We Care. We Excel. We Innovate. ALWAYS
Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
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We Care. We Excel. We Innovate. ALWAYS
Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
Contents
Chairman and the
Statement of the Chief Executive
4
Statement of Directors’ responsibilities in
respect of the Quality Accounts
6
What is a Quality Account?
7
Looking back - progress on our priorities
from 2013/14
Looking back - review of other quality
performance 2013/14
Clinical Effectiveness – Outcomes for
patients
18
Quality Improvement Priorities for 2015/16
35
Review of services
37
Goals agreed with Commissioners
8
26
37-39
Care Quality Commission
40
Participation in Clinical Audit
42
Participation in Clinical Research
42
Clinical Services Update
43
Data Quality
44
Statement from Commissioners
Healthwatch, OSC
51
Acknowledgement and feedback
54
Glossary
55
Appendices
60
Appendix 1 National and Local
Clinical Audit activity
60
Appendix 2 Independent Auditor’s
Limited Assurance Report
65
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
3
Chairman and the
Statement of the Chief Executive
Statement of the Chair
The Board of Mid Essex Hospital Services NHS Trust is fully committed
to delivering safe and effective care and the best possible patient
experience.
This Quality Account reflects our progress towards this goal in 2014/15.
We also outline our plans for 2015/16, which reflect our commitment to
deliver the quality improvement required following the Care Quality
Commission report for our hospitals. I hope that you find this information
useful.
Statement of the Chief Executive
Our Quality Accounts for 2014/15 sets out the
Trust’s progress on the quality initiatives and
standards we set ourselves last year, and the new
quality challenges we have set for ourselves for
the year ahead, including our Quality Improvement
Plan. We have made progress in developing our
services this year, including our new Surgical
Emergency Ward and Day Surgery Unit. We do
acknowledge that we still need to improve quality
in a number of service areas and we are
committed to doing so. I wish to recognise the
input and dedication of our staff and volunteers at
all levels in providing the best care in the right
environment and for this I extend my thanks to all
who support the delivery of care to our patients.
In 2014/2015 the Trust welcomed the Care Quality
Commission (CQC) Quality Report, following a
detailed inspection of our services, as part of a
programme of inspections across the NHS. This
has proved valuable and has led to quality
improvements and staffing adjustments across the
Trust and particularly in relation to care planning
and the provision of Emergency Services. For
example, we are pleased to be opening five new
treatment cubicles in May 2015 and an improved
paediatric environment within our Accident and
Emergency Department.
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
Professor Sheila Salmon
Chairman
Paul Forden
Chief Executive
The Care Quality Commission Report
rated MEHT overall as ‘Requires
Improvement’ and Braintree
Community Hospital as ‘Good’. The
Trust was rated overall ‘Good’ for
‘Caring’ across our services and the
CQC stated, “The trust was a caring
organisation throughout”.
In response to the CQC quality report
for our hospitals, we have taken a
proactive approach to developing our
quality improvement priorities for
2015/16.
Throughout the year, and as part of
the regular Board meeting cycle, both
Executive and Non-Executive
Directors have been visiting areas of
the Hospital together to meet with
staff and patients to assess service
provision and improving quality. This
is recognised as being valuable by all
involved, and will continue in 2015/16
as an essential “Board to Ward”
initiative.
In the preparation of these Accounts
the input and views of many
colleagues and the Patient
Experience Group have been taken
into account but I am particularly
indebted to Cathy Geddes, Chief
Nurse, Ronan Fenton, Chief Medical
Officer, Peter Davies, Associate
Medical Director in relation to core
aspects of quality service provision
and research, and to Helen Hughes,
Director of Planning and
Performance, Martin Callingham,
Chief Information Officer in relation to
quality performance review, data
quality and information governance
and Helen Clarke, Head of
Governance.
I hereby state that to the best of my
knowledge the information contained
within these Quality Accounts is
accurate.
A variety of further initiatives have
been developed through the year
which have impacted positively upon
the quality of the patient experience in
the Trust. In the last year over 10,000
of our patients have told us where we
are doing well and where we can
improve. We have listened and acted
upon the areas our patients have told
us we can do better. For example, we
have greatly improved patient
information at the bedside and
increased the number of available
wheelchairs. We also have a new
outpatient tour video on our website
which familiarises our patients with
the services available.
In these quality accounts we report on
improvements made and priorities for
future improvements.
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
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Statement of Directors’ responsibilities
in respect of the Quality Accounts
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 (in line with requirements set out in Quality
Accounts legislation).
In preparing their Quality Account, Directors should take steps to assure themselves
that:

the Quality Accounts presents a balanced picture of the trust’s performance over
the reporting period;

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 any Department of
Health guidance.
By order of the Board
Date: 29 June 2015 .............................................................. Chair
Date: 29 June 2015 ............................................................. Chief Executive Officer
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
What is a Quality Account?
Quality accounts are annual reports to the public from NHS organisations about the
quality of the services they provide. As a healthcare provider it is our aim to provide
high quality services by working collaboratively with our patients and their families
and carers and with our healthcare partners and by monitoring our performance
against a variety of rigorous quality measures. These quality measures include
those we have selected with our service users and national indicators developed by
the Department of Health. This Quality Account provides details of our progress in
the last 12 months and our plans for improvement in 2015/16.
In developing our report, we have tried to use non-technical language so that it is as
easy to read as possible. In some cases use of technical terms was unavoidable
and therefore a glossary is provided for reference.
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
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Looking back – progress on our
improvement priorities from 2014/15
Priority 1: to improve patient safety
1.a Re-assessment for risk of Venous
Thromboembolism at 24 hours
Led by: Dr Peter Davis, Deputy Medical
Director
Rationale - It is well known that when
patients are admitted to hospital they are
at increased risk of developing a blood clot
or VTE which can lead to a longer stay,
additional medication or intervention and
can on occasion result in death. This risk
was identified for action in last year’s
Quality Account. Whilst we have made
significant progress in reducing these risks
by consistently assessing patients on
admission we will continue to drive
improvements in the coming year.
Aim - To increase the number of adult
patients who are re-assessed at 24
hours for their risk of VTE. Specifically
to achieve a minimum of 10%
improvement in each quarter, with year
end compliance of no less than 95%.
What we achieved - Whilst the Trust has
sustained high levels of assessment for
the risk of Venous Thrombosis on
admission, we have not been successful
in achieving our aim of improving the reassessment of VTE risk at 24 hours.
Noting that re-assessment rarely alters
the prescribed management, we have
reviewed the literature and established
that there does not appear to be a firm
evidence base to support its effectiveness.
Based on this finding we intend to focus
efforts on sustaining high levels of
assessment on arrival rather than at 24
hours.
1.b To reduce by a minimum of
20%, the number of patients
suffering moderate or severe harm
as a result of falling in hospital
Led by: Cathy Geddes, Chief Nurse
Rationale - The risk of falling whilst in
hospital is recognised nationally as a
key patient harm. This is because
patients may be disorientated or
unsteady on their feet increasing the
likelihood of a fall. This risk was
identified for action in last year’s
Quality Account. Whilst we have
made significant progress in reducing
these risks by consistently assessing
patients on admission we will
continue to drive improvements in the
coming year
Aim - To reduce by a minimum of
20%, the proportion of patients
suffering moderate or severe harm
as a result of a fall.
What we achieved: During 2014/15,
inpatient falls continued to be one of
the highest categories of adverse
events reported and over the full
year, our aim was not achieved.
However many measures were
implemented to reduce the harm
suffered by our patients and in
February and March 2015 the
incidence of falls reduced. The Trust
will therefore continue to make the
reduction of harm from falls a key
focus for quality improvement in
2015/16.
The measures that were implemented
in 2015/16 were as follows:

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Development and appointment
into a Falls Practitioner role;
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15

Development of a
multidisciplinary Falls Panel
enabling all falls reported as
Clinical Adverse Events resulting
in serious harm being
investigated and lessons being
learnt;

Development of a Falls Root
Cause Analysis template to aid
timely investigation and thematic
analysis;

What we achieved: During 2014/15, the
quarterly incidence of avoidable hospital
acquired Grade 3 Pressure ulcers
reduced from 15 to 8 cases, a reduction
of 46% between quarter 1 and quarter 3
2014/15. This was achieved through:
a)
Continuation of Monthly Link Nurse
Meetings to cascade wound care
information and pressure ulcer
prevention expertise;
Environmental improvements
within bathrooms and toilets
through the implementation of
the Throne Project and
collaborative working with the
Dementia Clinical Nurse
Specialist;
b)
Trust – Wide Monthly Audit of
Tissue Viability Documentation
(including risk assessment, body
mapping and care planning);
c)
Cascade of Pressure Ulcer
competency assessment of all
nurses to all clinical nurses;

Provision of falls awareness
training to all newly qualified
registered nurses;
d)
Launch of an integrated Wound
Care Formulary in collaboration with
Provide Community Services;

Collaborative working with Anglia
Ruskin Health Partnership to
share best practice.
e)
Continuation of on-going Tissue
Viability Preceptorship Training and
training for overseas Nurses;
f)
On-going Pressure Ulcer Panel
Review of all acquired pressure
ulcer incidents;
g)
Introduction of LEAP (Learning
experience applied to practice)
following acquired Grade 2 to 4
pressure ulcer incidence;
h)
Improved timeliness of dynamic
pressure relieving equipment
provision;
i)
Successful clinical Mattress Covers
evaluation on Baddow and Braxted
Wards;
j)
Current Devon heel pads evaluation
being undertaken on Stroke,
Baddow, Rayne and Notley Wards;
k)
Increased focus of training on wards
with high PU Incidence.
1.c To maintain a zero tolerance
approach to avoidable, pressure
damage with no patients
developing avoidable, hospital
acquired Grade 3 or 4 Pressure
Ulcers
Led by: Cathy Geddes, Chief Nurse
Rationale - The risk of patients
developing pressure ulcer damage
whilst in hospital is recognised
nationally. This risk was identified for
action in last year’s Quality Account.
We have made significant progress in
reducing these risks by consistently
assessing patients on admission and
we will continue to drive
improvements in the coming year.
Aim - To maintain a zero tolerance
approach to avoidable, pressure
damage with no patients
developing avoidable hospital
acquired Grade 3 or 4 Pressure
Ulcers.
The Trust’s commitment to reducing
avoidable pressure damage, is reinforced
by our commitment to an arrangement
with our commissioners whereby grade 3
and 4 Pressure Ulcers will be designated
a local Never Event from April 2015.
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
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Priority 2: to deliver effective care
3)
2.a Improving the effectiveness of care
by reducing the risks of infection
Led by Louise Teare, Director of
Infection Prevention and Control and
Peter Davis, Deputy Medical Director
Rationale - If the Trust is to deliver
effective care, it is essential that we do not
allow our patients to pick up infections
during their stay. When patients are
admitted with serious or potentially serious
infection, they must be managed in a
timely and appropriate way.
Aim - To fully involve all staff in the
process of preventing and controlling
infection through the following specific
measures.
1)
To ensure the early recognition of
patients with sepsis.
What we achieved: there has been
marked improvement in the completion of
a package of care known as the Sepsis 6
care bundle, for patients who present in
hospital with the early signs of Sepsis.
Most notably timely antibiotic
administration, fluid resuscitation and
attainment of blood cultures within 1 hour.
The administration of high flow oxygen
has also seen an increase in compliance
nevertheless the Trust recognises there is
further improvement to be made.
2)
To reduce the incidence of
infection as a consequence of
surgical Intervention. Specifically
to extend surgical site infection
surveillance to colorectal
procedures.
What we achieved: We have completed
our January – March Inpatient Surgical
Site Infection Surveillance. In those three
months we have reduced our infection rate
in large bowel surgery by 10.3%. We are
now at 4.3% compared to the national
average of 10.1%. We have achieved this
by changing the Antibiotic Policy, the use
of Plus sutures and 2% Chlorhexidine in
spirit used across colorectal surgery.
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To maintain zero-tolerance
approach to hospital
associated Meticillin-related
Staphylococcus aureus
infection. Also to maintain
zero tolerance of MRSA
acquisition in the Trust
achieving a consistent
improvement each quarter
with rates of MRSA screening
on admission with 100%
compliance by year end.
What we achieved: 3 cases of
hospital attributed MRSA bacteraemia
occurred during 2014/15. On
investigation our systems and
processes were not found to be at
fault in 2 cases. In the third case,
whilst exemplary care was given, the
patient did unfortunately acquire
MRSA in the Trust. This was in spite
of an overall 46% reduction in MRSA
acquisition during 2014/15, stressing
the importance of sustaining high
standards of infection prevention and
control at all times.
4)
To reduce the incidence of
hospital associated
Clostridium difficile to 13
cases or below.
What we achieved: Our end of year
figure was 16 cases however, 3 of
these cases have been successfully
appealed because no fault was found
in the Trust’s systems. We have
therefore achieved this target. This is
confirmed by the data showing a
reduction in the rate of Clostridium
difficile per 100,000 bed days for
2014/15. Sustaining a reduction in the
number of patients developing
Clostridium difficile continues to be a
key priority for MEHT. We have
consistently reduced the number of
patients developing diarrhoea
associated with Clostridium difficile
since recording began reducing from
17 in 2012/13 to 13 in 2014/15.
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
2.b Medicines Optimisation
Led by: Jane Giles, Chief
Pharmacist
Rationale - Effective care depends on
patients having the right medication at
the right time. The Trust will work with
all patients, service users and clients
to ensure that where a medicine is
prescribed or recommended the user
will obtain the maximum benefit from
that medicine
Aims:
1)
To ensure that patients gain
the maximum benefits from
the medicines prescribed for
them with 90% of prescribed
doses of medicines
administered to patients as
prescribed or
non-administration recorded
appropriately on medicines
administration records.
What we achieved: monitoring over 5
months from September 2014 to
January 2015 indicates that this target
was exceeded with 95.7% of doses
administered in the notes that were
audited.
2)
To ensure that prescribed
medicines are safe and
appropriate with 90% of in
patients receiving a pharmacyled medicines reconciliation
during their admission.
What we achieved: between 55%
and 70% of patients received
medicines reconciliation in the period
September 2014 to January 2015. For
those not seen, all were either
weekend patients or patients
attending day surgery or with us for
less than 24 hour stays.
3)
To engage with patients and
carers to help them
understand the need for their
medicines, possible side
effects and enable them to
make choices about the
medicines that they take.
Specifically all out-patient’s receiving a
new medicine or a change in dose will be
counselled by a pharmacist when given
the medicine and will have access to
advice from a pharmacist either personally
at ward or dispensary level or via a
dedicated telephone line.
What we achieved: an outpatient counselling
audit in February 2015 found 88%
compliance. Observation found that all
patients are counselled at the pharmacy
dispensing hatch. The Medical Information
Service provides a dedicated patient helpline
that has received an average of 38 calls per
month since November 2014. Furthermore all
patients are able to contact a pharmacy
technician or ward pharmacist on the wards or
in the dispensary.
2.c End of Life Care
Led by: Cathy Geddes, Chief Nurse
Rationale - It is essential that patients
approaching end of life, and their carer’s and
relatives, are cared for in a suitable place of
their choice.
Aim - To enhance end of life care for
patients and their relatives and carers and
Improve our bereavement facilities.
What we achieved: during 2014/15, the End
of Life Steering Group has re-established to
actively develop and drive forward plans for
improvement in this important area of care.
Many of the changes are still to be
implemented but the key areas for
improvement are:

Replacing the Liverpool care pathway
with an End of Life Care Plan

Provision of information to patients and
family/loved ones having been identified
as being at End of Life

Education of staff

Developing an Advance Care Register

Improving access to specialist palliative
care and supporting information
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
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A Senior Nurse has been appointed to the
End of Life Facilitator post and has
commenced work with Baddow and
Braxted wards who will be piloting the
Trust’s End of Life Care Plan. Following a
successful outcome we plan to move on to
Danbury and Felsted wards.
It is the expectation that when
patients who attend our Emergency
Department, who may be at end of
life, the Advance Care Register is
checked to determine if they have any
clearly documented wishes, care
needs or package of care.
The Burns Intensive Therapy Unit have
also started to pilot the care plan.
Implementation is at an early stage,
but this development will not only
ensure we meet patient’s wishes, but
it will also avoid inappropriate
admissions for some people at end of
life.
The Facilitator’s work will involve working
alongside all clinicians in identifying the
dying patient and providing guidance on
how to use the care plan - this will be done
with the support of the Hospital Palliative
Care Team and Chaplaincy Team who will
support on symptom management/spiritual
care and communication.
A leaflet has been developed that will be
available for teams to give to patients and
their families / loved ones who have been
diagnosed as being at End Of Life. The
booklet explains the dying process and the
supportive care that will be offered.
Access to the Palliative Care Team
out of hours has been limited,
however the Trust is at establishment
and 7 day working was re-introduced
from April 2015.
Out of Hours telephone support is
provided by the Palliative Medicine
consultants accessible via
switchboard.
Dates for workshops on “Introduction to
End of Life Care” have been established
and once these have been evaluated we
plan to run these monthly with support from
our colleagues in the Community Palliative
Care Teams.
The Advance Care Register is now
operational and patients are being entered
by GP’s, Community Teams, Farleigh
Hospice via System1 which is currently
available in the Accident and Emergency
Department (A&E) and will in future be
accessible on the Emergency Assessment
Unit and Emergency Short Stay.
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
Priority 3: to listen to, and learn
from, feedback
3.a Listening to patient and staff
feedback
Led by: Christine Watts, Director for
Communications & Patient
Experience
Rationale Feedback from service
users, their carer’s and from staff must
be taken into account, if we are to
continue to improve the quality of the
care we provide.
Aim - To listen to, and learn from,
feedback via Patient Advice and
Liaison, Complaints and patient and
staff surveys so that we can make
tangible improvements to the
services we provide. We aim to be
the hospital of choice for patients
and staff. To do this we need to:
1.
2.
Roll out of the Department of
Health Friends and Family Test
and achieve an increase in
response rates
Implement the Friends and
Family Test in all Outpatient
and Day Case areas within the
Trust by the 1st October 2014
What we achieved - Friends and
Family Test (FFT) CQUIN
The FFT is the recognised framework
that is used to gather real time
feedback from patients on a daily basis.
This year over 10,000 patients provided
feedback to the Trust using this
method.

As planned the early rollout of the
FFT survey occurred for all
Outpatient and Day Case areas
within the Trust

As planned the Trust achieved a
20% response rate for the FFT for
patients who attended our
Accident and Emergency
Department

As planned the Trust achieved a 20%
response rate for the FFT for patients
who attended our Accident and
Emergency Department

As planned the Trust achieved a 40%
response rate for the FFT for
Inpatients who were discharged from
our Wards
The Trust collected feedback from patients
and their carers through the following
routes:

Friends and Family Test and free text
commentary

National surveys (Inpatient and
Accident and Emergency Department

Local Inpatient Surveys

Patient Council Surveys

NHS Choices

Patient Opinion

PALs and Complaints feedback
This feedback was then reviewed to
enable the Trust to identify the key areas
that required improvement that would
positively improve the patient experience.
The work programme of the Patient
Experience Team was determined by the
Patient Experience Group. The membership
of which is made up of service users,
members of HealthWatch Essex and Senior
Trust clinical and managerial staff.
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Putting Listening into Action
Some examples of how we have improved
the patient experience are detailed below:
Improving how we Inform and
Communicate with our Patients and
Visitors
All Wards now have:



Welcome Boards – These are
placed at all ward entrances. They
advise visitors to the ward of the
Senior Sisters name and they
provide useful information such as
telephone number and visiting time of
the ward.
Staff Photograph Boards - All
Inpatient wards now have
photograph boards of their staff that
welcome patients and visitors to the
ward team and explains what each of
the uniforms are.
Staffing Level Boards - Each
Inpatient ward now displays the
number of qualified nurses, health
care assistants and other key staff on
duty each day.
Each Bedside now has:
noise on the Inpatient wards to a
minimum to enable our patients to get
the rest they need.
All wards now have access to Sleep
Well packs. These contain ear plugs
and eye masks to aid a good night’s
sleep. The pack also contains socks
with a non slip tread to reduce the risk
of falls.
We have Improved Patient Access
to our Services

Outpatient Information videos
are now provided on the Trust
website which prepares them for
what to expect from their
Outpatient visit and how to
easily navigate the
Outpatient Department

The Trust has increased the
number of wheelchairs for our
patients and visitors to use

Volunteers have been trained to
assist patients and visitors with
visual impairments
Improvements to the Discharge
Process

Improvements to the Nurse
documentation has resulted in a
discharge checklist that includes
a Nurse led discussion which
ensures that all patients being
discharged understand the
medication they are going home
with and the possible side
effects that may occur with their
medication.

When required we are now able
to provide patients with free
brand new clothing that has
been donated by a charity on
their discharge. This service
preserves the patient’s dignity
and ensures they can keep
warm during their transfer home.
A Bedside Folder – Each patient’s bed
now has a bedside folder that provides key
information that is useful to a patient and
their family during their stay. It also
provides information on how they can talk
to a member of staff if they have any
questions or concerns
Bedhead Boards –The Bedhead board
advises the patient of who their Named
Nurse, and Consultant is.
We have Improved the Ward
Environments
The Trust re-launched the Sssh
Campaign. This campaign reminds all
staff of the importance of keeping the
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
Increasing and Improving Staff
Training to Improve the Patient
Experience
The Patient Experience Team provide
a number of opportunities for staff to
reflect upon how they can all provide
a positive patient experience. Training
is provided at Trust Induction,
Leadership training, Preceptorship
training and at bespoke training
sessions for all staff.
Raising Staff Morale
Research has proven that if an
organisation improves the morale and
wellbeing of its staff it will have a
positive impact upon the patient
experience. To this end a number of
initiatives have taken place in the last
year namely:
Staff OSCAs – Awards evening for
staff who have been nominated by
patients or colleagues for providing
outstanding service to patients
The Staff OSCA’s
20 February 2015
Long Service Awards – Recognition
event for staff with long service within
the NHS
Challenge 2014 – Events, games
and activities to encourage staff to be
more active and in order to keep fit
and improve or maintain physical
health and well-being
Thank you cards – feedback cards
for patients to leave positive
comments for staff who have cared
for them
Positive Feedback – Through
communication media the Trust
continuously makes staff aware and
celebrates the positive feedback the
Trust receives from users of the
service. In the coming year the
Patient Experience will build upon the
successes of the previous year.
Challenge 2014
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
15
3.b To improve the care of patients with
Dementia
Led by: Cathy Geddes, Chief Nurse
Rationale - The Trust recognises the
importance of early diagnosis of dementia.
Diagnostic assessment; caring for patients
in a suitable environment; taking into
account information and knowledge from
carers and timely referral to support
services all helps to minimise distress for
patients.
Aim
1) To achieve 90% compliance with
dementia diagnostic assessment of
relevant patients
What we achieved: MEHT have achieved
above 90% compliance consistently
throughout 2014/15. The importance of
this tool and the clinical need / benefits for
patients receiving a timely diagnosis is a
key theme throughout all levels of the Trust
Dementia Training Strategy. The Elderly
Assessment Team have built on this
further by providing targeted face to face to
Registered Nurses on all wards.
3)
What we achieved: the Trust uses a
combination of tools to understand
patient and carer satisfaction. Both
Care of the Elderly Wards are now
regularly using an observation tool to
understand the patient’s perspective
and identify areas of good or poor care.
The wards identify themes and have
developed individual dementia action
plans to improve the experience. The
Trust also uses information gained from
carers questionnaires to identify areas
for improvement. Examples of
improvements that have been made to
improve patient and carer satisfaction
are as follows:

The Trust is in the process of
embedding a system whereby all
patients who have a confirmed
diagnosis of dementia and their
relatives are provided with a
bespoke Information leaflet which
will signpost to both internal and
external support.

The Trust has amended the
visiting policy to ensure all
patients with dementia have open
visiting. This is confirmed on all
Welcome Boards outside the
wards throughout the hospital so
that family members are fully
aware there are no restrictions to
visiting times for these patients.

The Trust is endeavouring to
recruit specifically trained
Dementia Volunteers to support
patients with dementia to meet
physical, spiritual, psychological,
social and emotional needs as
this is central to providing
person-centred care and reducing
behaviours which can be
perceived as challenging.
2) To enhance the ward environment for
patients
What we achieved: Environmental
changes to the two care of the elderly
wards are in the last stages of completion.
Changes have focused on improvement of
lighting and signage, use of colour coded
bays and individualised bed spaces and
use of contrasting colour in toilets and
bathrooms. Work on the dementia friendly
garden began in November 2014 with the
aim of completion by the summer of 2015.
This project has been supported by Writtle
College and the 41 Club and has been
funded by generous charitable donations.
16
To increase patient and carer
satisfaction
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
Dementia Garden Dig 2014 Aiming for August 2015 Completion
3.c To improve provision of timely
Discharge Summaries to GPs.
Led by: Ronan Fenton, Chief
Medical Officer
Rationale - Patient experience is
enhanced when all clinicians involved
in their care communicate well. One
important aspect of that
communication is updating patients’
GPs when they are discharged from
hospital. The discharge summary tells
the GP about any diagnosis,
treatment plan and medication
changes so it is important that the GP
gets this update soon after discharge.
Aim - To meet a locally agreed
standard of 95% of discharge
summaries being provided to GPs
within 48 hours with the aim of
achieving 100% by year end.
What we achieved: Regrettably we
have not achieved this target this
year. We are greatly disappointed by
this as we agree that this is a key part
of our obligation to provide timely
updates to GP colleagues regarding
their patients. This issue is once again
at the forefront of the Executive
Teams priorities and an improvement
plan is being developed for 2015/16.
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
17
Review of other quality performance
2014/15
Many other quality initiatives were developed and progressed across the Trust
during 2014-15. In addition the Department of Health have developed a number of
national indicators for good quality services and MEHT performance against these
indicators should be reported within this account. These indicators are included in
detail below and include our performance and where it is available, the national
average and the range from lowest to highest performance amongst NHS Trusts.
Patient Safety
Improved Governance Framework
The first priority for any NHS
organisation striving to improve the
quality of care for the patients it
serves is to ensure that an effective
Governance framework is in place.
For MEHT, 2014/15 has been an
important year, with the Governance
arrangements formally reviewed and
strengthened. This review was in 2
parts:
18

Governance reporting framework the reporting arrangements were
reviewed and a Clinical
Governance Group was established
to allow greater clinical
engagement with the Patient Safety
and Quality Improvement agenda.
Each clinical area has since
identified a safety and quality lead
who reports into the group quarterly
on local issues. At each meeting
the members can discuss
performance and share learning
across the Trust.

Corporate Governance Team - the
corporate governance team has
been restructured to provide
additional support for the Clinical
directorates so that these teams
can more effectively deal with and
learn when things go wrong and
ensure that the Trust takes account
of the best practice in service
development.
As an organisation we are constantly
evaluating the effectiveness of this
Governance Framework and we will
strengthen it further in 2015/16. This
will include the establishment of an
Integrated Governance Committee that
will provide a forum to review all
elements of the Governance
Framework in one place.
Patient Safety and Quality Strategy
The Trust’s first Patient Safety and
Quality Strategy was developed and
launched in 2014/15. The strategy
takes into account the lessons of the
Francis report on Mid Staffordshire
Hospitals and the Berwick report into
Patient Safety (Francis 2013, Berwick
2013). The improvement priorities for
2015/16 set out within this Quality
Account reflect the aims of the strategy
and fall within the following overarching
ambitions, to deliver safe, effective care
with an excellent Patient Experience.
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
Patient Safety Week
The Trust held a Patient Safety and
Quality week in the week commencing
2nd February 2015. The programme
for the week included education and
awareness sessions provided by
Clinical leaders on:

Patient Dignity

Recognising and Managing
Sepsis

End of Life Care

Track and trigger NEWs scoring
and management of the
deteriorating patient

Human Factors

Quality improvement
methodology
clinical specialty and after every Trust
Board meeting, they will visit a ward or
department using the Royal College of
Nursing 15 steps methodology, speaking
to patients and staff to understand whether
services are delivering high quality care
with a good patient experience. The
findings are then discussed at the Board
meeting and actions agreed.
In addition, Trust leads from a variety
of safety and quality teams
showcased their activity on stands in
the Hospital’s Atrium during the week.
This provided valuable feedback for
future provision. For example we will
be improving the visibility and
availability of the Patient Experience
Team in future.
Quality Walk Rounds
During 2014/15, a programme of visits
to wards and departments was
developed. Each visit was led by a
senior member of staff and supported
by a multidisciplinary team.
Performance information was
reviewed and the team spoke to
patients, visitors and staff to find out
about the quality of care and the
services being delivered. We called
this process Engage and found that
feedback from all involved was very
positive.
In addition a programme of
Non-Executive Director (NED) visits to
clinical areas was established. Each
Non-Executive Director is aligned to a
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
19
Nurse Staffing review
Adequate nurse staffing levels are
essential to the delivery of safe, effective
and responsive nursing care. In 2014/15,
the Trust completed reviews of patient
acuity and dependency on inpatient wards
to ensure that staffing provision meets the
needs of the patient group they serve.
These reviews (using assessment tools
endorsed by NICE) led to a significant
investment in nursing staffing. The staffing
reviews will be undertaken on an on-going
basis to ensure that patient safety remains
a priority for the Trust.
In order to address the consistent
challenge of national nurse recruitment, the
Trust has recruited nursing staff from both
the EU and further afield. In 2014/15, 32
nurses have commenced employment from
India and the Philippines and the Trust is
supporting and mentoring their adaption
process to become registered nurses
within the UK. 48 nurses have commenced
within the Trust from within the EU and
these staff are already part of the
registered nurse workforce. The Trust
expects 39 more nurses from India and the
Philippines to commence employment in
2015/16. The Trust intends to continue its
recruitment campaign in the EU and is
looking to source another 40 nurses with
valid NMC registrations to join the
registered nursing workforce in September
2015.
Local recruitment continues to be a
challenge and the Trust has ventured into
more creative ways of attracting new staff.
The Trust has conducted 2 recruitment
open days that has yielded successful
applications and recruitment from nurses
within the region and retaining student
nurses that have been supported and
developed.
The Trust has also collaborated with Anglia
Ruskin University to provide mentorship
and training to nurses that are returning to
practice. This initiative will continue in
2015/16 to ensure that local talent is
encouraged and nurtured within Mid Essex
Hospital.
20
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Patient Safety Thermometer
The NHS Safety Thermometer is a national data collection which records the
presence or absence of four harms on a given day every month. The harms included
are pressure ulcers, falls, urinary tract infections (UTIs) in patients with a catheter
and new venous thromboembolisms (VTEs). This comprehensive dataset helps us
to identify where we need to focus our attention to improve the quality of services.
The tables below show performance in 2014/15.
Table 1: Monthly data for harm free care for the 12 months to March 2015
Table 2: types of harm for the 12 months to March 2015
Source www.hscic.gov.uk
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
21
Venous thromboembolism (VTE)
It has been estimated that every year in England 25,000 deaths occur as a result of
hospital-acquired VTE. In many cases, deaths resulting from blood clots that develop
during an inpatient stay are preventable. It is therefore important that adult patients
are assessed for their risk of developing a clot when they are admitted to hospital so
that measures can be put in place to reduce the risk. The percentage of our patients,
who are assessed for their risk of developing a VTE, is an important measure of the
quality of care we provide. This information is collated and reported on both within
the Trust and externally to our commissioners and regulators.
Table 3 the percentage of patients who were admitted to hospital and who were risk
assessed for venous thromboembolism during the reporting period.
Apr-
MEHT
E gla d
Highest
A ute Trust
Lo est A ute
Trust
.
%
.
%
%
.
%
.
Ma
.
%
.
%
%
.
%
.
Ju -
Jul-
Aug-
Sep-
O t-
No -
De -
Ja -
Fe -
Mar-
.
%
.
%
.
%
.
%
.
%
.
%
.
%
.
%
.
%
.
%
.
%
.
%
.
%
.
%
.
%
.
%
.
%
.
%
.
%
.
%
%
.
%
.
%
.
%
.
%
.
%
.
%
.
%
.
%
.
%
.
%
.
%
.
%
.
%
.
%
.
%
.
%
.
%
.
%
.
%
.
Source http://www.england.nhs.uk/statistics/statistical-work-areas/vte/ via Health & Social Care
Information Centre
The Trust is pleased to note that performance is consistently above the average for
England. The Trust has a training programme in place to ensure relevant staff are
made aware of the significance of VTE as a patient safety issue and how timely risk
assessment and intervention can reduce the risk of harm to our patients. The
Thrombosis Group monitors compliance with risk assessment and develops further
initiatives where they are required. The Trust will continue to focus on this area of
care as priority in 2015/16 and will;

undertake regular audit of compliance;

strengthen the membership of the Thrombosis Group;

monitor performance and progress with the Thrombosis Group action plan.
Clostridium difficile infection
The number of cases of acquired Clostridium difficile infection in hospital can be
used as a marker of effective infection prevention and control practice. Each
Healthcare provider is required to report monthly on the number of cases of
Clostridium difficile that are identified at 72 hours of admission. This allows national
data to be collated and monitored.
22
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
Review of national data allows the Trust to compare infection rates with other
organisations. The most recent national data relates to performance in 2013/14 –
see table 4 below.
Table 4 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.
Naio al I di ator
The rate per
,
ed da s of ases
of Clostridium diicile i fe io reported
ithi the Trust a o gst paie ts aged
or o er duri g the repori g period.
MEHT
/
Lo al
data
.
*
*MEHT
/
*Naio al
a erage
/
*Highest
rate
a o gst
NHS orga isaio s
/
.
.
.
*Lo est
rate
a o gst
NHS orga isaio s
/
*Based on 16 cases, 3 of which were successfully appealed.
Source http://www.england.nhs.uk/statistics/statistical-work-areas/vte/ via Health & Social Care
Information Centre
It is noted that the Trust remains well below the national average of 14.7 cases per
100,000 bed days for Clostridium difficile, in spite of caring for patients with
increasing dependency and multiple co-morbidities. This achievement is a great
credit to the MEHT.
Mid Essex Hospital Services Trust is committed to sustaining its position in the
coming year by continuing to ensure that infection prevention remains a
fundamental standard of patient care and so improve the quality of services.
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
23
Patient Safety Incidents
It is unfortunately the case that in a large organisation providing complex healthcare,
things will sometimes go wrong and result in patient harm. By encouraging staff to
report these incidents and maintaining an open and transparent culture, the Trust
has an opportunity to investigate the root causes of these adverse events and
change ways of working to ensure that the chance of recurrence is reduced.
The rate of patient safety incidents reported within the Trust relative to activity, and
the number and percentage of such patient safety incidents that result in severe
harm or death, are important indicators of the maturity of the organisation’s safety
culture. Organisations that report more incidents usually have a better and more
effective safety culture.
The most recent national data reporting incident rates relates to the period 1st April
to 30 September 2014. The reporting rate per 1,000 bed days at the Trust was 29.67
and Table 5 below provides national comparative data for this and the previous
reporting period.
Table 5 number and 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.
National data for 6 month period 1st April 2014 to 30th September 2014
(published Apr-15)
MEHT
All Acute
Trusts
Lowest
Acute
Highest Acute
Number of incidents occurring
2,749
587,483
41
3,795
Rate per 1,000 bed days
29.67
n/a
5.8
74.9
Percentage resulting in severe harm or death
0.47%
0.49%
0.00%
1.45%
National data for 6 month period 1st October 2013 to 31st March 2014
(published Sep-14)
MEHT
Number of incidents occurring
2,819
All Medium
Acute
Trusts
141,822
Lowest Medium Acute
Highest Medium Acute
1,048
4,915
Rate per 100 admissions
6.75
n/a
2.41
16.76
Percentage resulting in severe harm or death
0.67%
0.65%
2.10%
0.35%
The number of reported clinical incidents decreased in 2014/15 compared to
2013/14 so during the year, we have continued to raise awareness amongst staff
about the importance of reporting instances where patients have been, or could
have been, harmed. Each Directorate has a process in place to review the incidents
that occur in their areas and there is a daily meeting to review any serious or
potentially serious incidents that may require further investigation.
In recognition that the quality of investigations undertaken when incidents are
reported can be variable, we have developed an improved training programme for
key investigators and are reviewing how lessons are learnt across the
organisation.
24
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
Mid Essex Hospital Services Trust is
taking the following actions to improve
the reporting and management of
incidents:

continuing to raise awareness of
key patient safety issues at
induction, on mandatory training
and during incident investigation
training;

developing the framework for
reviewing and learning from
incidents within clinical services
and employing Governance
support staff to support this
process;


commissioning external training in
root cause analysis investigation
to develop a cohort of staff across
the Trust with this expertise;
updating the policies, procedures
and document templates to
ensure these are user friendly and
enhance the opportunities for
learning when things do go
wrong.
Never Events
Never Events are serious incidents that
are considered to be preventable as
guidance or safety recommendations
that provide strong systemic protective
barriers are available at a national level
and should have been implemented by
all healthcare providers. During
2014/15, the Trust reported 7 never
events:

In 1 case there was an ultrasound
guided injection to the wrong hip

In 1 case, chemotherapy was
wrongly prepared;

In 2 cases, the wrong tooth was
extracted;

In 3 cases, the wrong skin lesion
was removed.
implemented. In addition, the Trust
has commissioned a Human Factors
Expert to observe practice in our
Theatres to ensure that the safety
checks in place to prevent such
events, are effectively implemented,
and that there is strong team working
in place.
Patient restraint
Investigation into patient abuse at
Winterbourne View Hospital, indicated
that restrictive interventions have not
always been limited to use as a last
resort in both health and social care
settings.
In line with new Government
directives, work commenced during
2014/2015 whereby MEHT has
worked hard to produce a policy and
framework which can be used to
support clinicians in promoting
positive and proactive care.
Timely responses are needed when
delivering care and support to
vulnerable individuals. The shift in
approach and change in culture will
ensure patient safety and promote
their recovery with the aim of
developing therapeutic environments
across the health setting and
minimising all forms of restrictive
practices so they are only ever used
as a last resort.
Currently, there is very little statistical
or meaningful data on restrictive
practices used within the Trust but as
this has been an area of work in
progress, the plans drawn up for
2015/16 will address this. New
procedures being put into place will
guarantee more robust monitoring
and compliance in future.
Comprehensive investigations were
undertaken into these events and
significant changes to practice were
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25
Clinical Effectiveness
Summary Hospital-Level Mortality Indicator (SHMI)
The Summary Hospital-level Mortality Indicator (SHMI) was launched in 2011 and
reports on mortality at Trust level across the NHS in England. The SHMI covers all
deaths of patients admitted to hospital and those that occur up to 30 days after
discharge from hospital and is the ratio between the actual number of patients who
die and the number that would be expected to die on the basis of average figures,
given the characteristics of the patients treated. The Health and Social Care
Information centre produce the SMHI together with the number of patients coded as
receiving palliative care as this provides context to the mortality data.
Data for the MEHT SHMI was last published in January 2015 and covers the period
up to July 2013 to June 2014.
Table 6
This table demonstrates the value and banding of the Summary Hospital-Level
Mortality Indicator (SHMI) for the Trust for the reporting period with percentage of
patient deaths with palliative care coded at either diagnosis or specialty level for the
Trust for the reporting period.
MEHT
Period
S ore
Nu
Ba di g
O t-
to Sep-
.
- as e pe ted
Ja -
to De -
.
- as e pe ted
Apr-
to Mar-
.
- as e pe ted
Jul- to Ju O t- to Sep-
.
.
- as e pe ted
- as e pe ted
Higher
tha e pe ted
er of Trusts - E gla d
As e pe ted
Lo er
tha e pe ted
Total
July 2013 to June 2014
Percentage of admitted patients whose treatment included palliative care
1.2%
Percentage of patients who died whose treatment included palliative care
24.2%
Source: NHS IC Health and Social Care Information Centre *Rolling 1 year period, 6 months in arrears
It is of note that:
26

Mid Essex Hospital Services Trust has consistently maintained the SHMI
relative risk rate as within expected range over the last 12 months.

The latest published SHMI shows that the mortality relative risk has reduced by
5.5% compared to the same period in 2012/13 (1.08 down 1.02).

The proportion of patients who were admitted to hospital who subsequently died
in hospital has reduced by 3.3% compared to the same period in 2012/13.
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Mid Essex Hospital Services Trust intends
to take the following actions to improve its
mortality data by continuing to:

fully implement evidence based care
bundles or sets of medical
interventions that together significantly
improve patient outcomes.

improve the management of the
deteriorating patient through early
recognition and escalation for
treatment.

improve End of Life Care to support
patients who are dying to be cared for
in their preferred place.

work with clinical teams within the
hospital and across the community to
review and understand patient
pathways and identify areas for
improvement.
Helping people recover from
illness and injury
Patients undergoing elective inpatient
surgery for four common elective
procedures (hip and knee replacement,
varicose vein surgery and groin hernia
surgery) are asked to complete
questionnaires before and after their
operations. These Patient Reported
Outcome Measures (PROMs) calculate
health improvement from a patient
perspective by asking them about their
health and quality of life before and after
their specific operations.
Table 7 - Participation rates
MEHT
Participation
Rate
England
Participation
Rate
All Procedures
91.5%
77.3%
Groin Hernia
72.4%
60.8%
104.1%
87.1%
98.1%
95.1%
65.8%
40.7%
Hip
Replacement
Knee
Replacement
Varicose Vein
Of the 935 post-operative
questionnaires sent out to patients,
613 have been returned, a response
rate of 65.6% which is in line with the
England average of 67.8%.
Table 8 - Health gain from nationally
available data
April 2013 to March 2014, data
(published February 2015)
Adjusted Average
Health Gain
MEHT
England
Groin
0.099
0.085
Varicose Veins
*
0.093
Hip Replacement
(Primary)
Hip Replacement
(Revision)
0.446
0.436
*
0.255
0.323
0.323
*
0.245
Knee Replacement
(Primary)
Knee Replacement
(Revision)
Figures between 1 and 5 have been suppressed and replaced with "*" to protect
patient confidentiality.
Low numbers reported for most Trusts are
due to time-delay before post-operative
questionnaires are completed, returned
and processed or due to low numbers of
procedures performed.
Source: NHS IC Health and Social Care
Information Centre
Source: www.hscic.gov.uk
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27
Readmissions
Readmission to hospital within 28 days of discharge can be an important measure of
the quality of care provided to patients. The reasons for readmission are often
complex without one single causal factor. However there are opportunities to help
prevent potentially avoidable readmissions by reviewing comparative figures and
learning lessons where organisations have low readmission rates. The Trust has a
lower number of readmissions compared to the average for England.
Table 9 National comparison to England and other Medium Acute Trusts data for the
percentage of patients readmitted within 28 days of being discharged from a hospital
during 2011/12.
2011/12 READMISSIONS WITHIN
28 DAYS WHERE THE PATIENT IS
> = 16 YEARS OF AGE SPLIT BY
FINANCIAL YEAR
2011/12 READMISSIONS WITHIN
28 DAYS WHERE THE PATIENT IS
< 16 YEARS OF AGE SPLIT BY
FINANCIAL YEAR
MEHT
Local Data*
2014/15
MEHT**
England**
Lowest**
Highest**
2011/12
2011/12
2011/12
2011/12
10.3%
10.0%
12.0%
9.3%
15.7%
6.8%
7.9%
10.3%
5.2%
14.9%
*Source Local data from MEHT Information Services
**Source: NHS IC Health and Social Care Information Centre
Relative Risk Readmission or Standardised Readmission Ratio (SRR) is the relative
risk of 30 day emergency readmissions, (observed number of emergency
readmissions compared to expected)
Chart 1 - Mid Essex compared to East of England Trusts.
The Trust’s relative risk for 30 day readmissions is 94.02 (national average 100)
this means that the Trust has fewer readmissions than would be expected for the
patients that are treated. (Data source HED - April to December 2014)
In 2015/16 a stakeholder audit of readmissions will commence. Key parties including
Social Care, Commissioners and GP’s will be involved in maintaining low levels of
readmissions.
28
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
The Patient and Staff Experience
As described on page 13, the Trust has maximised the opportunities to receive
feedback from our patients and staff regarding the experiences they have had
whilst being cared for or being an employee of Mid Essex Hospital Trust. Our aim
is that every patient’s experience is an excellent one and we understand what
matters most to them and their families. Of equal importance to us is the feedback
we receive from our staff via the Friends and Family Staff Survey and the National
Staff Survey.
Friends and Family Test for Patients (FFT)
Table 11 provides the results of the NHS Friends and Family Test for Mid Essex
Hospital Trust for the last financial year.
Inpaients
A&E
MEHT
AprMa Ju JulAugSepO tNo De Ja Fe Mar-
%
%
%
%
%
%
%
E gla d
%
%
%
%
%
%
%
Highest
A ute
Trust
Lo est
A ute
Trust
%
%
%
%
%
%
%
MEHT
AprMa Ju JulAugSepO tNo De Ja Fe Mar-
%
%
%
%
%
%
%
E gla d
Highest
A ute
Trust
Lo est
A ute
Trust
-
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
Source http://www.england.nhs.uk/statistics/statistical-work-areas/friends-and-family-test/
Please note the reporting methodology changed from September 2014. In line with
the recommendations from the national review of FFT that took place in July 2014,
NHS England moved away from presenting data using the Net Promoter Score
(NPS) to using the percentage of respondents that would recommend/wouldn’t
recommend the service. The Trust notes that performance in the last 6 months
has been similar to that of peer organisations.
Table 12 shows data for the Trust’s responsiveness to the personal needs of it’s
patients. The most recent national data available is from 2013-14.
Responsiveness to
the personal needs of
its patients during the
reporting period
MEHT
2013-14
MEHT
2012-13
National
average
2013-14
Highest
2013-14
Lowest
2013-14
66.7
68.1
68.7
85
54.4
This relates to an average weighted score of 5 questions relating to responsiveness to inpatients'
personal needs (Score out of 100)
Source: the National Patient Survey Programme
Further i for aio is a aila le at: htps://i di ators.i . hs.uk/ e ie
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
29
Friends and Family Test for Staff
The NHS friends and family test provides a great opportunity to gain feedback from
our staff. This new survey for staff was introduced in 2013. Staff are asked ‘If a friend
or relative needed treatment I would be happy with the standard of care provided by
this organisation'.
Table 13
Provides the Friends and Family Staff Test results for the last financial year.
MEHT
All Orga isaio s
MEHT
All Orga isaio s
MEHT
All Trusts
Neither
Stro gl
agree or
disagree Disagree disagree
%
%
%
Agree
%
Stro gl
agree
%
Base
u er of
respo de ts
Agree
a d
Stro gl
Agree
%
%
%
%
%
%
%
%
%
%
%
247,819
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
199,142
%
%
%
250
99,456
Source http://www.nhsstaffsurveys.com/Page/1019/Latest-Results/Staff-Survey-2013-DetailedSpreadsheets/ Source: NHS IC Health and Social Care Information Centre
It is pleasing to note that the Trust score compared favourably when benchmarked
with other organisations. Mid Essex Hospital Services Trust plans to further improve
this score, and in turn improve the patient experience. These plans include:
30

To improve staff satisfaction and morale in their job. The Trust believes that
increasing staff morale and ensuring staff feel valued for the work they do will
positively impact on patient experience.

The Culture Project will facilitate increased engagement which will result in the
development of shared values and behaviours.
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
Corporate Strategic Change
Projects
In 2013/14 the Trust developed a
number of strategic projects. These
strategic change projects were
selected by our senior clinicians and
Trust Board to ensure delivery of safe,
effective care with outstanding patient
experience:
They focused on Urgent Care
(Hospital Flow), Theatre Efficiency,
Culture and Clinical Environment
1 - Urgent Care (Hospital Flow)
Transformation Programme Project
was identified as one of four key
projects to facilitate the provision of
patient centred care that was safe,
high quality and cost effective. The
key priorities for improvement for 2014
-2015 were agreed through numerous
patient flow process mapping
workshops, engaging over 300 front
line staff in the process giving them an
opportunity to share their ideas and
views to identify the priorities and
improvements required. The project
also expanded its scope to take on the
urgent care centre transformation and
walk in centre closure, this
collaborative approach resulted in a
primary care GP being based in the
Emergency Department to whom
primary care patients are streamed,
The project has made huge progress
over the last 12 months, key results
include:
•
The establishment of the Medical
Assessment Zone, resulting in greater
consultant prevalence, earlier patient
review by a senior clinician and
increased physical capacity for early
patient assessment.
•
Ambulatory Care Unit
development and participation in the
Ambulatory Care Network, a national
initiative to enable benchmarking and
sharing of best practice.
•
The provision of a dedicated
surgical emergency ward. This ensures
patients presenting with a surgical
emergency are seen in a dedicated
environment at the right time, staffed
with the right people with the right
skills.
•
The establishment of a dedicated
paediatric facility within the emergency
department ensuring children are seen
and treated in dedicated, safe and child
friendly environment.
•
Successful participation in the
Frailty 100 day challenge resulting in
system wide, collaborative working
around the frailty pathway. As a result
patients on the frailty register were
flagged within the emergency
department ensuring the right
professionals from both the community
and Trust being involved in the
patients care reducing the need for
admission where appropriate.
•
Development of a discharge
planning ethos from admission to
discharge. This element of the project
reviewed the existing discharge
planning processes and practices for
•
Revision of the triage process in
the Emergency department resulting in adults across the Trust and partner
agencies. The positive outcome saw
improvements in the time patients
have their first assessment resulting in the development of streamlined
processes. reducing the number of
a safer and positive patient
delayed transfers of care.
experience.
•
Increased nursing and medical
resource across the emergency floor
which includes the emergency
department, ambulatory care unit and
the emergency assessment unit.
•
Expansion of space within the
majors area of the emergency
department is in progress, this will
result in five extra cubicles. The
increased capacity is expected to
make a significant impact on improving
quality, safety and performance.
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
31
The patient flow project also expanded
its scope to take on the urgent care
centre transformation and walk in
centre closure, this collaborative
approach resulted in a primary care GP
being based in the Emergency
Department to whom primary care
patients are streamed.
The patient flow project has been a
huge project and still has a number of
streams of work in progress which will
ultimately benefit both our staff and
patients.
2 - Theatre Efficiency
Theatres Strategic Change Project –
Improving Theatre Patient Flows
Aims:

Reduce Theatre cancellations

Improve Theatre productivity

Reduce length of stay for
Emergency/ Elective Patients

Increase Day Case rates

Increase access to preoperative
assessment

Improve the patient experience
Achievements made so far:
The feedback we gained from listening
as part of the culture strategic change
project was used to help shape the
Trust’s Strategy.
Improved Theatre Productivity
The project group has implemented a
number of initiatives which have
increased theatre productivity namely:
The introduction of improved theatre
scheduling which matches Surgeon
Jobs Plans, the implementation of an
All Day Surgical Emergency CEPOD
list each day Monday to Friday has
increased elective theatre time
previously used for emergency
surgery. The service has increased
capacity by 8 beds which has
increased theatre throughput. Sterile
services has been reconfigured which
has improved the instrument
turnaround times.
Improved Length of Stay
As a result of the change project the
Trust has significantly reduced the
length of stay for Elective patients from
3.5 to 2.1 days and for Emergency
patients from 5.5 days to 3 days. 96%
of patients are now admitted on the
day of surgery.
Improved Preoperative Assessment
The Trust has implemented a Trust
Wide Pre-Operative Assessment policy
which has resulted in the introduction
of Standardised Pre-Assessment
documentation. Staffing rotas have
been reviewed and improved which
has significantly increased the capacity
by 50% of Pre- Assessment
appointments for patients.
Increased Day Case Rates
A number of service changes have
been made including the opening of
the new Day Surgery Unit which have
resulted in an increase in the Day Case
Rates from 61% to 73%.
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
3 - Culture – The Way We Do
things Around Here
One of the four strategic change
projects focused on culture during
2014, “Culture – The Way We Do
things Around Here”
Over the summer months we consulted
with patients, public, staff and
stakeholders and over 500 views were
shared about the culture of our
organisation. Feedback was shared
during events, through surveys, face to
face events and online. This
consultation explored our values and
behaviours, what would make Mid
Essex Hospitals NHS Trust the
hospital of choice and how we should
reward and recognise our staff. This
included development of a revised
Trust vision statement, “World Class
Healthcare for You in the Heart of
Essex”
The feedback we gained from listening
as part of the culture strategic change
project was used to help shape the
Trust’s Strategy.
This is very timely as NHS England
published in October 2014 the “Five
Year Forward View”, a new strategic
framework within which the NHS will
operate and develop in the
future. The framework brings in
noteworthy considerations with the
opportunity for new partnerships, new
models of care, a fresh focus on
prevention and support for healthier
lifestyles. It is also important to note
that Culture is at the heart of change
for the NHS with the Freedom to
Speak Up Review by Sir Robert
Francis QC driving to enable a more
open and honest reporting culture in
the NHS.
There are growing expectations of the
way care is provided from our
patients and community, many of
which were shared during our
engagement around culture. The way
the NHS in England is organised and
structured had changed nationally
and locally and our hospital has seen
new requirements from our patients
and community.
We have listened to the feedback
during the culture consultation. A
number of themes emerged for areas
of improvement. Where possible, we
used this feedback to make
immediate service improvements. An
example related to the lack of, and
ease of, locating wheelchairs. In
response, the Trust now has
additional wheelchairs available.
Our users also shared with us a need
for improved communication. As a
result we updated information
available for patients and visitors
across ward areas with new
photograph boards to help patients
and visitors understand who works on
the ward and new bedside folders to
better communicate about the
services available on our Broomfield
site.
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
33
4 - Clinical Environment Project
The clinical environment project has been
identified as one of the four strategic projects for
the senior leadership team. The clinical
environment project sought to support the work
from the theatre efficiency and the hospital flow
project. It aimed to address urgent clinical risk and
then continued to support the requirements of the
hospital flow project.
As part of the clinical environment project, a total
of 22 moves have been scheduled with the
remaining four moves scheduled during May 2015.
A new Day Surgery Unit with three operating
theatres opened in November 2014, and a
dedicated Surgical Emergency Ward opened in
April 2015 to enhance the care of patients with
surgical emergencies. The Emergency Short Stay
ward is now co-located on the emergency floor
with A&E and the Emergency Assessment Unit.
Within A&E we have introduced a separate area
for children that are treated in the emergency
department and will shortly open five additional
cubicles within the Majors side of the Emergency
Department to increase our capacity to deal with
some of our very sick patients. The GP out of
hours service was re-located to the Broomfield site
to improve access to out of hours GP services to
those patients who need not attend the
Emergency Department. We continue to work to
identify ways of improving the clinical adjacencies
and improve the efficiency of our accommodation.
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
Quality Improvement Priorities for
2015/16
In developing this Quality Account, we have consulted with our clinicians, executive
team and our Patient Experience Group to identify priorities for improvement in
2015/16. The priorities detailed in the tables below take account of the findings of
our CQC inspection, information on patient harm that occurred in 2014/15 and
initiatives linked to our Patient Safety and Quality Strategy.
Quality Domain
Proposed Priorities
Specific measures
Executive Lead,
2015/16
monitoring forum
Patient Safety: reducing avoidable harm and engaging and enabling staff to continuously improve
services
Reducing
Reduce the harm
To reduce by a minimum of 20%, the
Cathy Geddes
avoidable
resulting from Patient
number of patients suffering moderate
Falls Steering
harm
falls
or severe harm as a result of avoidable
Group
falls whilst in hospital
Reduce the incident of
To maintain a zero tolerance approach
Cathy Geddes
avoidable hospital acwith no patients developing avoidable,
Pressure Ulcer
quired pressure ulcers
hospital acquired Grade 3 or 4 PresPanel
sure Ulcers
Engaging
Assess and improve
To formally assess the organisation’s
Cathy Geddes
and enabling the safety culture of the safety culture using a recognised tool.
Ronan Fenton
staff
organisation.
To develop and implement organisaClinical
tion / team based culture development
interventions
Governance
Group
Increase the capability
To ensure each directorate has safety
of staff to utilise the
champions with expertise in Human
principles of safety sciFactors and incident investigation.
ence to drive improveTo develop and implement a training
ments to patient care
programme to support the delivery of
safe care.
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
35
Quality
Domain
Proposed Priorities
2015/16
Specific measures
Clinical Effectiveness: increasing the reliability of care
Reliable
Care
Executive
Lead,
monitoring
forum
Improve the early
recognition and
effective management
of patients with Sepsis.
To implement an education programme
for staff and monitor use of the Sepsis 6
care bundle to drive improvement.
Peter Davis
Improve Dementia Care
To ensure that patients with dementia
who are admitted to hospital are cared
for by appropriately trained staff. A pool
of specialist skilled practitioners will be
established who can provide clinically
effective, personalised, 1 to 1 care for
dementia patients including diversion
therapy.
To enhance end of life care for patients
and their relatives and carers and
improve the bereavement facilities.
Cathy
Geddes
Improve End of Life
care
To implement the End of Life Project
Plan administered by the End of Life
Steering Group.
Clinical
Governance
Group
Dementia
Multidisciplin
ary group
Cathy
Geddes
Peter Davis
End of Life
Steering
Group
Improving Patient Experience
To listen to and learn
from feedback from
service users and
staff.
To listen to, and learn from, feedback
received via:
Christine
Watts

Patient Advice and Liaison and
Complaints;

Quarterly Friends and Family
Test Surveys.
Bernard Scully
Patient
Experience
Group
Workforce
Governance
Group
The Trust recognises the value of
seeking feedback from staff through
participation in the national staff survey.
Levels of participation have been low
and the Trust is committed to
increasing the participation rate by 10%
in 2015/16 through developing and
implementing in partnership a staff
engagement strategy.
The trust also listens to staff through a
local staff impressions survey and the
quarterly staff friends and family test
questions.
The Trust will also implement a
programme of staff feedback
workshops (eg ‘listening into action’
type events) to learn from staff
feedback and improve staff experience
of working at the trust and ultimately,
patient services.
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
Review of services
During the period April 2014 to March 2015, Mid Essex Hospital Services Trust
provided 93 clinical services in 21 locations.
Mid Essex Hospital Services Trust has reviewed all the data available to them on
the quality of care in all of these NHS services.
The income generated by the NHS services reviewed in April 2014 to March 2015
represents100 per cent of the total income generated from the provision of NHS
services by the Mid Essex Hospital Services Trust for reporting period April 2014
to March 2015.
Goals Agreed With Commissioners
A proportion of Mid Essex Hospital Services Trust’s income in April 1 2014 to
March 31 2015 was conditional on achieving quality improvement and innovation
goals agreed between the Trust and any person or body they entered into a
contract, agreement or arrangement with for the provision of NHS services,
through the Commissioning for Quality and Innovation payment framework.
Further details of the agreed goals for April 1 2014 to March 31 2015 and for the
following 12 month period are available electronically at http://www.meht.nhs.uk/
about-us-/performance/cquin-goals-2015-16/
Review of 2014/15 CQUINs
Goal Name
Friends and Family Test
Description
Achieved
To improve the experience of patients
Progress
This national mandatory CQUIN is expected to have been fully achieved
Goal Name
NHS Safety Thermometer – Pressure Ulcers
Description
Partially
Achieved
To reduce patient harm
Progress
The Trust has been allocated a 39% achievement for this CQUIN.
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
37
Goal Name
Dementia
Description
To incentivise the identification of patients with dementia and other causes of cognitive
impairment alongside their other medical conditions, to prompt appropriate referral and
follow up after they leave hospital and to ensure that hospitals deliver high quality care
to people with dementia and support their carers.
Achieved
Progress
This national mandatory CQUIN was substantially achieved but unfortunately the Trust
didn’t meet the training requirement for Level 1 training which had a target of 100%
Goal Name
Surveillance of Surgical Site Infection
Description
To ensure continual monitoring and benchmarking against regional and national data,
enabling the opportunity for continual quality improvement in reducing infections after
surgery.
Achieved
Progress
This CQUIN expected to have been fully achieved. The Trust is carrying out work to
ensure improvement is sustained.
Goal Name
Medicines Optimisation
Description
Implementing the review of high risk identified patients to receive a medicines optimisation review by a dedicated pharmacist in order to ensure a holistic approach to a patients medication.
Achieved
Progress
Although Q1 milestones were not achieved, this CQUIN was fully achieved for the remainder of the year.
Goal Name
Frailty Pathway
Description
Using a recognised tool to ensure patients identified as frail are appropriately referred to
community teams in primary care.
Progress
Partially
Achieved
The implementation of the tool and training milestone was substantially achieved. The
achievement of inclusion of the frailty score on discharge summaries has not been
achieved.
Goal Name
Sepsis Pathway
Description
Ensuring an increase in the proportion of patients receiving all elements of Sepsis Six
Resuscitation Bundle and where indicated the Sepsis Four bundle to improve outcomes
for septic patients.
Progress
This CQUIN has created significant improvements in the treatment of emergency patients attending with sepsis. MEHT have not achieved the overly optimistic trajectories,
however due to the significant clinical improvements seen to date, Q3 and Q4’s trajectories have been re-set and are expected to be fully achieved.
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
Achieved
Goal Name
Patient Management System
Description
Implementation of an electronic solution for managing, recording and escalating the patient’s observations to improve patient care.
Achieved
Progress
This CQUIN is expected to have been fully achieved.
Goal Name
Visible Leadership in Practice
Description
Increasing the profile of nurse leadership within the Trust by ensuring senior
nursing staff become more visible and by developing future nurse leaders.
Achieved
Progress
This CQUIN is expected to have been fully achieved.
Goal Name – Specialist Services
Tackling Variation and Driving Quality to Improve use of Resources
Description
Collaborative working with the Specialist Commissioners to improve the quality
of specialist services creating a resultant financial saving, e.g Burns Enhanced
Recovery and Burns step down discharges.
Achieved
Progress
This CQUIN is expected to have been fully achieved.
Braintree Community Hospital
Goal Name
Frailty
Description
Identification of patients that are frail will enable them to commence on the
frailty pathway which will provide management for individuals to keep them
stable and minimise the rate of degeneration.
Achieved
Progress
This CQUIN is expected to have been fully achieved.
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39
Care Quality Commission
The Care Quality Commission (CQC) is the organisation which regulates and
inspects health and social care services in England. All NHS hospitals are required
to be registered with the CQC in order to provide services and are required to meet
fundamental standards in order to retain their registration.
Mid Essex Hospital Services Trust is required to register with the Care Quality
Commission (CQC). The Trust was not fully compliant with the registration
requirements of the CQC in 2014/15. Following inspection in August and November
2014 and return visits in February and March 2015 the position with regard to
compliance and enforcement is described below and concerns raised have been, or
are being, addressed by a comprehensive local action against timescales agreed
with the CQC.
In November, the CQC carried out a planned inspection, which included an
announced inspection visit to the Trust locations at Broomfield Hospital and
Braintree Community Hospital between the 26th and 28th November 2014, and a
subsequent unannounced inspection visit to Broomfield Hospital on 6 December
2014.
Broomfield Hospital received an overall rating of ‘Requires improvement’.
The inspection findings noted that throughout the organisation staff were
passionate, dedicated and cared about the work they delivered. However as a
result of the inspection, the CQC issued compliance actions and a warning
notice against the Trust relating to :


Compliance Actions:
•
Consent to Care and Treatment
•
Assessing and monitoring the quality of service provision
•
Staffing
Warning Notice:
•
Care and welfare of people who use services
In response the Trust has developed a comprehensive Quality Improvement
plan that will address all of the concerns raised by the CQC inspections. This
plan will be monitored weekly by Trust Executives and externally on a monthly
basis by the NHS Trust Development Authority and NHS England. Progress
reports will be publicly available on the Trust website (www.meht.nhs.uk).
Details of the full report can be found via http://www.cqc.org.uk/location/RQ8L0.
Braintree Community Hospital received an overall CQC rating of ‘Good’
Overall, the CQC found that the ratings and provision of care in each core
service inspected at Braintree Community Hospital to be good. They found that
the care provided to people in surgery and outpatients was good, services
were effective, the staff were caring, and locally within Braintree, the services
were well led. Overall, Braintree Community Hospital was rated as a good
service.
Details of the full report can be found via http://www.cqc.org.uk/location/RQ8RR.
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
Mid Essex Hospital Services Trust has participated in special reviews or investigations by the Care Quality Commission relating to the following areas during 2014/15.
Please refer to Table 14 below.
Table 14
Dates and Areas visited
Action taken
Progress
In August 2014, the CQC
undertook an
unannounced inspection
of the Accident and
Emergency Department.
As a result of the
inspection, the CQC
imposed compliance
actions against the Trust
relating to :
The Trust undertook the following
action to address the findings and
requirements reported by the CQC:

Improved the Accident and
Emergency working environment
by
 Relocating the Mental Health
room
 Ensuring the emergency
alarm from the additional
majors bay sounds in correct
department
 Providing a water cooler in
the adult waiting area
 Providing a dedicated
Paediatric Emergency Care
area

Staffing
 Continued the recruitment
programme for vacant nursing
and medical posts
 Implemented a rotational
programme to attract staff
 Appointed additional
management support
 Ensured conflict and
resolution training attendance
 Developed mechanisms to
share lessons from adverse
incidents and complaints and
implemented safety huddles
to ensure timely review of any
risks.

Developed Service Level
Agreement with Mental Health
Trust and acted to improve
collaborative working
arrangements; and completed
appropriate risk assessments.
By 31st March 2015
the Trust had made
the following progress
by:
 Ensuring work to
improve the
Accident and
Emergency
environment was
completed
 In light of national
shortages of
appropriately trained
staff, continuing the
recruitment
programme for
nursing and medical
staff. The nurse
numbers are
checked on a daily
basis to ensure safe
care can be
delivered.
 Ensuring Safety
huddles and
learning from
incidents meetings
take place regularly.
The Trust undertook the following
action to address the conclusions or
requirements reported by the CQC:

all nursing healthcare
professionals who work on
wards with the responsibility for
patients requiring advanced
nursing tasks are registered with
the Nursing and Midwifery
Council (NMC)

Nursing healthcare professionals
without registration with the
NMC were not permitted to
undertake tasks for which they
are not assessed as competent
nor have the appropriate
registration with professional
bodies to undertake

safe staffing levels were
maintained
By 31st March 2015 all
the associated actions
were implemented and
the CQC formally
removed the
conditions on the
Trust’s
registration on
28th April 2015.

Care and welfare of
service users.
 Assessing and
monitoring the quality
of service provision.
 Staffing levels
 Safety and suitability of
premises
In February 2015 a
focused review of the
Emergency Admissions
Unit following concerns
being raised about the
staffing levels. Some
overseas qualified nurse
members of the ward team
were found to be working
as registered nurses
without being registered
by the UK Nursing and
Midwifery Council. It was
also reported that
concerns raised by staff
were not addressed. As a
result of the inspection,
the CQC took enforcement
action under Section 31 of
the Health and Social
Care Act 2008 Requirements relating to
workers.
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
41
Participation in Clinical Audits
The reports of 18 national clinical audits
were reviewed by Mid Essex Hospital
Services Trust during the period April 1
Clinical audit is an important quality
2014 to March 31 2015, and the Trust
improvement process for the Trust. By
has included details of the review and the
participating in relevant national audits,
we can compare our practice with other actions it intends to take to improve the
similar organisations and identify whether quality of healthcare provided in table 2,
appendix 1.
we need to improve the services we
provide. In addition, we encourage all of
our clinical areas to perform local audits Improving services through
participation in local clinical audit
to measure the quality of patient care
they provide.
Local clinical audit provides an
National Clinical Audit participation opportunity for comparing the quality of
the services the Trust provides against
Participating in relevant national clinical best practice. The reports of 6 local
audits and confidential enquiries provides clinical audits were reviewed by the Trust
an important opportunity for the Trust to and table 3 identifies the actions that the
Trust has taken to improve the quality of
benchmark the quality of its services
healthcare provided.
against those of other providers and to
improve services where deficits are
identified.
During the period from April 1 2014, to
March 31 2015, 37 national clinical audits
and 4 national confidential enquiries
covered NHS services that Mid Essex
Hospital Services Trust provides.
During that period, the Trust participated
in 84% of the national audits and all of
the national confidential enquiries it was
eligible to participate in. Organisational
questionnaires were submitted for all the
NCEPOD studies, however not all patient
questionnaires were submitted.
The national clinical audits and national
confidential enquiries that Mid Essex
Hospital Services Trust was eligible to
participate in during the period April 1
2014 to March 31 2015 are listed in table
1 in Appendix 1.
Participation in Clinical Research
The number of patients receiving NHS
services provided or sub-contracted by
Mid Essex Hospital Services Trust in
April 1 2014 to March 31 2015 that were
recruited during that period to participate
in research approved by a research
ethics committee was 886.
Mid Essex NHS Trust was involved in
conducting 46 clinical research studies in
Non-Oncology and 50 Oncology Clinical
Research Studies during 1 April 2014 to
31 March 2015.
The improvement in patient health
outcomes in Mid-Essex NHS Trust
demonstrates that a commitment to
clinical research leads to better
treatments for patients. There were 24
clinical research nurse staff
The national clinical audits and national participating in research approved by a
confidential enquiries that Mid Essex
research ethics committee at Mid-Essex
Hospital Services Trust participated in,
NHS Trust during 1 April 2014 to 31
and for which data collection was
March 2015. These staff participated in
completed during the period April 1 2014 research covering 21 medical specialties.
to March 31 2015, are listed 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.
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Clinical Services Update
Anaesthetics and Theatres
Non-Invasive Ventilation Service
Over the last year there has been an
expansion of theatre capacity. The
day surgery unit has been redesigned providing us with a three
theatre complex.
We have also taken over the running
of Braintree Community Hospital with
its two Day Theatres, giving a total of
26 theatres.
There has been a drive to recruit, from
home and abroad, to establishment
for nurses and practitioners in
theatres, this continues. We have also
recruited direct from India to
Anaesthesia Middle Grades. The
successful candidates have made an
immediate impact on arrival
demonstrating a high level of skills
and motivation.
The Non-Invasive Ventilation service
introduced in the Trust is fully supported
by the physiotherapy service ensuring
safe and appropriate management of
critically ill patients.
GP order Comms
Radiology and Pathology are rolling out
their order comms system to GP
practices to allow for full electronic
requesting of diagnostic tests resulting
in a much faster and effective pathway
for their patients. Results are also being
handled electronically.
Increased access for Patients
Pathology have Opened the Phlebotomy
department in Broomfield from 7am to
6pm M-F to improve patient access
Improved Fertility Services
We have appointed 4 Consultant
anaesthetists in the last 6 months with
a view to advertising for more in the
very near future.
The laboratory have partnered with an
external company to extend the range of
fertility tests it can support, resulting in a
speedier more effective service.
We recently attended and presented
at The NHS Benchmarking Meeting.
Our presentation regarding improving
theatre activity was very well received.
Improved Turnaround
Diagnostics and Therapies
To reduce delays the service has
worked with several GP surgeries to
provide additional sample collections
that align with the practice’s clinic
sessions.
Continence Service
Physiotherapy have introduced a new
service for Pelvic Floor conditions
which provides specialist treatment of
continence patients in both antenatal
and post natal pathways.
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
43
Data Quality
Good quality information underpins the
effective delivery of patient care and is
essential in informing the Improvement of
services. Improving data quality can
therefore improve patient care and value
for money.
NHS Number and General Medical
Practice Code Validity
Mid Essex Hospital Services Trust
submitted records during April 1 2014 to
March 31 2015 to the Secondary Uses
Service for inclusion in the Hospital
Episode Statistics. The percentage of
records in the published data which
included the patient‘s valid NHS number
was:
the delivery, planning and
monitoring of patient care services

the planning and management of
Trust’s services

the collection of income.
The Trust was not subject to an Audit
Commission Coding Audit in 2014/15.
There was however an external
Clinical Coding Audit carried out as part
of the Information Governance Toolkit
requirements. The results were very
encouraging particularly the reduction of
Primary Procedures coded incorrectly
compared to the previous year.

Primary Diagnoses Incorrect 7%

Secondary Diagnoses Incorrect
9%

Primary Procedures Incorrect 5%

Secondary Procedures Incorrect
7%

99.9% for admitted patient care;

99.8% for out patient care; and
An improvement plan has been
developed for 2015/16.

97.5% for accident and emergency
care
The key clinical coding successes
throughout 2014/15 are:
The percentage of records in the published
data which included the patient’s valid
General Medical Practice Code was:

99.98% for admitted patient care;

99.99% for outpatient care; and

99.96% for accident and emergency
care
Clinical coding error rate

44

Clinical Coding is the translation of
medical terminology written by the
clinicians to describe the patient’s
diagnosis and treatment into
nationally standardised codes. This
information is vital to the Trust to
support:

the Team exceeded the
percentage of completed coding
targets set by Commissioners
throughout the year with over
98.5% of episodes coded by the
Flex date

a review and update of Outpatient
Procedure forms to ensure all
appropriate activity is recorded
and the correct income is received

the successful integration of
Braintree Hospital Coding
function into the central team
promoting staff development and
increased support and coverage
for the function

two Trainee Clinical Coders were
promoted to Senior Clinical
Coders following completion of
their two year training programme
and passing of an internal exam
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15

a Team Leader within Clinical
Coding successfully passed the
National Approved Clinical
Coding Auditor qualification in
December 14

the development of Clinical and
Service Excellence by working
with other directorates to ensure
improvements in clinical
documentation and data
recording are embedded across
the Trust. While this work is still
in the early stages it has
generated changes to working
processes, improvements in
documentation, improved patient
safety as well as increases in
Trust income.
The main challenge in the forthcoming
year is to continue the work with
clinicians within individual specialties
to review the quality and content of
clinical writings for coding purposes.
Information governance
Mid Essex Hospital Services Trust
Information Governance Assessment
Report overall score for April 1 2014
to March 31 2015 was 69% and was
graded GREEN from the
Information Governance Toolkit.
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
45
Medical Specialties
Stroke Unit
We have continued to improve
performance against key national
standards and targets.
Department of Medicine for the Elderly
Appointed three substantive consultants in
2014/15. For 2015/16, the Frailty
Assessment Zone is being planned to start
in August 2015. Furthermore, a limited,
pilot Surgical Liaison Service will be
started in mid-2015. We will aim to provide
a seven day consultant led ward round
from August 2015. Furthermore, six
additional medical registrars and four trust
doctors have been recruited to start in the
near future to help the night medical oncalls and weekends. A new dedicated
medical ward will open on Goldhanger
Ward in May 2015.
Cardiology
A fourth cardiologist has been appointed.
The business case is in progress to
repatriate ICD follow up & CT angiogram
repatriation from the CTD in Basildon.
Dermatology
A consultant dermatologist has been
appointed on a substantive basis and will
start working in August 2015.
Neurology
We have re-advertised a consultant post.
A recent Neurology Workshop was
successful for new ways of close team
working with the neurologists and the
specialist nurses in neurology. This will
further evolve in 2015/16.
Gastroenterology
A fourth consultant gastroenterologist has
joined the department.
46
The New Neurology Area
11th November 2014
Respiratory
There is a successful op basis pleural
clinic managed by a respiratory
consultant. A fourth consultant has
been appointed. There is a daily ward
round by the respiratory team
including weekends. A business case
has been approved for Sleep Apnoea
Clinic / CPAP service.
General Surgery
Surgical Emergency Ward
The emergency general surgical
service will benefit from the opening
of a dedicated emergency ward in
April 2015. The area will provide a
reception and assessment facility for
emergency surgical patients, a ward
office and bespoke shift handover
room, a treatment/minor operations
room, inpatient capacity for 19 beds
(including 2 isolation side rooms), and
a review clinic. This will reduce waits
for patients referred on an emergency
pathway, minimise unnecessary
hospital admissions, speed the flow of
patients who require surgery,
minimise length of stay and ensure
continuity of specialist
multidisciplinary care. The surgical
unit is delighted to be able to use the
newly refurbished area on the South
Wing to streamline the emergency
service.
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
The New
Emergency Surgery Ward
4 April 2015
Since September 2014, multidisciplinary
clinics have been set up to triage
patients with spinal complaints. The
Musculoskeletal Services continues to
provide high quality standards of care to STAMP clinic is run by Extended Scope
Practitioners triage referrals and works
their patients.
closely with spinal orthopaedic surgeons
and pain specialists to provide expert
Additionally, a new spinal service has
been set up in collaboration with Ipswich management decisions in
Hospital providing a streamlined network Multidisciplinary Team meetings.
Collaboration with Ipswich allows MEHT
approach to complex spinal surgical
to follow NHS England guidelines on
cases. Historically, patients referred by
spinal commissioning with complex
their GPs for treatment of spinal pain
tumour, trauma and infected cases being
may have had delays in their pathways
transferred through the network to
due to inappropriate referrals.
Ipswich while most general spinal
Spinal pain from multiple conditions can procedures are performed at MEHT by
our spinal surgeons. This is an example
be present with very similar symptoms
of best practice at work.
but the Spinal triage assessment and
management pathway (STAMP) has
been developed specifically to minimise
those delays.
Musculoskeletal Services
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
47
Women & Children and Sexual
Health
Neonatal Unit (NNU)
In 2014/15, service developments for the
NNU include the development and
implementation of an early warning tool,
specifically to be used within the
neonatal population. This early warning
tool enabled appropriate escalation by all
staff that was consistent and clearly
documented. In addition the
documentation looking at all aspects of
care including individualised care plans
and new observations charts was
updated.
Service development plans for the
forthcoming years:

Continue to develop our nursing
staff, to ensure high quality
neonatal care with neonatal trained
nurses.

Looking to develop a transitional
care ward, this will enable mothers
and baby’s to stay together even if
they need neonatal input.

To improve patient/family
experience when having their baby
on the Neonatal unit. This is to
Include technology to enable mums
to see their babies on the NNU,
even when they are unable to visit
or at another hospital.
Phoenix
Children services continues to provide an
excellent service to both children and
their families. We have been able to
manage a considerable number of small
children with respiratory compromise
enabling them to stay locally. Using the
optiflow system which the team have
embraced has reduced the number of
children being transferred out of the trust.
The team have also managed to facilitate
airway training for one of our cleft
patients, this enabled them to stay locally
and have arranged care packages for
children with complex needs to ensure
smooth discharges.
48
The team have embraced the care of
diabetic patients up to 18 years of
age on the ward thus ensuring they
receive good paediatric service.
We also now have a paediatric
epilepsy specialist nurse providing
dedicated support to children and
families.
Phoenix Ward has a strong team who
regularly receive positive feedback.
Outpatients
The department won the MEHT
patient experience award in 2015.
The team works well together
delivering on excellent service to
children. Patient feedback praises
staff for being caring, kind and
efficient including all members of the
team.
The department provides satellite
clinics for tertiary London hospitals
with specialist visiting which reduces
the need for children and their
families to travel to London.
Multidisciplinary clinics minimise
multiple clinic attendees causing less
disruption to families. The
environment is child friendly,
welcoming and provides activities for
children of all ages.
Maternity
William Julian Courtauld (WJC) The
midwifery led unit at Braintree is
piloting Carbon Monoxide (CO)
monitoring for all mothers at booking,
in conjunction with the Smoking
Cessation Team and this has seen an
increase in referral take up.
The one area of weakness in WJC
customer satisfaction is regarding
lack of continuity in the antenatal
period and this is being addressed by
allocating regular and routine clinic
days to midwives and mothers as a
pilot commencing on the next roster.
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
Following on from the extremely
successful open day last year, a second
event is planned for the summer to
promote the unit to the local population
and to raise awareness. A further open
day is being planned for WJC.
feeding support and parent education
sessions. Witham midwives are also
working closely with the FNP on
supporting young parents and are
making referrals for all who fit the
criteria.
The business case for a shower room
was agreed and will be commenced
soon. This will enhance the experience
for new mums at the unit.
Chelmsford Community midwives are
instigating evening clinics for women
who are unable to attend during the day
which will enhance choice and
appreciation of the service provision.
The inception of the Family Nurse
Partnership (FNP) in the Braintree and
Witham areas has been welcomed by
WJC staff who are referring all young
parents who fit the criteria for this
intensive support and are working
closely with the team.
We are in the process of obtaining a
second birthing pool and the first pool
has been improved for safety and
quality purposes and the room has
been redecorated.
The weekend clinics have been
introduced and are providing flexibility
for out of area women to come for
booking in appointments.
All community lone working staff now
have the benefit of security devices with
live communication and GPS in case of
dangerous or concerning circumstances
which alerts Police directly via a call
centre.
A pilot Team Approach to care is being
implemented within the Witham area
which is an area of deprivation and
social exclusion, to begin in June 2015.
This is aimed to provide enhanced
continuity and positive birth experience
with the plan being to roll out to other
areas following positive evaluation of
the pilot.
Positive birth classes are planned to
support women who have previously
suffered a traumatic experience and
need additional support in making birth
choices and preparing for birth. This
will be implemented prior to the team
pilot in June.
Home birth promotion classes are being
commenced to ensure choice is offered
and clearly available. These will run
alongside the current provision of breast
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
49
Consultant Unit
In September 2014 a second birthing pool
was installed in the low risk birthing unit in
response to the rising demand.
Maternity Services
Staffing has been reviewed and there has
been an increase in the staffing levels
within the Day Assessment/Antenatal Ward
and the Postnatal ward. A second midwife
has been employed to work within the
obstetric theatre to improve patient care
and experience. In addition, there has
been a rolling recruitment program and 14
midwives have been recruited since
December 2014, with recruitment
continuing.
A new clinic for women with medical
conditions i.e Cardiac conditions, is to be
implemented in 2015.
Hypno-birthing is being promoted with
midwifery staff now identified from all areas
of the Trust to attend training to become
competent and offer this service to our
women.
Newborn and Infant Physical Examination
(NIPE) Smart clinics are commencing 23rd
March 2015 and the introduction of the
electronic database will ensure the KPI and
audit process is robust.
Progress is being made towards the
implementation of a new maternity IT
system, with a specially funded project
team in place to ensure the new processes
go smoothly and to help staff take
ownership of the new system. The project
will incorporate the whole of the service
including community and MLU’s to provide
seamless and auditable care to mothers
and babies.
Specialist posts for Diabetes, Perineal
Trauma and Young Parents have been
introduced.
The Grow Programme has been
planned for implementation in April as
an initiative to reduce still birth rates
from undiagnosed growth restriction
and placental dysfunction. Training
has been offered to staff and
individualised growth charts
introduced.
Obesity clinics have been
implemented to address the need for
support to this higher risk group.
Baby Friendly Initiative assessment
has been prepared for
commencement in July 2015.
Project 2% was introduced by the
Supervisor of Midwives Team to
promote normality which will in turn
address the level of caesarean
sections. This initiative was
recommended for an award by the
RCM, receiving the second prize
Initiatives are in progress for the
multidisciplinary audit of caesarean
section decisions on a daily basis.
Mandatory training has been altered
to promote normality. Supervisors of
Midwives were each given individual
tasks to promote normality. Labour
ward practices have been reviewed
to ensure fetal blood sampling is
carried out prior to decision for LSCS
when appropriate.
The Supervisory team of Midwives
also received the Team of the Year
award from the East of England Local
Supervising Authority, and were
nominated for an OSCA award with
MEHT.
Gynaecology
An Early Pregnancy Unit is located
on the ward to ensure women are
seen in an appropriate location by
appropriate healthcare professionals.
In addition a new hycosy service for
infertility has been introduced.
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
Statements from commissioners,
Healthwatch, HOSC
Health Overview and Scrutiny Committee (HOSC)
The Trust have appeared before the HOSC twice in the past year to update it on its
performance and current challenges. Due to the recent publication of a critical Care
Quality Commission report highlighting regulatory concerns about certain service
areas at Broomfield Hospital, the Trust has been asked to attend the 3 June HOSC
meeting to re-assure it on the continued quality of services, patient safety, leadership and that it has a robust Improvement Plan in place and to evidence the progress being made against specific actions in that plan. A representative from the
local CCG will also be in attendance for that session.
Over the past six months a sub Group of the HOSC looking at Complaints Handling
in Acute Trusts has been working with staff from the Complaints Handling, Patient
Experience and PALs office at the Trust and has also spoken to the Chairman of the
Patients Council.
With the closure of the walk-in centre at Springfield the HOSC will be monitoring the
impact on local GP services and on the main Broomfield Hospital site. Whilst it may
be too early for any detailed analysis of the impact of the closure to be included in
the Quality Accounts, further commentary may be advised due to the publicity that
this closure attracted. In any case, the HOSC would expect such analysis to be included in next year’s accounts.
Whilst reviewing the overall impression and message given in the Quality Accounts,
I think it would be helpful in future to include expanded commentary on some of the
significant partnership working being undertaken, how you think it has benefitted
performance and assess its effectiveness and where it has most value and outlining
any plans for further joint working in future. The significant current work with partners on frailty and falls initiatives in mid Essex ( The 100 Day Challenge) particularly
comes to mind but also collaborative work with the Ambulance service, for example,
to re-signpost people.
I would also suggest that there could be more extensive commentary and analysis
of two key national indicators – A&E waiting times and cancer treatment waiting
times. Whilst you have chosen them as priority actions for improvement in future,
these measures receive significant media coverage and the Accounts would benefit
from more detailed performance analysis and commentary on these areas as they
are now.
Finally, in reviewing the contents of the Accounts, I struggled to find any analysis of
delayed discharges and re-admissions. I would suggest that this is important as
part of understanding the capacity pressures facing the Trust.
On behalf of the HOSC, may I thank you for the opportunity to comment on these
draft Accounts.
Jill Reeves
Chairman HOSC
Essex County Council
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
51
Response to MEHT Quality Account 2014-15 from Healthwatch Essex
Healthwatch Essex is an independent organisation with a vision to be a voice for the
people of Essex, helping to shape and improve local health and social care services. We believe that people who use health and social care services and their
lived experience should be at the heart of the NHS and social care services.
We recognise that Quality Account reports are an important way for local NHS services to report on what services are working well, as well as where there may be
scope for improvements. The quality of services is measured by looking at patient
safety, the effectiveness of treatments that patients receive and patient experience
of care. We welcome the opportunity to provide a critical, but constructive, perspective on the Quality Accounts for MEHT, and we will comment where we believe we
have evidence – grounded in people’s voice and lived experience – that is relevant
to the quality of services delivered by MEHT.
Healthwatch Essex acknowledges that it has been difficult and busy year for the
MEHT. However, the Trust has also begun to experience financial difficulties in
2014-15 – a fact which it has in common with many other acute Trusts. This coincides with other common factors that are placing an additional burden on the Trust’s
resources, such as bed capacity and high demand for services. It is important to remain vigilant to the impact this could have on patient and carer experience at
MEHT.
The Trust has a varying performance on patient experience. For example, the
Friends and Family Test results show an average patient experience for inpatients,
but a below average performance for A&E. In the CQC national inpatient survey,
MEHT scored average compared to other Trusts except for the section on overall
views of care and services which they scored worse. However, MEHT has recorded
low scores on 5 questions relating to leaving hospital, 3 on care and treatment, 2 on
hospital and ward, 1 on nurses and 1 on information about condition and treatment
in A&E. By contrast, in the National Cancer patient experience survey, a total of
89% of patients who responded rated their care as excellent or very good.
During the past year, MEHT consulted with patients, public, staff and stakeholders
about the culture of the organisation. The feedback from the consultation for the
‘culture strategic change project’ was used to help make improvements. For example, MEHT have updated the information available for patients and visitors, improved patient access to services and introduced a discharge checklist to improve
the process of leaving hospital.
In the priorities for 2015-16, the Trust aims to improve the way it listens to, and
learns from patient and staff experience. In addition, the Trust aims to improve staff
experience which it hopes will ultimately have a positive impact on patient experience. Healthwatch Essex supports the Trust in these endeavours, but would encourage the Trust to think about how other methods can be used to capture qualitative insights of people’s lived experiences of care, and to use this to continue to
drive improvement. We are pleased to be working with MEHT on a major research
project looking at the lived experience of hospital discharge, for example.
Healthwatch Essex believes that lived experience should be at the heart of services,
and believes that listening to the voice and lived experience of patients, service users, carers, and the wider community, is a vital component of providing good quality
care. We will continue to support the work of MEHT in this regard.
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Mid Essex CCG Response to Mid Essex Hospital Services NHS Trust 2014/15
Quality Accounts
Mid Essex Clinical Commissioning Group (MECCG) is the main commissioner of
services provided at Mid Essex Hospital Services NHS Trust (MEHT) and those provided by MEHT at Braintree Community Hospital.
MECCG welcomes this Quality Account as a commitment to an open dialogue with
the public regarding the quality of care in MEHT. Assurance from MECCG is required to ensure that the information in this Quality Account is accurate, fairly interpreted, and representative of the range of services delivered.
Though MECCG is aware that it is commenting on a draft version of this Quality Report, any comments on accuracy will have been fed back and it is anticipated that
these will be reflected in the final published version.
MECCG is however unable to assure all data reported, as some data may have
been providedor updated prior to publication.
You describe processes to monitor your own progress through the year, for all elements of patient safety, clinical effectiveness and patient experience these appear
robust.
MECCG notes the development of your Quality Improvement Plan,in relation to
compliance actions and a warning noticeagainstBroomfield Hospital following Care
Quality Commission (CQC) inspections,which will be available publicly.
Some of your areas for improvement in 2014/15 have been supported by MECCG
through agreement of CQUIN schemes, which provide financial incentives to improve quality and your achievement against the majority of those schemes is noted.
You give a comprehensive description of your participation in and learning from clinical audit and research. You give a summary of findings and learning from all clinical
audits undertaken.
We note your performance in relation to SHMI has remained within the control limits
for this reporting period.
Your Quality Targets for 2015/16 are:

To reduce avoidable harm from falls and pressure ulcers

Engaging and enabling staff by assessing and improving the organisation safety culture, introducing Safety Champions

Providing reliable care by building on the Sepsis 6 care bundle, improving dementia care and care at the end of life.

Promoting feedback from staff
Some of which are continuation and development of schemes already underway.
In conclusion the MECCG considers Mid Essex Hospital Services NHS Trust Quality
Accounts for 2014/15 as providing an accurate and balanced picture of the reporting
period. MECCG encourages the Trust to continue to implement the multiple and
wide-ranging efforts and initiatives to improve the quality of its services.
Carol Anderson
Director of Nursing and Quality
Mid Essex Clinical Commissioning Group
May 2015
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
53
Acknowledgements
and feedback
Acknowledgements
The Trust Board would like to thank the Corporate and clinical teams and the
many individuals and groups representing patients and the public for their
contribution to the Quality Account for 2014-15. In particular The Trust is
grateful for those senior clinicians, clinical teams, commissioners, patients and
patient representatives who contributed in the identification of our key priorities
for improving quality in 2015-16.
Feedback
To continue to drive forward improvement, we welcome feedback from readers
about the information we include in our Quality Account. If you would like to
comment or request further information please contact our Communications
Team.
Post:
MEHT Communication Team
Broomfield Court
Broomfield Hospital
Court Road
Broomfield
Chelmsford
Essex CM1 7ET
Email: communications@meht.nhs.uk
Amendments made subsequent to report being shared with
stakeholders
The final version of this Quality Account includes:
54

Updated C diff data

Year end performance data for VTE, CQUIN, Re-admission rates, Data
Quality, IG Toolkit and Clinical Audit

Further data on the trust’s responsiveness to the personal needs of its
patients
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
Glossary
Berwick Report
Comfort rounds
The Department of Health
commissioned a report from Don
Berwick in response to Mid
Staffordshire inquiry (A promise to
learn - a commitment to act, improving
safety of patients in England from the
National Advisory Report).
Nurses proactively visiting patients on an
hourly basis, in addition to their usual
rounds.
Clostridium difficile
A spore-forming bacterium which is
present as one of the normal bacteria
in the gut of up to 3% of healthy
adults. People over the age of 65 are
more susceptible to developing illness
due to these bacteria. C Difficile
diarrhoea occurs when the normal gut
flora is altered, allowing C Difficile
bacteria to flourish and produce a
toxin that causes watery diarrhoea.
Procedures such as enemas, gut
surgery, and drugs such as antibiotics
and laxatives cause disruption of the
normal gut bacteria and increase the
risk of developing C Difficile diarrhoea.
Clinical audit
Measures the quality of care and
services against agreed standards
and suggests or makes improvements
where necessary.
Clinical coding
Clinical coding officers are responsible
for assigning a code for every
inpatient stay and day case visit (or
‘episode’). The coding process
enables patient information to be
easily sorted for statistical analysis.
Commissioners
Organisations that buy services on behalf
of people living in a defined geographical
area. They may purchase services for the
population as a whole, or for individuals
who need specific care, treatment and
support.
Commissioning for Quality & Innovation
(CQUIN)
The CQUIN payment framework is a
national framework for locally agreed
quality improvement schemes. It makes a
proportion of provider income conditional
on the achievement of ambitious quality
improvement goals and innovations
agreed between commissioner and
provider, with active clinical engagement.
The CQUIN framework is intended to
reward genuine ambition and stretch,
encouraging a culture of continuous
quality improvement in all providers. In
order to earn CQUIN money, providers of
acute, ambulance, community, mental
health and learning disability services
using national contracts must agree a full
CQUIN scheme with their commissioners.
CQUIN schemes are required to include
goals in the three domains of quality:
safety, effectiveness and patient
experience; and to reflect innovation.
Department of Health
The department of the UK government
responsible for policies on health, social
care and the NHS in England.
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
55
Duty of candour
The duty of candour places a legal
obligation on all providers of health and
adult social care requirement to be open
with patients when things go wrong.
Providers should establish the duty
throughout their organisations, ensuring
that honesty and transparency are the
norm in every organisation registered by
the CQC.
Failure to rescue
A failure in the recognition or management
of a patient whose condition deteriorates.
Francis Report
in June 2010 the Secretary of State for
Health, announced a full public inquiry into
the role of the commissioning, supervisory
and regulatory bodies in the monitoring of
Mid Staffordshire Foundation NHS Trust.
The Inquiry was chaired by Robert Francis
QC, and reported to the Secretary of State
making recommendations based on the
lessons learnt from Mid Staffordshire.
Global Trigger Tool
The Institute for Healthcare
Improvement’s (IHI) Global Trigger Tool
for measuring adverse events provides a
useful method for identifying adverse
events and measuring the rate over time.
The trigger tool methodology uses a
retrospective review of randomly-selected
patient records using triggers (or clues) to
detect adverse events.
Healthcare Associated Infection
An avoidable infection that occurs as a
result of the healthcare that a person
receives.
Human Factors
Human factors encompass all those
factors that can influence people and their
behaviour. In a work context, human
factors are the environmental,
organisational and job factors, and
individual characteristics which influence
behaviour at work.
56
Joint Health Scrutiny Committee
(known as Overview and Scrutiny
Committees (OSCs))
Since January 2003, every local
authority with social services
responsibilities has had the power to
scrutinise local health services. OSCs
take on the role of scrutiny of the
NHS – not just major changes but the
on going operation and planning of
services. They bring democratic
accountability into healthcare
decisions and make the NHS more
publicly accountable and responsive
to local communities.
Methicillin Resistant Staphylococcus
Aureus (MRSA)
An antibiotic-resistant form of a
common bacterium called
Staphylococcus Aureus that can
cause infection in a range of tissues
such as wounds, ulcers, abscesses or
bloodstream. Staphylococcus Aureus
is found growing harmlessly on the
skin in the nose in around one in
three people in the UK.
National Confidential Enquiry into
Patient Outcome and Death
(NCEPOD)
They have published 30 reports
looking at specific aspects of care
and identifying best practice through
detailed case note review of the
management of patients.
NHS Number
The only national unique patient
identifier, used to help healthcare
staff and service providers match you
to your health records.
National Institute for Health Research
(NIHR)
Maintains a health research system in
which the NHS supports outstanding
individuals conducting leading edge
research focused on the needs of
patients and the public.
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Mid Essex Hospital Services NHS Trust - Quality Account 2014 / 15
It is funded through the Department of
Health to improve the health and
wealth of the nation. Costing
Templates are required documents for
any research and development
submission and are used for
generating commercial study costs to
provide cost transparency and
predictability when negotiating local
site budgets.
Never Event
These are serious patient safety
incidents identified at a national level
that should not occur as the risks are
known and preventative measures
available.
Net Reporter
The Net Promoter Score is obtained
by asking patients a single question,
“How likely is it that you would
recommend this service to friends and
family?” Based on their responses,
customers are categorised into one of
three groups: Promoters, Passives,
and Detractors. The percentage of
Detractors is then subtracted from the
percentage of Promoters to obtain a
Net Promoter score (NPS). NPS can
be as low as -100 (everybody is a
detractor) or as high as +100
(everybody is a promoter).
NEWS:
NEWS is an early warning scoring
system based on a patient’s
physiological measurements. Six
simple physiological parameters form
the basis of the scoring system respiratory rate, oxygen saturations,
temperature, systolic blood pressure,
pulse rate and level of consciousness.
A score is allocated to each as they
are measured, the magnitude of the
score reflecting how extreme the
parameter varies from the norm. The
score is then aggregated and used to
flag up patient deterioration. This
allows timely intervention by the
clinical team.
PROMs
Patient Reported Outcome Measures
(PROMs) measure quality from the patient
perspective. Initially covering four clinical
procedures, PROMs calculate the health
gain after surgical treatment using pre and
post-operative surveys.
Quality Domains
The Government Paper, High Quality Care
for All, published in June 2008, defined 3
domains of quality:
Patient Safety - doing no harm to patients
Clinical effectiveness - measured using
survival rates, complication rates, measures
of clinical improvement, and
patient-reported outcome measures
Patient experience - care should be
characterised by compassion, dignity and
respect.
Risk Assurance Frameworks
Documents that map out risks to
Directorates or the Trust achieving their
objectives and the progress with actions
developed to address these risks.
Research
Clinical research and clinical trials are an
everyday part of the NHS, and often
conducted by medical professionals who
also see patients. A clinical trial is a
particular type of research that tests one
treatment against another. It may involve
either patients, or people in good health, or
both.
Root Cause Analysis (RCA)
A structured investigation of an incident to
ensure effective learning to prevent a
similar event happening. Safety Express:
National safety initiative targeted towards
high impact areas as part of the QIPP
programme. The focus includes pressure
ulcers, catheter care, VTE and falls.
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Sepsis
WHO Surgical Checklist
Sepsis is a life threatening condition that
arises when the body’s response to an
infection injures its own tissues and
organs. Sepsis leads to shock, multiple
organ failure and death especially if not
recognized early and treated promptly.
Ensure that a checklist is completed
for every patient undergoing a
surgical procedure (including local
anaesthesia). Ensure that the use of
the checklist is entered in the clinical
notes or electronic record by a
registered member of the team.
Sign Up to Safety
Sign up to Safety is designed to help
realise the ambition of making the NHS the
safest healthcare system in the world by
creating a system devoted to continuous
learning and improvement. This ambition is
bigger than any individual or organisation
and achieving it requires us all to unite
behind this common purpose. We need to
give patients confidence that we are doing
all we can to ensure that the care they
receive will be safe and effective at all
times. Sign up to Safety aims to deliver
harm free care for every patient, every
time, everywhere. It champions openness
and honesty and supports everyone to
improve the safety of patients. Sign up to
Safety’s 3 year objective is to reduce
avoidable harm by 50% and save 6,000
lives.
Thrombolysis
This means dissolving blood clots by
injecting a special clot-dissolving drug into
the artery directly into the blood clot. This
can lead to a marked improvement in blood
flow and may avoid the need for an
operation. Once a clot starts to form in a
blood vessel it may carry on getting bigger
until the whole vessel is blocked. Although
the blood clot can be removed by an
operation, it is also possible to dissolve the
clot.
Venous thrombo-embolism (VTE)
A condition in which a blood clot
(thrombus) forms in the vein. These blood
clots are a known complication of
immobility and surgery.
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Appendices
Appendix 1, table 1
National Clinical Audit Participation 2014/15
Participated
April
2014 to
March
2015
Yes
Number /
% of cases
submitted
Yes
100%
National Cardiac Arrest audit - NCAA
Yes
100%
Fractured neck of femur (care in emergency departments)
No
CEM: Assessing for cognitive impairment
in older people
CEM: Initial management of fitting child
Yes
100%
Yes
100%
National clinical audit participation
Elective surgery (National PROMs Programme)
Adult critical care (case mix programme)
- ICNARC/ CMP
60
Comments/ Rationale for
non-participation
100%
Full submission and a very good standardised mortality ratio compared to likesized units.
Audit completed in 2012 but RCEM did
not receive the audit due to technical
glitch with electronic submission.
CEM: mental Health
Yes
100%
Moderate or severe asthma in children
(care provided in emergency departments)
Yes
100%
National comparative audit of blood
transfusion
National Adult Diabetes Audit
Yes
100%
National audit of intermediate care
(NAIC) 2014
Rheumatoid and early inflammatory arthritis
Cardiac rhythm management
Yes
No
Did not participate.
Yes
to be
confirmed
to be
confirmed
100%
Acute coronary syndrome or Acute myocardial infarction (MINAP)
Yes
100%
National Heart Failure audit
Yes
100%
Falls & Fragility Fractures Audit Programme, includes National Hip Fracture
Database & National audit of falls and
bone health)
Yes
100%
Epilepsy 12 audit
Yes
100%
Diabetes (Paediatrics) - NPDA
Yes
100%
Yes
Audit completed and report received
from RCEM. Gap analysis completed
and submitted.
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Data submitted however numbers not
accurate from report sent nationally.
Have informed CRM and awaiting response.
1. Falls; 2. Fracture Liaison Service
Database; 3. National Hip Fracture Database (submitted for all)
There has not been a national audit
2014-15, this will take place 2015-16.
BTS: Adult Community Acquired
Pneumonia
No
The British Thoracic Society make
several audits available annually, the
Trust is unable to contribute to all of
these and so must prioritise those that
have the greatest potential to impact on
patient care.
BTS: Pleural Procedure
No
BTS: Non-invasive ventilation - adults
No
National COPD (Secondary care) audit
Yes
COPD discharge audit (European Audit)
No
Lung cancer - NLCA
Yes
to be
confirmed
Inflammatory Bowel Disease - IBD
Yes
100%
Renal Replacement Therapy (Renal
Registry)
Sentinel Stroke National Audit
Programme (SSNAP)
National Joint Registry: hips, knees,
shoulder & ankles
Severe Trauma (Trauma Audit &
Research Network)
yes
100%
Yes
496 cases
Yes
98%
Yes
300 cases
100%
The Trust is unable to contribute to all
audits and must prioritise those that
have the greatest potential to impact on
patient care.
National Care of the dying audit for
hospitals
Head & Neck Oncology - DAHNO
Yes
100%
Yes
100%
Oesophago-gastric cancer (NAOGC)
Yes
Prostate cancer
Yes
Bowel Cancer - NBOCAP
Yes
National emergency laparotomy audit NELA
National Vascular Registry: Carotid
interventions audit (CIA), AAA, Peripheral
vascular surgery/ VSCBI Vascular
surgery database
Yes
150 cases
Yes
100%
Neonatal Intensive and Special Care
(NNAP)
Yes
100%
National Confidential Enquiries
The audit data collection is changing so
data has not been submitted as yet,
anticipate 100% submission.
Data collection continuing.
100%
Data collection continuing.
Participated
April 2014 to
March 2015
NCEPOD: Lower limb amputation study
Yes
NCEPOD: Tracheostomy
Yes
NCEPOD: Sepsis
Yes
NCEPOD: Gastrointestinal Haemorrhage
Yes
Organisational questionnaires submitted,
come cases review submitted.
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Appendix 1, table 2
Review of relevant national clinical audit and confidential enquiry
reports
National clinical audit
Benchmarking / Performance / Improvements made or to be made
Neonatal Intensive and
Special Care (NNAP)
Nov 2014 - The outcome for this year's report has been above the national and
regional average in most domains. The NNAP board ask for action plan from
outliers Trust only. No action is required based on this report.
Adult Diabetes Audit
Current education strategy by DSN team to address ward staff knowledge
regarding insulin administration, Hypo management, insulin regimes and safety
needles. This programme will be repeated throughout the year. Work has been
undertaken with CCG in relation to a diabetes specific discharge plan that
address follow-up arrangements for admission avoidance.
Head & Neck Oncology DAHNO
Data submission to this audit closed November 2014. Data has been submitted
up to the closing date. No report has yet been released and there is no
forthcoming information regarding a new audit tool.
National heavy menstrual
bleeding audit
Jan 2015 - Site specific report published, to be discussed in the next
departmental audit meeting and generate an action plan if any.
Report distributed, gap analysis template provided based on the report
recommendations, awaiting review.
NJR report is generally very satisfactory for MEHT. All of our surgeons are in
funnel plot of being 'satisfactory' compared to other peer surgeons in terms of
mortality and revision rates for hip and knee arthroplasty. This puts the hospital
as a whole safely within the funnel plot. Previously our compliance rates for NJR
form filling was a problem but we are now at 98% for the last year which is good.
National Joint Registry:
hips, knees, shoulder &
ankles
National Care of the dying
audit for hospitals
Published May 2014, Being reviewed as part of transform project together with
NICE guidance, findings presented at various forums.
Acute coronary syndrome
or Acute myocardial
infarction (MINAP)
Summary of improvements 2013-14 audit - The Trust's use of effective
secondary prevention remains high. We are working with bed office to ensure
that a higher proportion of heart attack patients are transferred to the cardiology
ward.
Summary of improvements 2013-14 audit - The Trust has embarked on further
training for our cardiac nurse practitioners to maintain high use of appropriate
medical therapies for heart failure patients.
National Heart Failure
audit
Adult critical care (case
mix programme) ICNARC/ CMP
National Cardiac Arrest
audit - NCAA
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In the latest ICNARC report (nationally collected audit data for Intensive Care
Medicine), Broomfield hospital performed extremely well in key performance
indicators eg. no transfers out for non-clinical reasons, 1% early re-admission
rate, 0% unit acquired blood infections, 0% early deaths. Compared to similar
sized units in the UK patients are more likely to survive in Broomfield ICU
compared to the national average.
MEHT data benchmarked against UK data shows cardiac arrest teams respond
more rapidly and achieve a higher success rate with cardiac arrest patients with a
shockable rhythm. Cardiac arrest rates/1000 population are now below the
national median. Areas for improvement are identifying patients with irreversible
disease (and subsequent PEA arrest) earlier as well as patients deteriorating on
day of admission and during the night. An action plan has already been put in
place to concentrate the trigger Response teams efforts in emergency admission
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Lung cancer - NLCA
Data reported at Network level, not site level. Summary of improvements 2013-14
audit - Data completeness has improved. There was a significant improvement in
surgical resection rate nationally but the Trust remains below the national average.
Prostate cancer
National audit 2014 made several recommendations: access to multimetric MRI,
availability of personal support services, multi-disciplinary clinics and the support of
uro-oncology CNS. MEHT is compliant with all of these though there is limited MRI
capacity. Psychological counselling was also noted as an area of improvement in the
national audit. MEHT have identified this as a problem and are awaiting training of
CNS.
All patients with a new diagnosis of Ulcerative Colitis are seen by the IBD nurse
during admission. All patients admitted are weighed and have a nutritional risk
assessment completed.
Inflammatory Bowel
Disease - IBD
Diabetes (Paediatrics) NPDA
National Vascular
Registry: Carotid
interventions audit (CIA),
AAA, Peripheral vascular
surgery/ VSCBI Vascular
surgery database
National comparative
audit of blood transfusion
National emergency
laparotomy audit - NELA
Bowel Cancer NBOCAP
Oesophago-gastric
cancer (NAOGC)
There have been significant improvements in the recording of individual care
processes, albeit that the proportion of patients receiving all seven care processes is
still extremely low. The median HbA1c has fallen by 2 mmol/ mol since 2011-12.
Case mix adjustment in mean HbA1c and % of patients with poor outcomes (>80
mmol/ mol) for each PDU allows units to observe their outlier status before and after
adjustment for their patient characteristics. The peer review quality assurance
programme has facilitated the sharing of all the good practices that influence
improved outcomes.
The NVR (publically available via VSQIP website) shows MEHT has excellent
outcome figures for abdominal aortic aneurysm repairs. The Standardised mortality
ratio is 0.7 (national average 1). This means survival is more likely at MEHT
compared to the national average. Data for carotid endarterectomy outcomes show
MEHT are as good as the national average for this procedure.
Audit of patients observations recording during a blood transfusion has been a yearly
process since 2011. Over this time the improvement of the compliance of
observations, especially the 15 minute recordings, has improved from 17% to 79%.
The blood product transfusion record will be updated with a note on to remind doctors
that blood transfusions should be administered in 'core hours'. If the patient's clinical
condition determines they require transfusing overnight, this should be documented.
Emergency laparotomy patient pathways, and the data collection required, is often
prolonged and complex with multi-disciplinary involvement. As such, "ownership" of
this audit requires more than a single clinician input. The audit department will aim to
increase support for such audits to help ensure complete and robust data
submission.
Summary of improvements 2013-14 audit - The NBOCAP audit results have been
discussed extensively at the cancer board. In addition Essex's returns have been
discussed at the regional cancer group on two occasions and internally and externally
are part of our peer review process.
Oesophago-gastric cancer patient pathways, and the data collection required, is often
prolonged and complex with multi-disciplinary involvement. As such, "ownership" of
this audit requires more than a single clinician input. The audit department will aim to
increase support for such audits to help ensure complete and robust data.
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Appendix 1 table 3 - Local Audits
Audit Title
Inter-hospital
transfer audit
Indication
The majority of cases of inter-hospital
transfers occur for appropriate clinical
reasons where patients require further care
not available in the referring hospital, e.g.
neurosciences, cardiology, paediatrics,
spinal and burns. Such transfers often
occur outside normal working hours and
can take place at short notice. Effective
communication and documentation is
required to ensure the safe and efficient
transfer to patient of the accepting unit.
Key Learning
The Audit identified that documents were
poorly filed and observation charts often
incomplete, or a different chart was used on
the area. The team were looking at
developing a template that allows for clear
documentation of relevant information for the
transfer of a patient to the accepting hospital.
Audit of the
legibility and
identifiability of
doctors’
surnames and
bleep numbers
The Royal College of Physicians Record
Keeping standard states that ‘every entry in
the medical record should be dated, timed,
legible and signed’. This audit was
undertaken to establish whether within the
patient record, doctors were identifiable
and their contact details recorded.
The audit showed that the identifiability and
contactability of doctors was poor. And 50%
of MEHT doctors were not documenting in
accordance with national guidelines.
A business plan was agreed to provide a
name stamp for each new doctor from
August 2014. This stamp details full name,
GMC number and bleep number.
A re-audit showed improvement of
identifiability by 20%.
Sepsis audit
The significance of Sepsis as a patient
safety issue is recognised internationally
and locally. Severe Sepsis is a time-critical
condition and is often poorly recognised
and treated internat. The overall mortality
rate for patients admitted with severe
sepsis is 35%. To raise awareness and
improve the timely treatment of patients,
the Sepsis 6 care bundle has been
developed and implemented.
A quarterly audit of patient observations is
undertaken to gain assurance of sustained
improvement in the documentation of
patient observations and the management
of patients at risk of deteriorating.
All patients, outpatients, visitors and staff
are assumed to be for Cardiopulmonary
Resuscitation. Where there is no written
DNAR order full resuscitation measure
must be initiated. A DNAR order comes
into effect only when it has been clearly
documented in the medical notes using the
appropriate DNAR form.
The audit showed overall poor compliance
with the bundle with many clinical tests/
treatments not occuring in the recommended
time frame. Training was given to all HCA/
HCSWs on escalating sepsis patients and
those with high NEW scores. Blood culture
training was also given to nurses. Posters
have been displayed around the trust and a
sepsis study day has been arranged.
A quarterly audit of patient observations is
undertaken to gain assurance of sustained
improvement in the documentation of
patient observations and the management
of patients at risk of deteriorating.
The audit showed there is improvement in
recording a baseline set of observations.
The documentation of physiological
parameters improved or remained of a good
standard in comparison with the previous
cycle. The number of completed sets having
a CEWT score improved and all scores were
correct.
Adult Patient
Observations
audit
Do Not Attempt
Resuscitation
(DNAR) audit
Paediatric
observations
audit
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Documentation of patient demographics and
physiological parameters was of a high
standard. Patient observations were
documented at least 12 hourly in 97% cases.
The Audit showed that the DNAR forms were
usually easy to locate and the rationale for
the DNAR decision was well documented.
The forms were consistently signed and
dated with designation recorded.
Documentation could improve regarding
NHS number, patient and relative
involvement in the decision. No DNAR forms
had review dates recorded: indefinite was
entered in 83 of the 105 forms.
Appendix 2 Independent Auditor’s Limited Insurance Report
INDEPENDENT AUDITOR’S LIMITED ASSURANCE REPORT TO THE DIRECTORS OF MID ESSEX
HOSPITAL SERVICES NHS TRUST ON THE ANNUAL QUALITY ACCOUNT
We are required to perform an independent assurance engagement in respect of Mid Essex Hospital Services
NHS Trust’s Quality Account for the year ended 31 March 2015 (“the Quality Account”) and certain
performance indicators contained therein as part of our work. NHS trusts are required by section 8 of the
Health Act 2009 to publish a Quality Account which must include prescribed information set out in The National
Health Service (Quality Account) Regulations 2010, the National Health Service (Quality Account) Amendment
Regulations 2011 and the National Health Service (Quality Account) Amendment Regulations 2012 (“the
Regulations”).
Scope and subject matter
The indicators for the year ended 31 March 2015 subject to limited assurance consist of the following
Indicators:

Percentage of patients risk assessed for venous thromboembolism (VTE); and

Rate of clostridium difficile infections.
We refer to these two indicators collectively as “the indicators”.
Respective responsibilities of Directors and auditors
The Directors are required under the Health Act 2009 to prepare a Quality Account for each financial year. The
Department of Health has issued guidance on the form and content of annual Quality Accounts (which
incorporates the legal requirements in the Health Act 2009 and the Regulations).
In preparing the Quality Account, the Directors are required to take steps to satisfy themselves that:

the Quality Account presents a balanced picture of the trust’s performance over the period covered;

the performance information reported in the Quality Account is reliable and accurate;

there are proper internal controls over the collection and reporting of the measures of performance
included in the Quality Account, and these controls are subject to review to confirm that they are working
effectively in practice;

the data underpinning the measures of performance reported in the Quality Account is robust and
reliable, conforms to specified data quality standards and prescribed definitions, and is subject to
appropriate scrutiny and review; and

the Quality Account has been prepared in accordance with Department of Health guidance.
The Directors are required to confirm compliance with these requirements in a statement of directors’ responsibilities within the Quality Account.
Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything has
come to our attention that causes us to believe that:

the Quality Account is not prepared in all material respects in line with the criteria set out in the
Regulations;

the Quality Account is not consistent in all material respects with the sources specified in the NHS
Quality Accounts Auditor Guidance 2014/15 issued by the Department of Health (“the Guidance”); and

the indicators in the Quality Account identified as having been the subject of limited assurance in the
Quality Account are not reasonably stated in all material respects in accordance with the Regulations
and the six dimensions of data quality set out in the Guidance.
We read the Quality Account and conclude whether it is consistent with the requirements of the Regulations
and to consider the implications for our report if we become aware of any material omissions.
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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 March 2015;

papers relating to the Quality Account reported to the Board over the period April 2014 to March 2015;

feedback from the Commissioners dated 26/05/2015;

feedback from Local Healthwatch dated 01/06/2015;

feedback from the HOSC dated 27/05/2015

the trust’s complaints report published under regulation 18 of the Local Authority, Social Services and
NHS Complaints (England) Regulations 2009, included in the Annual Report dated 04/06/2015;

the latest national patient surveys dated 02/12/2014 and 08/04/2014;

the latest national staff survey dated 2014;

the Head of Internal Audit’s annual opinion over the trust’s control environment dated April 2015;

the annual governance statement dated 03/06/2015;

Care Quality Commission Intelligent Monitoring Reports dated July and December 2014; and

Care Quality Commission Quality Report published 16/04/2015.
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 Mid Essex Hospital Services
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 Mid Essex Hospital Services NHS Trust for our work or
this report save where terms are expressly agreed and with our prior consent in writing.
Assurance work performed
We conducted this limited assurance engagement under the terms of the Guidance. Our limited assurance
procedures included:

evaluating the design and implementation of the key processes and controls for managing and reporting
the indicators;

making enquiries of management;

testing key management controls;

limited testing, on a selective basis, of the data used to calculate the indicator back to supporting
documentation;

comparing the content of the Quality Account to the requirements of the Regulations; and

reading the documents.
A limited assurance engagement is narrower in scope than a reasonable assurance engagement. The nature,
timing and extent of procedures for gathering sufficient appropriate evidence are deliberately limited relative to
a reasonable assurance engagement.
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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 Mid Essex Hospital Services NHS Trust.
Basis for qualified conclusion in respect of indicator – VTE risk assessment
Our testing of the VTE indicator identified a number of errors in relation to the accuracy, reliability,
completeness, timeliness and validity of the data underpinning the indicator. We were unable to conclude that
these errors were isolated. The control environment and management arrangements were not sufficiently
strong to mitigate the risk that the indicator is not reasonably stated in all material respects and therefore our
conclusion is qualified on this basis.
Qualified conclusion
Based on the results of our procedures, with the exception of the matter reported in respect of the VTE
Indicator in the basis for qualified conclusion paragraph above, nothing has come to our attention that causes
us to believe that, for the year ended 31 March 2015:

the Quality Account is not prepared in all material respects in line with the criteria set out in the
Regulations;

the Quality Account is not consistent in all material respects with the sources specified in the Guidance;
and

the indicators in the Quality Account subject to limited assurance have not been reasonably stated in all
material respects in accordance with the Regulations and the six dimensions of data quality set out in
the Guidance.
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