services.

Emergency Department (Accident and Emergency).

Acute inpatient care: medicine and surgery, both elective (planned) and emergency
(unplanned).

Critical care (Intensive Care) and Theatres.

Daycare.


Outpatient care.
Maternity services.


Gynaecology services.
Children’s services.


Therapy services.
Pathology, Radiology and Pharmacy services
The income generated by the relevant health services reviewed in 2014/15 represents 88.6
per cent of the total income generated from the provision of relevant health services by the
Dartford and Gravesham NHS Trust for 2014/15.
The Trust receives the other 11.4% of its income for other aspects of work for example;
training and education, research and development, recharges of salaries and wages for staff
working at other organisations and other direct credit and miscellaneous income.
Each clinical directorate is led by a senior doctor, who is responsible for monitoring quality in
the directorate through the directorate’s governance processes and the directorate Quality
DGT 2014/15 Quality Account – final
25
Laboratories (Q-Labs). For Q Labs the information is collated and produced by Caspe
Healthcare Knowledge Systems (CHKS), the Trust’s partner for data analysis and is a
significant element of this assurance process. The Q-Lab is a clinical meeting at which
multidisciplinary teams (doctors, nurses, therapists, midwives and managers) review detailed,
comparative clinical quality indicators and patient care data, mortality rates at speciality level,
with complications and re-admissions.
Services are managed through a clinical directorate structure
Chairman
Janardan Sofat
Chief Executive
Susan Acott
Deputy
CEO/Director of
Operations
Gerard Sammon
Radiology
Department Clinical
Director
Dr Paul Holder
Medical Director
Annette Schreiner
Vikki Carruth
Surgical Directorate
Clinical Director
Mr Jacek Adamek
Pathology
Directorate Clinical
Director
Dr Maadh Aldouri
Director of Nursing
and Quality
Emergency
Department Clinical
Director
Dr Winston Martin
Medical Directorate
Clinical Director
Dr Philip Mairs
Children’s
Directorate Clinical
Director
Dr Selwyn D’Costa
Theatres, ITU and
Critical Care
Directorate Clinical
Director
Dr Mike Protopapas
Women’s
Directorate Clinical
Director
Mr Rob McDermott
Orthopaedic
Directorate Clinical
Director
Mr Farid Moftah
Clinical Directorate Structure April 2014-March 2015
The clinical directorates each have individual governance meetings which report into the
Trust’s Quality and Safety Committee, which is a sub-committee of the Trust Board and
chaired by a Non Executive Director. Each month the Directorate Governance Committees
review complaints and compliments, incidents, compliance with national requirements and
standards and data from clinical audits. The agenda is centred on patient safety, patient
experience and clinical effectiveness.
The Q-Lab is our in-house system to compare ourselves against other providers. It is a
process of systematically reviewing the Trust's data firstly to ensure that no untoward
outcomes go unnoticed and secondly to present data to clinicians at regular intervals to
enhance their understanding and ownership of these data and the outcomes they represent.
Q-Lab usually takes a one hour slot in the monthly directorate clinical audit meetings every
three to four months.
Sometimes being an outlier requires further investigation or a review of the clinical pathway or
DGT 2014/15 Quality Account – final
26
protocol, for example; in December 2013 the General Surgery Directorate looked at
readmissions which overall were comparable to peer, but were high for appendicectomy
patients age over 18. It was decided to look into these cases in more detail.
At the April 2014 meeting it was fed back that these cases had been reviewed and it was
mainly due to postoperative pain, not to any other complications. As a result the department
decided to improve information regarding postoperative care to be given to the patients, and
also to review prescription of postoperative analgesia (pain relief).
Board to Ward to Board
The Executive and Non-Executive Director members of the Board have ‘adopted’ a ward or
clinical department. This is very helpful in allowing Board members to understand the
successes and challenges of those areas. For example, the practical difficulties of maintaining
the provision of single sex accommodation. This creates a meaningful ‘Board to Ward to
Board’ relationship and dialogue. The relationship is equally valued by staff who have a direct
pathway to an Executive Director.
The Trust Board receives regular clinical presentations from nursing and/or medical staff as
part of the agenda each month which keeps them abreast of clinical initiatives.
Participation in National Clinical Audits and National Confidential Enquiries in 2014/15
The required wording has been used by the Trust in this section of the Quality Account.
Clinical audit aims to improve the quality of patient care by looking at current practice and
modifying it where necessary.
During 2014/15 31 national clinical audits and 4 national confidential enquiries covered
relevant health services that Dartford and Gravesham NHS Trust provides.
During 2014/15 Dartford and Gravesham NHS Trust participated in 97% national clinical
audits and 100% national confidential enquiries of the national clinical audits and national
confidential enquiries which it was eligible to participate in.
The national clinical audits and national confidential enquiries that Dartford and Gravesham
NHS Trust was eligible to participate in during 2014/15 are as follows: these are presented in
the table on page 28.
The national clinical audits and national confidential enquiries that Dartford and Gravesham
NHS Trust participated in during 2014/15 are as follows: these are presented in the table on
page 28.
The national clinical audits and national confidential enquires that Dartford and Gravesham
NHS Trust participated in, and for which data collection was completed during 2014/15, are
listed below alongside the number of cases submitted to each audit or enquiry as a
percentage of the number of registered cases required by the terms of that audit or enquiry.
DGT 2014/15 Quality Account – final
27
Participation
Y, N or N/A
Audit Title
No. of cases
submitted
% of cases
submitted
Acute Care
Adult Community Acquired Pneumonia
Y
Data entry in progress
Case mix Programme (CMP) ICNARC
Y
645
100%
Major Trauma: The Trauma Audit & Research Network (TARN)
Y
116
45%
National Complicated Diverticulitis Audit
Y
53
100%
National Emergency Laparotomy Audit (NELA)
Y
119
80%
National Joint Registry (NJR)
Y
1372
100%
Pleural Procedure
Y
6
75%
Y
13
100%
Bowel Cancer (NBOCAP)
Y
130
100%
Lung Cancer (NLCA)
Y
National Prostate Cancer Audit
Y
177
100%
Oesophago-gastric cancer (NAOGC)
Y
86
100%
Blood and Transplant
National Comparative Audit of Blood Transfusion programme
Cancer
Data entry in progress
Heart
Acute Coronary Syndrome or Acute Myocardial Infarction
(MINAP)
Y
Cardiac Rhythm Management (CRM)
Y
Congenital Heart Disease (Paediatric cardiac surgery)
N/A
Data entry in progress
awaited
-
-
Coronary Angioplasty / National Audit of PCI
Y
Data entry in progress
National Cardiac Arrest Audit (NCAA)
Y
National Heart Failure Audit
Y
National Vascular Registry
N/A
-
-
Pulmonary Hypertension Audit
N/A
-
-
Adult Diabetes Audit
Y
0
0%
National Diabetes Foot Care Audit
Y
0
0%
Paediatric Diabetes Audit (NPDA)
Y
350
100%
Inflammatory Bowel Disease (IBD) programme
N
-
-
Renal Replacement Therapy (Renal Registry)
N/A
-
-
Rheumatoid and Early Inflammatory Arthritis
N/A
-
-
106
91%
Data entry in progress (261
cases submitted to Dec 14)
Long term conditions
DGT 2014/15 Quality Account – final
28
Mental Health
Mental health (Care in emergency departments)
Y
50
100%
Falls and Fragility Fractures Audit Programme (FFFAP)
 National Hip Fracture Database – ongoing data collection
 Falls – starts May 2015
 Fracture Liaison Service – feasibility study in 2013
Y
807
100%
Older people (care in emergency departments)
Y
100
100%
Sentinel Stroke National Audit Programme – Organisation
Audit
Y
Sentinel Stroke National Audit Programme – Clinical Audit
Y
Older People
100% organisational data
submitted
Final quarter
data collection
in progress
Other
Elective Surgery (National PROMs Programme)
Y
Fewer than
minimum
number of
patients
National Audit of Intermediate Care
Y
34
68%
Fitting child (care in emergency departments)
Y
47
94%
Maternal, Newborn and Infant Clinical Outcome Review
Programme (MBRACE)
Y
10
100%
Neonatal Intensive and Special Care (NNAP)
Y
817
100%
N/A
-
-
For detail
see page
43
Women’s and Children’s Health
Paediatric Intensive Care Audit Network
Source – Trust locally validated data Apr 2013 – Mar 2014
These audits are reviewed and managed by the Trust Audit Leads Committee and reported to
the Quality and Safety Committee.
In addition Dartford and Gravesham NHS Trust was eligible to, but did not, participate in
these national clinical audits and national confidential enquiries.
Audit Title
None
Source – Trust locally validated data Apr 2013 – Mar 2014
Participation in National Confidential Enquiries into Patient Outcome and Death
A National Confidential Enquiry into Patient Outcome and Death (NCEPOD) is an
investigation into an area of healthcare. When the enquiry is complete a report is produced
which details recommendations for improvement.
N
The NCEPOD documents have been discussed within the directorate and a report provided to
the Trust Quality and Safety Committee. The Quality and Safety Committee monitors and
DGT 2014/15 Quality Account – final
29
advises the Trust Board on progress against the NCEPOD recommendations requesting
action plans as appropriate.
In addition there are 4 current NCEPOD studies:
National Confidential Enquiry into Patient
Outcome and Death
Participated in
2014/15
% of cases
submitted
Sepsis
Yes
80%
Gastrointestinal haemorrhage
Yes
On going
Lower limb amputation study
Yes
100%
Tracheostomy Care
Yes
91%
Source – Trust locally validated data
Maternal and Perinatal Mortality Notification
The National Patient Safety Agency took over the monitoring of maternal and perinatal
mortality from the Centre for Maternal and Child Enquires (CEMACE) from April 2011.
Maternal and Perinatal Mortality Notification
Participated in
2014/15
% of cases
submitted
Maternal mortality surveillance i.e. mothers
Yes
100%
Perinatal mortality surveillance i.e. babies
Yes
100%
Source – Trust locally validated data
National Audits reviewed by the Trust in 2014/15
The reports of the three national clinical audits were reviewed by the provider in 2014/15 and
Dartford and Gravesham NHS Trust intends to take the following actions to improve the
quality of healthcare provided.
1. Severe Sepsis and Septic Shock in Adults – College of Emergency Medicine
This national audit measured compliance with the ‘surviving sepsis’ care bundle for septic
patients through six different standards of management. Although the Trust met the target
for administering antibiotics within one hour of septic patients being in the ED, there were
other areas where standards were not met. Subsequent to the publication of the national
report the Trust has introduced specific ED teaching sessions on the early recognition and
treatment of septic patients, and developed a new algorithm for sepsis which is widely
available on electronic systems as well as laminated copies in appropriate areas of the ED.
2. National Care of the Dying Audit for Hospitals – Royal College of Physicians
This audit recognised several areas of good practice at this Trust, including being one of
only 21% of hospitals providing a 7-day face to face visiting service in line with
recommendations and has sustained this since 2011. The Trust compares favourably
against other organisations, achieving higher than national scores in discussion and
communicating care plans, anticipatory prescribing, hydration and nutrition, and scored
100% for achievement of five or more assessments in the last 24 hours of life –
demonstrating very high levels of care for the dying patients. Understandably in an audit of
DGT 2014/15 Quality Account – final
30
this size, some areas for improvement were highlighted and actions taken to address these
include the development of bereavement support service and information and the
introduction of further training to improve the recognition of dying patients within the Trust.
3. Asthma in Children – Royal College of Emergency Medicine
The audit identified room for improvement across all Emergency Departments in processes
for repeating vital signs in patients after intervention; however this Trust was within the
upper quartile for recording respiratory rate, pulse, blood pressure and temperature.
Identified actions being taken forward as a result of this audit included the compilation of a
local pathway for the management of children with acute asthma, highlighting the
timeliness of reassessment.
Local initiatives in Clinical Audit
The Trust uses a locally devised scoring system to indicate the priority that completed audits
have been given, known as the Implementation of Clinical Effectiveness (ICE) score; this
system has also been shared with a number of other organisations for their own use.
The score ranges from ICE 1 (indicating a high level of priority) to ICE 3 (low implications or
priority). Giving a score to an audit presents an effective way of managing the findings from
audit activity across the Trust. All ICE 1 audits are reported to the Trust Quality and Safety
Committee and the action plans are monitored at specialty audit meetings.
All local audits registered with the Trust’s Clinical Audit and Effectiveness Department are
required to be presented at directorate/specialty audit meetings where the findings and
implications are discussed, and the ICE score and action plan agreed. These action plans
are then monitored by the department and, once fully implemented, a re-audit is undertaken
to confirm changes in practice have been achieved.
The reports of the three local clinical audits were reviewed by the provider in 2014/15 and
Dartford and Gravesham NHS Trust intends to take the following actions to improve the
quality of healthcare provided.
1. A Review of Current Practice in Post First-TURBT Intravesical Instillation of
Mitomycin-C (MMC)
Clinical guidelines recommend the chemotherapy drug MMC should be given within six
hours of primary Transurethral Resection of Bladder Tumour (TURBT), although the first
round of audit identified that we did not always manage to meet this standard, with many
patients not receiving the MMC instillation until 15 hours after. Actions were undertaken to
improve the coordination between urology nurse and pharmacy to ensure the availability of
MMC for patients booked for TURBT, and funding was made available to provide a MMC
trolley in theatres to enable the instillation whilst the patient is still in theatre.
A subsequent audit has shown significant improvements in the pre-operative requests for
MMC with 100% of patients now receiving this within the recommended six hours, with the
average time to MMC delivery being only 11 minutes.
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2. Retrospective Review of Quality of Documentation in Patients Discharged ‘Home to
Die’ from Hospital.
Around half of all deaths in England occur in hospitals but many patients would like to die
in their own place of care. The Trust recognises its core responsibility to deliver high
quality care for patients in their final days of life, including respecting their wishes to
achieve preferred place of death, and to provide appropriate support to those close to
them. This audit was designed to review the quality of discharge documentation of patients
discharged for end of life care at home, ensuring appropriate level of supporting
medications and communication to relevant healthcare professionals. Overall the audit
found high compliance in the prescribing of crisis medications but a need to improve
aspects of documentation and communication. Actions taken included the introduction of a
new training programme for medical and nursing staff on the processes involved in
discharging a patient home to die to ensure all steps are completed, and to update the
discharge notification system to ensure GP’s are aware of the patient’s choice to avoid
unnecessary readmissions to hospital.
3. Re-audit of Malnutrition Universal Screening Tool (MUST)
The MUST is a five step tool designed to aid in the identification of individuals at risk of
malnutrition, as many patients are. The audit was designed to ensure the MUST too is
consistently completed and used in line with local and national recommendations and that
all patients are being correctly monitored and treated accordingly. Actions taken as a
result of this audit include the introduction of regular ward based training including the
calculation of BMI and weight loss, and the development of more effective referral
procedures to specialist nutritionists and dieticians when needed.
Participation in clinical research
Clinical research involves gathering information to help understand the best treatments,
medication or procedures for patients. It also enables new treatments and medications to be
developed. Research involving patients must be approved by an ethics committee.
The number of patients receiving relevant health services provided or sub-contracted by
Dartford and Gravesham NHS Trust in 2014/15 that were recruited during that period to
participate in research approved by a research ethics committee was 547.
Participation in clinical research demonstrates the Trust’s commitment to improving the quality
of the care we offer and to making our contribution to wider health improvement priorities.
Our clinical staff stay abreast of the latest possible treatments and actively engage in
participation in research.
Dartford and Gravesham NHS Trust was involved in conducting clinical research studies in
cancer, cardiology, diabetes, epilepsy, gastroenterology, hepatology, infection control,
intensive care, mental health, paediatrics, obstetrics, respiratory, stroke, surgery and urology
during 2014/15. There were 61 clinical staff participating in research approved by a research
ethics committee at Dartford and Gravesham NHS Trust 2014/15. These staff participated in
research covering 15 medical specialties.
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Goals agreed with Commissioners
Commissioning for Quality and Improvement (CQUIN) 2014/15, progress and
achievement
The Clinical Commissioning Group (CCG) held the NHS budget for their area in 2014/15 and
decided how money was spent on hospitals and other health services. This is known as
‘commissioning’. Dartford Gravesham and Swanley CCG was the main commissioner of
services at Dartford and Gravesham NHS Trust. The CCG set performance targets based on
quality and innovation.
A proportion of Dartford and Gravesham NHS Trust income in 2014/15 was conditional upon
achieving quality improvement and innovation goals agreed between Dartford and
Gravesham 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: http://www.england.nhs.uk/nhsstandard-contract/
CQUIN 2014/15 progress and achievement
For 2014/15, the Trust had 7 CQUIN indicators (3 mandatory and 4 local) to achieve.
CQUIN for 2014/15 was set at a level of 2.5 per cent value for all healthcare services
commissioned through the NHS Standard Contract, excluding high cost drugs, devices and
listed procedures. CQUIN is now worth around £4.5 million for the Trust.
The trust achieved 90% delivery against the seven indicators in 2014/15, approximately £4m.
DGT 2014/15 Quality Account – final
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The following information gives details of the CQUIN goals and achievements for the year
2014/15.
National Indicators:
There are three national CQUIN goals applicable to the Trust for 2014/15.
RAG - Red = Not Achieved, Amber = Partially Achieved, Green = Achieved in full.
1. Staff and Patients Friends and
Family Test (FFT)
Description: Improve the experience of
patients in line with domain 4 of the NHS
Outcomes Framework. The Friends and
Family Test will provide timely, granular
feedback from patients about their
experience.
Indicator
1a. Implementation of staff
FFT
%
weighting
and RAG
30%
Value
Green
1b. Early implementation of
the patient FFT in outpatient
and day case departments.
1c. Increased patient FFT
response rate in A&E
1d. Increased response rate
in Acute Inpatient services -
15%
£200K
(0.125%)*
Green
15%
Red
40%
Amber
Actions
 Aim to increase the number of surveys in A&E using alternative methods of collection.
 Increase the visible profile with new posters in A&E with a QR code to encourage responses.
 New patient experience FFT and generic displays being provided on each ward with performance.
 Provision of covered Patient Experience Boards on each ward.
 Staff Friends & Family Test – High profile information via Trust communication platforms.
 The QMH site clinics have been set up to start collation FFT.
2. Safety Thermometer
To reduce harm. Requires monthly survey
of all appropriate patients (as defined in the
NHS Safety Thermometer Guidance) to
collect data on three elements. 2.1a.
Indicator
2.1a. Reduction in the
prevalence of new pressure
ulcers hospital acquired. ( 2
and above including
ungradeable)
2.1b. Reduction in the
prevalence of community
acquired pressure ulcers
through a collaborative
health economy steering
group and action plan
%
weighting
and RAG
50%
Value
Green
£410k
(0. 25%)*
50%
Green
Actions
 Collated data circulated to nurse managers, matrons, ward sisters and other interested parties.
 Clinical Fridays with the Director of Nursing continue.
 Tissue Viability Nurse attended a multi- agency pressure ulcer workshop in June 2014.
 The Tissue Viability team are participating in the Kent Surrey and Sussex Patient Safety Collaborative.
DGT 2014/15 Quality Account – final
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3. Dementia
To incentivise the identification of patients
with dementia and other causes of
cognitive impairment alongside their other
medical conditions, to promote appropriate
referral and follow up after they leave
hospital to ensure that hospitals deliver
high quality care to people with dementia
and support their carers.
Indicator
3.1 Find, Assess, Investigate
and Refer
3.2 Clinical Leadership
3.3 Supporting Carers of
people with Dementia
%
weighting
and RAG
60%
Green
10%
Value
£200K
(0.125%)*
Green
30%
Green
Actions
 Designated Carer Support and two Dementia Buddy Co-ordinators in place.
 Current model under review in response to feedback from carers via carer support worker.
 Carers Clinic - carer support worker to give 1-1 sessions to carers – increased to twice weekly.
 Carer support worker is setting up a community group for carers requiring longer term support.
 Level 1 "holistic skills for dementia" - on-going programme, delivered quarterly.
 Joint Education committee work stream on-going. Sessions delivered with clinicians at the Grand round.
* FFT, Safety Thermometer and Dementia cover all three key contracts - DGS, Bexley and Specialist commissioning.
Local Indicators
There are four local CQUINS - the reduction of emergency admissions, which is a whole
system CQUIN, reducing pressure ulcers (Braden score), improving assessment of nutritional
status using Malnutrition Universal Screening Tool (MUST) and an indicator for Bexley CCG
on smoking cessation.
1) Reduction in Emergency Admissions
(whole system CQUIN)
This CQUIN will be mirrored in the
contracts with Dartford and Gravesham
NHS Trust, Kent Community Health NHS
Trust, South East Coast Ambulance NHS
Foundation Trust and Kent and Medway
and Medway Partnership NHS Trust.
NHS Dartford, Gravesham and Swanley
CCG has set a challenging goal of This
CQUIN is designed to incentivise whole
system collaboration and achievement of
the goal. The full CQUIN payment will only
be achieved if local health economy actions
achieve the reduction in emergency
admissions.
Indicator
By the end of quarter 3
2014/15 there will be a 6%
reduction in emergency
admissions compared to
the same period in 2013/14.
%
weighting
and RAG
Value
Amber
(90%)
£2.2m
(1.9%)
Pro-rata payments will be
made where emergency
admissions are reduced
and these will be calculated
based on percentage
reductions seen.
Actions
 Integrated discharge team established.
 Group established to improve collaborative working between providers of various services.
 Scheme to be monitored and managed at Executive level meetings.
 The Emergency Care Redesign Project work streams in progress.
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Braden Risk Assessment – Pressure
Ulcer Prevention / Treatment
Indicator
1) To risk assess patients to identify
potential development of pressure
ulcers and ensure on-going
management.
Submit audit report on
review of Braden risk
assessment tool usage on 4
specified wards.
2) To ensure relevant referrals to
appropriate services are made.
Complete and submit overall
audit report outlining the
collective findings, outcomes
and any change
implemented.
3) To ensure transfer of care information
is provided to appropriate services.
%
weighting
and RAG
Value
50%
£250k
(0.05%)*
50%
4) To audit outcomes
Actions
 Braden template design revised prior to implementation.
 Key outcomes from the Q4 audit - Re-enforce / educate clinical staff on policies, NICE guidelines and
CQUIN requirements.
 Disseminate audit results at tissue viability study days/sessions for all staff grades.
 Reactivation of Trust Tissue Viability Task Force.
*The Braden and Nutrition CQUINs cover Bexley and DGS CQUIN contracts and exclude Specialist commissioning.
2) Nutritional Assessment – using
Malnutrition Universal Screening
Tool (MUST) risk assessment and
audit
1) To assess the quality of nutritional
assessments undertaken and review of
care plan in place.
2) To ensure nutritional assessment and
relevant information is included on the
discharge summary
Indicator
Submit audit report on
review of MUST risk
assessment tool usage on 4
specified wards.
Complete and submit overall
audit report outlining the
collective findings, outcomes
and any change
implemented.
%
weighting
and RAG
Value
50%
£250k
(0.05%)*
50%
Actions
 Dietician’s responsible distribution of audit results and arranging training as required.
 MUST is included as part of the Tissue Viability Study day.
 MUST audit results are reported to the Trust Quality and Safety Committee.
 Dietician referral is available on Trust electronic referral systems. The MUST is a mandatory section to
complete to allow the referral to be made.
* The Braden and Nutrition CQUINs cover Bexley and DGS CQUIN contracts and exclude Specialist commissioning.
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4) Smoking Cessation
To deliver a quality smoking targeted
intervention service, at Queen Mary’s
Hospital, Sidcup, to include:
1) Appointment of a smoking cessation
coordinator to lead across the site.
2) Delivery of a staff training programme
that supports staff to provide advice,
appropriate interventions and referrals.
3) Maintain IT systems to monitor the
referrals and establish pathways into
the local ‘stop smoking’ service.
Indicator
Referrals into the Bexley
Stop
Smoking cessation work
group held quarterly with
agreed action plan to
increase referrals
Project lead and staff to
undertake IT NCSCT
training
%
weighting
and RAG
20% for
each quarter
achieved max 80%
Value
£120k
(0.5%)*
10%
10%
Actions
 Contact maintained with the Bexley smoking cessation team.
 Staff maintaining manual referral system and providing patient information.
 An alternative IT system is being investigated using existing workstations and tools to provide the
Tobacco Control & Bexley Stop Smoking Service Manager.
Source – Trust data management and recording system.
*The Smoking cessation CQUIN related only to the Bexley contract and £120k equated to 0.5% of the 2.5% Bexley CQUIN allocation.
What others say about the provider:
The Care Quality Commission
The Care Quality Commission (CQC) regulates and inspects health organisations.
Dartford and Gravesham NHS Trust is required to register with the Care Quality Commission
and its current registration status is ‘registered’. Dartford and Gravesham NHS Trust has the
following conditions on registration.

There are no conditions on the registration.
The Care Quality Commission has not taken enforcement action against Dartford and
Gravesham NHS Trust during 2014/15.
Dartford and Gravesham NHS Trust has not participated in any special reviews or
investigations by the Care Quality Commission during the reporting period.
In 2013 the CQC introduced a new style of inspection and the Trust was inspected in
December 2014, having volunteered to pilot the new ratings methodology. The review
assessed the Trust’s services in five domains and the Trust was found to be meeting these
essential standards for safety, effectiveness, caring and leadership. The CQC identified some
improvements required in the ‘responsiveness’ domain.
The CQC report mentions that inspectors spoke with patients, relatives of people who used
the service and also to staff. Patients and their relatives said they had been involved in
DGT 2014/15 Quality Account – final
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making decisions about their care and treatment. Staff said that they felt well supported. They
said that they liked working at the hospital and had the training and information they needed.
CQC Ratings awarded to the Trust
Overall rating for acute services at this trust
Are acute services at this trust safe?
Are acute services at this trust effective?
Are acute services at this trust caring?
Are acute services at this trust responsive?
Are acute services at this trust well-led?
Rating
Good
Good
Good
Requires improvement
Good
Green
Green
Green
Amber
Green
CQC Quality Report – Darent Valley Hospital, February 2014
The CQC National Inpatient Survey results 2014
The Trust also reports on the results of the annual National Inpatient Survey conducted by the
Care Quality Commission.
People are asked what they thought about different aspects of the care and treatment they
received. Each NHS trust receives scores out of 10, based on the responses given by their
patients. A higher score is better. The results take into account the age, gender and method
of admission (emergency or elective) of respondents for each trust. The survey information is
collected anonymously, and all responses are confidential.
Table to show national inpatient survey results 2014 and 2013
Q32
Q35
Q37
Q56
Q63
Adult inpatient survey questions 2014 and 2013
Question
2014 score (out of 10) 2013 score (out of 10)
Were you involved as much as you
wanted to be in decisions
6.9
same
6.9
about your care and treatment?
Did you find someone on the hospital
staff to talk to about your
worries and fears?
Were you given enough privacy when
discussing your condition or
treatment?
Did a member of staff tell you about
medication side effects to
watch for when you went home?
Did hospital staff tell you who to contact if
you were worried about
your condition or treatment after you left
hospital?
5.3
worse
5.7
8.2
same
8.3
4.1
worse
4.6
7.6
same
7.7
Source – Care Quality Commission 2014
The questionnaire was sent to 850 inpatients who had been treated at Dartford and
Gravesham NHS Trust in August 2014 and responses were received from 389 patients
(48%). The five questions shown above (the survey includes over 70 questions) were
included in an overall ‘patient responsiveness’ score in 2013 and have been matched to the
same questions in the 2014 survey.
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Quality of Data
This measure of data quality refers to whether the Trust recorded patients’ NHS and GP
numbers in their clinical notes.
Dartford and Gravesham 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:
99.22% for admitted patient care;
98.79% for outpatient care; and
97.42% for accident and emergency care.
-
which included the patient’s valid General Medical Practice Code was:
100% for admitted patient care;
100% for outpatient care; and
100% for accident and emergency care
Information Governance Toolkit attainment levels
Information governance means keeping information about patients and staff safe. The
Information Governance Toolkit is an annual assessment that all NHS organisations are
required to complete.
Dartford and Gravesham NHS Trust Information Governance Assessment Report overall
score for 2014/15 was 75% and was graded ‘green’.
Clinical Coding Error rate
Clinical codes are a way of recording patient diagnosis and treatment. NHS hospitals are paid
different amounts for different groups of codes. This system is called Payment by Results.
Dartford and Gravesham NHS Trust was subject to the Payment by Results clinical coding
audit during the reporting period by the Audit Commission and the error rates reported in the
latest published audit for that period for diagnoses and treatment coding (clinical coding) were
2014/15
Primary Diagnoses coded correctly
90.5%
Secondary Diagnoses coded correctly
92.9%
Primary Procedures coded correctly
88.2%
Secondary Procedures coded correctly
83.1%
Source: the Audit Commission.
DGT 2014/15 Quality Account – final
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Statement on relevance of data quality
Dartford and Gravesham NHS Trust will be taking the following actions to improve data
quality:
 Maintaining full compliance with the recommendations in the Audit Commission report
on Payment by Results for the Trust’s data.
 Working with primary care clinicians to resolve differences in data collected.
 Continue the on-going collaboration between clinicians and clinical coders which
supports the accuracy and consistency of coding.
 Embedding the use of real time bed management and order communications across
the organisation; this increased use of information technology in direct patient care
leads to an improvement in overall data quality.
 Developing enhanced data quality reporting to allow errors to be detected earlier in the
data submission cycle.
Department of Health Core Quality Indicators
In 2012/13, for the first time, the Department of Health required the inclusion of a core set of
indicators in the Quality Account and these have been continued in 2014/15.
The Department of Health guidance on wording and presentation is prescriptive and there is
no latitude. For convenience and clarity we have labelled these core indicators (A) to (H).
A) Summary hospital mortality indicator (SHMI)
The data made available to the trust by the Health and Social Care Information Centre with
regard to:
a) The value and banding of the summary hospital-level mortality indicator (SHMI) for the
trust for the reporting period; and
b) The percentage of patient deaths with palliative care coded at either diagnosis or
specialty level for the trust for the reporting period.
The Dartford and Gravesham NHS Trust considers that this data is as described for the
following reasons: the Trust has made regular and timely data submissions to the Health and
Social Care Information Centre and the figures are consistent with those produced by Caspe
Healthcare Knowledge Systems (CHKS), the Trust’s information partner.
The Dartford and Gravesham NHS Trust intends to take the following actions to improve the
indicator and percentage in (a) and (b), and so the quality of its services, by:
 Mortality indices will continue to be an agenda item at Directorate Governance
meetings and featured at Q-labs.
 Outliers identified will be subject to scrutiny and review.
 The Trust Quality and Safety Committee will receive a report on mortality quarterly to
enable assurance to be given to the Trust Board.
DGT 2014/15 Quality Account – final
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Table to show SHMI, trust banding and percentage palliative care coding
The value and banding of the
summary hospital-level mortality
indicator (“SHMI”) for the Trust
for the reporting period.
The percentage of patient
deaths with palliative care coded
at either diagnosis or specialty
level for the trust for the
reporting period.
Apr 13 –
Mar 14
Jul 13 –
Jun 14
National
average
Lowest
reported
trust
Highest
reported
trust
1.001
(Band 2)
1.018
(Band 2)
1.00
0.541
(Band 3)
1.198
(Band 1)
30.7%
32.8%
25.01%
7.4%
49.0%
Source: Health and Social Care Information Centre
B) Patient reported outcome measures (PROMS)
The data made available to the trust by the Health and Social Care Information Centre with
regard to the trust’s patient reported outcome measures scores for:
I. Groin hernia surgery,
II. Varicose vein surgery,
III. Hip replacement surgery, and
IV. Knee replacement surgery, during the reporting period
The Dartford and Gravesham NHS Trust considers that this data is as described
for the following reason: the Trust has made regular and timely data submissions to the
Health and Social Care Information Centre.
The Dartford and Gravesham NHS Trust intends to take the following actions to improve
this score, and so the quality of its services, by:
 Continuing to make timely PROMS data submissions.
The health gain index used in PROMS
PROMS uses a standardised instrument for use as a measure of health outcome. It is
applicable to a wide range of health conditions and treatments and provides a simple
descriptive profile and a single index value for health status. A higher score indicates better
health and/or greater improvement in function after the operation.
The health gain index is primarily designed for self-completion by respondents and is ideally
suited for use in postal surveys, in clinics and face-to-face interviews. It is cognitively simple,
taking only a few minutes to complete. Instructions to respondents are included in the
questionnaire.
Table (a) PROMs for groin hernia
Period
04/2013-03/2014
04/2014-11/2014
Groin Hernia
Adjusted Health National
Gain (Trust)
Average
-*
-*
0.085
0.081
Highest Reported
Trust
Lowest reported
Trust
0.139
0.130
0.008
-0.014
Source: Health and Social Care Information Centre
*Fewer than minimum number of samples/patients
The adjusted average health gain for groin hernia surgery, see table (a), indicates fewer than
DGT 2014/15 Quality Account – final
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the minimum number of samples/ patients surveys obtained in 2013/14.
Table (b) PROMS for varicose veins
Period
Varicose Veins
Adjusted Health National
Gain (Trust)
Average
04/2013-03/2014
04/2014-11/2014
-*
-*
0.093
0.100
Highest Reported
Trust
Lowest reported
Trust
0.150
0.142
0.023
0.054
Source: Health and Social Care Information Centre
*N/A – Fewer than minimum number of samples/patients
The adjusted average health gain for varicose veins surgery, see table (b), indicates fewer
than the minimum number of samples/ patients surveys obtained in 2013/14.
Table (c) PROMS for hip replacement
Period
Hip Replacement
Adjusted Health National Highest Reported
Gain (Trust)
Average
Trust
04/2013-03/2014
04/2014-11/2014
0.457
0.416
0.436
0.442
0.545
0.501
Lowest reported
Trust
0.342
0.350
Source: Health and Social Care Information Centre
The adjusted average health gain for hip replacement surgery, see table (c), indicates an
average improvement in health status of those patients surveyed in 2013/14.
Table (d) PROMS for knee replacement
Period
Knee Replacement
Adjusted Health National Highest Reported
Gain (Trust)
Average
Trust
04/2013-03/2014
04/2014-11/2014
0.345
0.348
0.323
0.328
0.416
0.394
Lowest reported
Trust
0.215
0.249
Source: Health and Social Care Information Centre
The adjusted average health gain for knee replacement surgery, see table (d), indicates an
average improvement in health status of those patients surveyed in 2013/14.
C) 28 day readmissions
The data made available to the trust by the Health and Social Care Information Centre with
regard to the percentage of patients aged:
(i)
(ii)
0 to 15 and
16 or over
Readmitted to a hospital which forms part of the trust within 28 days of being discharged from
a hospital which forms part of the trust during the reporting period.
The Dartford and Gravesham NHS Trust considers that this data is as described
for the following reasons: the Trust has made regular and timely data submissions to the
Health and Social Care Information Centre and the figures are consistent with those produced
DGT 2014/15 Quality Account – final
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by Caspe Healthcare Knowledge Systems (CHKS), the Trust’s information partner.
The Dartford and Gravesham NHS Trust has taken the following actions to improve these
percentages, and so the quality of its services, by:



Increasing numbers of Elderly Care Consultants
Progression and development of dementia services – this work has been recognised
by the Care Quality Commission, and has resulted in better discharge arrangements
for this vulnerable patient group.
The development of more ambulatory care pathways.
Table to show 28 day readmissions under 16 years
28 day readmissions Age <16
Trust
National
Average
Highest
Reported Trust
Lowest reported
Trust
Highest
Reported Trust
Lowest reported
Trust
*
*
Source: Health and Social Care Information Centre
Table to show 28 day readmissions over 16 years
28 day readmissions Age 16+
Trust
National
Average
*
*
Source: Health and Social Care Information Centre
*NOTE: The Health and Social Care Clinical Indicators team has provided the following information:
‘Unfortunately the publication for the emergency readmissions to hospital within 28 days of discharge indicators has been delayed this year
while we bring their production in-house from an external contractor. We are taking the opportunity to review the methodology and
specifications which impacts on when they will be published. It is highly unlikely that they will be published this year’.
D) Responsiveness to needs of patients
The data made available to the trust by the Health and Social Care Information Centre with
regard to the trust’s responsiveness to the personal needs of its patients during the reporting
period.
The figures are an average score from a selection of questions from the National Inpatient
Survey measuring patient experience. The score is out of 100 and data is available up to
the 2014 survey.
The Dartford and Gravesham NHS Trust considers that this data is as described for the
following reason: the Trust has made participated in the national Care Quality Commission
(CQC) inpatient survey which provides the data used by the Health and Social Care
Information Centre.
The Dartford and Gravesham NHS Trust has taken and intends to take the following actions
to improve this percentage, and so the quality of its services, by:
 The Trust has implemented a Quality Improvement plan as a result of the findings of
the inspection by the Care Quality Commission (CQC) in December 2013.
 Redesign of the Emergency Department (ED) as part of the redesign of the ED.
 The Trust has used the patient feedback to improve the experience of patients
DGT 2014/15 Quality Account – final
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attending the Outpatient clinics by reducing the number of hospital cancellations of
appointments.
Responsiveness to needs of patients indicator score
Year
Trust average
score
National Average
Highest Reported
Trust*
Lowest reported
Trust
2013
73.3
76.5
88.2
66.8
2014
73.5
76.9
87
67.1
Source: Health and Social Care Information Centre
*a higher score indicates greater improvement
E) Staff recommendation to family or friends
The data made available to the trust by the Health and Social Care Information Centre with
regard to the percentage of staff employed by, or under contract to, the trust during the
reporting period who would recommend the trust as a provider of care to their family or
friends.
The HSCIC links to data produced in the Department of Health NHS Staff Survey. The
highest and lowest scores are unavailable for this question however the average for acute
trusts is included below.
The Dartford and Gravesham NHS Trust considers that this data is as described for the
following reason: the figure is taken from the National NHS Staff Surveys 2012/13 and 2014
published by the Department of Health. This annual survey is a poll of a percentage of
randomly selected Trust staff each year.
The Dartford and Gravesham NHS Trust has taken the following actions to improve this
percentage, and so the quality of its services, by:
 The Trust has continued to use of 85% staff with current appraisal at Directorate level
as a quality metric in 2014/15.
 All staff have direct access to the Trust Occupational Health Services as well as direct
access to independent counselling services.
Staff recommendation of the Trust as in the National Staff Survey Results for 2013 and 2014
for the indicator: ‘Staff recommendation of the trust as a place to work or receive treatment’
Year
Trust score
National Average
Highest Reported
Trust*
Lowest reported
Trust
2013
3.92
3.68
4.25
3.05
2014
4.01
3.67
4.20
2.99
Source: Health and Social Care Information Centre / Department of Health annual staff survey.
*Note: This is a scale summary score for which the maximum achievable is 5.0 and the lowest possible score is 1.0
DGT 2014/15 Quality Account – final
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F) Assessment for venous thromboembolism (VTE)
The data made available to the trust by the Health and Social Care Information Centre with
regard to the percentage of patients who were admitted to hospital and who were risk
assessed for venous thromboembolism during the reporting period.
Percentage of adult inpatients (over 18 years) assessed for risk of developing VTE
Year
Quarter
Number of
admissions
to Trust
assessed
for VTE
2012-13
Q1-Q4
50,586
53,421
Percentage
of admitted
patients
risk
assessed
for VTE
94.7%
2013-14
Q1
13,503
14,016
2013-14
Q2
13,487
2013-14
Q3
2013-14
Highest
Reported
Trust
Lowest
reported
Trust
National
Average
100%
80.8%
93.9%
96.8%
100%
78.8%
98.0%
14,093
95.7%
100%
81.7%
95.7%
14,979
15,721
95.3%
100%
77.7%
98.4%
Q4
16,254
16,967
95.8%
100%
78.9%
96.0%
2013-14
Q1-Q4
58,223
60,797
95.9%
100%
79.30%
97.0%
2014-15
Q1
16,137
16,801
96.05%
100%
87.20%
96.16%
2014-15
Q2
16,330
17,054
95.75%
100%
86.40%
96.19%
2014-15
Q3
16,449
17,126
96.05%
100%
81.19%
95.96%
2014-15
Q4
16,029
16,678
96.0%
100%
79.0%
95.9%
2014-15
Q1-Q4
64,945
67,659
96.0%
100%
83.44%
96.05%
Total
Admissions
to Trust
Source: Health and Social Care Information Centre
The Dartford and Gravesham NHS Trust considers that this data is as described for the
following reasons: the Trust has made regular and timely data submissions to the Health and
Social Care Information Centre and the figures are consistent with those produced by the
Trust internal information systems.
The Dartford and Gravesham NHS Trust has taken the following actions to improve this
percentage, and so the quality of its services, by:


VTE assessment and prescribed VTE prophylaxis are now included as a mandatory
section on the Trust patient drug chart.
Hospital acquired VTE cases are reviewed by the Consultant led VTE monitoring group
and reported to the Trust Patient Safety Committee. For each case of avoidable
hospital acquired VTE in 2014/15 an RCA summary investigation will take place. There
were no hospital acquired, avoidable VTE cases in 2014/15.
DGT 2014/15 Quality Account – final
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G) Hospital acquired C-difficile infections and post 72 hour C-difficile cases per 100,000
bed days
The data made available to the trust by the Health and Social Care Information Centre with
regard to the rate per 100,000 bed days of cases of C-difficile infection reported within the
trust amongst patients aged 2 or over during the reporting period.
Period
Trust C-difficile
cases
Trust rate (per
100,000 bed
days)
National
average rate
for acute trusts
Trust with
highest rate
Trust with
lowest rate
04/2012-03/2013
26
13.5
17.4
31.2
0
04/2013-03/2014
21
10.9
14.7
37.1
0
Source: Health and Social Care Information Centre (GOV.UK - Clostridium difficile infection: annual data (10/07/2014)
The Dartford and Gravesham NHS Trust considers that this data is as described for the
following reasons: the Trust has made regular and timely data submissions to the Health and
Social Care Information Centre and the figures are consistent with those produced by the
Trust internal data systems
The Dartford and Gravesham NHS Trust has taken the following actions to improve this rate,
and so the quality of its services, by:





Training and education of ward and department staff on the risk assessment
process/isolation /and stool specimen collection.
C-difficile /Bowel risk assessment training to be undertaken by key staff identified by
Matrons.
Enhanced measures undertaken following each case of post 72 hour C-difficile.
Audits of C-difficile risk assessment compliance, of patient management for all Cdifficile cases, of hand hygiene and of commode cleanliness.
Review of cleaning processes following discharge of infected patients and on a daily
basis.
H) Patient safety incidents resulting in severe harm or death
The data made available to the trust by the Health and Social Care Information Centre with
regard to the number and, where available, rate of patient safety incidents reported within the
trust during the reporting period, and the number and percentage of such patient safety
incidents that resulted in severe harm or death.
The Dartford and Gravesham NHS Trust considers that this data is as described for the
following reasons: the Trust has made regular and timely data submissions to the National
Recording and Learning System (NRLS) which provides the data used for the Health and
Social Care Information Centre figures.
The Dartford and Gravesham NHS Trust has taken the following actions to improve this
number and/or rate, and so the quality of its services, by:
DGT 2014/15 Quality Account – final
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

Timely monthly data submissions to the National Recording and Learning System for
incidents report in the Trust.
Training, individual and group, of staff in use of the new Datix web system.
Patient Safety Incidents resulting in severe harm and death as reported to the National
Recording and Learning System
Oct 13 - Mar 14
Patient safety incidents
reported
Apr 14 - Sep 14
Rate per
1,000
bed days
Number
Rate per
1,000 bed
days
Number
Trust
26.6
2,436
29.52
2,709
National average Acute
(non-specialist)
organisations
33.3
2,185
35.9
4,196
Trust with highest score
74.9
2,854
74.96
3,795
Trust with lowest score
5.8
301
0.24
35
Source: Health and Social Care Information Centre
DGT 2014/15 Quality Account – final
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Part Three
Other information
How we performed on Quality in 2014/15
This section describes some of the 2014/15 highlights, awards and achievements of the last
year.
The Intensive Care Unit
Darent Valley Intensive Care Unit staff are proud to have been ranked highly in the Family
Reported Experiences Evaluation (FREE) by Intensive Care National Audit and Research
Centre (ICNARC) for recruiting families and carers to assist with research into Intensive Care.
The study invited families and carers visiting patients in Intensive Care to share their views
and experience of the care of their loved one’s stay by answering a specially designed
questionnaire.
Phillipa Wakefield (Senior ITU Audit Nurse) says “This is a
whole team approach, which involves thorough training,
support and encouragement for staff to embrace research
and recruit participants. It’s not easy; staff have to pick the
right time to approach a family/carer sensitively.
I’m delighted with their enthusiasm and success so far. It’s highly important to know whether
we’re getting it right, as well as what we’re missing. Intensive Care patients, due to their
condition are not normally able to offer feedback, or to remember their experience, and this is
why the research focuses on ‘family reported experiences’.
The Nursing Technology Fund
Dartford and Gravesham NHS Trust is one of seventy five NHS Trusts across the country to
make a successful bid to the Nursing Technology Fund. The fund is for nurse-led projects
which deliver real improvements to patient
care and safety and the Trust was awarded
£88,000 to support its 'Patient at a Glance and
Emergency Vital Signs Tracking' project.
The Trust was able to show that this project will move patient tracking on the wards away
from the conventional and resource intensive handwritten, wall mounted whiteboards and will
replace them with an electronic 'real time' solution. The Trust will install large monitor screens
on each ward which will display 'real time' views of bed management information in
accordance with Information Governance and patient dignity rules.
Midwifery
Sharon Hurst, a midwife at Dartford and Gravesham NHS Trust, recently presented at a
national conference held jointly by The Royal College of Midwives (RCM) and Stillbirth &
Neonatal Death charity (SANDS) on the improvements and achievements made to the
bereavement service and also how the team had worked together to implement these
changes in practice.
DGT 2014/15 Quality Account – final
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The conference, Uncertainty and Loss in Maternity and Neonatal Care, took place in
Northern Ireland in June 2014.
Sharon won the RCM Excellence in
Bereavement Award in 2013. This award
provided a scholarship to support training and
enhance the care provided to those parents who
experience bereavement and neonatal loss.
Sharon leads in-house training and has also undertaken a counselling course so that parents
have practical and emotional support throughout this sad and difficult time.
The bereavement team includes 12 midwives who are dedicated and passionate about
providing support to women from the first moment of contact through to labour, delivery and
post birth. Through their efforts the Trust is now seen as offering one of the best practice
bereavement services.
Top 100 Places to Work
Dartford and Gravesham NHS Trust is one of the Top 100 Places
to work according to the Health Service Journal (HSJ).
In the article it states “These organisations have proven that they
know what it takes to create environments where people love to
come to work”. The information gathered by this survey was used
by HSJ to complete organisational profiles and determine what
makes them a great place to work. The Trust was also shortlisted
for a HSJ 2014 Award in the Staff Engagement category.
Judges are looking for organisations where staff can express concerns and receive an
effective response and where there is partnership with trade unions. There were many
different criteria’s that had to meet which included:
 An environment where staff are at the heart of decision making processes, feel valued,
and understand the values of the organisation.
 Staff being able to express concerns and receive an effective response.
 Engagement and partnership working with trade unions.
Urogynaecology Unit
The Urogynaecology Unit has been accredited by the British Society of
Urogynaecology (BSUG). Accreditation is a demanding process which
assesses whether a unit has high standards of personnel, procedures,
audit and outcomes. Darent Valley Hospital is only the 11th unit in the
UK to receive such accreditation which places a strong emphasis on
multidisciplinary team working and patient-reported assessment of
surgical outcomes. The Urogynaecology Unit team provide services at
Queen Mary’s Hospital, Sidcup and Darent Valley Hospital, Dartford.
DGT 2014/15 Quality Account – final
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Queen Mary’s is an excellent choice with waiting times lower than two weeks in some
specialties. Patients requiring surgery or procedures can expect to access the high quality
treatment and care sooner and in many cases within ’one stop’. Pre-surgical assessments of
fitness for surgery and admission dates can be offered on the same day as the first
appointment. On admission, patients are greeted and treated by professional staff who
remain dedicated to ensuring all patients experience first class care.
Being local, accessible, with easy parking and with faster appointments, treatment at Queen
Mary’s still makes an excellent choice as well as reducing waiting and worry times.
Those suitable for treatment at Queen Mary’s are low risk or without complicated health
issues and, as there are no emergency cases arriving, cancellations or long delays for
surgery are extremely rare.
Patient-led assessments of the care environment (PLACE)
The latest results from the annual Patient-Led Assessments of the Care Environment
(PLACE) have rated cleanliness at Darent Valley Hospital in Dartford amongst the best in
England.
The scores reflect how the environment at
the hospital supports patients' privacy and
dignity, food, cleanliness and the condition
of the building. The highest and most
improved score (more than 8%
improvement) was received for food
service where during the last 12 months
the Carillion team has introduced fresh homemade soup,
improved the presentation and quality of sandwiches and salads
and amended the ordering system so that more patients get their
first choice of meal.
Cleanliness, food and building condition are above the national average with the score for
cleanliness placing Darent Valley Hospital in the upper quartile for England.
The Kent Surrey and Sussex Patient Safety Collaborative
The Kent Surrey Sussex (KSS) Patient Safety Collaborative is one of 15
new patient safety collaboratives established across England in October
2014, putting patients, carers and clinical staff at the heart of patient
safety improvements. Patient Safety Collaboratives have been
developed in response to The Francis Inquiry into patient deaths at Mid
Staffordshire NHS Foundation Trust and the Berwick review into patient
safety, two major reports that highlight how basic safeguards breaking
down or being ignored can lead to tragedy. In January 2015 Dartford & Gravesham NHS
Trust won a Patient Safety Award for a project on "timely treatment for patients with
neutropenic sepsis" at the KSS AHSN Expo awards ceremony. The Trust is participating in
DGT 2014/15 Quality Account – final
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the other Safety Collaborative work streams include pressure damage, safe discharge and
transfer, medication errors and acute kidney injury.
Other Quality Indicators
Falls resulting in fracture occurring in hospital
In 2014/15 there have been 22 patients who fell whilst in hospital and sustained a fracture
compared to 14 patients in 2013/14. However, this should be seen against the background of
increased admissions and the numbers of frail and elderly patients coming to the Trust. The
Trust is working to reduce falls in all inpatient settings.
Falls resulting in a fracture over time, April 2013 – March 2015, per 1,000 bed days
Falls per 1,000 bed days
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Apr-13
Jul-13
Oct-13
Jan-14
Apr-14
Falls per 1,000 bed days
Jul-14
Oct-14
Jan-15
Linear (Falls per 1,000 bed days )
Source – Trust data management and recording system.
All falls resulting in a fracture are investigated as a Serious Incident (SI) so that causes may
be identified. Of the 22 falls shown above 15 were deemed ‘unavoidable’ on investigation.
The term ‘unavoidable’ is used when all actions, appropriate to the care of a patient, to
prevent a fall have been put in place but despite this the patient fell. Learning from such
cases and from those which are deemed’ avoidable’ is included in the action plan resulting
from the investigation.
Recent improvements achieved
 The Trust has introduced the use of low rise beds with side bumpers (to reduce
entrapments) and alarm cushions (to notify staff when a vulnerable patient is in need
of support)
 The times at which falls occur has been analysed for significant patterns which may be
related to staffing levels or the times of meals and medication rounds, for example.
DGT 2014/15 Quality Account – final
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Analysis of inpatient falls 2013-2014
Source – Trust data management and recording system.
Comparison of falls 2012/13 - 2014/15 against admissions to the Trust
Analysis of inpatient falls Apr 2012 to Mar 2015
Activity
(elective
plus nonelective
spells)
Total
falls
Falls
rate
No
harm
*Low harm
(requires
minimal
additional care
due to fall)
*Moderate (short
term harm
requiring further
intervention
*Death
(caused
by
incident)
59,075
1038
1.76%
800
227
10
1
2013/14
65,715
1224
1.86%
904
303
17
0
2014/15
72,498
1282
1.77%
989
271
21
1
2012/13
Source – Trust data management and recording system and CHKS.
The Trust increased its bed base in October 2013 by taking on services at Sidcup and Priory
Mews.
The overall falls rate to total elective and non-elective admissions is 1.77%% in 2014/15; this
is a decrease of 0.09% compared to 2013/14, this is encouraging as there has been an
overall 9.4% combined increase in elective plus non-elective admissions.
Pressure Ulcers
Some patients have a pressure ulcer (an area where the skin breaks down) when admitted to
our hospital. The Trust focus on reducing avoidable harms includes actions to prevent
pressure ulcers developing in hospital, by increasing vigilance and use of preventative
measures, and halting any further deterioration when patients are admitted with pre-existing
pressure area damage.
DGT 2014/15 Quality Account – final
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Graph to show new pressure ulcers by grade over four years – 2011 to 2015
Source – Trust data management and recording system.
Pressure ulcers can occur in patients especially those who are frail, vulnerable and bed
bound. The tissue viability team has worked closely with medical and nursing colleagues to
prevent pressure ulcers from developing in hospital. These measures have included:




Review of policy and practice, making sure that nurses and medical staff are ‘doing
the right thing’ and documenting care – e.g. the ‘SKIN’ bundle, a pressure ulcer
prevention initiative, with charts for turning and positioning patients.
The use of a new bed and mattress contract to ensure timely and cost effective
provision of suitable preventative equipment.
Training - ensuring staff have relevant skills, knowledge and competence.
Analysis of incidents through the Root Cause Analysis method – particularly on
Grade 3 and 4 hospital-acquired ulcers to focus on learning and prevention.
Responding to Complaints
There were 368 complaints received in the period 1st April 2014 to 31st March 2015, which
includes 37 complaints relating to services at Queen Mary’s Hospital (QMH) site, compared to
451 for the same period in 2013-14.
Within the time period 40 complaints were reopened, compared to 21 reopened in 2013/14.
This is usually because the person who has complained is not satisfied with the response and
asks for additional clarification.
The Trust supported and facilitated 16 local resolution meetings (LRM). This is an opportunity
for the person who has made the complaints to meet with senior staff – usually the Consultant
and the Matron for the service, and to discuss any outstanding issues face to face. These
LRMs are documented and a transcript provided in addition to a formal response.
Three cases have been accepted for further investigation by the Parliamentary and Health
Service Ombudsman (PHSO). This is the next stage of the NHS Complaints Process if the
person who made the complaint is dissatisfied with the Trust’s response. One of these
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53
referrals was not upheld by the PHSO and two were partially upheld.
Graph to show formal complaints received in months Apr 2014 to Mar 2015
Source: Trust information management system (Datix).
Management of Complaints
Each new complaint is screened to determine the most appropriate means of responding –
this could be by a phone call, a face to face meeting, or by letter. The complaint is then taken
forward by the Complaints Officer working with the directorate. All complaints are tracked to
monitor deadlines and achieve timely responses.
The majority of complaints result in action being taken to identify what went wrong, and to put
systems in place to avoid this happening in future.
Performance for the initial acknowledgement of complaints for the year within 3 days was
96% and issue of a final response was 51%, which is outside the departmental monitoring
target of 85%. However, the Complaints Department has changed the way in which
complaints are assessed and for those which are of a more complex nature the person
making the complaint is advised that it may take longer than 25 days (the previous
departmental target) to complete the work involved.
This means that there are a number of complaints which will sit outside the local 25 day
target.
DGT 2014/15 Quality Account – final
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Prominent themes of Complaints 2014-2015
Source: Trust information management system (Datix).
Complaint themes and trends are monitored by the Director of Nursing and reviewed each
month by the Trust Quality and Safety Committee. Any emerging themes or variation is
scrutinised in detail with further breakdown on the numbers to directorate and ward level.
Directorates are asked to provide action plans in response to complaints received about
services.
NICE Standards compliance
The National Institute for Health and Clinical Excellence (NICE) guidance is designed to
promote good health and prevent ill health, is based on the best evidence and intended to
deliver good value for money, weighing up the cost and benefits of treatments.
New NICE guidance is received monthly and the Medical Director decides the appropriate
clinician to review the guidance to see that the Trust is compliant.
Chart to show number and type of NICE guidances received Apr 14 – Mar 15
NICE Guidances received 2014/15
33
30
20
5
1
Source: Trust information systems
DGT 2014/15 Quality Account – final
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4
NICE Guidances received in 2014/15 and status as at March 31st 2015*
Nice Guidances received and status as at 31/03/2015*
61
28
29
23
0
Not applicable
Awaiting
response
Fully compliant
Partially
compliant
Not compliant
Source: Trust information systems
* Includes NICE Quality Standards
NICE guidance is discussed at local meetings to ensure all clinicians are aware of the latest
guidance and are practising in accordance with the guidance. In the very rare situation that a
department or directorate decides not to adhere to the guidance there must be a formal
record of this decision made.
There are no guidances where the Trust has declared non-compliance.
Workforce – our quality resource
The Trust’s workforce is critical to the provision of high quality services to our patients. This
section of the Quality Account outlines the number of staff we employ, feedback on the staff
survey, and our approach to staff engagement.
We have continued to grow our workforce during 2014/15 as a result of service
developments, and investments in nursing staff are being made as a result of a
comprehensive staffing review. We will continue to review our needs and invest in our staff
during 2015.16.
DGT 2014/15 Quality Account – final
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The table below shows the Trust’s headcount; vacancy, turnover and sickness rates at 31st
March 2015
Total staff
headcount (full-time
and part-time) as at
31 March 2015
3036
Vacancy rate
as at 31
March 2015
Turnover rate
Sickness rate
Turnover = total number of
leavers over the period
divided by average number
employed as at 31 March
2015
Total number of days over the
period divided by the number of
sickness days for all employees
over the same period (averaged
over 2014/2015)
11.38%
To follow – figure for annual report is
calculated by DH and provided to the
Trust for the annual report (and this
figure needs to align with that in the
annual report
7.8%
Source: Trust information management systems
A key development for the Trust during 2014/15 was the development of Our Values. With
the support of NHS Elect the Trust spoke to over 300 staff across of our sites and staff groups
to develop agreed values:
1. Delivery high quality CARE WITH COMPASSION to every patient.
2. Demonstrating RESPECT AND DIGNITY for patients, their carers’ and our colleagues.
3. STRIVING TO EXCEL in everything we do.
4. Sustaining the highest PROFESSIONAL STANDARDS, showing honesty, openness and integrity in all
our actions.
5. WORKING TOGETHER to achieve the best outcomes for our patients.
Our Values were approved by the Trust Board in October 2014, and the Trust has
incorporated them into appraisal processes, induction, training, recruitment and corporate
communications. We will continue to embed Our Values in 2015/16.
A key component of embedding Our Values has been to realign Our Behaviours – the core
standards we expect from all of our staff:
DGT 2014/15 Quality Account – final
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Staff Survey
The Department of Health highlights the five key findings with which the Trust compares most
favourably and least favourably with other acute trusts in England. These are shown below.
Five top ranking scores
Key factor
Support from immediate managers
Percentage of staff suffering work-related stress in the last
12 months
Percentage of staff reporting good communication between
senior management and staff
Staff job satisfaction
Percentage of staff able to contribute towards improvements
at work
2014 Trust
score
2014 national
average
score
2013 Trust
score
3.83
3.65
3.68
30%
37%
32%
40%
30%
39%
3.74
3.60
3.70
74%
68%
70%
In addition to the above five key factors the Trust was rated in the top 20% of acute trusts for
13 out of 29 factors. The Trust was also rated above average for 6 key factors.
DGT 2014/15 Quality Account – final
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Staff responses to the national staff survey rated the Trust in the top 20% of acute trusts for
the proportion of staff who would recommend the Trust as a place to work or receive
treatment. Staff also rated the Trust highly on this measure throughout the year through
quarterly Staff Friends and Family tests.
In 2014/15 the Trust also saw an overall improvement in responses to the General Medical
Council’s survey of doctors in training.
Bottom five ranking scores
Key factor
2014 Trust
score
Percentage of staff experiencing harassment, bullying or
abuse from patients, relatives or the public in the last 12
months
Effective team working
Percentage of staff reporting, errors near misses or
incidents witnessed in the last month
Percentage of staff appraised in the last 12 months
Percentage of staff experiencing physical violence from
patients, relatives or the public in the last 12 months
2014 national
average score
2013 Trust
score
31%
29%
32%
3.72
3.74
3.74
89%
90%
93%
83%
85%
85%
16%
14%
17%
Source: Department of Health annual Staff Survey
The above five ratings are the only five key factors where the Trust was ranked below
average. The Trust had no factors in the worst 20% of acute trusts.
Although the Trust is ranked below average for appraisal completion, it continues to be
ranked in the top 20% of acute trusts for having well-structured appraisals.
Trust has developed an action plan to improve below average ratings.
Staff engagement and empowerment
The Chief Executive has held open sessions throughout the year and across the hospital sites
to speak directly to staff, and leads a monthly briefing session. The Trust has constructive
discussions with staff representatives through Joint Consultative Committee and Local
Negotiating Committee.
The Trust was also rated within the top 20% of acute trusts for staff engagement. During
2014/15, the Trust was rated the top acute trust for Staff Engagement by Listening into
Action, and was shortlisted for National Health Service Journal award in the Staff
Engagement category.
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Annex 1
Statements from other organisations
1) Dartford Gravesham and Swanley Clinical Commissioning Group comments on the
2013/14 Quality Account for Dartford and Gravesham NHS Trust (DandG).
The Trust’s draft Quality Accounts document was sent to Clinical Commissioning Groups
(CCGs) for consultation and comment. The CCGs have a responsibility to review the Quality
Accounts of the Trust each year, using the Department of Health’s Quality Accounts checklist
tool to ascertain whether all of the required elements are included within the document.
The CCG confirms that all required data has been included and that the account contains
accurate information in relation to the NHS Services provided or sub contracted.
The report is clear, well written and easily understood and a consistent, well-structured
approach has been maintained throughout the document. There are defined levels of care
and compassion demonstrated and the Chief Executive statement is effective in outlining staff
pride and commitment for the organisation which they work within.
The Trust has ensured it outlines its successes and achievements during 2014/15 but
acknowledges the areas where further improvements are required and identifies its
commitment in doing so. It is recognised that achievement was not attained in all of the
priorities set for 2014/15, predominately within the patient experience priority, therefore it is
positive to see a focus identified for 2015/16 is to achieve better patient representation and
engagement in the services provided by the Trust.
The Trust has identified three key areas of focus, where improvements are a priority for
2015/16 of which the CCG are in agreement and the Quality and Safety Team welcome the
opportunity to work with the Trust and support the improvements, as outlined within the
report. The trust may want to consider how it shares progress of quality account priorities with
its patients and the public, as the report currently identifies that progress will be monitored
through Trust internal committees only.
In conclusion, the report identifies that providing a safe and effective service whilst
maintaining patient’s quality of care is a high priority for the Trust and that this is only
achieved and supported by an effective and committed workforce.
The CCG thanks the Trust for the opportunity to comment on this document and looks
forward to further strengthening the relationships with the Trust through closer joint working in
the future.
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2) Healthwatch Medway commentary on Dartford and Gravesham NHS Trust Quality
Account.
Healthwatch Kent response to the Quality Account for Dartford and Gravesham NHS Trust
As the independent champion for the views of patients and social care users in Kent we have read the Quality
Accounts with great interest.
Our role is to help patients and the public to get the best out of their local health and social care services and
the Quality Account report is a key tool for enabling the public to understand how their services are being
improved. With this in mind, we enlisted members of the public and Healthwatch staff and volunteers to read,
digest and comment on your Quality Account to ensure we have a full and balanced commentary which
represents the view of the public.
On reading the Account, our initial feedback is that the account is still very lengthy and we would welcome an
additional summary document to be produced to make the information more accessible to the public reading
it. Having said this, the CEO report is very readable and highlights the successes the trust has had, while
acknowledging where improvements can be made and the process for doing so. One of these improvements is
aimed at hospital discharge, something Healthwatch Kent is keen to work with the Trust on. We are particularly
interested in the experience of patients as they are discharged from hospital into the community.
The account also expresses the need to make sure there is adequate provision for services to absorb the
increased demand from the Ebbsfleet development. Concerns over this have also been brought to Healthwatch
Kent’s attention so we are pleased to note this is being considered by the Trust.
There is a clear statement of priorities for improvement in 2015-16 which are evidence based with realistic
targets and routes to assess the progress being made. We particularly welcome plans for better patient
representation and engagement within the trusts services. Healthwatch Kent recognises designs to increase
Friends and Family Test responses particularly in A&E. We would welcome more information on how seldom
heard groups are being engaged with, and their experiences being heard. The high ratings for staff engagement
must also be noted and there seems to be attention given to how staff are involved in decision making,
identifying issues and planning solutions.
In summary, we would like to see more detail about how you involve patients and the public from all seldom
heard communities in decisions about the provision, development and quality of the services you provide. We
hope to continue and develop our relationship with the Trust to ensure we can help you with this.
Healthwatch Kent June 2015
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3) Kent County Council Health Overview and Scrutiny Committee (HOSC)
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Dartford and Gravesham NHS Trust response to the comments received from other
organisations.
We would like to thank all the above organisations for their comments on this Quality Account.
These will be helpful in further developing the document for the Quality Account 2015-16.
Following receipt of these comments no amendments have been made to the Quality Account
2014-15.
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Annex 2
STATEMENT OF DIRECTORS' RESPONSIBILITIES IN RESPECT OF THE QUALITY
ACCOUNT
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 Account presents a balanced picture of the Trust’s performance over the
period covered.
The performance information reported in the Quality Account is reliable and accurate.
There are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Account, and these controls are subject to review
to confirm that they are working effectively in practice.
The data underpinning the measures of performance reported in the Quality Account is
robust and reliable, conforms to specified data quality standards and prescribed
definitions, and is subject to appropriate scrutiny and review; and
The Quality Account has been prepared in accordance with Department of Health
guidance.
The directors 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
NB: sign and date in any colour ink except black
Date: 25/06/2015
Chief Executive
Date: 25/06/2015
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Annex 3
Criteria applied for the measurement of the indicators tested by PricewaterhouseCoopers LLP
Our external auditors PricewaterhouseCoopers LLP are required under NHS England’s ‘NHS Quality Accounts
Auditor Guidance 2014-15’ to perform testing on two national indicators. A detailed definition and explanation of
the criteria applied for the measurement of the indicators tested by PricewaterhouseCoopers LLP is included
below.
Rate of Clostridium Difficile infections
The Trust uses the following criteria for measuring the indicator for inclusion in the Quality Account:

The indicator is expressed as the rate of Clostridium Difficile per 100,000 bed days for patients;

Infections relate to patients aged two year old or more;

A positive laboratory test result for Clostridium Difficile recognised as a case according to the Trust's
diagnostic algorithm;

Positive results on the same patient more than 28 days apart are reported as separate episodes, irrespective
of the number of specimens taken in the intervening period, or where they were taken; and

The Trust is deemed responsible. This is defined as a case where the sample was taken on the fourth day or
later of an admission to that trust (where the day of admission is day one).
The rate of Clostridium Difficile infections for 2014/15 is 9.6
.
Percentage of patient safety incidents that result in severe harm or death
The Trust uses the following criteria for measuring the indicator for inclusion in the Quality Account:

The indicator is expressed as a percentage of patient safety incidents reported to the National Reporting
and Learning Service (NRLS) that have resulted in severe harm or death;

A patient safety incident is defined as ‘any unintended or unexpected incident(s) that could or did lead to
harm for one of more person(s) receiving NHS funded healthcare’; and

The ‘degree of harm’ for patient safety incidents is defined as follows: ‘severe’ – the patient has been
permanently harmed as a result of the incident; and ‘death’ – the incident has resulted in the death of the
patient.
The percentage of patient safety incidents that result in severe harm or death for 2014/15 is 0.15%
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Annex 4
Independent auditors opinion
INDEPENDENT AUDITORS’ LIMITED ASSURANCE REPORT TO THE DIRECTORS OF
DARTFORD AND GRAVESHAM NHS TRUST ON THE ANNUAL QUALITY ACCOUNT
We have been engaged by the Board of Directors of Dartford and Gravesham NHS Trust to perform an
independent assurance engagement in respect of Dartford and Gravesham 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
England:
in the Quality Account, consist of the following indicators as mandated by NHS
Specified indicators criteria
Specified Indicators
Rate of Clostridium Difficile infections
Page 65
Percentage of patient safety incidents that
result in severe harm or death
Page 65
Respective responsibilities of Directors and auditors
The Directors are required under the Health Act 2009 to prepare a Quality Account for each financial year. The
Department of Health has issued guidance on the form and content of annual Quality Accounts (which
incorporates the legal requirements in the Health Act 2009 and the Regulations).
In preparing the Quality Account, the Directors are required to take steps to satisfy themselves that:

the Quality Account presents a balanced picture of the Trust’s performance over the period covered;

the performance information reported in the Quality Account is reliable and accurate;

there are proper internal controls over the collection and reporting of the measures of performance
included in the Quality Account, and these controls are subject to review to confirm that they are
working effectively in practice;

the data underpinning the measures of performance reported in the Quality Account is robust and
reliable, conforms to specified data quality standards and prescribed definitions, and is subject to
appropriate scrutiny and review; and

the Quality Account has been prepared in accordance with Department of Health guidance.
The Directors are required to confirm compliance with these requirements in a statement of directors’
responsibilities within the Quality Account.
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
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
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 period April 2014 to June 2015;

papers relating to the Quality Account reported to the Board over the period April 2014 to June 2015 ;

feedback from Healthwatch Kent dated 24/06/2015;

feedback from the Commissioners Dartford, Gravesham and Swanley Clinical Commissioning Group
dated 22/06/2015;

the Trust’s complaints report published under regulation 18 of the Local Authority, Social Services and
NHS Complaints (England) Regulations 2009, dated March 2015;

the latest national patient survey dated 2014;

the latest national staff survey dated 2014;

the Head of Internal Audit’s annual opinion over the Trust’s control environment dated May 2015;

the annual governance statement dated 28/05/2015;

Care Quality Commission Intelligent Monitoring Report dated May 2015; and,

the results of the Payment by Results coding review dated May 2015.
We consider the implications for our report if we become aware of any apparent misstatements or material
inconsistencies with these documents (collectively the “documents”). Our responsibilities do not extend to any
other information.
This report, including the conclusion, is made solely to the Board of Directors of Dartford and Gravesham 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 Dartford and Gravesham 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.
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A limited assurance engagement is narrower in scope than a reasonable assurance engagement. The nature,
timing and extent of procedures for gathering sufficient appropriate evidence are deliberately limited relative to a
reasonable assurance engagement.
Limitations
Non-financial performance information is subject to more inherent limitations than financial information, given
the characteristics of the subject matter and the methods used for determining such information.
The absence of a significant body of established practice on which to draw allows for the selection of different but
acceptable measurement techniques which can result in materially different measurements and can impact
comparability. The precision of different measurement techniques may also vary. Furthermore, the nature and
methods used to determine such information, as well as the measurement criteria and the precision thereof, may
change over time. It is important to read the Quality Account in the context of the criteria set out in the
Regulations.
The nature, form and content required of Quality Accounts are determined by the Department of Health. This
may result in the omission of information relevant to other users, for example for the purpose of comparing the
results of different NHS organisations.
In addition, the scope of our assurance work has not included governance over quality or non-mandated
indicators which have been determined locally by Dartford and Gravesham NHS Trust.
Conclusion
Based on the results of our procedures, nothing has come to our attention that causes us to believe that, for the
year ended 31 March 2015:

the Quality Account is not prepared in all material respects in line with the criteria set out in the
Regulations;

the Quality Account is not consistent in all material respects with the sources specified 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
Savannah House
3 Ocean Way
Ocean Village
Southampton
SO14 3TJ
25 June 2015
Note: The maintenance and integrity of Dartford and Gravesham 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.
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Abbreviations and Acronyms
AandE
Accident and Emergency Department
ACS
Acute Coronary Syndrome
AKI
Acute Kidney Injury
AKIN
Acute Kidney Injury Network
AMI
Acute Myocardial Infarction
CAUTI
Catheter Associated Urinary Tract Infection
CCG
Clinical Commissioning Group
CD
Clinical Director
CDU
Clinical Decision Unit
CEA
Carotid Endarterectomy
CEMACE
Centre for Maternal and Child Enquiries
CHD
Coronary Heart Disease
CHKS
Caspe Healthcare Knowledge Systems
CNST
Clinical Negligence Scheme for Trusts
COPD
Chronic Obstructive Pulmonary Disease
CQC
Care Quality Commission
CQS
Composite Quality Score
CQUIN
Commissioning for Quality and Improvement
CT
Computerised Tomography
DandG
Dartford and Gravesham
DOLS
Deprivation of Liberty Safeguards
DVH
Darent Valley Hospital
EBUS
Endobronchial Ultrasound
ECIST
Emergency Care Intensive Support Team
ED
Emergency Department
EDN
Electronic Discharge Notification
EQ
Enhancing Quality
FYTD
Full Year To Date
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GP
General Practitioner
GI
Gastrointestinal
GMC
General Medical Council
HAPPI
Hospital Antimicrobial Prudent Prescribing Indicators
HES
Hospital Episode Statistics
HF
Heart Failure
HOSC
Health Overview and Scrutiny Committee
HSJ
Health Service Journal
HSCIC
Health and Social Care Information Centre
HSMR
Hospital Standardised Mortality Ratio
ICE score
Implementation of Clinical Effectiveness score
ICNARC
Intensive Care National Audit and Research Centre
IT
Information Technology
ITU
Intensive Therapy Unit
IG
Information Governance
KPI
Key Performance Indicator
LOS
Length of Stay
LRM
Local Resolution Meeting
MET
Medical Emergency Team
MINAP
Myocardial Ischaemia National Audit Project
MMC
Mitomycin-C
MRSA
Meticillin Resistant Staphylococcus Aureus
MSSA
Meticillin Sensitive Staphylococcus Aureus
MUST
Malnutrition Universal Screening Tool
NBOCAP
National Bowel Cancer Audit Programme
NCDAH
National Care of the Dying Audit - Hospitals
NCEPOD
National Confidential Enquiry Into Patient Outcome and Death
NCAG
National Chemotherapy Advisory Group
NDA
National Diabetes Audit
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NHFD
National Hip Fracture Database
NHS
National Health Service
NHSLA
National Health Service Litigation Authority
NICE
National Institute for Health and Clinical Excellence
NIV
Non Invasive Ventilation
NJR
National Joint Registry
NLCA
National Lung Cancer Audit
NNAP
National Neonatal Audit Programme
NPSA
National Patient Safety Agency
NRLS
National Reporting and Learning System
NSF
National Service Framework
ODP
Operating Department Practitioner
OSC
Overview and Scrutiny Committee
PAR score
Patient At Risk score
PAS
Patient Administration System
PCI
Primary Coronary Intervention
PCT
Primary Care Trust
PEAT
Patient Environment Action Team
PHSO
Parliamentary Health Service Ombudsman
PROMS
Patient Related Outcome Measures
PSC
Patient Safety Committee
Q Labs
Quality Laboratories
QIPP
Quality Innovation Productivity and Prevention
RAG
Red Amber Green
RTT
Referral To Treatment
SCBU
Special Care Baby Unit
SHA
Strategic Health Authority
SHMI
Standardised Hospital Mortality Indicator
SI
Serious Incident
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SINAP
Stroke Improvement National Audit Programme
SSNAP
Sentinel Stroke National Audit Programme
SIRO
Senior Information Risk Owner
ST
Safety Thermometer
SUS
Secondary Uses Service
TARN
Trauma Audit and Research Network
TIA
Transient Ischaemic Attack
UK
United Kingdom
UNICEF
United Nations Children's Fund
UoG
University of Greenwich
UTI
Urinary Tract Infection
VTE
Venous Thromboembolism
WHO
World Health Organisation
How readers can comment on the Quality Account
By email –
glyn.oakley@dvh.nhs.uk
By letter –
Susan Acott, Chief Executive,
Darent Valley Hospital, Dartford,
Kent DA2 8DA
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How readers can comment on the
Quality Account
By email – glyn.oakley@dvh.nhs.uk
By letter – Susan Acott, Chief Executive,
Darent Valley Hospital, Dartford,
Kent DA2 8DA
Dartford and Gravesham NHS Trust
Darent Valley Hospital
Darenth Wood Road
Dartford, Kent DA2 8DA
Tel: 01322 428100
www.dvh.nhs.uk
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