Quality Account 2014/15
Quality Account 2014/15
Contents
Part 1
Part 3
Overview of Achievements in
Quality
Other Information - Review of
Quality Performance
t on Quality from the
 Overview of 2014/15 Performance Page 28
 Statement on Quality from the Chief
Executive – Page 3
 An Overview of the Quality of Care
Based on Performance in 2014/15 with
an Explanation of the Underlying
Reason(s) for Selection of Additional
Priorities – Page 28
Part 2
Our Quality Achievements
 Performance on Quality in 2014/15
against 2014/15 Priorities as set out in
the 2013/14 Quality Account – Page 5
 Performance Against Key National
Priorities – Page 28
 Selected Priorities for Quality
Improvement for 2014/15 – Page 7
 Additional Information in Relation to
The Quality of NHS Services – Page
34
 Statements of Assurance from the
Board of Directors – Page 12
 Quality Account Production - Page
57
 Information on the Review of Services
– Page 12
 How to Provide Feedback on the
Quality Account – Page 57
 Participation in Clinical Audits and
National Confidential Enquiries – Page
12
 Quality Account Availability
Part
4
 Our Website
 Participation in Clinical Research In
2014/15 – Page 17
Appendices
 Appendix A
Statements from Clinical Commissioning
Groups, Local Healthwatch and Local
Overview and Scrutiny Committees –
Page 58
 Commissioning for Quality and
Innovation Payment Framework Page 18
 Registration with the Care Quality
Commission and Special Reviews Page 19
 Appendix B
Statement of Directors’ Responsibilities in
Respect of the Quality Report – Page 63
 Information on the Quality of Data
Page 20

 Appendix C
Glossary of Abbreviations/Glossary of
Terms - Page 64
Core Quality Indicators - Page 22
2
Part 1: Statement on Quality from
Jackie Daniel, Chief Executive
Introduction
I am pleased to present to you our Quality Account for 2014/15 which is an annual review of the quality of
NHS healthcare services provided by University Hospitals of Morecambe Bay NHS Foundation Trust during
2014/15. It also outlines the key priorities for improvement in 2015/16. The quality report incorporates all of
the requirements of the Quality Accounts Regulations as well including a number of additional reporting
requests set by Monitor as detailed below.
Part 1: Statement on quality from the Chief Executive of the NHS foundation trust
This section includes a statement by the Chief Executive explaining the importance of quality to the Trust,
and provides an overview of achievements in quality.
Part 2: Priorities for improvement and statements of assurance from the board
This section includes a review of the Trusts performance against the priorities set for the 2014/15 Quality
Account, the priorities for improving the quality of services in 2015/16 that were agreed by the Board of
Directors in consultation with stakeholders and the legislated statements of assurance from the Board of
Directors.
Part 3: Other information
This section contains an overview of the quality improvement work which has taken place across the
organisation during 2014/15. The section provides detailed information and commentary on a selected
range of improvement areas relating to patient safety, clinical effectiveness and patient experience.
Part 4: Appendices
This section contains details of formal feedback from local organisations and stakeholders, statement of
director’s responsibilities and a glossary of abbreviations and terms.
Statement on Quality
The University Hospitals of Morecambe Bay NHS Foundation Trust (UHMBFT) aims to be one of the safest
organisations within the NHS with our staff committed to providing safe, high quality care to patients all of the
time.
Whilst recognising that 2014/15 has been a challenging year, significant progress has been made on a wide
range of fronts and this Quality Account highlights some of the work that has been undertaken. It includes an
overview of the improvements and achievements we have made in 2014/15 and sets out our priorities for
2015/16.
2014/15 proved to be a challenging year for the Trust. Significant increases in emergency activity, sickness
and vacancies in key clinical posts, the delivery of significant cost improvements and dealing with the actions
of the Care Quality Commission Improvement Plan have meant that financial and operational targets have not
been met consistently.
It is important to note that many of the actions needed to improve performance in key areas have been in
place from early in the year. These actions continue to have a positive impact but performance remains
inconsistent with the Trust working hard to put sustainable improvements in place as part of its 2015/16
operational planning.
We continue to make improvements in performance against the quality indicators. Mortality rates continue to
fall and the Trust is currently the 5th best performing hospital across the twenty two North West Trusts and just
7 points above the best performing Trust for Hospital Standardised Mortality Ratio (HSMR).
We are continuing to see excellent performance against the NHS Safety Thermometer figure, which measures
the percentage of patients receiving care with no harms. The March 2015 figure is 94% of UHMBFT patients
3
did not experience any harms. The Trust has also observed an overall downward trend in the incidence of new
pressure ulcers attributed to the Trust and this is the fourth consecutive month where no grade 3 and 4
pressure ulcers have been reported.
For Clostridium Difficile infections the April 2014 to March 2015 year to date figure is 42 cases reported
against a trajectory of 46. Of the 42 cases, 29 were deemed to have involved a lapse in care whilst the
remainder were deemed to be unavoidable. There were no Methicillin Resistant Staphylococcus Aureus
(MRSA) infections reported for March 2015 although the year to date (YTD) figure remains at 2 cumulatively.
Performance against the national stroke indicator for 80% of patients to spend 90% of their time in a hospital
stroke unit is currently 2% below the required target of 80%. A UHMBFT stroke action plan has been
developed and monitoring of actions and progress is reported to the Quality Committee. However, with regard
to the Advancing Quality (AQ) indicators for stroke UHMBFT is currently ranked as the 4th best performing
Trusts out of a total of 21 Trusts achieving 75.93% against a target of 66.6%. The AQ indicators measure the
proportion of stroke patients who received all relevant interventions and is therefore a measure of "perfect
care". The caesarean section rate target is set at 26% and whilst the March 2015 figure is showing a decrease
from last month it remains above target at 27.49% with the year to date (YTD) figure also above target at
27.04%. An action plan and performance continues to be reported to the Quality Committee.
The Trust participated in a Care Quality Commission (CQC) review under the new Chief Inspector of Hospitals
inspection method in February 2014. The outcome of the inspection was published in June 2014. An
improvement plan has been developed to address recommendations identified and progress made to address
areas for improvement. A copy of the final report is available at www.cqc.co.uk. The Trust is anticipating a
th
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th
CQC re-inspection that will take place on the 14 , 15 and 16 July 2015.
The following pages contain more detailed information and I would encourage you to read about changes that
have improved care and reduced avoidable harm. Our plans for continuing to improve and demonstrate quality
over the next year are described in the Trust’s Better Care Together - Quality Improvement Plan 2014/17. This
plan supports our longer term, transformational clinical strategy: better care together. Our Quality
Improvement Plan is the first time we have brought together all of our key planning and operational delivery
documents, ensuring that they all work together to achieve our commitment of delivering safe, high quality
care for all of our patients, as well as making our hospitals, modern and efficient places to work. Together, it
will help us to realise our aspiration of making our hospitals great places to be cared for; and great places to
work.
Our Quality Improvement Plan reiterates the Trust Board’s commitment to delivering high standards of safe,
quality care to our patients, as well as providing a working environment and culture which promotes and
welcomes honesty, safety first, openness and compassion in everything we do.
The areas we have chosen as our quality improvement priorities for 2015/16 have been set following
consultation with our Governors, local health scrutiny committees, local Healthwatch, healthcare user group,
our Commissioners and importantly, by talking to staff, patients and carers.
Progress described within this document is based on data and evidence collected locally and nationally, much
of which is presented as part of our performance framework each month and in our public board meetings,
Council of Governors meetings and to our Commissioners.
To the best of my knowledge the information in the document is accurate and provides a balanced account of
the quality of services we provide.
Jackie Daniel
Chief Executive
th
Date: 27 May 2015
4
Part 2: Our Quality Achievements
In this section the Trust’s performance in 2014/15 is reviewed and compared to the priorities that were
published in the Trust’s Quality Account in 2013/14.
2.1 How we performed on Quality in 2014/15 against the 2014/15 Priorities as
set out in the 2013/14 Quality Account
This section tells you about the quality initiatives we progressed during 2014/15 and how we performed
against the quality improvement priorities we set ourselves last year.
A programme of work was established that corresponded to each of the quality improvement areas we
targeted. Each individual scheme within the programme has contributed to one, or more, of the overall
performance targets we have set. Considerable progress and improvements have been delivered through staff
engagement and the commitment of our staff to make improvements.
Wherever applicable, the report will refer to performance in previous years and comparative performance
benchmarked data with other similar organisations. This will enable you to understand progress over time and
is a means of demonstrating performance compared to other Trusts. This will enable you to understand
whether a particular number represents good or poor performance. Wherever possible, references to the data
sources for the quality improvement indicators will be stated within the body of the report or within the
Glossary of Terms, including whether the data is governed by national definitions.
Please note that some 2013/14 comparators may differ than the Quality Accounts dated 29 May 2014 due to
national and local Trust data not being finalised.
We are pleased to report the significant progress made against our priorities. An overview of performance
targets in relation to the priorities for quality improvement that were detailed in the 2013/14 Quality Account is
provided in Table 1. A more detailed description of performance against these priorities for patient safety,
clinical effectiveness and the patient experience will be reported on in detail in Part 3, section 3.4
Table 1: Performance Against Trust Priorities 2014/15
Target Achieved/On Plan
Close to Target
Key
Behind Plan
2012/13
2013/14
Target
2014/15
Actual
Performance
2014/15
Not reported in
2012/13
Not reported in
2012/13
Awaiting figure
from resu. team
Not reported in
2013/14
10%
Achieved
28% reduction
Reduce avoidable hospital acquired pressure ulcers by 15% from the 2013/14
baseline
Not reported in
2012/13
0.70%
15%
Reduce avoidable hospital inpatient falls resulting in harm by 10% from the 2013./14
baseline
Not reported in
2012/13
0.15%
10%
Reduce hospital acquired clostridium difficile infections in line with the national
contract calculation (46)
Not reported in
2012/13
50 or less
46 or less
Priority 1: Patient Safety
Cardiac Arrests
Reduce cardiac arrests by 10% against the 2013/14 baseline
Review 50 deaths in a year through a multi-disciplinary team
50
Achieved > 50
Harm Free Care (Trust target) – Measures
Achieved
0.5% /
1000 bed days
Achieved 8%
below national
average
Achieved
27 cases
Priority 2: Clinical Effectiveness
Develop and deliver a multi-professional ward/.board rounds in 50% of all wards in
year moving to 100% in year 2
Improving continuity of care at discharge through timely and robust discharge
information by improving the availability of quality discharge summaries to 90% within
24-hours and 95% within 48-hours
Comprehensive assessment of all patients over 75 years old to be undertaken within
24-hours of admission. Streamlined pathways of care to be delivered based on the
outcome of the assessment.
5
Not reported in
2012/13
Not reported in
2012/13
Not reported in
2013/14
Not reported in
2013/14
50%
90% in 24hrs
95% in 48 hrs
Not reported in
2012/13
Not reported in
2013/14
As per
measure.
Achieved
90 rounds
84.40% 24hrs
91.47% 48hrs
Achieved
2655
assessments
Priority 3: Patient Experience
Complaints - Measures
Reduce formal complaints by 10% from the 2013/14 baseline(1)
(1)
Not reported in
433
10%
Not Achieved
2012/13
baseline
560 complaints
In 2014/15 the Trust had 12,824 more attendances than the previous year, an increase of 1.9% more activity. Complaints increased by 0.9% during
2014/15, which is a lower increase than the activity.
Increase compliments by 100% from the 2013/14 baseline
Introduction and improvement through I Want Great Care
Not reported in
2012/13
252
baseline
100%
No target set
for 2012/13
No target set
for 2013/14
Improvement in
score
Achieved
- had 347
compliments
Achieved
40.1%
Staff Survey
Improvement in staff survey outcomes
No target set
for 2012/13
2012/13
Priority 1: Patient Experience (Continued)
No target set
for 2013/14
2013/14
Improvement in
scores
Target
2014/15
18 Areas
showing
improvement
Actual
Performance
2014/15
Donors
Not reported in
2012/13
Not reported in
2012/13
Family approach rate of 100% to suitable potential donors
Consent rate of 60%, rising to 80% by 2020
Clinical Quality - Commissioning for Quality and Innovation (CQUIN) Schemes
Clinical Quality - Commissioning for Quality and Innovation (CQUIN) Schemes
Patient Safety Thermometer – to include a 20% improvement goal in reducing the
median number of old and new pressure ulcers reported through the Safety
Thermometer, and a 10% reduction in avoidable hospital acquired pressure ulcers
reported through local incident reporting data.
Dementia and Delirium – to expand the 90% FAIR (Find, Assess and Investigate,
Refer) delivery into delirium care
Friends and Family Test (FFT) – to increase response rates and implement a staff
FFT.
Not reported in
2012/13
Not reported in
2012/13
End of Year Project KPI Target
14/15
5-month median max 17 old and
new cat 2-4
Max 13 avoidable hospital acquired
cat 2-4
Find – 90%
Assess/Investigate – 90%
Refer – 90%
A & E response rate – 20%
Inpatients – 30%
Inpatients stretch target – 40%
Cumulative KPI Target 2014/15
(ACS)
Regional CQUIN Scheme
Pneumonia, Hip & Knee, Acute Heart Attack, Heart Failure & Stroke, Chronic Chest
Conditions / Chronic Obstructive Pulmonary Disease (COPD) – delivery of stretched
targets in each pathway.
Local CQUIN Schemes
End of Life and Spiritual Care – to include Gold Standard Framework (GSF)
accreditation, personalised care plans and holistic needs assessments.
AMI – 89%
Heart Failure – 70%
Hip & Knee – 85.8%
Pneumonia – 75.6%
Stroke – 66.6%
COPD – 50% (Target Dec 2014Mar 2015 only)
25
11
93%
95%
100%
29%
43%
43%
Actual
Performance
Apr-Dec 2014
Discharges
96.3%
73.3%
91.7%
81.2%
66.6%
50.0%
90% of patients on the GSF register
will have had an opportunity for
meaningful End of Life discussion
100%
Frail & Elderly Care (including 7 day working) – assessment of over 75 year olds
within an agreed time frame
Rolling 12 months average Length
of Stay (LoS) performance
for non-elective admissions 75
years and over to be reduced down
to maximum 16.2 days
Achieved
100%
Achieved
100%
Actual Project Final Project KPI
Performance performance RAG
March 2015
Rating
Latest Actual
Performance
Q4
100% of young people with
Diabetes/Epilepsy/ Asthma under
the care of a Paediatrician to have
commenced a transition plan
6
60%
Q4 KPI Target 2014/15
Children’s Transition Care – transition care plans for 14-18 year olds with long term
conditions moving into adult services that enhances care and treatment.
Harm Free Care - Medicine Management – implementation of training and a broad
range of initiatives to support nursing staff on counselling patients at discharge and
compliance of antimicrobial prescribing .prescribing.
Harm Free Care - Fragility Fractures – assessment of bone density for patients over
100%
100% of
named patients
in cohort who
were seen by
Acute Trust
within project
period/did not
decline option
to have a
transition plan
At end of Mar
15 – 16.8 days.
Audit of those
who had a
CGA showed
11.47 days
¼ reporting to CCG’s on actual
numbers
¼ reporting
numbers
¼ reporting on roll-out
¼ reporting on
50 years of age presenting with fractures.
roll-out
Harm Free Care - Early Warning Scores - reduction in cardiac arrests outside critical
care, learning lessons once and utilising agreed warning tool.
Shared Decision Making – Roll Out To Elective Services (e.g. Bowel Enhanced
Recovery & Hip Surgery) - to build on the successful methodology for shared decision
making.
NHS England CQUIN schemes
Dental – provide an information pack to patients on discharge. roll out patient FFT for
Dental/Maxillofacial Outpatients/Day cases and undertake a scoping and planning
exercise for the implementation of a consistent coding model.
Breast Screening –conducting a survey to understand why patients Do Not Attend
Reduce numbers of potentially
avoidable cardiac arrests down to a
maximum of 55%
38%
Reporting on roll-out
Reporting on
rollout
No KPI
No target
Improve on baseline position of
16% RLI DNA rate
Total cost of wasted chemotherapy
drugs for the year to be < £100,000
Adult Chemotherapy – to include the reduction in chemotherapy waste and
introducing patient held self-care plans.
95% of patients to have a patient
held record
85% ROP screening on time
Neonatal Care - to achieve 95% screening rate for retinopathy of prematurity (ROP)
and to improve access to breast milk in preterm infants.
Final data will
be available in
Oct 2015
£38,793 at end
of Q4
99% at end of
Q4
86% at end of
Q4
45% at end of
Q3
(Note: 2012/13 and 2013/14 data is not included in some of the sections as the measures were different and therefore comparable
data is not available)
2.2
51% receiving mother’s breast milk
Selected Priorities for Quality Improvement in 2015/16
This section tells you about how we prioritised our quality improvements for 2015/16. This section
also includes the reason for the selection of these priorities and how the views of patients, the wider
public and staff were taken into account. Information on how progress to achieve the priorities will be
monitored, measured and reported is also outlined in this section.
2.2.1 How we prioritised and consulted on our selection of Quality Improvements
for 2015/16
In June 2014 the Trust published a timetable for the process of developing the Quality Account for 2014/15,
including consultation with stakeholders, our Governors and importantly, by talking to staff, patients and
carers.
A draft Annual Quality Account was produced in January 2015 and circulated to stakeholders and governors
with a request to help identify quality improvement areas based on the Trust’s Better Care Together - Quality
Improvement Plan for 2014/17.
The Trust has taken the views of patients, relatives, carers and the wider public into account, for the selection
of priorities for quality improvement, through the completion of feedback forms which are available from the
Trust’s website. The Governors were consulted during meetings of the Strategy Subgroup.
Other methods of obtaining the views of patients, public, staff and governors included feedback from local and
national patient and staff surveys, information gathered from formal complaints, comments received through
the Patient Relations Team and various local stakeholder meetings and forums.
Governors also obtained the views of patients, public and staff by obtaining feedback through local CQC
mock assessment visits, Review, Audit, Inspection Standards (RAISE) Visits, patient safety walkabout visits,
15 steps to challenge undertaken.
Listening to what our staff, governors, patients, their families and carers tell us, and using this information to
improve their experiences, is a key part of the Trust’s work to increase the quality of our services.
In September 2014 a workshop was undertaken with clinical staff to generate a list of possible quality
improvement projects. This was included for consideration by the Trust Executive Directors Group and led to
the development of a Trust’s Better Care Together - Quality Improvement Plan for 2014/17 which was
endorsed by the Board of Directors on 29th October 2014.
7
2.2.2
Rationale for the Selection of Priorities in 2015/16
In October 2013, the Trust published a one-year Quality Governance Strategy. The Quality Governance
Strategy described the Trust’s quality vision and outcomes that the Trust must deliver in line with the NHS
Outcomes Framework. In October 2014 the Trust published its Better Care Together - Quality Improvement
Plan 2014 – 2017 which was designed to support the Trust in defining the quality improvement indicators that
the Trust will focus on during 2015/16 and how it would set out to achieve them.
The priorities chosen link closely to the Trust’s work with commissioners and are closely aligned to the Care
Quality Commission (CQC) five domains of safe, effective, caring, responsive and well led organisations. They
also link to work relating to improvements in patient safety and Commissioning for Quality and Innovation
(CQUIN) priorities and are aligned to the Trust’s Annual Plan.
The Trust’s priorities for improvement encompass three equally important quality improvement elements.
These are:

Better – Care that is safe
Working with patients and their families to reduce avoidable harm and mortality.

Care – Care that is clinically effective
Not just in the eyes of clinicians but in the eyes of patients and their families

Together - Care that provides a positive experience for patients, their families and our staff
As evidenced by I Want Great Care and Staff Surveys
The Trust has taken the feedback received into account when developing its priorities for quality improvement
for 2015/16 and based on what it believes will have maximum benefits for our patients. The following quality
improvement priorities outlined in table 2 were agreed in principle at the Quality Committee meeting held on
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20 March 2015 and submitted for approval by the Board of Directors on 26 March 2015.
Seven additional quality improvement priorities have also been selected by the Board of Directors and are
detailed in Table 2 in bold italics.
Table 2: Priorities for Quality Improvement 2015/16
Quality Goal
Key Priority
Measurable Outcome
Improvement Outcome 1 – Care that is safe
Maintain Hospital Acquired Pressure Ulcers at grades 3 and
above below the national median
Achieve at least 99% of patients receiving
Harm Free Care, consistent across every
ward as measured by the Department of
Health ‘Safety Thermometer Tool’ within 5
years.
Maintain Catheter Associated Urinary Tract Infections below
the national median
Maintain Venous Thromboembolisms below the national
median
Achieve at least 94% Harm Free Care by
year end 2014/15
Reduce Patient Falls resulting in Harm from a baseline of
0.42% monthly average in 2014/15 to a target of 0.40% in
2015/16. The national median is 0.57%.
Reduce Hospital Acquired C-difficile infections and maintain
below the figure set by NHS England
Reduce MSSA infections by 50% from the baseline
50% Reduction in Hospital Acquired
Infections by the end of 2015/16
Reducing Harm
Zero Tolerance for avoidable Hospital
Acquired MRSA Bloodstream Infections
0 MRSA Hospital Acquired Bloodstream Infections
0 Never Events
Zero Tolerance for Never Events
Develop a medication work stream for
harms linked to the omission of critical
medicines and missed doses of all
prescribed medication.
Work stream to have been developed and initiated by year
end 2014/15. For 2015/16 commence reporting to establish
baseline for reduction.
Baseline to be established 2015/16
Establish a baseline figure for Ventilator
Acquired Pneumonia.
Baseline 6.4% per 100,000 bed days (Trust attributable
MSSA)
Establish a baseline figure for MSSA
Reducing
Avoidable
Maintain scores consistently in the
‘statistically as expected’ range, or better, for
8
HSMR of 98 or less
Table 2: Priorities for Quality Improvement 2015/16
Quality Goal
Key Priority
Mortality
Measurable Outcome
both the HSMR and SHMI measures
SHMI within expected statistical range
Reduce the actual numbers of crude
deaths
Reduce the actual numbers of crude deaths in 2015/16 from
a baseline of 0.27% in 2014/15
Improvement Outcome 2 – Care that is clinically effective
Deliver Effective
and Reliable Care
The Trust will achieve compliance with new
AQ quality standards
Care Bundles be developed by end of 2015/16 for the new AQ
quality standards :
Stroke

AMI

Heart Failure

Pneumonia

Sepsis

Dementia

Hip and Knee
Commissioning for Quality and
Innovation (CQUIN)
Develop and maintain 95% delivery as a minimum for
2015/16
The Trust will scope and develop a programme plan to
support implementation of the Ward Accreditation scheme
in *2017/18.
Ward Accreditation scheme
Ward Accreditation takes at least 2 years to implement as
described below.
*Programme Plan 2015/16
*Implementation plan to commence 2016/17
*Implementation roll out 2017/18
Introduce 7-day working across key areas of
service provision
Implement 7 day working in 5 specialities
Improvement Outcome 3 – Care that provides a positive experience for patients
Improve Patient
Maintain 100% of Inpatient Wards undertaking “I Want Great
All Inpatient areas to deliver “I Want Great
and Family
Care” by year end 2015/16
Care”
Centred Care
Reduce formal complaints by 50% from 2014/15 baseline
Complaints
Reduce formal complaints by year end
per 1,000 bed days.
Staff ability to contribute to improvements at work (65%)
Improve Staff
Experience
Achieve a 33% reduction in Key Result
Areas in the Worse Than Average/Worst
20%
Staff recommendation of the Trust as a place to work or receive
treatment (3.39 out of 5)
Staff motivation at work (3.76 out of 5)
Commissioning for Quality and Innovation (CQUIN) Schemes in 2015/16
Working closely with our Commissioners we have developed a comprehensive CQUIN programme for
2015/16 and beyond focusing on delivering key quality outcomes for patients, rather than process
outcomes. The local schemes have been developed jointly focusing on key quality priorities for
Commissioners and the Trust. This has included a local measurement for improvement workshop with
stakeholders and work with AQuA. The delivery of schemes will be via teams from across our clinical
divisions supported by colleagues in information technology and governance so that improvements are fully
embedded in a sustainable way.
There are currently 17 CQUIN Schemes proposed for 2015/16. These are across a number of commissioning
organisations including Lancashire North Clinical Commissioning Group (CCG), Cumbria CCG, Specialist
Commissioning and Public Health England.
Due to the volume of CQUIN schemes, Table 3 below lists the selected CQUIN schemes for 2015/16 that will
be reported on in the Quality Account 2015/16.
Table 3 : CQUIN Schemes for 2015/16
National CQUIN Scheme
Acute Kidney Injury
Target
Acute Kidney Injury diagnosis and treatment in
hospital and the plan of care
9
Table 3 : CQUIN Schemes for 2015/16
Sepsis
Dementia and Delirium
Reducing the proportion of avoidable emergency
admissions to hospital
Sepsis screening
Find, Assess, Investigate, Refer and Inform (FAIRI)
Avoidable emergency admissions as a proportion of
all emergency admissions
Regional CQUIN Scheme
None identified
NA
Target
Local CQUIN Schemes
Out of hospital North Lancs
Out of hospital Cumbria
Women and children
Target
To be confirmed
To be confirmed
Integrated working of children’s and maternity
services to reduce hospital attendance for children
and increase normal birth
Planned care
Implementation of Planned Care Clinical Pathways
Tranche 1
Implementation of Planned Care Clinical Pathways
Tranche 1
NHS England CQUIN schemes
Breast Screening
Target
Increasing uptake of breast screening with people
with learning difficulties
Quality Dashboard
Consistent coding
Dental
Dental
The Trust will strive to maintain and improve upon its year on year significant improvement of CQUIN
achievement. Our ambition for 2015/16 is to maintain a 95% delivery as a minimum, carrying this through into
2016/17. For schemes in future years we plan to continue to start the process of agreeing CQUIN schemes
much earlier in the financial year and will be looking to initiate discussions with Commissioners from October
2015.
2.2.3 Rationale for the Selection of Priorities to be removed in 2015/16
This section includes a list of areas that the Board of Directors have chosen to remove from the quality
improvements priorities for 2015/16. The rationale for the de-selection of these priorities is that considerable
progress and improvements have been delivered / put in place and other improvements have become a
priority.
Information regarding the improvements made to demonstrate evidence for their removal is outlined in Part 3.
It has been agreed to remove the following:

Cardiac arrest. Review 50 deaths.

Introduction of a decant, deep clean and fogging programme.

Comprehensive assessment of over 75 year old patients.

Develop a plan for 7-day working across key areas of service provision
and produce an action plan;
Undertake a gap analysis
o
Further develop and deliver the multi-professional ward/board rounds in 50% of all wards inyear moving to 100% in year 2
o
Develop a dashboard that front line staff can access that provides them with the information
they need to understand how reliable the care they provide is.
Please Note: The next phase of the 7 day working is detailed in Table 2.

Deliver values based induction Develop and implement a values based corporate induction
programme for all new employees.

Introduction and improvement through I Want Great Care.
established;
10
Dedicated Executive lead to be

Feedback to be displayed publicly every month outside each ward and department;

Learning from comments to be shared. from ward to board at least on a monthly basis

Director sponsorship of Divisions to be developed. Executive Director to be identified to support
Divisional Teams and support divisional teams.

Commitment by all managers to spend time on the front line, working alongside staff. All Executive
Directors and Managers will be required to spend time with front line staff. System of reviewing and
communication of visits and results to be developed.

CQUIN targets for 2014/15 removed as new CQUIN targets set for 2015/16.
2.2.4 How we will Monitor, Measure and Report on-going progress to achieve our
priorities for quality improvement 2015/16
There will be a governance framework in place to support delivery of priorities for quality improvement and to
demonstrate its impact on improved patient and staff experience:
 Each of the three outcomes Better - Care that is safe; Care – Care that is clinically effective; Together Care that provides a positive experience for patients, their families and our staff) will have a nominated
board executive director lead;
 The Quality Committee and the Workforce Committee will be responsible for monitoring and reporting ongoing progress to the Board of Directors regarding patient safety, clinical effectiveness, patient
experience, staff surveys and front line engagement activities;
 Each Divisional Management Team will be responsible for delivery, monitoring and reporting of progress
against the key outcomes;
 Each work-stream will have a nominated lead to champion and ensure delivery of the improvements as
agreed, supported by monitoring through the Project Management Office;
 Task and finish groups will be used to support any work-streams that are failing to achieve the
improvement outcomes and the executive director leads will ensure that adequate support and training are
available to deliver these;
 Governors will contribute to the oversight of the Quality Improvements.
The overall progress will be reported on a monthly basis though the Quality Committee which will be
responsible for providing the Board of Directors with assurance that the improvements are being delivered.
The priorities for Quality Improvement in 2015/16 will continue to be monitored and measured and progress
reported to the Board of Directors at each of its meetings as part of the updated performance quality reports
and the Executive Dashboard. For priorities that are calculated less frequently, such as the staff survey, local
staff survey and frontline engagement measures, these will be monitored at the Workforce Committee and will
be monitored by the Board of Directors by the submission of an individual report. The Trust has wellembedded delivery strategies already in place for all the quality priorities, and will track performance against
improvement targets at all levels from ward level to Board level on a monthly basis using the performance
dashboard at the Quality Committee. This will be augmented by and triangulated with soft-intelligence from
stakeholders. Risks that arise through the day to day working towards the delivery of quality improvements will
be monitored through the Corporate Risk Register and Divisional Risk Register process.
The Trust will also report on-going progress regarding implementation of the quality improvements for 2015/16
to our staff, patients and the public via our performance section of our website which can be accessed at the
following link: http://www.uhmb.nhs.uk/about-us/key-publications/. You can visit our website and find up-todate information about how your local hospitals are performing in key areas: infections, death rates, and
patient falls and medication errors. Improving Better - Care that is safe; Care – Care that is clinically effective;
and Together - Care that provides a positive experience for patients, their families and our staff by delivering
the highest quality care to our patients is our top priority. We believe that the public have a right to know about
how their local hospitals are performing in the areas that are important to them. As well as information on key
patient outcomes, the website also includes data on our waiting times, length of stay, complaints, cleanliness,
hospital food, and patients and staff opinion of our hospitals.
We are keen to build on the amount of data we publish but we want to make sure that the information is what
you want to see and that it is easy to understand. Please have a look at the web pages and let us know if
there are any areas that could be improved http://www.uhmb.nhs.uk/about-us/key-publications/
11
2.3 Statements of Assurance from the Board of Directors
The information in this section is mandatory text that all NHS Foundation Trusts must include in their
Quality Account. We have added an explanation of the key terms and explanations where applicable.
2.3.1 Review of Services
During 2014/15 the University Hospitals of Morecambe Bay NHS Foundation Trust provided and/or
subcontracted 46 relevant Health Services.
The University Hospitals of Morecambe Bay NHS Foundation Trust has reviewed all the data available to them
on the quality of care in 46 of these relevant Health Services.
The income generated by the relevant Health Services reviewed in 2014/15 represents approximately 99 per
cent of the total income generated from the provision of relevant Health Services by the University Hospitals of
Morecambe Bay NHS Foundation Trust for 2014/15.
The data reviewed on various activities enable assurance that the three dimensions of quality improvement for
patient safety, clinical effectiveness and patient experience is being achieved including:



Divisional performance reports;
Clinical audit activities and reports;
Internal and External independent audits.
The introduction of the local CQC mock assessment visits, Review, Audit, Inspection Standards (RAISE)
visits, patient safety walkabout visits, 15 steps to challenge undertaken by the Directors, Non-Executive
Directors, Governors and Stakeholders have helped in communication with patients, visitors and ward staff.
These initiatives have been of great value and aid our understanding of what we do well and what we can
improve.
2.3.2 Participation in Clinical Audits and National Confidential Enquiries
During 2014/15, 35 national clinical audits and 5 national confidential enquiries covered relevant Health
Services provided by the University Hospitals of Morecambe Bay NHS Foundation Trust.
During 2014/15 University Hospitals of Morecambe Bay NHS Foundation Trust participated in 94% (31/33)
national clinical audits and 100% national confidential enquiries of the national clinical audits and national
confidential enquiries which it was eligible to participate in. The national clinical audits and national confidential
enquiries that University Hospitals of Morecambe Bay NHS Foundation Trust was eligible to participate in
during 2014/15 are detailed in Tables 4 and 5.
The national clinical audits and national confidential enquiries that University Hospitals of Morecambe Bay
NHS Foundation Trust participated in during 2014/15, and for which data collection was completed during
2014/15, are listed in Column A of Tables 4 and 5 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
identified in Column B and C of Tables 4 and 5.
Table 4
List of National Clinical Audits in which University Hospitals of Morecambe Bay NHS Foundation
Trust was eligible to participate during 2014/15
Number Title of National Clinical Audit
Column A
Column B
Column C
Participate
Cases Submitted
Cases submitted
(% of cases
required)
1
Acute Coronary Syndrome or Acute
Yes
Continuous
Ongoing
Myocardial Infarction (MINAP)
2
Adult Community Acquired
Yes
Still open
Ongoing
Pneumonia
3
Bowel cancer (NBOCAP)
Yes
Continuous
Ongoing
4
Cardiac Rhythm Management
Yes
Continuous
Ongoing
(CRM)
5
Case Mix Programme (CMP)
Yes
Continuous
Ongoing
12
Table 4
List of National Clinical Audits in which University Hospitals of Morecambe Bay NHS Foundation
Trust was eligible to participate during 2014/15
Number Title of National Clinical Audit
Column A
Column B
Column C
Participate
Cases Submitted
Cases submitted
(% of cases
required)
6
Diabetes (Adult)
No
7
Diabetes (Paediatric) (NPDA)
Yes
Still open
Ongoing
8
Pregnancy in Diabetes
Yes
FGH (3)
RLI (5)
Not available
9
Epilepsy 12 audit (Childhood
Epilepsy)
Yes
FGH (4)
RLI (18)
Not available
10
Falls and Fragility Fractures Audit
Programme (FFFAP) - National Hip
Fracture Database (NHFD)
Fitting child (care in emergency
departments) (CEM)
Yes
Continuous
Ongoing
Yes
FGH (15)
Not available
Head and neck oncology (DAHNO)
Inflammatory Bowel Disease (IBD)
Lung cancer (NLCA)
Major Trauma: The Trauma Audit &
Research Network (TARN)
National Cardiac Arrest Audit
(NCAA)
National Chronic Obstructive
Pulmonary Disease (COPD) Audit
Programme Pulmonary Rehab
National Comparative Audit of
Blood Transfusion programme patient information & consent
Yes
Yes
Yes
Yes
Continuous
Continuous
Continuous
Continuous
Ongoing
Ongoing
Ongoing
Ongoing
Yes
Continuous
Ongoing
Yes
62 (FGH)
100 (RLI)
Not available
Yes
RLI (14)
FGH (9)
58%
38%
National Comparative Audit of
Blood Transfusion programme sickle cell disease
National Emergency Laparotomy
Audit (NELA)
National Heart Failure Audit
National Joint Registry (NJR)
National Prostate Cancer Audit
National Vascular Registry
Neonatal Intensive and Special
Care (NNAP)
Oesophago-gastric cancer
(NAOGC)
Older people (Care in Emergency
Departments) (CEM)
Paediatric Intensive Care Audit
Network (PICANet)
Pleural Procedure
Rheumatoid and Early Inflammatory
Arthritis
Sentinel Stroke National Audit
Programme (SSNAP)
No
Trust opted out as
not enough patients
Not available
Yes
Continuous
Ongoing
Yes
Yes
Yes
Yes
Yes
Continuous
Continuous
Continuous
Continuous
Continuous
Ongoing
Ongoing
Ongoing
Ongoing
Ongoing
Yes
Continuous
Ongoing
Yes
100
100%
Yes
Continuous
Ongoing
Yes
Yes
8
Continuous
100%
Ongoing
Yes
Continuous
Ongoing
Yes
FGH (21)
RLI (34)
Continuous
Not available
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Mental Health (CEM)
33
Elective surgery (National PROMs
Yes
Ongoing
Programme)
Data source: Clinical Audit Programme and final reports. This data is governed by standard national
definitions
13
Table 5: List of National Confidential Enquires that University Hospitals of Morecambe Bay NHS
Foundation Trust was eligible to participate in during 2014/15.
Number Title of National Confidential
Column A
Column B
Column C
Enquiries
Participate
Cases submitted
Cases submitted
In
(% of cases
required)
1
Maternal, Newborn and Infant Yes
Continuous
Ongoing
Clinical
Outcome
Review
Programme (MBRRACE-UK)
2
Medical and Surgical Clinical
RLI (4) FGH (2)
100%
 SEPSIS
Outcome
Review
Programme
(NCEPOD)
3
Medical and Surgical Clinical
RLI (4) FGH (5)
100%
 Gastroint
Outcome
Review
Programme
estinal
(NCEPOD)
bleeding
4
Medical and Surgical Clinical
Outcome
Review
Programme
(NCEPOD)
 Acute
Pancreati
tis
Starts March 2015
Survey submitted
100%
 NHS
survey
Mortality
reviews
Data source: Clinical Audit Programme and final reports. This data is governed by standard national
definitions
5
Medical and Surgical Clinical
Outcome
Review
Programme
(NCEPOD)
The reports of 8 National Clinical Audits were reviewed by the provider in 2014/15 and University Hospitals of
Morecambe Bay NHS Foundation Trust intends to take or has taken the following actions to improve the
quality of healthcare provided, as shown in Table 6. The full list of actions can be found in the Clinical Annual
Audit Report which is published on the Trusts website at: http://www.uhmb.nhs.uk/about-us/key-publications/
Table 6
No.
Title of National
Clinical Audit
reports received
in 2014/15
1
National Audit of Patient
Information and Consent
2
3
Massive
Audit
National
Audit
Haemorrhage
Chest
Lung
Drain
4
National
Audit
Cancer
5
Intensive Care National
Audit and research Centre
(ICNARC)
Details of actions taken or being taken to improve the quality of
local services and the outcomes of care.
1. Email clinical and governance leads with link to patient information
leaflet ordering site.
2. Email clinical and governance leads with results of actions required
3. Present audit findings at divisional audit meetings
4. Re-audit January 2015
1. Re-write Massive Haemorrhage Policy
2. Re-audit monthly
1. Re-launch new care plan in Emergency Department, AMU and ITU
2. Pleural procedure room on respiratory ward
3. Use of bedside ultrasound for pleural effusions
4. Standardised single chest drain kit for the whole Trust
5. Re-audit
1. Improve presence of Lung Cancer specialist Nurse at Diagnosis:
2. Plan: Increase hours/WTE number for LCNS
3. Improve attendance of Surgeons in LCMDT
4. Improve core-members attendance in LCMDT
5. Improve rate of Histological diagnosis
1. Improve co-operation from all medical staff in the coding process
which will maintain a good data processing time. Data processing
should ideally be completed on the day of admission and daily
thereafter
2. Provide data to support the business case for an outreach 24 hour/7
day per week outreach service on site.
3. Reduction / Review of ‘Early Deaths’ – Each case to be reviewed to
determine if these have been avoidable or not, all information will be
14
Table 6
No.
Title of National
Clinical Audit
reports received
in 2014/15
6
National audit of Heart
Failure
7
National
Paediatric
Diabetes Audit
8
Sentinel Stroke National
Audit (SSNAP)
Details of actions taken or being taken to improve the quality of
local services and the outcomes of care.
passed to the CCDG for case review
4. Improve assessment of the critically ill patient on site in terms of
assessing the appropriateness and timeliness of admission to ICU.
5. Reduction in the number of out of hour, early and delayed discharges
Improved communication from critical care via the daily bed
management meetings (proforma in draft stage), to be presented by
the nurse in charge or unit managers
6. All out of hours discharges / delayed discharges to be reported as an
adverse incident on Ulysses system
7. All out of hours discharges / delayed discharges to be case reviewed
and presented for discussion at the CCDG to inform service
development
8. Improve infection acquisition rates (MRSA, CDFF)
- All acquired infections to be reported as an adverse incident
- All acquired infections to be reviewed as an RCA
- All RCA findings to be implemented and shared as part of unit
governance and ongoing protocols / procedures in terms of
infection prevention to be adhered to
9. Improve ventilation weaning procedures.
- Local protocol has been devised for team discussion
- Implementation of the protocol / education
- Purchase of the NAVA software for the Maquet ventilators via
charitable funds
1. Ensure correct coding of patients discharged with a diagnosis of
heart failure- significant over and is diagnosis of patients in
UHMBFT.
2. Ensure patients with HF are seen by a member of the cardiology/ HF
team before DC- Additional HF nurse resource required especially to
cover weekends as well as mandating all non-cardiologists refer the
patients- some colleagues still do not do so despite advice
3. Treatment on a specialist ward is not possible at UHMBFT as we
have no dedicated cardiology wards other than CCUs
4. Review within 2 weeks after DC- this is achieved if the patient is
referred to the HF team- see point 2 above
5. Treatment with appropriate HF medications is achieved when the
patient is referred to the HF team
6. Ensure HF nurses are appropriately funded to allow upload of data to
the national HF database- we achieved few entries in 12-13 as there
were no HF nurses before that point-next year’s compliance will be
much better but this take up a lot of their time.
1. Further improving mean HbA1c and also number of children with
HbA1c less than 58 mmol/mol by robustly adopting SOP- for
example high HbA1c policy
2. Provide more support to all the diabetes patients- DNS employed,
diabetes night on call service, more dietetic time, transitional clinics
3. Provide Psychology Service – Clinical Psychologist employed in
2014
4. Further Improve team communications and help in diabetes data
management and audits including NPDA - Data Manager employed.
5. Diabetes teaching to all medical and nursing staff
6. School education programme
7. National diabetes audit annually
1. SSNAP Action plan and progress reported monthly through the
Quality Committee.
2. Stroke Clinical Nurse Specialists to cover 7 days to ensure that all
patients with stroke like symptoms are assessed rapidly for
thrombolysis and treatment commenced in a timely manner.
3. Encourage immediate referral via bleep for stroke nurse review,
15
Table 6
No.
Title of National
Clinical Audit
reports received
in 2014/15
Details of actions taken or being taken to improve the quality of
local services and the outcomes of care.
when stroke is suspected
(Action Plan available on request)
Data source: Clinical Audit Programme and final reports. This data is governed by standard national
definitions
Local clinical audit is important in measuring and benchmarking clinical practice against agreed markers of
good professional practice, stimulating changes to improve practice and re-measuring to determine any
service improvements.
The reports of 162 local clinical audits were reviewed by the provider in 2014/15 and a sample of
improvements made to the quality of healthcare provided as a result of audit findings are detailed in Table 7
below. The figure indicates that the results of these clinical audits were reported within clinical areas. Staff
undertaking clinical audit are required to report any actions that should be implemented to improve service
delivery and clinical quality.
Additional information can be found in the Annual Clinical Audit Report 2014/15 which is published on the
Trusts website at: http://www.uhmb.nhs.uk/about-us/key-publications/. A copy of the Annual Clinical Audit
report is available on request.
University Hospitals of Morecambe Bay NHS Foundation Trust intends to take or has taken the following
actions to improve the quality of healthcare provided as shown in Table 7.
Table 7
Local
Clinical
Audits
presented for assurance to
the Board of Directors
2014/15
Aseptic
Non
Touch
Technique ANTT AUDIT
2014
Audit on assessment of
delirium in acute medical
admissions to FGH in
patients over 65 years
Acute Kidney Injury Audit
2014
Details of actions taken to improve the quality of local services and the
outcomes of care.
1. Individual feedback given to staff member at time of audit
2. Audit presented at cross bay clinical skills team meeting.
3. Audit data shared with Clinical Skills Team to enable information sharing
during workshops and during contact with staff on wards.
4. Audit presented at the Infection Prevention Operational Group (IPOG).
5. ANTT Update sessions being delivered to key trainers. Audit presented
during these sessions.
6. Audit presentation and report sent to ward based ANTT key trainers/
practice educators/ infection prevention team FGH.
7. Report and presentation published to Intranet
8. ”Scrub the Hub” poster campaign. Laminated posters sent to ward
based key trainers at FGH.
9. ANTT E-learning programme to be updated
1. Increase awareness of the importance of delirium screening with
posters in key areas (Design and display posters in areas of maximum
effect, e.g. Dr’s office MAU)
2. Make the 4AT forms easily available in MAU and A&E, to be included
with the clerking package
3. Improve rates of confusion screening with reminders to first check for
then find a cause for confusion (Design and display posters in areas of
maximum effect, e.g. Dr’s office MAU)
4. Re-auditing this in the next 2 months to see if there has been any
improvement will also raise the issue again and help improve
awareness in the next cohort of doctors coming into the trust
1. Identification of patients at risk of developing AKI (Poster with AKI risk
factors in MAU and wards, Education of Nurses and doctors)
2. Documentation of cause and Details of AKI (Education of Doctors)
3. Staging of AKI (as above)
4. 100% monitoring of urine output in patients with AKI (Education of
nurses, and HCSW)
16
Table 7
Local
Clinical
Audits
presented for assurance to
the Board of Directors
2014/15
Re-audit of heart failure
RCOA standard 8.5- Audit of
antacid prophylaxis in labour
Audit of the practice of YAG
laser capsulotomy
undertaken at RLI
Caesarean Section
Classifications 1 & 2 FGH
Audit
of
Recordkeeping
Intrapartum Notes Cross Bay
July 2014
Details of actions taken to improve the quality of local services and the
outcomes of care.
5. AKI bundle (Education of health support workers, Nurses and doctors)
6. Reduce Readmission (Patient education/family. Patient advise note to
avoid certain drugs that are nephrotoxic, if unwell or dehydrated)
1. Use NHYA or more descriptive classification to assist with severity
grading
2. All patients with heart failure should see a member of the heart failure
team on each admission
1. Inform obstetricians and midwives on audit and that opiates in labour
should trigger ranitidine prescription
2. Re-audit
1. To circulate new grading guidelines to all doctors involved in grading
referrals
2. Ancillary actions include evidence based discussion of post-operative
drops following laser capsulotomy as an educational session
1. Improve compliance in completing audit proforma’s
2. Audit form to be added to Lorenzo.
3. Ensure all Midwives/Doctors/ Theatre team are all aware that Grade 1
C/section can proceed straight to theatre without waiting for call ( unless
theatre 3 already in use)
4. Improve documentation surrounding Caesarean Section
5. Reasons for not meeting Decision to Delivery Interval (DDI) must be
recorded and incident form created
1. Escalate to matrons/managers to develop action plan.
2. Monthly self-audit on Intrapartum / Postnatal Mother and baby notes for
all midwives as mandatory to promote personal development within
record keeping – as part of supervisory/KSF
3. Liaise with education dept. to commence staff training on completion of
maternity notes – to incorporate current MW’S, new starting MW’s,
student mw’s. discussed at Seniors meeting to have another mandatory
study day around record keeping/accountability incorporated into next
year’s education programme
4. Advise MW’s via monthly news re requirement to document signposting
of patient information/health promotion with signature and date
5. Re-audit notes once changes implemented
1. Ensure Swab counts are completed – signed and countersigned on the
appropriate pages in the birth notes by the appropriate staff involved.
Audit of Pre / Post-delivery
And Pre / Post Perineal
Repair Swab Count
Data source: Clinical Audit Programme and final reports. This data is governed by standard national definitions
2.3.3 Participation in Clinical Research in 2014/15
The number of patients receiving relevant Health Services provided or sub-contracted by University Hospitals
of Morecambe Bay NHS Foundation Trust in 2014/15 that were recruited during that period to participate in
research approved by a research ethics committee was 1984. This information is identified in Graph 1, of
which the number of patients recruited to National Institute of Health Research (NIHR) Portfolio Studies is
1962. This research covers a broad spectrum of medical and healthcare specialties.
th
It should be noted that in 2014/15 NIHR Portfolio Study data is not signed off nationally until 30 June 2016
and the patient participation figure is therefore un-validated at this time.
17
Number of patients
Graph 1: Participation in Clinical Research
2200
2000
1800
1600
1400
1200
1000
800
600
400
200
0
Number of patients recruited to NIHR Portfolio studies
1962
1204
1014
2012/13
Year 2013/14
2014/15
Data source: NIHR Portfolio Database of studies. This data is governed by standard national definitions.
The National Institute of Health Research (NIHR) portfolio studies are high quality research that have full
funding and have undergone a rigorous peer review in order for them to be adopted onto the portfolio. In
England, studies included in the NIHR portfolio have access to infrastructure support via the NIHR Clinical
Research Network. This Trust receives this infrastructure support which supports the salaries of a team of
Research Practitioners who are employed by the Trust and take responsibility for the set- up of research
studies, recruitment of patients to research and their subsequent follow up.
Participation in clinical research demonstrates University Hospitals of Morecambe Bay NHS Foundation
Trust’s commitment to improving the quality of care offered and to making our contribution to wider health
improvement. Our clinical staff keep up to date with the latest possible treatment possibilities and active
participation in research leads to successful patient outcomes.
University Hospitals of Morecambe Bay NHS Foundation Trust was involved in conducting 121 clinical
research studies during 2014/15. There were over 150 clinical staff supporting research activity at University
Hospitals of Morecambe Bay NHS Foundation Trust during 2014/15. These staff assisted with research
covering 17 healthcare specialties as outlined in Table 8 below.
Table 8 : Number of patients recruited to National Institute of Health Research Portfolio studies
Specialty
No. of Patients
No. of Patients
No. of patients
Recruited 2012/13
Recruited 2013/14
recruited
2014/15
Age and aging
20
27
0
Anaesthetics and Pain
0
0
104
Cancer
228
286
126
Cardio-Vascular
69
120
46
Critical Care
36
49
3
Dementia and
212
36
6
Neurodegenerative Diseases
Research (DeNDRoN)
Dermatology
14
7
7
Diabetes
125
115
11
Gastro Intestinal
18
53
1
Health Services Research
6
3
4
Infection
12
18
14
Ophthalmology
3
4
7
In addition, over the last three years, collaborations with the University of Lancaster on Cochrane systematic
reviews of medical and healthcare related topics have increased and these reviews are beginning to be
publish, which demonstrates a clear commitment to increase the wealth of knowledge in health and medical
fields to improve patient outcomes and experience across the NHS. The improvement in patient health
18
outcomes in University Hospitals of Morecambe Bay NHS Foundation Trust demonstrates that a commitment
to clinical research leads to better treatment for patients.
2.3.4 Information on the use of the Commissioning for Quality and Innovation
Payment Framework (CQUIN)
The Commissioning for Quality and Innovation (CQUIN) payment framework aims to support the cultural shift
towards making quality the organising principle of NHS services. In particular, it aims to ensure that local
quality improvement priorities are discussed and agreed at board level within and between organisations. The
CQUIN payment framework is intended to embed quality at the heart of commissioner-provider discussions by
making a small proportion of provider payment conditional on locally agreed goals around quality improvement
and innovation.
A proportion of University Hospitals of Morecambe Bay NHS Foundation Trust’s income in 2014/15 was
conditional on achieving quality improvement and innovation goals agreed between University Hospitals of
Morecambe Bay NHS Foundation Trust and any person or body they entered into a contract, agreement or
arrangement with for the provision of relevant Health Services, through the Commissioning for Quality and
Innovation payment framework (CQUIN).
For 2014/15 the baseline value of the CQUIN was £5.2m. If the agreed quality indicators were not met during
the year or the outturn contract value was lower than the baseline contract, then a proportion of the monies
would be withheld.
The planned monetary total value for income of CQUIN in 2014/15 conditional upon achieving quality
improvement and innovation goals is £5.3m; however, it is estimated that the Trust will achieve a monetary
total value of £5.0m (currently projected value) for the associated payment in 2014/15 (Compared to 2013/14,
the Trust achieved a monetary total value of £5.0m). This is a provisional sign off based on achievement to
date as, for a few indicators, the final results will not be known until later in the year.
Further details of the agreed goals for 2014/15 and for the following 12 month period 2015/16 are available
electronically via our performance section of our website which can be accessed via the following link:
http://www.uhmb.nhs.uk/about-us/key-publications/.
2.3.5
Registration with the Care Quality Commission and Periodic/Special Reviews
Statements from the Care Quality Commission
University Hospitals of Morecambe Bay NHS Foundation Trust is required to register with the Care Quality
Commission (CQC) and its current registration status is compliant with conditions.
The CQC has not taken enforcement action against University Hospitals of Morecambe Bay NHS Foundation
Trust during 2014/15. Staffing and the quality of service provision standards were not met on Ward 39 at the
Royal Lancaster Infirmary and a warning notice was imposed in 2013/14 The Trust developed an action plan
to address the two areas not met in relation to staffing and assessing and monitoring the quality of service
provision. A monthly staffing exception report is taken to the Board of Directors to ensure that we are
delivering high quality care across all areas. The Trust is anticipating a CQC re-inspection in July 2015 to
assess compliance with the standards.
Special Reviews/Investigations/Planned Reviews

Planned Reviews
University Hospitals of Morecambe Bay NHS Foundation Trust has participated in a Chief Inspector of
Hospitals inspection by CQC under the new inspection method and visited all our sites in February 2014.
th
In their report published on 26 June 2014, the Care Quality Commission gave our hospitals a rating of
“inadequate”. This was a huge disappointment to us all, but has made clear for us the things we must do at
pace to bring our services to the good, safe standards our patients deserve. A copy of the final CQC report is
available at www.cqc.org.uk.
Since the February 2014 CQC inspection, staff have worked together to make important changes to the way
we run some of our services, while leaders and senior managers have been doing all they can to support
them.
19
Our CQC Improvement Plan was developed in partnership with our regulators and partners, and is updated
every month to take account of the developments and milestones we have already achieved, as well as the
challenges that still remain.
You can look at our latest CQC Improvement Plan and progress made to address areas for improvement via
the following link http://www.uhmb.nhs.uk/patients-and-visitors/cqc, where you can also find out more about
the developments and milestones we are reaching every month.

Special Reviews
University Hospitals of Morecambe Bay NHS Foundation Trust has not participated in any special reviews by
the Care Quality Commission in 2014/15.
Unannounced visits
The Care Quality Commission has not carried out any unannounced visits during 2014/15.
2.3.6 Information on the Quality of Data
It is well known that good quality information and data underpins the effective delivery of improvements to the
quality of patient care. Improving data quality will therefore improve patient care and improve value for money.
High quality information means better patient care and patient safety. High quality information and data is
essential for:









The delivery of safe, effective, relevant and timely patient care, thereby minimising clinical risk;
Free from duplication (for example, where two or more different records exist for the same patient);
Providing patients with the highest level of accurate and up-to-date clinical and administrative information;
Providing efficient administrative and clinical processes such as communication with patients, families and
other carers involved in patient treatment;
Adhering to clinical governance standards which rely on accurate patient data to identify areas for
improving clinical care;
Providing a measure of our own activity and performance to allow for appropriate allocation of resources
and manpower;
External recipients to have confidence in our quality data, for example, services agreements for healthcare
provisions;
Improving data quality, such as ethnicity data, this will thus improve patient care and improve value for
money;
Engaging public trust.
University Hospitals of Morecambe Bay NHS Foundation Trust undertake the following actions to improve data
quality:
 Daily validation to reduce the percentage of missing NHS numbers.
 Daily validation to improve ethnicity recording for hospital activity.
 Daily validation processes to reduce the number of duplicate registrations.
 Regular review of all outpatient appointments without recorded outcome for hospital activity.
By validating the above metrics we ensure that personal data held on the Trust’s systems is accurate in
keeping with the Data Protection Act. Furthermore it prevents the formation of duplicate records ensuring the
safety of patients and enabling high quality care.
NHS Number and General Medical Practice Code Validity
University Hospitals of Morecambe Bay NHS Foundation Trust submitted records during 2014/15 to the
Secondary Uses Service for inclusion in the Hospital Episode Statistics which are included in the latest
published April 2014 to March 15. The percentage of records in the published data:
which included the patient’s valid NHS Number was:



99.8% for Admitted Patient Care;
99.9% for Outpatient Care; and
98.7% for Accident and Emergency Care.
20
which included the Patient’s valid General Practitioners Code was:



100% for Admitted Patient Care;
100% for Outpatient Care; and
100% for Accident and Emergency Care.
Information Governance Assessment Report 2014/15
The Information Governance Toolkit is an online system which allows NHS organisations and partners to
assess themselves against Department of Health Information Governance policies and standards. It is
fundamental to the secure storage, transfer, sharing and destruction of data both within the organisations and
between organisations.
University Hospitals of Morecambe Bay NHS Foundation Trust’s achieved an Information Governance Toolkit
(IGT) internal assessment compliance score of 77% (Satisfactory) and graded (Green) Satisfactory for
2014/15. This reflects a sustained satisfactory rating as the score for 2013/14 was 77%.
This rating links directly to the NHS Operating Framework which requires organisations to achieve Level 2 or
above in all requirements. A list of the types of organisations included along with compliance data is available
on the Connecting for Health website (www.igt.connectingforhealth.nhs.uk).
University Hospitals of Morecambe Bay NHS Foundation Trust will continue to work towards maintaining and
improving compliance standards during 2015/16 monitored by the Trust’s Information Governance Steering
Group which is reported to the I3 Steering Group.
The Data Quality and Records Management attainment levels assessed within the Information Governance
Toolkit provide an overall measure of the quality of data systems, standards and processes within an
organisation.
Payment by Results (PbR) Clinical Coding Audit
University Hospitals of Morecambe Bay NHS Foundation Trust was subject to the Payment by Results (PbR)
clinical coding audit in November 2014 and undertaken by CHKS part of the CAPITA Group. The percentage
of correctly coded episodes is shown in table 9 below.
Table 9
SPECIALTY
Primary
Diagnosis
Secondary
Diagnosis
Primary
Procedure
Secondary
Procedure
All Totals
93.5%
93.8%
96.2%
83%
Trauma and
Orthopaedic
96%
94.9%
98%
80.6%
Procedures not
carried out
(HRG WA)
91%
93%
83.3%
100%
Auditor Comments
1. The case notes for Trauma and Orthopaedics and HRG WA were in a poor condition.
2. No main training issue was identified but coders were omitting mandatory co-morbidities and coder’s
books did not appear to be updated with changing guidance from the Health and Social Care
Information Centre (HSIS). Auditors would recommend protected time for coders to undertake
updates.
3. National standards for coding were in some cases not followed.
4. Auditors would recommend a feedback/discussion session to all staff on the main errors.
University Hospitals of Morecambe Bay NHS Foundation Trust are taking the following actions to improve data
quality
21
Coding actions
1. Coding staff to be congratulated on the high level of accuracy in the majority of areas. However, all
staff will be reminded of the coding rules and the guidance reinforced in the areas of low accuracy.
2. The Coding Manager, Team leaders and Coding trainer to feedback to staff on errors found.
3. Full Audit findings were highlighted during Coding Team Building day March 2015.
4. Staff to be allocated time to update coding books.
All staff are required to attend a refresher course every 3 years with an accuracy level of at least 90% to be
achieved.
Please note that for clinical coding the results should not be extrapolated further than the actual sample
audited; and services reviewed within that sample.
2.3.7 Reporting Against Core Quality Indicators
Since 2012/13 all NHS Foundation Trusts have been required to report performance against a core set of
Quality indicators using the standardised statement set out in the NHS (Quality Accounts) Amendments
Regulations 2012.
To ensure consistency in understanding of these indicators, NHS England has published a “data dictionary” for
the quality accounts (see the quality accounts area of the NHS Choices website)
http://www.nhs.uk/Pages/HomePage.aspx. The data dictionary includes a definition for each indicator.
Set out in Table 10 are the care quality indicators that trusts are required to report performance in their Quality
Accounts. In addition, where the required data is made available to the trust by the Health and Social Care
Information Centre (HSCIC), a comparison of the numbers, percentages, values, scores or rates of the trust
(as applicable) are included for each of those listed in Table 9 with:
a) the national average for the same; and
b) with those NHS Trusts and NHS Foundation Trusts with the highest and lowest for the same, for the
reporting period.
Further information on these HSCIC definitions can be accessed at www.hscic.gov.uk.
Table 10: Core Quality Indicators – Prescribed Information
The data made available to the Trust by the Health and Social Care Information Centre (HSCIC) is with regard to :(a) The value and banding of the summary hospital-level mortality indicator (“SHMI”) for the Trust for the reporting
period; and
(b) the percentage of patient deaths with palliative care coded at either diagnosis or specialty level for the Trust for the
reporting period.
Period
Oct 2011 to Sep
2012
Oct 2012 to Sep
2013
Oct 2013 to Sep
2014
Trust
SHMI
England
England
Average
Highest
England
Lowest
Trust
Palliative Care Coding
England
England
England
Average
Highest
Lowest
1.04
1.00
1.21
0.685
17.6%
18.90%
43.30%
0.20%
1.04
1.00
1.18
0.63
23.2%
23.94%
48.5%
0%
1.04
1.00
1.18
0.80
27.3%
25.44%
49.4%
0%
Data includes the most recent publication on the Health and Social Care Information Centre, published in April 2015
The University Hospitals of Morecambe Bay NHS Foundation Trust considers that this data is as described for the
following reasons:
 The Trust has embarked on an improvement plan for mortality review building on the recommendations of Mersey
22

Internal Audit Agency.
The Trust has included mortality reduction in its Sign up to Safety programme for 2015-18
The University Hospitals of Morecambe Bay NHS Foundation Trust has taken the following actions to improve this
rate/number, and so the quality of its services, by undertaking the following actions:
 The Trust has shown an improvement in HSMR throughout the year. The most recent SHMI mortality measure has
risen, against the trend of other measures and it is anticipated to improve when 2015 data is published.
The data made available to the Trust by the Health and Social Care Information Centre (HSCIC) with regard to the
Trust’s patient reported outcome measures scores for the following during the period reported:
(i) groin hernia surgery;
(ii) varicose vein surgery;
(iii) hip replacement surgery; and
(iv) knee replacement surgery.
Groin Hernia - Percentage of patients with improvement in EQ-5D health scores
Year
Eligible Episodes
Trust
National Average National Highest
National Lowest
2011/12
85
37.6
51.0
65.5%
35.1%
2012/13
72
45.8%
50.2%
82.9%
36%
2013/14
142
45.1%
50.6%
58.8%
34.1%
2014/15
Data release for 2014/15 is November 2015 from Health and Social Care Information Centre
(HSCIC)
Varicose Veins - Percentage of patients with improvement in EQ-5D health scores
Year
Eligible Episodes
Trust
National Average National Highest
National Lowest
2011/12
68
39.7%
53.6%
67.4%
39.7%
2012/13
34
47.1%
52.8%
71.1%
39.5%
2013/14
32
56.3%
51.6%
57.1%
38.6%
2014/15
Data release for 2014/15 is November 2015 from Health and Social Care Information Centre
(HSCIC)
Hip Replacement - Percentage of patients with improvement in EQ-5D health scores
Year
Eligible Episodes
Trust
National Average National Highest
National Lowest
2011/12
214
88.8%
87.5%
92.4%
74.2%
2012/13
201
91.5%
88.3%
97.7%
82.7%
2013/14
235
87.7%
87.3%
96.8%
79.6%
2014/15
Data release for 2014/15 is November 2015 from Health and Social Care Information Centre
(HSCIC)
Knee Replacement - Percentage of patients with improvement in EQ-5D health scores
Year
Eligible Episodes
Trust
National Average National Highest
National Lowest
2011/12
201
75.6%
78.8%
82.9%
65.7%
2012/13
243
79.4%
81.7%
87%
69.7%
2013/14
285
81.1%
81.3%
97.6%
68.6%
2014/15
Data release for 2014/15 is November 2015 from Health and Social Care Information Centre
(HSCIC)
Please note: 2013/14 Data to March 2015 will not be available until November 2015
The University Hospitals of Morecambe Bay NHS Foundation Trust considers that this data is as described for the
following reasons:
 1038 pre-operative questionnaires were distributed of which 72.4% (752) were completed. A final post-operative
response rate of 10.2% (106) was achieved. The weakness in the process is the return rate of the independently
run post-operative survey six months after the surgery.
The University Hospitals of Morecambe Bay NHS Foundation Trust intends to take the following actions to improve this
percentage, and so the quality of its services, by the following actions:
 Will continue to improve the quality of major joint surgery through the AQuA Advancing Quality programme
 Will continue to work with patients to improve information on knee replacement surgery which will enable them to
make more informed and appropriate choices
 Will engage with patients at discharge to ensure they understand the value of completing the six month postoperative survey and the value that gives to the Trust and can help shape future services.
23
The data made available to the Trust by the Health and Social Care Information Centre (HSCIC) with regard to the
percentage of patients aged—
(i) 0 to 15; and (ii) 16 or over,
readmitted to a hospital within 28 days of being discharged from a hospital which forms part of the Trust during the
reporting period.
Year
Categories
16+ Years
>16 Year
Trust
10.88
11.53
England Average
11.45
Not recorded
2010/11
England Highest
22.76
16.05
England Lowest
0
0
Trust
10.5
10.2
England Average
11.08
11.45
2011/12
England Highest
19.36
41.65
England Lowest
0
0
Trust
6.7
10.7
England Average
5.8
8.3
2012/13
England Highest
Not yet published by Health and Social Care Information
Centre – Scheduled publication date not yet available
England Lowest
Trust
6.9
6.9
England Average
5.5
5.5
2013/14
England Highest
Not yet published, publication scheduled for Dec 2015
England Lowest
Trust
Not yet published
England Average
2014/15
Not yet published, publication scheduled for Dec 2016
England Highest
England Lowest
Not yet published
Please note: Figures are complete to the end of January 2014. These will be updated as further data becomes
available This is not scheduled until December 2015.
The University Hospitals of Morecambe Bay NHS Foundation Trust considers that this data is as described for the
following reasons;
 The data shows that the work being undertaken across the health economy has started to impact on the
percentage of readmissions seen at the Trust; with a small reduction in the total number of readmissions.
 The higher percentage return rate within paediatrics reflects the service offered to parent whereby they are
encouraged to return to the ward if further problems are encountered. This is a service that is highly valued by
parents.
The University Hospitals of Morecambe Bay NHS Foundation Trust has taken the following actions to improve this
percentage and so the quality of its services, by the following actions:
 An action plan, led by the Clinical Directors is in place to review the level of emergency readmissions.
The data made available to the Trust by the Health and Social Care Information Centre (HSCIC) with regard to the
Trust’s responsiveness to the personal needs of its patients during the reporting period.
Year
Trust
England Average
England Highest
England Lowest
2011/12
65.3
67.4
85
56.5
2012/13
66.6
68.1
84.4
57.4
2013/14
70.6
76.9
87.0
67.1
2014/15
NA
NA
NA
NA
Please note: The 2014/15 information is not available (NA) and will only be published by the Health and Social Care
Information Centre in September 2015
The University Hospitals of Morecambe Bay NHS Foundation Trust considers that this data is as described for the
following reasons:
 The Trust considers patients feedback to be pivotal in ensuring our services continue to develop in order for the
Trust to meet individual patient needs.
24
The University Hospitals of Morecambe Bay NHS Foundation Trust intends to take the following actions to improve this
score, and so the quality of its services:
 We continue to focus energy and efforts on improvements to patient outcomes, quality care and patient experience
 The Trust has continued to focus on the importance of the Friends and Family Test and has made the information
available to staff, patients and visitors on ward boards.
Additional monies have been identified to support increased nurse recruitment to enhance patient experience.
The data made available to the Trust by the Health and Social Care Information Centre (HSCIC) with regard to the
percentage of staff employed by, or under contract to, the Trust during the reporting period who would recommend the
Trust as a provider of care to their family or friends. This indicator was introduced in April 2014.
Year
Trust
England Average
England Highest
England Lowest
2011/12
2012/13
Staff Friends and Family Test (FFT) only introduced in April 2014
2013/14
2014/15
57%
Not calculated by
NHS England
95%
22%
The University Hospitals of Morecambe Bay NHS Foundation Trust considers that this data is as described for the
following reasons:
 The Trust is disappointed in the slow rate of improvement and work is being undertaken to focus on improvements
in these areas.
The University Hospitals of Morecambe Bay NHS Foundation Trust has taken the following actions to improve this
percentage, and so the quality of its services:
 We continue to focus energy and efforts on improvements to patient outcomes, quality care and patient experience
 The Trust is part way through a training programme to help staff to be at their best more of their time when
delivering care to patients
 The Trust and its commissioners have included the Friends and Family Test in the CQUIN programme
 Additional monies have been identified to support increased nurse recruitment to enhance patient
 The Trust will continue its general and nursing leadership programmes and has introduced a weekly Chief
Executive briefing communication.
The data made available to the Trust by the Health and Social Care Information Centre (HSCIC) with regard to the
percentage of patients who were admitted to hospital and who were risk assessed for Venous Thrombo-Embolism
during the reporting period.
Year
Trust
England Average
England Highest
England Lowest
2011/12
95.42%
93%
100%
8.8%
2012/13
98.4%
94.2%
100%
84.6%
2013/14
99.4%
95.97%
100%
76%
2014/15
93.3%
96%
100%
86.4%
Please note: Figures for 2014/15 are complete to the end of December 2014 – these will be updated as March 2015
data becomes available (in September 2015)
The University Hospitals of Morecambe Bay NHS Foundation Trust considers that this data is as described for the
following reasons:
 The Trust has aimed to implement current best practice guidelines in order to ensure that all adult inpatients receive
a Venous Thrombo-Embolism (VTE) Risk Assessment on their admission to the hospital, and that the most suitable
prophylaxis is instituted.
The University Hospitals of Morecambe Bay NHS Foundation Trust has taken the following actions to improve this 90
percentage compliance indicator and so the quality of its services, by undertaking the following actions:
 The Trust has revised the VTE policy and has implemented the associated changes in documentation, assessment
and prescribing, together with training to support the changes.
25
 The Trust is making efforts to roll out an electronic assessment tool to give “live” information about compliance. This
will help us to give feedback to individual areas and address poor performance pro- actively.
The data made available to the Trust by the Health and Social Care Information Centre (HSCIC) with regard to the rate
per 100,000 bed days of cases of Clostridium Difficile infection reported within the Trust amongst patients aged 2 or
over during the reporting period.
Rate per 100,000 bed days of cases of Clostridium Difficile infection
Year
Trust
England Average
England Highest
England Lowest
2011/12
23.5
22.2
58.2
0
2012/13
20.4
17.4
30.8
0
2013/14
22.8
14.7
32.5
0
2014/15
NA
NA
NA
NA
Please note: The 2014/15 information is not available (NA) and will only be published by the Health and Social Care
Information Centre in September 2015.
The University Hospitals of Morecambe Bay NHS Foundation Trust considers that this data is as described for the
following reasons:
 The Trust has continued to embed measures to reduce levels further within the organisation;
 There have been 29 cases of Clostridium Difficile Infection (CDI) attributed to the Acute Trust to March 2015.
The University Hospitals of Morecambe Bay NHS Foundation Trust has taken the following actions to improve this
trajectory and so the quality of its services, by undertaking the following actions:
 Ensured that all staff are retrained annually in hand hygiene;
 Maintained a high profile campaign on beating bugs;
 Maintained surveillance teleconferences every two weeks to support the monitoring of cases and continue a
thorough review of all cases;
 In 2014/15 the reduction in infections has been identified as a priority in the Trust’s Better Care Together and the
Quality improvement Plan 2014-2017;
 Establish the prevalence of Clostridium Difficile in the community by the Clinical Commissioning Groups and work
closely with them and Public health to take a whole healthcare system approach;
 Clostridium Difficile root cause analysis meetings are undertaken for all Clostridium Difficile cases attributed to
UHMB;
 Wards complete weekly audits of an adapted preventing Clostridium Difficile care bundle.
The data made available to the Trust by the Health and Social Care Information Centre (HSCIC) with regard to the
number and, where available, rate of patient safety incidents reported within the Trust during the reporting period, and
the number and percentage of such patient safety incidents that resulted in severe harm or death
Rate per 100 admissions
Percentage of incidents
Incidents
Resulting in severe harm or death
Period
Trust England Highest Lowest Trust England Highest
Lowest
Oct 2014 to Mar 2015
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Apr 2014 to Sep 2014*
4.40
3.59
7.50
0.02
0.3
0.5
3.1
0
Oct 2013 to Mar 2014
9.78
7.2
12.46
1.72
0.4
0.5
2.6
0
Apr 2013 to Sep 2013
9.21
6.79
11.06
3.85
0.5
0.6
3.0
0
Oct 2012 to Mar 2013
12.7
7.21
12.7
3.0
0.75
0.72
3.46
0
Apr 2012 to Sep 2012
13.6
6.2
13.6
1.99
0.33
0.72
2.54
0.04
Oct 2011 to Mar 2012
9.6
5.9
9.75
1.93
0.1
0.75
3.26
0
Please note: Figures are those published by the Health and Social Care Information Centre in April 2015.
*Figures for Apr 2014 to Sep 2014 are on the basis of all Non-Specialist Acute Trusts. The NRLS discontinued the use
of the large Acute Trust cohort at its publication in April 2015. Data for Oct 2014 to Mar 2015 is not available and will be
published in September 2016.
The University Hospitals of Morecambe Bay NHS Foundation Trust considers that this data is as described for the
26
following reasons:
 There has been a steady increase in the number of patient safety incidents over the last 5 years and the Trust now
has an excellent reporting culture.
The University Hospitals of Morecambe Bay NHS Foundation Trust has taken the following actions to improve the
percentage of patient safety incidents resulting in harm, and so the quality of its services, by undertaking the following
actions:
 The trust will continue to encourage and maintain a strong reporting culture
 Training has been increased for staff on reporting and managing patient safety incidents;
 Weekly senior manager review of all incidents causing moderate or greater harm have been maintained;
 Review of serious incidents by the Serious Incident Requiring Investigation (SIRI) Panel has strengthened
throughout the year and lessons learned are identified;
 Duty of candour is applied and monitored.
Further details on incidents and risks can be found in the Annual Risk Management Report 2014/15 which is published
on the Trust’s website at http://www.uhmb.nhs.uk/about-us/key-publications/. A copy of the report is available on
request.
The data made available to the Trust by the Health and Social Care Information Centre (HSCIC) with regard to the
Trust’s responsiveness to the results of the Friends and Family Test (FFT) – Patient element - for all acute providers of
adult NHS funded care, covering services for inpatients and patients discharged from Accident and Emergency (types 1
and 2) during the reporting period. As of 1st October 2013 the survey was extended to include all women of any age
who use NHS funded maternity services.
Emergency Departments
Trust
England
Oct 2014
(Q2)
83%
87%
Percentage Recommended
Inpatients
Trust
England
91%
94%
Trust
96%
Maternity
England
95%
The NHS England review of the patient FFT, published in July 2014, recommended a move away from the Net
Promoter Score (NPS) and the introduction of a simpler scoring system in order to increase the relevance of the FFT
data for NHS staff, patients and members of the public. Based on the findings of the review, NHS England is now
calculating and presenting the FFT results as a percentage of respondents who would/would not recommend the
service to their friends and family. This change was introduced in the first publication of Staff FFT results on 25
September 2014 and across all existing patient FFT settings on 2 October 2014.
NHS Choices is undertaking ongoing user testing of the presentation of the FFT results on the NHS Choices website.
The University Hospitals of Morecambe Bay NHS Foundation Trust considers that this data is as described for the
following reasons:

The Trust considers patients feedback to be pivotal in ensuring our services continue to develop in order for the
Trust to meet individual patient needs.
The University Hospitals of Morecambe Bay NHS Foundation Trust intends to take the following actions to improve this
score, and so the quality of its services:

Text surveys to continue to be sent automatically to patients who have a mobile phone number with the option to
opt out of the survey, rather than the previous requirement to gain consent and ask patients to opt in, we anticipate
increased participation rates in the survey.

Interactive voicemail for patients who do not have a mobile telephone has been introduced.
27
Part 3: Other Information - Review
of Quality Performance
The Quality Account has provided an overview of the Quality Improvement work which has taken
place across the organisation. There are a number of projects which we will be taking forward into the
coming year and focusing our attention upon. We would however, like to highlight the following
projects as key priorities for 2014/15:
3.1 An Overview of the Quality of Care Based on Performance in 2014/15
with an Explanation of the Underlying Reason(s) for Selection of Additional
Priorities
Table 1 in Part 2 sets out the priorities for improvement which were identified in the 2013/14 report. Additional
information regarding the rationale for the priority selection is detailed in 2.2.2 and 2.2.3.
Section 2.2.3 included a list of priorities that have been chosen to be removed by the Board of Directors from
the quality improvements priorities for 2015/16. The rationale for the de-selection of the following priorities is
that considerable progress and improvements have been delivered or put in place and other improvements
have become a priority. It has been agreed to remove the following:












Cardiac arrest. Review 50 deaths.
Comprehensive assessment of over 75 years patients
Develop a plan for 7-day working across key areas of service provision. Undertake a gap analysis and
produce an action plan;
- Further develop and deliver the multi-professional ward/board rounds in 50% of all wards in-year
moving to 100% in year 2
- Develop a dashboard that front line staff can access that provides them with the information they need
to understand how reliable the care they provide is.
- Please Note: The next phase of the 7 day working is detailed in Table 2.
Introduction of a decant, deep clean and fogging programme.
Deliver values based induction. Develop and implement a values based corporate induction programme
for all new employees.
Introduction and improvement through I Want Great Care. Dedicated Executive lead to be established;
Feedback to be displayed publicly every month outside each ward and department
Learning from comments to be shared. from ward to board at least on a monthly basis
Director sponsorship of Divisions to be developed. Executive Director to be identified to support Divisional
Teams and support divisional teams.
Commitment by all managers to spend time on the front line, working alongside staff. All executive
directors and managers will be required to spend time with front line staff.
CQUIN targets for 2014/15 removed as new CQUIN targets set for 2015/16.
Information regarding the improvements made to demonstrate evidence for their removal is described in Part 3
– Section 3.4.1 and 3.4.2.
3.2
Performance against Key National Priority Indicators and Thresholds
The NHS Outcomes Framework for 2014/15 sets out high level national outcomes which the NHS should be
aiming to improve. The Board of Directors monitors performance compliance against the relevant key national
priority indicators and performance thresholds as set out in the NHS Outcomes Framework 2014/15. This
includes performance against the relevant access targets and outcome objective and performance thresholds
set out in Appendix A of Monitors Risk Assessment Framework 2014/15 which can be accessed via the
following link: https://www.gov.uk/government/publications/risk-assessment-framework-raf.
28
Monitor uses a limited set of national measures of access and outcome objectives as part of their assessment
of governance at NHS Foundation Trusts. Monitor uses performance against these indicators as a trigger to
detect potential governance issues.
NHS Foundation Trusts failing to meet at least four of these requirements at any given time, or failing the
same requirement for at least three quarters, will trigger a governance concern, potentially leading to
investigation and enforcement action. Except where otherwise stated, any trust commissioned to provide
services will be subject to the relevant governance indicators associated with those services.
Part 3, Section 3.2 and detailed in table 10 sets out the relevant indicators and performance thresholds
outlined in Appendix A of Monitors Risk Assessment Framework. Unless stated in the supporting notes, these
are monitored on a quarterly basis.
Please note: where any of these indicators have already been reported on in Part 2 of the quality report, in
accordance with the Quality Accounts Regulations, they will not be repeated here. Only the additional
indicators which have not already been reported in part 2 will be reported here to avoid duplication of
reporting.
Performance against the key national priorities is detailed on the Integrated Performance Report to the Board
of Directors each month and is based on national definitions and reflects data submitted to the Department of
Health via Unify and other national databases.
3.2.1 Our Performance- National Quality Standards
Despite being an extremely busy and challenging year, the Trust delivered on the majority of local and national
quality standards. Most notably each of the national cancer standards were met across each quarter following
the implementation of the 62 day cancer plan, which aimed to deliver shorter waiting time for patients. Early in
2014, it was acknowledged nationally that the number of patients waiting over 18 weeks for treatment was
increasing. Therefore a RTT national amnesty was put in place allowing Trusts to plan to under achieve the
admitted, non-admitted and incomplete Referral to Treatment Time standards in order to reduce waiting times.
Following the achievement of the 95% standard for patients to be treated, discharged or transferred within 4
hours from May to December 2013, the increased pressures exhibited in Quarter 4 (January to March)
continued into 2014/15. The underlying issues were higher than ideal length of stay and the hospital was too
full. During the year a series of actions were put in place including to increase the frequency of medical review,
challenge any delays in the patient pathway either within the hospital or across Social Services, primary and
community services, increased nurse staffing with the A&E departments and on the wards and dedicated staff
to support the safe discharge of patients from hospital. Table 11a & b shows the results from the Trust’s
assessment of performance against the healthcare targets and indicators over the past 3 years, as currently
reported in section 5a of the Integrated Board Performance Report and/or the Executive Dashboard which is
submitted to the Board of Directors on a monthly basis.
Table 11a: Performance against Quality Standards and Indicators
2012/13
Standard
Maximum time of 18 weeks from
referral to treatment– admitted
Maximum time of 18 weeks from
referral to treatment– non-admitted
Maximum time of 18 weeks from
referral to treatment–incomplete
A&E: maximum waiting time of four
hours from arrival to admission/
transfer/ discharge
All cancers: 31-day wait for second
or subsequent treatment- surgery
All cancers: 31-day wait for second
or subsequent treatment- drug
treatment
All cancers: 62-day wait for first
treatment from urgent GP referral
for suspected cancer
All cancers: 62-day wait for first
treatment from NHS Cancer
Screening Service referral
2013/14
Q1
Q2
Q3
Q4
Q1
Failed to
Meet
Failed
to
Meet
Failed
to
Meet
Met
Met
Met
Met
Met
Met
Met
Met
Met
Failed to
Meet
Failed
to
Meet
Met
Q3
Q4
Met
Met
Failed
to
Meet
Met
Met
Met
Met
Met
Met
Met
Failed to
Meet
Met
Met
Met
Met
Met
Met
Met
Met
Met
Failed
to
Meet
Failed
to
Meet
Failed
to
Meet
Met
Met
Failed
to
Meet
Failed to
Meet
Failed to
Meet
Failed to
Meet
Failed to
Meet
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Failed
to
Meet
Met
Met
Failed
to
Meet
Met
Met
Met
Met
Met
Met
-after
breach
reallocatio
ns
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
29
Q2
2014/15
Q1
Q2
Q3
**Planned
** Planned ***Planned
under
under
under
achievem
achievement achievement
ent
Q4
**Planned
under
achievem
ent
All cancers: 31-day wait from
diagnosis to first treatment
Cancer: two week wait from
referral to date first seen- all urgent
referrals
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
*Locally agreed RTT amnesty in May and June 2014
** National RTT Amnesty July- December 2014
Table 11b: Performance against healthcare targets and indicators
Quality Standard
2011/12
2012/13
Average length of stay (non-elective
admissions)
Day case rate
Readmissions within 30 days
SHMI
CHKS RAMI (year to date compared
with 2013 base)
Deaths within 30 days of elective
surgery (year to date compared with
2013 base)
Deaths within 30 days of elective
surgery (year to date compared with
2013 base)
Deaths in low mortality Healthcare
Resource Groups (year to date
compared with 2013 base)
Sickness absence rate
Mandatory training
Appraisal rate
Clostridium Difficile – Target 46 for
2014/15
MRSA (Post 48 hours)
Compliance with requirements regarding
access to healthcare for people with
learning disabilities
2013/14
2014/15
5.3
4.9
4.7
5.0
81.0%
6.6%
82.9%
7.3%
107.48
101.2
84.5%
7.8%
101.39
(to June 2013)
115
106
91
84.8%
Not available
108.00
(to December 2014)
Not reported.
HSMR 89.79
January 2015
0.034%
0.041%
0.024%
Not available
1.4%
1.5%
1.6%
Not available
0.103%
0.092%
0.068%
Not available
3.77%
4.61%
95.5
91.1
92.8
86.8
4.31%
82%
72.4%
Met
Failed to meet
Failed to meet (50)
Failed to meet
Failed to meet
*0
Not available
Not available
Not available
40 cases with 27
attributed to UHMB
Failed to meet (2)
Met
Not available
Met
Met
*Hospital acquired MRSA infections at University Hospitals of Morecambe Bay remain lower than the national rate. During 2013/14 a
zero tolerance approach has continued in relation to avoidable cases of Methicillin resistant Staphylococcus Aureus (8) blood stream
infections. There have been 2 Methicillin resistant Staphylococcus Aureus (8) bloodstream infections acquired 48-hours after
admission (hospital acquired) in the Trust during the year. There have been two community acquired (pre-48 hour cases)
where the Trust has been identified as being the organisation with most to learn and have been assigned to the Trust so that
learning can be applied.
Data Source: CHKS, Trust Training Management System and HSCIS (*data to March 2015 will not be available (NA) until September 2015)
3.2.2 Other Quality Indicators
Advancing Quality Indicators
Results for December 2014 discharges. (Latest released data)
Table 12 : Advancing Quality Indicators
AQ Indicator
Acute Myocardial
Infarction
Heart Failure
Hip and Knee
replacements
Pneumonia
Stroke
COPD
Hip fracture
(New measure) data collection only
for 3 months for a
baseline
Sepsis (New
measure) - data
collection only for 3
months for a
baseline
2014/15 Target
89.0%
Trust
97.22%
RLI
100.0%
FGH
90.00%
WGH
Not applicable
70.0%
85.8%
75.00%
94.12%
68.75%
90.00%
87.50%
93.10%
Not applicable
97.22%
75.6%
66.6%
50.0%
To be set
81.25%
75.93%
50.00%
17.02%
81.54%
68.42%
56.25%
27.59%
80.65%
93.75%
25.00%
0.00%
Not applicable
Not applicable
Not applicable
Not applicable
To be set
70.73%
61.90%
80.00%
Not applicable
30
Referral to Treatment (RTT) Data
Despite being an extremely busy and challenging year, the Trust delivered on the majority of local and national
quality standards. Most notably each of the national cancer standards were met across each quarter following
the implementation of the 62 day cancer plan, which aimed to deliver shorter waiting time for patients. Early in
2014, it was acknowledged nationally that the number of patients waiting over 18 weeks for treatment was
increasing. Therefore a RTT national amnesty was put in place allowing Trusts to plan to under achieve the
admitted, non-admitted and incomplete Referral to Treatment Time standards in order to reduce waiting times.
Following the achievement of the 95% standard for patients to be treated, discharged or transferred within 4
hours from May to December 2013, the increased pressures exhibited in Quarter 4 (January to March)
continued into 2014/15. The underlying issues were higher than ideal length of stay and the hospital was too
full. During the year a series of actions were put in place including to increase the frequency of medical review,
challenge any delays in the patient pathway either within the hospital or across Social Services, primary and
community services, increased nurse staffing with the A&E departments and on the wards and dedicated staff
to support the safe discharge of patients from hospital.
Month on month RTT performance for 2014-15.
Table 13
RTT
Performance
2014/15
Apr14
May14
Jun14
Jul14
Aug14
Sep14
Oct14
Nov14
Dec14
Jan15
Feb15
Mar15
YEAR
END
14/15
91.06
%
73.41
%
74.68
%
92.72
%
76.12
%
80.35
%
81.25
%
76.15
%
92.18
%
91.29
%
84.90
%
69.19
%
82.03%
97.33
%
97.94
%
97.61
%
96.65
%
96.49
%
96.52
%
95.81
%
95.26
%
96.58
%
96.97
%
97.43
%
93.48
%
96.48%
92.46
%
93.29
%
94.32
%
93.22
%
93.50
%
93.85
%
93.89
%
94.16
%
92.06
%
90.80
%
90.09
%
93.45
%
92.46%
RTT admitted 90%
<18 weeks
RTT - nonadmitted 95%
<18 weeks
RTT Incomplete
92%
<18 weeks
The Average
Incomplete
standard for
the year
The Average Incomplete standard for the year was 92.92%
Emergency Readmissions within 28 days.
Data for the full year’s activity was available at the end of April 2015.
Emergency readmissions occur when a patient is readmitted to the Trust following a previous elective or
emergency stay. As part of the required definition, the admissions might not be connected. For example, the
first admission could be for a hip replacement and the second (emergency) admission for a cardiac episode.
With Monitor, we measure readmissions within 28 days of discharge from the first admission.
Avoidable emergency readmissions can be linked to incorrect recording of treatment, incomplete support from
community services or inappropriate discharge, resulting in patients being sent home without appropriate
support in place. This results in a poor experience for patients as well as increased cost for the Trust through
financial penalty via the contract for emergency readmissions. This also costs the Trust more money due to
patients needing additional treatment.
Between 1st April 2014 and 31st March 2015, 5,279 patients were admitted as an emergency readmission
within 28 days of a discharge from a planned or emergency admission. This equates to 12.4% of total
admissions.
A breakdown by Division for Inpatient readmissions within 28 days from 1st April 2013 – 31st March 2014
compared to 2014/15 is shown in table 14.
31
Table 14: Inpatient readmissions within 28 days
Division
Acute Medicine
Elective Medicine
Women’s and Children’s
Children’s
Core Clinical Services
Surgery
TRUST TOTAL
Number of Monitor
Readmissions < 28 Days
2013/14
2014/15
1952
2644
541
73
1285
1026
27
3
1304
1347
4923
5279
Percentage (%) of
Monitor
Readmission Rate
< 28 Days
2013/14 2014/15
13.12%
14.2%
15.71%
5.64%
12.29%
11.65%
5.26%
20.00%
9.57%
9.99%
11.57%
12.40%
Number of Spells
2013/14
14,873
3,443
1,295
8,809
513
13,630
42563
2014/15
18614
10454
15
13486
42569
Data Source: UHMB Data Warehouse Readmissions Model (please note Monitor readmission rate calculation applies exclusion criteria)
NB The algorithm used to identify 28 readmissions has identified 17 patients who were readmitted within 28
days where the original admission was within Core Clinical Services.
Cancer 62 day Waiting Time Standard for first treatment
When a patient visits their GP and the GP suspects that the patient may have cancer symptoms, they are
referred on an urgent 2 week wait referral. This starts the cancer pathway for the patient and the national
standard is to treat patients that are diagnosed with cancer within 62 days from this urgent 2 week wait
referral.
The actual numbers of patients that are treated and that waited longer than 62 days for their treatment are in
the table 15 below:
Table 15: Performance against Cancer 62 day waiting time target for first treatment
Trust
Total Patients
Number of patients
Performance
Month
Treated
that breached
for Month
National Standard
2013/14
Q1
199
32.5
83.67%
85%
Q2
232
29
87.50%
85%
Q3
206
29.5
85.68%
85%
Q4
205.5
44
78.59%
85%
Total: 83.98%
2014/15
Q1
210.5
30.5
85.51%
85%
Q2
231
32
86.15%
85%
Q3
206
24
88.35%
85%
Q4
220
32
85.45%
85%
Total: 86.34%
Data Source: Open Exeter
Our patients that require specialist treatment for their cancer are referred on to other tertiary providers for
treatment and we share the activity and the breach performance with these other providers.
There are many reasons why a patient may wait longer than 62 days for treatment, including:





Patient choice: patients are often unavailable for work or social reasons within their cancer pathways;
Complexity: a number of patients require multiple, repeat tests before an appropriate treatment plan for
the patient can be formulated;
Fitness: some patients have to undergo fitness tests or treatments for other conditions before their cancer
treatment can begin;
Capacity at tertiary providers: there is pressure within the whole region for capacity for certain cancer
treatments;
Delays within the cancer pathways: tracking of the patients’ pathway could in some instances be
improved, to streamline the patient care and minimise delays.
32
Reduce the Trust’s Hospital Mortality Rate / Summary Hospital Mortality Indicators (SHMI)
The Trust has shown marked improvements in HSMR and SHMI mortality measures that have historically
portrayed the Trust in a poor light.
The latest nationally available figure for SHMI is 108.00. Graph 2 below shows that UHMB (shown by the
yellow diamond is within the expected range for SHMI.
Graph 2
The Trust continues to be part of a North West Collaborative Programme for mortality reduction and has
implemented actions specifically around the care of patients with pneumonia and patients with severe
sepsis. In addition to this work hospital mortality has been improved by reducing harm from hospital acquired
infections, Venous Thrombo-Embolism (VTE) and by strict adherence to quality measures as part of the North
West Advancing Quality initiative and improving the management of deteriorating patients and increased
nurse to patient staffing levels.
Monthly Hospital Standardised Mortality Ratio (HSMR)
HSMR measures in-hospital mortality and adjusts for a number of factors including demographics, comorbidities and palliative care.
The UHMB position for HSMR January 2015 (latest data available) is 89.79% against a target to remain below
100.00%. The Trust current position is therefore, 10.21% below this target and reflects continued positive
actions.
The Trust continues to with its improvement plan for reducing mortality both in hospital and within 30 days of
discharge. The Mortality Review Group oversees a series of distinct work streams to ensure that national
mortality ratio measures accurately reflect the Trust’s position as well as ensuring safe, appropriate, harm free
care is being delivered, and these include but are not limited to:

Improving the process of consultant sign-off for coding of deaths. The purpose of this is to ensure that all
diagnoses are accurately coded. This allows us to identify areas of high mortality and plan appropriate
action.

Improved documentation processes to ensure safer handover of clinical care and ensure information is
available to attribute accurate clinical codes.

Engagement with Northwest area AQuA team to develop a definitive action plan for mortality
improvement.

Mortality reviews undertaken by senior consultants.
33
At the same time we have maintained our focus on harm reduction strategies such as reducing medical
outliers (medical patients receiving treatment on non-medical wards), MRSA hospital acquired infections and
medication errors.
Risk Adjusted Mortality Index (RAMI) was provided by CHKS but is no longer reported nationally.
3.3
Additional Other Information in Relation to the Quality of NHS Services
The Morecambe Bay Investigation – Kirkup Report
Introduction
The Morecambe Bay Investigation was established by the Secretary of State for Health in September 2013
following concerns over serious incidents in the maternity department at FGH.
The Morecambe Bay Investigation published its report on Tuesday 3 March 2015. The full report is available
from the Trust’s website
The Investigation Panel also reviewed pregnancies at other maternity units run by University Hospitals of
Morecambe Bay NHS Foundation Trust. It found serious concerns over clinical practice were confined to FGH.
Covering January 2004 to June 2013, The report makes 44 recommendations for the Trust and wider NHS,
aimed at ensuring the failings are properly recognised and acted upon. 18 of the recommendations are for the
Trust to address.
The investigation report details 20 instances of significant failures of care in the FGH maternity unit which may
have contributed to the deaths of three mothers and 16babies. Different clinical care in these cases would
have been expected to prevent the death of one mother and 11 babies. This is almost four times the frequency
of such occurrences at the Trust’s other main maternity unit, at the RLI.
The report, covering the period January 2004 to June 2013, says the maternity department at FGH was
dysfunctional with serious problems in five main areas:
- Clinical competence of a proportion of staff fell significantly below the standard for a safe, effective
service. Essential knowledge was lacking, guidelines not followed and warning signs in pregnancy
were sometimes not recognised or acted on appropriately.
- Poor working relationships between midwives, obstetricians and paediatricians. There was a
‘them and us’ culture and poor communication hampered clinical care.
- Midwifery care became strongly influenced by a small number of dominant midwives whose ‘overzealous’ pursuit of natural childbirth ‘at any cost’ led at times to unsafe care.
- Failures of risk assessment and care planning resulted in inappropriate and unsafe care.
Trust response
Immediately following publication, the Trust issued an unreserved apology for the failings in care, together with
accepting the recommendations made, in full.
The findings in the report are shocking. A number of families have suffered unnecessary life changing trauma
and distress as a result of the way the Trust cared for mothers and babies.
The Chair and Chief Executive of the Trust held a press conference on the day the report was published,
where they both read out statements. The statements are available as recordings on the Trust’s website:
http://www.uhmb.nhs.uk/patients-and-visitors/the-morecambe-bay-investigation/
Recommendations and action plan
The Report makes 44 recommendations,18 of which are directed at the Trust, with the remainder for the wider
NHS. The Trust’s recommendations are also time bound, with one requiring completion by April 2015.
An action plan has been developed and a robust programme management process established. This entails a
number of key projects agreed some of which require input and lead from other Divisions.
Governance and management arrangements
Robust governance arrangements will be required to ensure the recommendations are monitored and
implemented in full.
34
Learning from Patient Safety Incidents
Learning from patient safety incidents is a key feature of the Trusts Risk Management Strategy and staff
endeavour to use the knowledge gained from their investigation to improve care. The Trust has a good
reporting culture and reported over 15,097 patient safety incidents in 2014/15 which has shown that the trust is
in the highest 25% of reporters as shown from our reporting of incidents to the NPSA between 1 October 2013
to 31 March 2014. The National Reporting and Learning System (NRLS) helps the NHS to understand why,
what and how patient safety incidents happen, learn from these experiences and take action to prevent future
harm to patients. National data can be found at: www.nrls.npsa.nhs.uk/patient-safety-data/. Graph 3 below
shows the total number of incidents reported and the number reported to the national patient safety agency.
The difference between the two figures is in relation to incidents related to services provided outside the Trust.
Graph 3 – Patient Safety Incidents by year
Reported Patient Safety Incidents (PSI)
15097
16000
13653
Number of incidents
14000
12365
11672
12000
9229
10000
9284
8927
7600
8000
NRLS
6000
Total
4000
2000
0
2011-12
2012-13
2013-14
2014-15
Year
Data source: NPSA and Trust Incident Management System. This data is governed by standard national definitions.
Lesson to be learnt are identified as part of the investigation process. These are cascaded to relevant staff
and some are distributed throughout the Trust in monthly divisional newsletters. The following example topics
were included in newsletters in January 2015:
 Managing awaiting results access plans (Elective Medicine)
 Sepsis, Nutrition, Depravation of Liberty Safeguards, Patient Observation Track and Trigger System,
Safeguarding, Communication, Record keeping, Patient transfers, Cannula care (Acute and
Emergency Medicine)
 Clinical documentation, Do Not Attempt Resuscitation, Failure to rescue, Infection control (Surgery
and Critical Care)
 Anti-D immunoglobulin, Children’s Patient Observation Track and Trigger System, Cannula care,
Senior clinical reviews, Weighing babies, Blood transfusion, Resuscitation trollies, New-born
bloodspot sampling (Women’s and Children’s Services)
Table 16 below shows the number of incidents reported to the National Reporting and Learning System
(NRLS) each month for the year. The NRLS then use the numbers reported and calculate a standardised ratio
of incidents reported per 1000 days patients are in hospital beds. This is then published nationally with
comparisons to other hospitals in the NHS (see Table 10).
Table 16 – Patient Safety Incidents by year
2014
04
2014
05
2014
06
2014
07
2014
08
2014
09
2014
10
2014
11
2014
12
2015
01
2015
02
2015
03
1 No Injuries
443
430
502
509
487
489
520
459
455
365
332
325
2 Minor
251
252
249
284
218
246
245
226
190
189
173
153
3 Moderate
28
22
24
20
24
23
21
23
21
22
11
10
35
4 Major
1
5
Catastrophic
2
3
2
1
4
1
1
2
1
1
3
4
2
2
1
6 Near Miss
48
59
55
63
48
59
82
63
66
66
41
43
Grand Total
771
766
834
880
779
822
871
775
735
644
557
531
Data source: Trust Incident Management System. This data is governed by standard national definitions
Table 17 shows the rate per 100 admissions based on the total number of inpatient admissions (denominator)
and total number of incidents (numerator) and percentage of incidents resulting in severe harm based on total
number of incidents (denominator) and total number graded as NPSA Severity rating 4 & 5 (numerator).
Table 17
Rate per 100 admissions
Percentage of incidents
Incidents
Resulting in severe harm or death
Period
Oct 2014 to Mar
2015
Trust
England
Highest
Lowest
Trust
England
Highest
Lowest
1.33
N/A
N/A
N/A
0.29
N/A
N/A
N/A
Notes :
Total Number of Inpatient admissions of: 309,759
Total Number of Incidents (In patient and Out Patient) of: 4113
Total Number of Severe Harm / Death Incidents (NPSA Severity rating 4 & 5) of: 12
Data source: Trust Incident Management System. This data is governed by standard national definitions. SUS data.
Never Events
In 2014/15 to 31/03/2015 the Trust had no never events in comparison to four never events in 2013/14. Never
Events are incidents that the NHS considers unacceptable and eminently preventable. In 2013/14 each
incident was fully investigated and the investigation scrutinised by senior staff. An action plan was produced
and completed; as a result these incidents should not be repeated. Table 18 below details the number of
Never Event incidents compared to 2013/14.
Table 18 – Never Events
Year
2013/14
Incident
4
2014/15
0
Data source: NPSA and Trust Incident Management System. This data is governed by standard national definitions
In January 2014 the Trust introduced ‘weekly meetings’ led by the Executive Chief Nurse and the Medical
Director. These meetings are designed to ensure all incidents / complaints resulting in moderate harm are
investigated promptly and identify any trends or themes arising from these investigations. They are cross
divisional meetings attended by Clinical Directors, senior nurses, midwives and governance leads from across
the Trust. These meetings have continued in the year and have improved clinical engagement in incident
investigation.
Serious Incidents Requiring Investigation (SIRI) continue to be investigated and scrutinised at the SIRI Panel
with the assistance of commissioners.
The Trust continues to share information on patient safety incidents with commissioners and partner
organisations where patient treatment or concerns cross the healthcare boundary. We receive details of
incidents that our partner organisations have identified that relate to our care and we investigate them
appropriately.
External Incidents Reported
Our staff also report incidents that relate to events occurring outside our Trust. These are summarised and
discussed with colleagues outside the Trust. Table 19 below shows the number of external incidents that have
been reported in 2014/15.
Table 19 – External Incidents Reported
Incident Group
2011/12
36
2012/13
2013/14
2014/15
Tissue Viability
781
944
1121
1378
Safeguarding - (Children)
38
134
956
1362
Other Incidents
428
12
81
385
Safeguarding - (Adults)
15
65
169
289
Data source: Trust Incident Management System. This data is not governed by standard national definitions
National Inpatient Survey
All Acute NHS Trusts are required to undertake the National Inpatient Survey each year along with one
additional survey of either maternity, A&E or outpatient services as part of a 3 year rolling survey programme.
In 2014, a total of 850 adult inpatients from UHMB received a postal questionnaire in the autumn. 819 patients
were eligible for the survey, of which 389 patients returned completed questionnaires giving a response rate
for the Trust of 47%. The average response rate for the 78 “Picker” Trusts was 45%.
The following information identifies areas of good practice from the Picker report:
 The survey highlighted many positive aspects of patient experience:

85% of patients rated the care they had received as 7+ out of 10

84% of patients said they were treated with respect and dignity

79% of patients said they always had confidence and trust in the Doctors treating them

98% of patients said the room or ward was very or fairly clean

97% of patients said that toilets and bathrooms were very or fairly clean

90% of patients said there was always enough privacy when they were being examined or treated
Table 1:
Have we improved since 2013?
A total of 60 questions were used in both the 2013 and 2014
surveys.
Compared to the 2013 survey, the latest survey illustrated
that we were;
 Significantly BETTER on 2 questions
 Significantly WORSE on 1 question
 The scores show no significant difference on 57
questions
Significantly Better and Worse Questions
Question
Planned admission: specialist not given all the
necessary information
Care: not always enough emotional support
from hospital staff
Surgery: Results not explained in a clear way
2013
5%
2014
1%
46%
35%
24%
36%
Table 1a:
The National Perspective for the “Better” & “Worse” Questions
Question
Scores
2014
MBHT
MBHT
2014
Score
Comparison
Lowest
Trust Score
Achieved
Highest
Trust Score
Achieved
No of MBHTFT
Respondents
Planned admission: specialist not given all
the necessary information
Care: not always enough emotional support
from hospital staff
Surgery: Results not explained in a clear
way
9.2
8.7
8.0
9.7
140
8.0
7.1
5.7
9.0
236
7.9
8.3
6.7
9.0
220
37
Table 2:
The survey showed that MBHT is;
 Significantly BETTER than average on 10 questions
 Significantly WORSE than average on 3 questions
 The scores were within the national average range on 49
questions
Significantly Better and Worse Questions
Question
MBHT 2014
AVERAGE 2014
Lower scores are better
Admission: had to wait long time to get to bed on ward
Hospital: shared sleeping area with opposite sex
Hospital: patients in more than one ward, sharing sleeping area
with opposite sex
Hospital: patients using bath or shower area who shared it with
opposite sex
Hospital: toilets not very or not at all clean
Hospital: hand-wash gels not available or empty
Nurses: did not always get clear answers to questions
Care: staff contradict each other
Care: not always enough emotional support from hospital staff
Overall: did not always feel well looked after by staff
Discharge: not given any written/printed information about what
they should or should not do after leaving hospital
Overall: not asked to give views on quality of care
Overall: Did not receive any information explaining how to
complain
28%
5%
1%
33%
8%
5%
9%
12%
3%
3%
24%
26%
35%
18%
37%
6%
4%
31%
32%
42%
23%
31%
73%
64%
68%
57%
Table 2a:
The National Perspective for the “Better” & “Worse” Questions
Higher scores are better
Question
Scores
2014
MBHT
MBHT
2014
Score
Comparison
Lowest
Trust Score
Achieved
Highest
Trust Score
Achieved
No
of
MBHT
Respondents
Admission: had to wait long time to get to
bed on ward
Hospital: shared sleeping area with
opposite sex
Hospital: patients using bath or shower
area who shared it with opposite sex
Hospital: toilets not very or not at all clean
8.3
8.0
5.5
9.9
377
9.6
9.5
7.8
9.8
309
9.1
9.1
6.3
9.8
348
8.6
8.8
7.3
9.5
375
Hospital: hand-wash gels not available or
empty
Nurses: did not always get clear answers
to questions
Care: staff contradict each other
9.8
9.6
8.8
9.9
362
8.7
8.7
7.1
9.3
338
8.4
8.3
7.4
9.1
385
Care: not always enough emotional
support from hospital staff
Overall: did not always feel well looked
after by staff
Discharge: not given any written/printed
information about what they should or
should not do after leaving hospital
Overall: not asked to give views on
quality of care
Overall: Did not receive any information
explaining how to complain
8.0
7.1
5.7
9.0
236
9.0
Not in the
2013 survey
7.8
9.8
382
6.4
5.8
5.3
9.1
373
1.7
1.3
0.8
6.0
324
2.3
1.3
1.4
5.8
307
38
Next steps
The results of the survey need to be communicated and priorities for service improvement need to be
identified and agreed across the organisation. The key stages are as follows;





Compare results within the trust to help identify problem areas and examples of best practice
Target areas where improvements are most needed
Look at patient comments for details and suggestions
Develop action plans
Raise awareness about the patient surveys – publish results and action plans
It is necessary to focus on the poorer areas identified in the survey outcomes, which naturally need
improvement, but also to examine the areas that have significantly improved, in order to identify why and to
share best practice.
There are some key areas that need consideration and work before the next survey is conducted;

When examining the problem score areas, in terms of overall importance, the question members of the
public felt that was the most significant to them was in respect of when they were referred to see a
specialist, whether or not they were offered a choice of hospital for the first hospital appointment.
Although the results were only marginally above the average for a high problem score, this is the question
that has the most significant weighting in terms of importance through the eyes of the public.
It is an issue that is very challenging due to the geographical issues for a multi-site Trust of this size and
also, depending on the nature of the concern, a longer journey might be unavoidable when travelling to a
specialist service provider outside of the area. It would be useful to examine activity levels for particular
specialties and determine the appropriateness of satellite services (bringing initial consultations closer to
home). Where a choice of hospital cannot be offered, it is important to ensure that the patient
understands why this cannot be an option. Communication around this issue needs to be reaffirmed
regularly during the course of the treatment journey.

There are two other lower level scores that weren’t as significant in terms of importance through the eyes
of the patients, but nevertheless, the Trust still performed below the average of the 78Trusts that used
Picker to conduct this national survey. The first issue relates to the information the specialist has been
given from the referring person. There is still room for improvement in this area. Is the amount of
information provided fit for purpose? Are we asking unnecessary questions when we already have the
information? Do we simply need to reassure our patients that, although we have received information, it is
important to check that it is still up to date and reflects their current circumstances?

The second issue is about how clean the toilets and bathrooms are in hospital. The significance of this
can really alter the perception of a patient about other hygiene and general treatments standards in
hospital. Patients often relate cleanliness with quality. A review of how we monitor our bathrooms and
analysis of results could be useful.
There were some other areas that, although they scored just above average, they need to be monitored so
that they do not become issues if they are poorly managed.

The first is about the level of information about a condition or treatment the patient gets in the A&E
Department. We must ensure that communication is clear and suitable at this point of care.

The second is about noise at night from other patients. This one is difficult to improve, but certainly noise
at night generally could be a theme that is routinely discussed at ward management meetings. Staff could
to be reminded about consideration for patients whilst carrying out their duties, particularly during the
night.
Communication crops up across the survey. It is apparent that some patients either do not feel they get
enough information or, perhaps, as a result of being in hospital (which can be frightening), their ability to retain
information can be influenced. Patients need to feel confident about what is happening to them, what is going
to be done, how, when and what happens after treatment at hospital has ended. All touch points need to be
reviewed across the Divisions in order to feel confident that the information being provided is fit for purpose.
39
Finally an area that received a poor score was in relation to patients not being told how they can raise an issue
or make a complaint (the score was slightly higher than the previous year for MBHT, but still has room for
improvement when comparing it against the national results). The Patient Relations Department has gone
through significant change over the past 12 months and a great deal of work has been conducted internally so
that staff know what services are available and how to signpost patients towards them. It is envisaged that the
next survey score in this area should show a marked improvement.
Monitor Governance Framework
The Monitor Quality Governance Framework has demonstrated that the Trust started to embed and cascade
across all the Divisions its new Governance systems and procedures and being able to evidence a change in
the culture of the organisation at all levels. Following the publication of the CQC Wave 2 Inspection report in
June 2014 an action plan has been developed and submitted to the Quality Committee, Finance Committee,
Workforce Committee and the Audit Committee to provide assurance on actions implemented and
improvements made.
The Trust receives the Care Quality Commission (CQC) Intelligent Monitoring reort on a regular basis. The
Intelligent Monitoring is a tool which assesses risk within care services. It has been developed to support
CQC’s regulatory function and purpose of ensuring that health and social care services provide people with
safe, effective, compassionate, and high quality care. The tool highlights those areas of care to be followed up
through inspections and other engagements.
The Intelligent Monitoring Report identifies the Trust as having a Monitor Governance Risk Rating risk rating of
red. This is due to the Trust being subject to enforcement action and in special measures from the Care
Quality Commission. Further information can be found in ‘Our Finance’ section of the annual report.
3.4
Detailed Description of Performance on Quality in 2014/15 against
Priorities in 2013/14 Quality Accounts
This section provides a detailed description regarding the quality initiatives (see Table 1) that have been
progressed by the Trust based on performance in 2014/15 against the 2013/14 indicators for the following
priorities:



Priority 1: Patient Safety;
Priority 2: Clinical Effectiveness and
Priority 3: Patient Experience.
3.4.1 Priority 1: Patient Safety
We know that our services must not only be of high quality and effective but that they must always be
safe. We have a range of processes and procedures to ensure that safety remains a top priority.
Reduce cardiac arrests by 10% against the 2013-14 baseline
March 2015 (calendar year) there is an overall reduction in total numbers of unavoidable cardiac arrests by
28% compared with the same period in 2014.
Recognition of Deteriorating Patient Working Group was set up and which agreed the definition of avoidable
cardiac arrests. Retrospective audits of cardio respiratory arrest together with rapid reviews of failure to
rescues were undertaken in Q1. A proposed target of 10% reduction in avoidable adult cardio-respiratory
arrests was agreed in conjunction with Commissioners.
Medical Engineering experienced issues with approval for procurement of manual sphygmomanometers,
stethoscopes and pulse oximeters. A proposal is being developed and was presented to the Trust Executive
Chief Nurse. There is phased training which has commenced at RLI and FGH through a combination of the
Trust Training Management System (TMS) e-learning module and face-to-face sphygmomanometer
workshops, facilitated by Practice Educators/Clinical Skills. All staff are required to undertake a
sphygmomanometer assessment. There is a nominated Project Lead working with a Work stream Lead to
devise a proposal for CCGs for identification of evidence to be provided in Q3.
40
Review 50 deaths in the year through a multi-disciplinary team
All deaths in hospital are considered for review, which is undertaken by a multi-disciplinary team based at both
at RLI and FGH under the leadership of the Associate Medical Directors. The results and findings from these
reviews is reported via the Mortality Review Group to the Quality Committee according to the Quality
Committee Schedule of Business.
The reviews categorise the care under NCEPOD and Hogan scores and if significant failings are identified the
death is reported as a significant incident and is investigated appropriately. Incidental failures in care are
referred to speciality mortality and morbidity meeting for discussion.
The framework for reviewing mortality has undergone a complete review during 2014/15. The Trust
commissioned a report by external audit to review arrangements and recommend changes to improve. A
report was provided in July 2014 which made a number of recommendations. The Deputy Medical Director
has developed a revised framework and this is currently being implemented.
At present well over 50% of all deaths, which equates to well above the 50 per year target, are audited at RLI
and FGH and UHMB’s aim is to get to 100% by the autumn of 2015. The audits are led by a Consultant
Anaesthetist and Associate Specialist Anaesthetist with input from colleagues. All cases where care or
documentation may be considered to be suboptimal are notified directly to the lead Consultant who receives a
copy of the review. The cases are then discussed at the Divisional mortality meetings.
Harm Free Care – Pressure Ulcers

Reduce avoidable hospital acquired pressure ulcers grade 2 or above by 15% per 1000 occupied
beds from the 2013-14 baseline
The Trust position as reported by the National Safety Thermometer reports show that the Trust average is
significantly below the national average, see Graph 4 below. The March 2015 percentage is now 8% below
the national average for the year.
The Trust has demonstrated consistent improvement in practice with zero hospital acquired grade 3 or 4
pressure ulcers in 11 out of 12 months.
Graph 4: Grade 3 and 4 Pressure Ulcers
Y axis =
percentage
X axis= Month
Data Source: National Patient Safety Thermometer
Actions continue to ensure sustained delivery of this indicator, these include:








Continued nursing leadership
Increased awareness of monitoring patients during Intentional Comfort Rounds;
Zero Tolerance of avoidable pressure ulcers;
Early assessment and the use of heel protectors and/or other prevention measures must be implemented
at an early stage;
Early referral to acute pain nurse;
Implement the Abbey Pain score on all ward areas for dementia/confused patients;
All patients who fall at home recognised as being at a high risk of pressure damage. The use of pressure
relieving mattresses implemented on or as soon as possible after admission;
The ward Link Nurse should be the first responder at ward level to assess and refer on to the tissue
viability nurse;
41



Regular audit of the Skin and Safety Bundle to identify non-compliance and provide assurance that early
interventions are implemented for higher risk patients on admission re-assessment or change in the
patient’s condition;
Development of specific RCA advice and prompts to enable investigating staff to continue to improve the
analysis of pressure ulcers to aid specific lines of enquiry resulting in more effective learning from review
of pressure ulcer incidents.
Ensure that nutrition and hydration issues are recognised at an early stage and acted upon.
Harm Free Care – Falls

Reduce avoidable in-hospital patient falls resulting in harm by 10% from the 2013-14 baseline
The target for 2014/15 was to reduce avoidable in-hospital patient falls resulting in harm by 10% from a
2013/14 baseline. This target was met for the year 2014/15. Graph 5 below shows the target expressed as a
rate per 1000 bed days and the monthly outcomes.
Graph 5 – Falls resulting in unavoidable harm
Y axis =
percentage
X axis= Month
Data source: Hospital Incident Reporting System. This data is not governed by standard national definitions.
During the year a number of initiatives were undertaken, including:
 TABS sensor pads were introduced to each inpatient area, more have been ordered by individual wards
 Falls leaflets were introduced during Q2
 A post falls checklist has been introduced during Q2
 Crash mats were introduced in Q3
 Links to Community teams were established in North Lancashire and Cumbria who accept direct referrals
 High supervision bay in place on ward 7 at FGH
 There is an updated falls assessment and care plan within the new version of the safety bundle.
Following a reduction from 2012/13 total falls causing moderate or more harm during 2014/15 has remained
stable. See table 24 below:
Table 24
Total Patient Slips, Trips and Falls (STF)
Measure
Slips, trips and falls resulting in no harm
Slips, trips and falls resulting in minor harm
Slips, trips and falls resulting in moderate or greater harm
Total number of falls reported incidents
2012/13
Trust Performance
2013/14
2014/15
1510
469
57
2042
1415
525
31
1976
1227
520
33
1795
Data source: hospital Incident reporting system. This data is not governed by standard national definitions.
There have been small variations in the numbers reported each month, see graph 6 below:
Graph 6: Total patient slips, trips and falls
42
Y axis= Number
Total Patient Slips, Trips and Falls
250
200
150
100
50
0
2012 4
2012 5
2012 6
2012 7
2012 8
2012 9
2012 10
2012 11
2012 12
2013 1
2013 2
2013 3
2013 4
2013 5
2013 6
2013 7
2013 8
2013 9
2013 10
2013 11
2013 12
2014 1
2014 2
2014 3
2014 4
2014 5
2014 6
2014 7
2014 8
2014 9
2014 10
2014 11
2014 12
2015 1
2015 2
2015 3
X axis= Month & Year
Data source: Hospital Incident Reporting System. This data is not governed by standard national definitions.
Table 25 shows the reduction in the categorisation of falls which has contributed to the preventative measures
undertaken by wards and departments across the Trust.
Table 25
Patient Slips, Trips and Falls (STF)
Measure
Trust Performance
Slips, trips and falls where the patient is found having fallen
Slips, trips and falls when the patient has fallen whilst mobilising
Slips, trips and falls where the patient has fallen from the bed
2012/13
2013/14
2014/15
1047
361
189
965
338
209
913
278
173
Data source: hospital Incident reporting system. This data is not governed by standard national definitions.
Falls whilst mobilising first fell in 2012/13 and this reduction has been maintained throughout 2014/15 as
shown in table 25.
Similarly falls from beds first fell in 2012/13 and the reduction has been maintained in 2014/15 as shown in
table 26. This is in line with the actions that have been taken with the replacement of old bed stock with
electronic beds that can be lowered when a patient is assessed as at risk, the increased provision of training
for staff and the implementation of sensor cushions at the bedside. The Trust has also worked hard to help
staff understand how and when it is appropriate to use bed-rails, it is therefore particularly pleasing that falls
from beds fitted with bed-rails has reduced by 63% since 2011/12, see table 26.
Table 26
Patient Slips, Trips and Falls (STF)
Measure
2012/13
Slips, trips and falls where the patient has fallen from a
bed fitted with bedrails
64
Trust Performance
2013/14
48
2014/15
36
Data source: hospital Incident reporting System. This data is not governed by standard national definitions.
Reduce hospital acquired Clostridium Difficile Infections in line with the national contract calculation
(46)
The annual trajectory for 2014/15 was set at 46 cases for UHMB. This is a reduction of 4 cases from our
2013/14 actual cases. During the year there were 42 cases of hospital attributed Clostridium difficile identified.
Our aim is that no patient is harmed by a preventable infection and this is a maximum number of cases, not a
target. During the year 29 of the 42 cases of CDI have been attributed to the Trust due to lapses in care.
Graph 7: C Difficile by year
43
Y axis= Cases
X axis= Year
Data source: hospital Incident reporting system. This data is not governed by standard national definitions.
The Trust reviewed all post 72 hours CDI case and carried out Post Infection Reviews (PIR). These were led
by the Ward Manager responsible for the patient’s care and were supported by clinical staff involved in the
patient’s journey. The Matron and Lead Nurse attended monthly HCAI meetings to review all CDI cases with
the co-ordinating commissioners for North Lancashire and south Cumbria and Lancashire County Council
(LCC) Public Health Infection Prevention Team. This provided an additional opportunity to further discuss each
case and conclude whether the cases were linked with lapses in care and therefore apportioned to UHMB.
42 CDI cases were reviewed over the year resulting in 29 attributed to UHMB. To comply with national
reporting requirements the total number of CDI cases assigned to UHMB remains as a raw actual number on
the National Public Health England Data Capture System (DCS), i.e. the number of cases identified post 72
hours after a patient has been admitted. The reduced ‘apportioned’ number is the number used for contractual
purposes against the UHMB annual target of 46 (see graph above).
A lapse in care would be indicated by evidence that policies and procedures consistent with national guidance
and standards were not followed by the relevant provider. This would include evidence of:




Transmission of CDI in hospital confirmed by ribotyping
Poor compliance in cleaning standards
Poor compliance with infection prevention precautions such as hand hygiene
Concerns identified with choice, duration, or documentation of antibiotic prescribing
It must be noted that true causes of infection can rarely be identified. However, themes across UHMB mirror
those nationally. These include issues in relation to hand hygiene compliance and the prescribing of
antimicrobials and proton pump inhibitors (PPI).
Actions taken to support improvements in CDI

In January 2014 the Matron for Infection Prevention requested an external review into UHMB’s approach
to CDI. This was undertaken by the Deputy Director of Nursing and infection prevention and control staff
from North Tees and Hartlepool NHS Foundation Trust. The review resulted in recommendations to help
support improved care and subsequent reductions in CDI cases. The UHMB Project Management Office
(PMO) developed an action plan to monitor compliance with the improvements suggested in this external
review. This action plan has been completed in full with on-going actions included in the 2015/16 Infection
Prevention Control (IPC) Annual Plan.

The IPC teams across Cumbria together with Public Health England colleagues have coordinated a
process to establish a Cumbria PIR analysis CDI data base. This will provide an epidemiological picture
across the county supporting the whole health economy work.

Monthly meetings were held between the IPC Matron, IPC lead nurse and the co-commissioners, with
Lancashire County Council to review all health care associated infections (HCAI).
44

Quarterly strategic infection prevention meetings were held between the IPC Matron, microbiologists,
PHE, NHSE and Lancashire County Council to review IPC strategies across the health economy of
Lancashire and Cumbria.

Infection Prevention Operational Group (IPOG) meet monthly to review, monitor and action operational
infection prevention issues. This group reported to the Infection Prevention and Control Committee
(IPCC).

The IPCC, a sub-committee of the board of directors and chaired by a non-executive director, met
quarterly to present assurance on UHMB’s Infection Prevention co-commissioning contract.

Antimicrobial Sub-Committee meet quarterly to review, monitor and action any issues related to
antimicrobial management.

Multidisciplinary walk rounds including, CQC Mock Inspections (led by the Executive Team and
operational staff and supported by patient representatives, Health watch and CCG’s) and RAISE
inspections (led by Strategic Nursing team and supported by operational staff including students) are
undertaken on a regular basis across the Trust and reported through the Governance structure.

IP Matron recently presented an update for the governors at the January 2015 Strategic Sub Group.

The IPC team began to work with Information Technology (IT) to develop a robust alert system for patients
affected with HCAI’s to ensure that through the patients journey across UHMB staff are aware of the
patients potentially infectious status.

Staff IPC mandatory training, aseptic technique and hand hygiene training continued to be centrally
collated on a live database in the Training Management System (TMS).
3.4.2 Priority 2: Clinical Effectiveness
There are many schemes and initiatives that we can participate in that help us deliver high quality
care. By meeting the exact and detailed standards of these schemes and initiatives we must achieve a
particular level of excellence, this then directly impacts on the quality of care and provides evidence
for the Trust that we are doing all we can to provide clinical effectiveness of care.
Develop a plan for 7-day working across key areas of service provision
A draft high level plan for 7 day working across key areas of service provision has been developed. A further
review of the draft high level plan will be needed to ensure that it accurately reflects the organisational
approach and timeliness, particularly in relation to recruitment and implementation. The high level plan will
detail complementary initiatives and projects currently being delivered at UHMB which when completed, with
addition of high level milestones, will identify how the organisation will meet the 10 clinical standards
Following a presentation to Trust Management Board, clinical divisions reviewed existing service provision
against the 10 clinical standards and highlighted gaps in resources and specifically the resource needed to
meet the standards.
Assurance was provided by a series of Check and Challenge workshops which divisions were invited to
attend. The work undertaken by the HFMA on the Cost of Seven Day Services was referenced, and divisions
further reviewed and updated their figures.
Costs for urgent and emergency care and supporting diagnostics have been based on the existing two acute
site configuration at FGH and RLI.
Divisions have not made allowance for any future growth in demand. The costs also exclude interventional
radiology which would be subject to a network solution.
45
Despite continued investment in other areas, there are insufficient resources available to meet the prescribed
clinical standards Monday to Friday i.e. full medicines reconciliation. Providing a compliant service across the
entire week will incur additional expenditure.
The detailed costs of implementing the Keogh standards are approximately £8.7m, they represent 3.6% of
patient income (240m) and should be viewed against the costs which exclude emergency department costs
and any prior investment in front end services.
Next steps
To work up and identify a shortlist of alternative options to meet the clinical standards for the Trust Executive
to consider.
In line with the above, to identify and propose options for financing of the suggested options.
To develop a communications strategy and plan.
Develop project workbook and documentation in accordance with Programme Management Office
requirements.
Further develop and deliver the multi-professional ward/board rounds in 50% of all wards in-year
moving to 100% in year 2
This target has been achieved. There have been a total of 90 ward to board rounds, where an Executive was
st
st
in attendance, for the period 1 April 2014 – 31 March 2015, WGH:20 RLI:35 FGH:35.
Comprehensive assessment of all patients over 75 years old to be undertaken within 24-hours of
admission. Streamlined pathways of care to be delivered based on the outcome of the assessment.
2,655 Comprehensive Geriatric Assessments have been recorded as having been completed by the Care of
the Elderly Teams for non-elective patients aged >75 since November 2014.
Screening Tool and Comprehensive Geriatric Assessments (CGAs) is undertaken. Length of Stay reduction is
performing better than trajectory target to January 2015. The Screening Tool has been in place since August
2015. An amended version of the CGA was completed at the end of September 2015 following a testing phase
at FGH and RLI and the final version is now in use. Issues have been encountered with staff sign-up to the
new process; and a project team have been meeting regularly with clinicians where concerns have been
expressed in order to work through problems. A formal user group has been established to introduce further
improvements in the process as required. A case note audit framework has been agreed to assess the
CQUIN target for care plans implementation. Both CCGs have been updated on progress. The completion of
the assessments is reliant on the newly introduced care of the elderly teams and a business case has been
developed to continue these teams which include six full time staff made up of nurses and AHPs.
Develop a dashboard that front line staff can access that provides them with the information they need
to understand how reliable the care they provide is. This will include the cost of harm both in terms of
clinical outcome and financial consequence.
This target has been achieved. An Executive Level Dashboard has been produced to give the Board the
required oversight of key performance targets including Mortality, Harm and Staffing. Further dashboards
were produced and rolled out in September 2014 to provide oversight to the Quality Committee, Trust
Management Board and Workforce Assurance Committee regarding the achievement of key performance
indicators relating to Harm, Mortality, Staffing Levels and Performance Targets.
The Divisional Dashboards have been developed and were ready for use on 24/12/2014, these have been
well received. Training is ongoing for the divisions regarding use of the dashboards. Ongoing work will
continue with the divisions to incorporate specialist key performance indicators and associated data.
Deliver values based induction
This target has been achieved. In early 2014 the Trust completely reviewed and updated its approach to
induction. From April 2014 the Trust introduced a new values based Corporate Induction Programme. This 1
day programme is led by one of the Executive Directors and includes an extensive and interactive session on
the updated Trust Vision and underpinning Values. Making UHMB a “Great Place to be Cared for; A Great
Place to Work” is the thread that runs through the whole induction programme. In addition, the start date for all
46
new starters has been aligned with the Corporate Induction Programme days, which run twice a month (once
at RLI and once at FGH), which means that the vast majority of new starters attend Corporate Induction on
their first day of commencement. Feedback from new starters on our new values based approach to induction
is overwhelmingly positive with approximately 90% of new starters rating the programme either “Very Good” or
“Excellent”.
Furthermore, our Local Workplace Induction has been reviewed and updated. There is now in place an
electronic checklist of essential induction topics and items that all new starters systematically work through,
with their ward or department manager, with a view to ensuring they are able to quickly and effectively settle
into their new job.
Improving continuity of care at discharge through timely and robust discharge information by
improving the availability of quality discharge summaries to 90% within 24-hours and 95% within 48hours
This target has not been achieved for the year end March 2015.

Immediate Discharge Summaries (IDS): Sent within 24 hours 84.40% against a target of 90%. This is an
increase of 3.1% on the February figure.

Immediate Discharge Summaries (IDS): Sent within 48 hours 91.47% against a target of 95%. This is a
decrease of 1.8% on the February figure.
Actions are being taken across the Divisions to further improve performance to meet this standard.
3.4.3 Priority 3: Patient Experience
Reduce formal complaints by 10% from the 2014/15 baseline
A Key Performance Indicator was set by the Trust of a 10% reduction in complaints for 2014/2015 based on
the total complaints received for 2013/2014 of 481.
The target of 433 was not achieved as the Trust received a total of 560 formal complaints, missing the target
by 127. While there was an increase in complaints received there was also a significant rise in activity with the
Trust treating 12,824 more patients than the previous year. This equates to a 1.9% increase in activity but
only a 0.9% increase in complaints based on the extra 127 complaints received against the 12,824 patients
treated.
Graph 8: Complaints Performance Data
Comparative Data
1600
1488
Number of Enquiries
1400
1265
1200
1000
800
600
742
2012/2013
481
2013/2014
400
177
200
2
0
Complaint
Compliment
PALS
Enquiry Type
Data source: Hospital Complaints Reporting System.
47

March 2015 – 560 Complaints Received against a trajectory of 433
The number of complaints to date has increased above the trajectory target for 2014/15. Significant work has
been undertaken to promote the numerous pathways available for complaints and comments to patients and
visitors, providing a more visible presence of the service, which could account for the growth.
This promotion includes creating the dedicated web page for Patient Relations and PALS on the Trust’s
internet site; the amendment of the complaint leaflet with the creation of the Concerns or complaints leaflet on
what to do to raise a comment or complaint; and promotion within the Trust’s weekly newsletter, Weekly News
and Divisional Complaints Workshops and presentations
The Patient Relations department is working towards forging improved relationships with divisional staff and
by providing complaints workshops in 2015/16 and beyond, the aim is to promote local resolution to resolve a
concern or complaint at source. This, it is predicted, will result in the number of concerns/complaints being
resolved at a local level.
Through the attendance at the Complaints, Litigation, Incidents and PALS (CLIP) monthly group, it is
anticipated that the sharing of information from these departments with Divisional Governance Leads will have
a positive impact on identifying trends of concerns and complaints throughout the Trust and ultimately result in
robust lessons learned when taken forward by the divisions.

Complaint Themes, Lessons Learned and Actions Taken
Below are examples of complaint themes and action taken as a result of the complaint. See table 27 below.
Table 27
Theme
Diagnosis
Problems
Actions/ Lessons Learned





Administrative
Procedures





Communications to GP practices’ regarding diagnostic facilities when sites are
closed
All discrepancies are discussed at the Radiology Discrepancy Meeting which are held
by the Trust’s Consultant Radiologists. These meetings are in accordance with
national guidance for Radiological Practice and assist in reducing the risk of errors in
reporting.
Radiology Department now attempts to copy reports to GP’s in all cases where there
is a significant find or need of a follow-up.
Optimising priority given to urgent CT cases
A process of regular audits on a monthly schedule to check data items transferred
into the results holding system match those held in the pathology information system.
A service improvement has been made in both the FGH and RLI laboratories. All
non-complex results received from Lancashire Teaching Hospitals are now entered
manually onto the laboratory IT system and this should allow for improved turnaround
times and give greater access to results for users.
Anticoagulation monitoring is commissioned by the CCG and in the Lancaster locality
they have commissioned a laboratory based service, compared with Blackpool who
have commissioned and service run the hospital but in the community. We are
working with the local commissioners to try to get agreement to implement this type of
service in Lancaster.
The Trust is currently working towards the delivery of a ‘seven day service’ in all
aspects of the patients’ care, whereby patients will see no variation in the level of
care available at weekdays and during weekends.
A new process for communicating clinic cancellations has been put in place.
Working with the GP practices to encourage the of Choose and Book system.
48
Table 27
Theme
Actions/ Lessons Learned

Missing
Medical
Records




Communication
/ Info to Patents





Attitude and
the way in
which our
patients are
spoken to.






One to one training provided to all reception staff regarding the out coming of clinics
taken place
Service Modernisation project for the Patient Records Service which includes the
implementation of ‘paperlite’ working by increased use of our electronic patient record
system, Lorenzo
When case notes are missing for a clinic the medical records staff escalate this to
their team leader or their manager to investigate the matter further.
All clinical incidents relating to ‘missing medical records’ investigated and any impact
to patient care identified and urgently actioned
On-going implementation and review of the track and trace procedures across the
three hospital sites
A weekly rolling programme of education by the Diabetic team has been implemented
which will provide on the spot training to wards.
A 'self-management of insulin' policy approved and implemented
Process implemented for staff to inform patients of any delays during clinic.
Reinforced the importance of doing so with the nursing and reception staff and
reminded that they should always be proactive in keeping patients updated
Use of passport for patients and access to in house support shared with staff in
regular staff meetings
Project on-going working with patients and GPs to develop an advisory leaflet
regarding patients cancelling appointments by choice (Access Policy)
Focused staff training on ASU on attitudes and behaviours within nursing teams,
focuses on standard setting and improving the staff experience on the unit.
Individual clinician feedback with CD following instances where complaints have
raised individual attitudinal issues.
Task & Finish group in progress to address patient experience issues raised through
patient safety specifically in maxillo facial and ENT.
Commissioned leadership training for leaders within the division at Clinical Leader
level, ward manager, Clinical Lead and divisional management level to set the tone
required.
Development of clinical leader handbook in the division to focus on bright star
development and setting of standards at ward level.
Increase compliments by 100% from the 2014/15 baseline.
A Key Performance Indicator was set by the Trust of a 100% increase in compliments for 2014/2015 based on
the total compliments received for 2013/2014. The Trust target was achieved receiving a total of 347
compliments against a trajectory of 252.
Compliments currently received into the Trust via Trust headquarters, or directly into the Patient Relations
department, are now recorded centrally on the Ulysses Web system. Patient Experience is also working on
capturing compliments through iWGC. This is an amendment and improvement to the previous process that
did capture all compliments.
Work is continuing to collate and record centrally a larger proportion of the positive feedback received at ward
or department level, and through the means of social media. The Ulysses Web module will continue to
improve how we record compliments and provide a central point from which the data can be analysed.
Co- produce a training programme in partnership with Age UK to support age awareness training for
all staff.
Although it was anticipated that the Trust would work with Age UK a bespoke training programme has been
developed working with a locum who specialises in these training packages. This was supported with monies
secured as a result of an external bid.
The programme has been developed over 2014/15 as a bespoke package. Roll-out of the programme will
commence June 2015 to qualified health professionals at Bands 5 and 6 to support care of our frail elderly
patients. The areas covered include dementia, delirium, falls and end of life. The programme is delivered as
49
an E-learning module together with classroom based training with the requirement to deliver a project on
completion.
As the programme is bespoke the June 2015 roll-out phase will be assessed as a pilot to ensure the
programme delivers the required outcomes prior to anticipated roll-out to a wider audience.
Introduction and improvement through I Want Great Care
The target has been achieved.
Patient Experience is at heart of everything we do and I Want Great Care is a very open and transparent
mechanism which reports “real time” patient experiences, both good and bad. The public feel confident that
the information they read using this platform is “unfiltered” and based on real life experiences from patients,
relatives and carers who have had first-hand experience of care provided under the umbrella of Morecambe
Bay Hospitals Trust.
Internally iWGC provides staff who work within the Trust a valuable insight into how their services are being
perceived. Information is filtered into the various, wards, departments and units and monthly reports are
downloaded and sent to all. The reports give a clear indication of how each area is performing in relation to
their Friends and Family Test responses, they highlight individual 5 star score ratings and they list all
additional comments that have been recorded by patients.
The vast majority of comments are extremely positive and they are worth sharing and celebrating, as they
validate areas of good practice and can boost staff morale which, in turn, can lead to even greater efforts
being made in terms of continuously striving to achieve excellent patient experiences. Any lower level
feedback (1 or 2 stars out of a possible 5) is reported on a daily basis and directed to the relevant department
for them to consider and, where necessary, rectify.
During 2014/15 there have been two national stepped performance measures in terms of Friends and Family
(FFT) response rates for the Emergency Department and Inpatients. The Trust has performed well in both of
these areas;

National target FFT response rates for adult inpatient and adult ED discharges for 2014/2015
compared to UHMB performance
Graph 9: Friends and Family Test
Y axis = Response rate
X axis = Year
Data Source: I Want Great Care

The Average 5 Star rating is 4.82 for 2014/15 out of a review count of 37,008. The percentage likely
to recommend is 91.59% and unlikely is 3.21%
Graph 10: Start rating
50
5 Star Rating
5
4.8
4.6
4.4
Y axis=Star rating
5 Star Rating
X axis=Year
Data Source: I Want Great Care
All FFT returns are facilitated through the iWGC platform and the breakdown of responses can be seen below.
The stepped performance response rate requirement for Inpatients rose to 40% nationally in March 2015 and
MBHT attained this goal and exceeded it by getting a 43.4% rate.
Table 28
Inpatients
November 2014
December 2014
January 2015
February 2015
March 2015
I Want Great Care
(Paper
Responses)
847
607
728
705
754
Healthcare
Communications
(SMS/IVM)
121
129
106
137
243
Total
Responses
No.
968
736
834
842
997
Final
Reported
Response Rate
45%
38%
40%
37%
43.4%
Data Source: I Want Great Care
As well as monitoring feedback generally, iWGC will also be used to facilitate individual Clinician feedback.
This will come on line towards the autumn.
Work continues in relation to sharing positive comments, as well as acting on and learning from poor
experiences. As iWGC and the Friends and Family requirements become more embedded within the Trust,
the aim is to set local key performance indicators in terms of collecting representative numbers of comments
and FFT questionnaires for different Divisions and demonstrating that not only are we a Trust that listens, but
we also act on feedback we receive.
Director sponsorship of Divisions to be developed
Executive Directors have been identified to support Divisional Teams as referenced in the Table 29 below.
Table 29
Division
Executive support
Core Clinical Services
Women and Children’s Service
Acute Medicine
General Surgery
Estates
Medicine
Director of Finance
Director of Governance
Executive Chief Nurse
Deputy Medical Director
Director of Human Resources
Chief Operating Officer
To date 96 Executive Walkabouts have been undertaken at RLI and FGH for the period April 2014 – March
2015.
Directors used a template feedback form that was developed to provide feedback from Patient Safety
Walkabouts. Structured feedback was collated and submitted for consideration at Executive Directors Group
15/04/2014 and 02/09/2014.
Commitment by all managers to spend time on the front line, working alongside staff
51
Patient safety remains a priority for all staff within the Trust and is led by the Board of Directors demonstrating
their continued commitment to improving patient safety. Throughout 2014/15 the Executive Directors have
carried out structured patient safety walkabouts together with adhoc patient safety walkabouts to all wards and
departments across the Trust. The outcome of these walkabouts has been captured in individual action plans
and where areas have been identified as requiring improvement progress against these actions is monitored
on a monthly basis.
The benefit of Patient Safety Walkabouts is recognised by staff and patients and includes:





An opportunity to truly engage staff and patients allowing members of the Patient Safety team time to
listen to any concerns the staff and patients may have
The inclusion of Non-Executive Directors and Governors of the Trust on the Patient Safety
Walkabout enables a wider assessment of the safety issues within the wards and departments
During Patient Safety Walkabouts the patient’s views are sought to ensure any areas where they feel
their experience could have been enhanced is shared with staff
The Patient Safety Walkabouts recognise good practice as well as areas where improvements may
be considered and provides robust feedback to the Ward/Departmental Manager for dissemination to
staff in the area and for further action
The Patient Safety Walkabout provides an opportunity for staff to discuss any concerns or
complaints raised by patients with the Executive Team
The following walkabouts are undertaken regularly at the Trust and are summarised as follows:
 Quality Peer Review Visits (RAISE)
RAISE visits endeavour to assess the ward from three different aspects; the environment, clinical care and
patient experience. The team have a checklist and specific questions that are asked in order to appropriately
score each one of the three areas and feedback to the ward.
 15 Steps Challenge
15 Steps Challenge is a toolkit with a series of questions and prompts to guide staff through first impressions
of a ward to enable them to view it from a patient’s perspective and identify potential improvements to
enhance the patient experience.
 Formal/Informal Walkabouts
Formal walkabouts are conducted by a small team consisting of an executive director, non-executive director,
governor and stakeholders. The visit allows a broad assessment of the safety issues within the wards and
departments and enables the recognition of areas of good practice which can be shared across the
organisation. Following the visit feedback is provided to the ward manager and a report and action plan is
agreed and published on SharePoint. This is monitored on a monthly basis.
 CQC Mock Inspections
The mock inspections are designed to emulate an actual CQC inspection. These will assess the progress
made so far and identify areas which still need to be improved.
Health and Safety Walkabouts
These follow a similar format to the Formal Walkabouts but are undertaken by the Health and Safety team,
assessing areas specific to their department.
A programme of Patient Safety Walkabouts was developed with visits undertaken throughout 2014/15 as
detailed in the Table 30 below:Table 30 Patient Safety Walkabouts
Apr
Royal Lancaster Infirmary
Formal Walkabouts
Informal Walkabouts
RAISE Reviews
15 Steps Challenge
Health & Safety Reviews
CQC Mock Inspections
Furness General Hospital
Formal Walkabouts
Informal Walkabouts
RAISE Reviews
15 Steps Challenge
14
1
5
May
14
2
1
Jun
14
1
1
Jul
14
2
Aug
14
1
Sep
14
1
Oct
14
1
Nov
14
Dec
14
1
Jan
15
Feb
15
Mar
15
1
Feb
15
1
1
Mar
15
18
4
4
3
0
Apr
14
0
0
May
14
2
2
0
0
Jun
14
2
5
2
Jul
14
Aug
14
2
2
Sep
14
2
15
Oct
14
6
3
52
1
Nov
14
2
2
Dec
14
1
1
Jan
15
Health & Safety Reviews
CQC Mock Inspections
Westmorland General Hospital
Formal Walkabouts
15 Steps Challenge
Health & Safety Reviews
1
Apr
14
2
May
14
1
Jun
14
1
1
1
1
Jul
14
2
1
1
Aug
14
1
Sep
14
Oct
14
3
Nov
14
7
1
1
Dec
14
Jan
15
4
1
Feb
15
Mar
15
1
Improvement in 2014 staff survey outcomes
The results of the 2014 annual NHS staff Survey were published in February 2015 – for the second year
running there were no statistically significant deteriorations in the scores however 2 areas have increased
significantly, with 18 areas showing improvement. There are very positive movements in areas such as
visibility of leadership, care being the organisation’s top priority, Communications and engagement.
A specific focus group has been established to review the findings and agree the actions for the remainder of
the year. Inclusive of this group are 2 DGM’s, 1 ACN, Lead AHP, staff side representatives, Respect at Work
Lead, Head of Communications and a HRBP. The agreed actions for the forthcoming months in 2015/16 are:






Developing middle & junior managers to be supportive and effective leaders
Improving incident reporting :dealing with incidents & day to day issues
Appraisals; ensuring training & development is a key focus area; is appropriate & supported
Improving health & wellbeing
Equality, diversity and inclusiveness
Embedding values & behaviours
Further information can be found in ‘Our Staff’ section of the annual report.
Organ Donation
 Develop a Communication Strategy
Every year, hundreds of lives are saved with the help of donated organs such as hearts and kidneys, but
patients and the public may not appreciate that donated tissue such as skin, bone and heart valves can also
save and dramatically improve the quality of life for many.
 Family approach rate of 100% to suitable potential donors
Staff have worked during the year to raise awareness of tissue donation within the Emergency Departments
and has worked closely with specialist nurses, the Organ Donation Committee, and the National Referral
Centre, who have supported the work to raise the subject of tissue donation with families at particularly
sensitive times. Monitoring through the Potential Donor Audit (PDA) to ensure that we have 100% referral of
all potential solid organ donors.
 Consent
Staff have worked to ensure that all patients who are artificially ventilated are discussed with the transplant coordinator before any decision is made to discontinue treatment, in order that potential organs donors are not
missed. Following discussion with the SnoD - All families are approached for discussion of organ donation in
a timely and appropriate way.
 Develop a Training Strategy
Senior staff have also carried out training and support for staff around tissue donation, this is on-going. The
option for bereaved families to consider tissue donation is embraced as part of end of life care within the
Emergency Department, to optimise choice and tissues for transplant. This work has resulted in the Trust
having amongst the highest tissue donation referral rates in the country.
Work will continue to include:
 Continually monitor through the Potential Donor Audit to ensure that we have 100% referral of all
potential solid organ donors.
 Ensuring that all families are approached for organ donation in in a timely and appropriate way.
 Continuing the established a regular teaching program in the Intensive Therapy Unit and Emergency
Departments
 We also want to be pro-active and increase awareness within our local communities in and around
Lancaster and Barrow. To achieve this we have an advertising campaign which we are soon to
launch to promote Organ Donation. This is to reach the wider community, with information on how to
join the organ donor register.
53
 Organ Donation Committee
The Trust has a Specialist Nurse for Organ Donation (SnoD) and together with Dr Mark Wilkinson oversee the
Organ Donation Committee. This Committee reflects the requirements of the government guidelines in
response to a national drive to raise awareness of organ donation and increase solid organ donation.
The committee continues to function and is very well attended. At meetings the Committee is able to identify
any issues and formulate plans to address these issues and also to build on the success and achievements
made. In taking issues and achievements forward the Committee ensures the highest quality of care and
standards are maintained with regard to organ donation.
The main aim is to ensure that every family is given the option of organ/tissue donation as part of all end of life
decisions.
2014 Update provided by Specialist Nurse for Organ donation
 Continual monitoring through the Potential Donor Audit (PDA) to ensure that we have 100% referral of all
potential solid organ donors.
 Following discussion with the SnoD - All families are approached for discussion of organ donation in a
timely and appropriate way.
 Establishment of a regular teaching program in the Intensive Therapy Unit (ITU) department
 The ED pathway has been officially launched. Training will be on going to accommodate and capture new
staff and maintain awareness for current staff.
 SnOD and team to be pro-active and increase awareness within the local communities of Lancaster and
Barrow supported by an advertising campaign soon to be launched. There is also ongoing work with the
Communication Department to promote Organ Donation with information posted on local buses. This will
allow the message of potential organ donation to be delivered to the wider community. The information will
also include details on how to join the Organ Donor Register.
To achieve Commissioning for Quality and Innovation (CQUIN) Schemes for 2014/15 as detailed in
Table 31
The key aim of the CQUIN framework for 2014/15 was to secure improvement in the quality of services and
better outcomes for patients, whilst maintaining strong financial management. Schemes were established at
national level to support national priorities. At a regional level the wide ranging Advancing Quality programme
continued to improve the treatment of patients in the Trust who were admitted with a stroke. These schemes
were augmented by local priorities set by the Clinical Commissioning Groups (CCGs). Detailed targets and
timescales for each CQUIN scheme were included in the contract signed between the Trust and its
commissioners.
Table 31 : CQUIN Schemes for 2014/15
National CQUIN Scheme
Patient Safety Thermometer – to measure and
reduce the prevalence of harms – falls, pressure
ulcers, VTE, Catheter & UTI. The power of the NHS
Safety Thermometer lies in allowing frontline teams
to measure how safe their services are and to deliver
improvement locally. Analyzer is a UHMB Trust
system which records all incidences of harms, and is
populated by the Trust Risk Register Safeguard.
Target
This project prioritised reducing the prevalence of
pressure ulcers, with the following targets:
-
-
-
-
Number of category 2-4 old and new pressure
ulcers to be below baseline median value [Safety
Thermometer Data].
Reduce 5-month Q4/Q4 median by 20% for
category 2-4 old and new pressure ulcers [Safety
Thermometer Data].
Reduce avoidable category 3-4 hospital acquired
pressure ulcers by 100% [Safeguard/Analyzer
Data].
- Reduce avoidable category 2-4 hospital acquired
pressure ulcers by 10% [Safeguard/Analyzer
Data].
Progress report
Latest data for March shows performance has improved, however not all KPI targets were met. Avoidable
hospital acquired grade 2-4 from Safeguard incident reporting: 11 in Mar, final target maximum 13.
Avoidable hospital acquired grade 3/4 from Safeguard incident reporting: 0 in Mar, zero tolerance target
54
Table 31 : CQUIN Schemes for 2014/15
already met in Q3 and maintained throughout Q4. Safety Thermometer category 2-4 old and new:
26/26/22/25/21 in Nov/Dec/Jan/Feb/Mar, target maximum 21 for Nov 2014-Mar 2015. Safety Thermometer 5
month median: 25 in Mar, target maximum 17 by Mar. However Trust performance better than national mean
for 9 out of 12 months during Apr-Mar and 5-month rolling median better than national figures for all months
in the year (measure available since Aug); Commissioners asked for data to be presented in this way too. Elearning package rolled-out as mandatory for registered nurses; completion rates being monitored on an
ongoing basis and areas of low compliance being targeted with direct communications. Successful 'Harm
Free Care Week' held across sites in w/c 17th Nov.
Regional CQUIN Scheme
Pneumonia, Hip & Knee Replacement, Acute
Delivery of stretched ACS targets in each pathway.
Myocardial Infarction (AMI), Heart Failure, Stroke,
Chronic Chest Conditions/Chronic Obstructive
Pulmonary Disease (COPD).
Progress Report
Data for January 2015 will not be available until later in May 2015. Latest available cumulative performance
data is for April-December 2014:
AMI – 96.3% against annual target of 89%.
Heart Failure – 73.3% against annual target of 70%.
Hip & Knee Replacement – 91.7% against annual target of 85.8%.
Pneumonia – 81.2% against annual target of 75.6%.
Stroke – 66.6% against annual target of 66.6%.
COPD - April discharges were the first month ever of this data collection and the Advancing Quality Alliance
advised that the 50% target would not need to be met until December discharges (monthly performance
data shows this target was just met, with achievement of 50.0%).
Local CQUIN Schemes
End of Life and Spiritual Care – to include Gold
Standard Framework (GSF) accreditation,
personalised care plans and holistic needs
assessments.
90% of patients on GSF register will have had an
opportunity for meaningful End of Life discussion.
Clinically applicable Hogan 1 classified (definitely not
preventable death) will have documented evidence of
a personalised care plan.
Progress Report
Extra questions added to Mortality Review to audit/gather data on Best Practice of the Dying (Hogan 1
definitely preventable deaths) - outcome of reviews showing that recording in notes is definitely improving.
Gold Standards Framework (GSF) training is continues on Cohort 1 and 2 wards, with RLI Ward 23
submitted a detailed portfolio and has been successful in becoming one of the first two Acute Hospital
Wards nationally to receive GSF accreditation. GSF patient experience survey rolled out across sites at
end of Sep. New discharge pathways rolled-out across sites. Implementation and active monitoring of
discharge planning ongoing. A survey audit of End of Life discussions held found that 100% of responders
had the opportunity to discuss future care (against a 90% target).
Children’s Transition Care – transition care plans for
100% of children with epilepsy, diabetes and/or
14-18 year olds with long term conditions moving into asthma to have transition care plans for 14-18 year
adult services that enhances care and treatment.
olds with long term conditions moving into adult
services that enhances care and treatment.
Progress report
Q4 target of 100% of patients with long-term conditions to have commenced Ready Steady Go transition
plan – achieved 100% of those named patients in the cohort who were seen by the Acute Trust within the
project period and did not decline the option to have a transition plan.
Frail & Elderly Care (including 7 day working) –
Length of stay reduced by 0.5 days compared to
assessment of over 75 year olds within an agreed
Baseline position
time frame
Progress report
Six new Care of the Elderly (COTE) posts were recruited to and all were in post from 1st Oct. New team
supporting completion of Screening Tool and Comprehensive Geriatric Assessments (CGAs). Length of
Stay (LoS) performed better than trajectory target to November, however rose from December onwards due
to a number of factors out of the control of the projects’ remit. As a result the final target of 0.5 day
reduction was not met, however an audit records show that since robust recording of the assessment
process began in November 2014, 2470 patients aged over 75 who were admitted non-electively had
received a CGA. An audit of the CGAs was undertaken in March 2015, using a random sample of 139
patients (61 at RLI and 78 at FGH). The average LoS for this sample was 11.47, substantially lower than
the 16.8 baseline.
55
Table 31 : CQUIN Schemes for 2014/15
Harm Free Care - Medicine Management –
Nursing and pharmacy staff to have received
implementation of training and a broad range of
medicines management training by end of March
initiatives to support nursing staff on counseling
2015.
patients at discharge and compliance of antimicrobial
prescribing
Progress report
Latest data shows that 74.1% of staff have completed the training to date. Work is ongoing to increase this.
Harm Free Care - Fragility Fractures – assessment of Increase quarter on quarter number of bone health
bone density for patients over 50 years of age
assessment undertaken/completed for those patients
presenting with fractures (scheme commissioned by
over 50 years of age presenting with fracture
LNCCG, therefore reporting is for Lancashire North
patients only).
Progress report
Use of tool and referral process for DexA scans communicated to GPs at CCG Membership Council
meeting on 1st Oct; DexA referral pathway flowchart developed to facilitate this.
FRAX Bone Health Assessment rolled-out for hip fractures in Q2 and all other inpatient fractures in Q3.
Was planned to be rolled out for all outpatient fractures in Q4 however due to staffing pressures within
Trauma & Orthopaedics this did not happen.
During Q2-Q4 bone heath assessments were completed by the Orthopaedics & Trauma team for 156 in
patients with fractures. Of these, 80 were assessed as low risk (green), 66 were assessed as intermediate
risk (amber), and 10 were assessed as high risk (red). Appropriate follow-up action was undertaken for
each of these patients
Harm Free Care - Early Warning Scores - reduction
Demonstrate 10% reduction in adult cardio
in cardiac arrests outside critical care, learning
respiratory arrests whilst as an inpatient or those who
lessons once and utilising agreed warning tool.
arrest post arrival to A & E by March 2015.
Progress report
An audit of baseline data undertaken in Q1 showed of 91 cardiac arrests during January-June 2014, 65%
were found to be potentially avoidable. Roll-out of sphygmomanometers and stethoscopes to all wards was
undertaken, along with phased training at RLI and FGH through combination of TMS e-learning module and
face-to-face workshops, facilitated by Practice Educators/Clinical Skills. In Q4 January-March 2015 the
proportion of avoidable cardiac arrests was 38%, exceeding the 10% reduction target.
Shared Decision Making – Roll Out To Elective
Improve patient experience through heightened levels
Services (e.g. Bowel Enhanced Recovery & Hip
of knowledge of understanding in order to ensure
Surgery) - to build on the successful methodology for
realistic patient expectations.
shared decision making.
Progress report
Questionnaires developed in order to assess baseline levels of patient knowledge and extent to which their
THR/Colorectal surgery experience met their expectations. This was rolled-out across sites in May.
Slightly different questionnaires were developed in order that data may be gathered from patients at each of
three separate touch points for both THR and Colorectal (pre-op, post-op and recovery). Final results
informed development of topic guides for patient interviews. Using these topic guides, two patient voices
DVDs (one for THR, one for Colorectal) filmed in July; final edited versions of film clips (6 for each specialty)
received and made available via external Trust website. DVDs/video clips and survey to assess usefulness
of the tools rolled out across sites, with business cards being given out to publicise website hosting online
film clips. Analysis of survey responses showed that 98% of THR patients and 68% of colorectal surgery
patients agreed that their expectations had been met, indicating realistic expectations had been promoted.
NHS England CQUIN schemes
Dental/Oral Surgery/Maxillofacial
Phased expansion of implementation of Friends and
Family Test (FFT) in all areas of Dental services – to
improve patient experience and to gain timely
feedback about their experience. Consistent coding
for oral surgery and Maxillofacial surgery procedures.
Progress report
Roll-out of patient FFT completed in w/c 1st September, meeting the CQUIN requirement of before 1st
October.
Requirements of the Consistent Coding CQUIN discussed with the Dental/Maxillofacial team at Business
meeting in June, with further departmental discussions held in September and December. Audit
undertaken in October in order to assess key areas of difference in coding practice/recording in the notes
and the level of risk to Trust income as a result of implementing consistent coding for oral and maxillofacial
surgery - both inpatient spells and outpatient procedures. Results discussed by the Project Team and
56
Table 31 : CQUIN Schemes for 2014/15
outline implementation and communications plan drawn up.
Breast Screening – research project to understand
Conducting a survey to understand why patients ‘Do
nd
why women Do Not Attend (DNA) their 2 timed
Not Attend’, and address key learning points from
appointments.
feedback in order to reduce DNA rates.
Progress report
2013/14 baseline DNA rate identified as 16%. Questionnaire developed and rolled-out from 28th May clinic
onwards. Responses collated and key themes identified to inform actions being taken to improve
attendance rates. Project Lead has started work to scope option of introducing SMS system for reminders.
Communications conducted with staff in order that they may help encourage attendance. Final 2014/15
DNA data will not be available until October 2015, since women are given six months to attend a
subsequent appointment before being counted as a DNA.
Adult Chemotherapy – to include the reduction in
10% reduction in chemotherapy waste from baseline
chemotherapy waste and introducing patient held
2013/14. 95% of patients to have a patient held
self-care plans.
record by end of March 2015.
Progress report
5 drug wastage reduction initiatives were implemented; impact was measured by individual initiative since
September for 3 of the initiatives, for other 2 initiatives impact was reflected in overall figures. Drugs
wasted with value >£1000 recorded as clinical incidents. 10% wastage reduction target met in Q2/Q3/Q4.
Manual audit undertaken in order to determine % of chemotherapy patients with patient held records. Q1
82% against 75% target, Q2 91% against 85% target, Q3 95% against 92% target, Q4 99% against 95%
target.
Neonatal Intensive Care
To achieve 85% screening rate for Retinopathy of
Prematurity (ROP) by end of March 2015.
To improve access to breast milk in preterm infants
(51% by end of March 2015).
To provide a neonatal ICU dashboard.
Progress report
Q1-Q4 cumulative data: ROP 86%, breast milk 45%. Met ROP target but missed breast milk target due to
the mothers of five infants not wanting to breastfeed/express in Q4 (equal to 12% of total year patient cohort).
Collation of Q1/Q2/Q3/Q4 data for each of below four dashboard indicators completed:
(1) % of babies born <32 weeks gestation and/or with birth weight <1501g who receive specialist neonatal
care and undergo retinopathy screening in line with national guidelines on timing.
(2) Rate of blood stream infection per 1000 catheter days taken after 72 hours of age.
(3) % of newborn babies with admission temperature of <36C who receive specialist neonatal care.
(4) % of network ex-utero transfers refused admission to the unit due to lack of capacity/staffing.
3.5 Statements from Local Clinical Commissioning Groups (CCG’s), Local
Healthwatch Organisations (HO) and Overview and Scrutiny Committees
(OSCs)
The statements supplied by the above stakeholders in relation to their comments on the information contained
within the Quality Account can be found in Annex A of Part 4. Additional stakeholder feedback from
Governors has also been incorporated into the Quality Account. The lead Clinical Commissioning Group has
a legal obligation to review and comment on the Quality Account, while Local Healthwatch organisations have
been offered the opportunity to comment on a voluntary basis. Following feedback, wherever possible, the
Trust has attempted to address comments to improve the Quality Account whilst at the same time adhering to
Monitor’s Foundation Trusts Annual Reporting Manual for the production of the Quality Account and additional
reporting requirements set by Monitor.
3.6
Quality Account Production
We are very grateful to all contributors who have had a major involvement in the production of this Quality
Account.
57
The Quality Account was discussed with the Council of Governors which acts as a link between the Trust, its
staff and the local community who have contributed to the development of the Quality Account.
3.7
How to Provide Feedback on the Quality Account
The Trust welcomes any comments you may have and asks you to help shape next year’s Quality Account by
sharing your views and contacting the Chief Executive’s Department via:
Telephone:
01539 716698
Email:
Paul.Jones4@mbht.nhs.uk
Company Secretary
University Hospitals of Morecambe Bay NHS Foundation Trust
Trust Headquarters
Burton Road
Kendal
LA9 7RG
3.8
Quality Account Availability
If you require this Quality Account in Braille, large print, audiotape, CD or translation into a foreign language,
please request one of these versions by telephoning 01539 716698.
Additional copies of the Quality Account can also be downloaded from the Trust website:
http://www.uhmb.nhs.uk/about-us/key-publications/
3.9
Our Website
The Trust’s website gives more information about the Trust and the quality of our services. You can also sign
up as a Trust member, read our magazine or view our latest news and performance information via:
http://www.uhmb.nhs.uk/trust/
58
Part 4: Appendices
Annex A: Statements from relevant Local Clinical Commissioning
Groups (CCGs groups (as determined by the NHS (Quality Accounts)
Amendment Regulations 2012), Local Healthwatch Organisations (HO)
and Overview and Scrutiny Committees
1.1
Statement from NHS Lancashire North Clinical Commissioning Group on the Quality Accounts
– 15.05.2015. Statement from NHS Cumbria Clinical Commissioning Group on the Quality
Accounts – 15.05.2015
Cumbria and Lancashire North CCGs welcome the opportunity to comment on the 14/15 quality
account for University Hospital Morecambe Bay. The CCGs have worked closely with the Trust
throughout the year, gaining assurance of the delivery of safe effective services.
Patient quality and experience is monitored via the CCGs’ clinical insight walk round programme
implemented in conjunction with the Trust as well as more formal joint CCG and Trust quality
performance meetings.
External independent reviews including CQC regulators, Peer Review Teams and outcomes from the
Investigation into Maternity Services have significantly fused a strong collaborative approach for
quality improvement across the Health economy. The Trust has in turn demonstrated collaborative
working with CCGs in their commitment to respond to patient safety and enhanced patient experience.
They have clearly reaffirmed and articulated their values, vision and behaviours, with staff committed
to provide safe, high quality care to patients at all times.
On specific aspects of the Quality Account the CCGs welcome the openness of the Trust in publishing
this data, the Trust’s participation in the Clinical Research and National Audits and the CCGs would
like to congratulate the Trust on achieving the 13/14 Quality and Innovation Payment monies.
Conversely the CCGs are disappointed in the reduction of patients assessed for Venous
thromboembolism (VTE) and the variability in meeting the 18 week referral to treatment target but are
pleased that the Trust have committed in this account to take action to continually improve this for the
coming year. The CCGs are concerned that 16% of patients said they were not treated with dignity
and respect, and that 21% of patients did not always have confidence and trust in the Doctors treating
them. We also note that 73% of patients were not asked to give their views on the quality of care they
received and 64% did not receive any information explaining how to complain which we feel may
hinder the Trust’s ability to learn from complaints. The CCGs note the continued difficulties
experienced in General Practice in receiving good quality and timely discharge summaries. The
CCGs are concerned at a number of results of the staff survey and would welcome substantial
improvement across these specific areas of the staff survey results in the coming year.
The CCGs welcome the significant reduction in total numbers of cardiac arrests and commends the
Trust in the work they have done to achieve this over last year. The CCGs also commend the Trust in
its consistent improvement in practice with regard to hospital acquired pressure ulcers, and in the
work to reduce the prevalence of these over the past year. The CCGs welcome the reduction of
patient falls that occurred over the last year and further commends the Trust for this reduction. The
CCGs recognise the Trust’s hard work in improving their incident reporting and we value the way the
Trust has worked with both CCGs to review Serious Incidents.
The CCGs commend the Trust in its commitments to ‘Walkabouts’ and the mock Care Quality
Commission (CQC) inspection process it undertook within the year, through this, both CCGs were
able to gain a great deal of assurance that the Trust was able to see the issues it faced and address
these issues. The CCGs would also like to thank the Trust for including CCG representatives within
these internal processes.
59
Last year the CCGs requested an increased emphasis on the application for measurement for
improvement methodology which is not consistently evident within the account. The CCGs ask that
the Trust advances its ability to demonstrate that the changes it is making are improving patient care
and can be maintained. We ask the organisation to test changes and measure impact for success.
The CCGs feel this is essential for the organisation so that it continually improves.
The CCGs have a growing confidence in the Trust’s approach to the recruitment, development and
support of its nursing and care staff, utilising innovative solutions to ensure staff with the right skills at
the right time are available to care for our patients. The Trust’s focus to improve patient experience
and listening to the voice of the patient and staff is also evident particularly through the Better Care
Together, ‘I Want Great Care’, CQC Improvement Plan and its response to the Maternity Investigation.
The Report of the Morecambe Bay Investigation was published on 3 March 2015. Following receipt
the Trust and its partners have put in place the arrangements and processes to enable full
implementation of recommendations. The first recommendation relates to the Trust recognising past
failings and apologising to the families affected. They have apologised unreservedly to the families of
those who suffered as a result of poor care in the maternity unit at Furness General Hospital between
2004 and 2013. The Trust and the CCGs welcome the publication and accepts and acknowledges its
recommendations without reservation.
The CCGs are in no doubt of the commitment of the Trust Board, Executive Directors and other
Clinical Leaders to the Organisation’s strategy for quality improvement. Both CCGs are committed to
working with the Trust to ensure that improvements continue.
1.2
Quality Accounts commentary from University Hospitals Morecambe Bay NHS Foundation
Trust Governors - 14.05.2015
Involvement of Governors in development of the Trust’s Quality Account 2015/16 The Trust
continually strives to improve quality and an integral part of this is to produce an annual Quality
Account (report) which focusses on improvement priorities. Governors expressly said they wanted to
be involved in the development of the Quality Account and it was agreed the Council of Governors
Strategy Group would take this forward.
The Council of Governors Strategy Group met in January and March 2015 to discuss in particular the
proposed performance indicators for audit and the structure and content of the Quality Account.
Through this process of consultation Governors are developing a far greater understanding of the
Quality Account and how they can contribute to the process for the benefit of the Trust.
1.3
Quality Accounts commentary from Healthwatch Cumbria – 18.05.2015
Quality Accounts 2014/15 – Stakeholder Feedback
1.
What do you like about the 2014/15 Quality Accounts?
1.1.
The overall presentation and layout of the document is good. This is a comprehensive account
of the Trust’s quality performance over the past year.
2.
What do you dislike about the 2014/15 Quality Accounts?
2.1.
The amount of clinical data and information contained within the report makes reading and
identifying key themes very difficult. As with most QA reports they are rarely written with the
public in mind. A simplified, public facing version of the report maybe something that
providers consider for the future.
2.2.
In some cases it was difficult to form an opinion of performance as ‘final data not yet available’
was inserted in the columns or was completely missing from some of the columns (page 5).
2.3.
In some cases (various pages throughout the document) the data appeared to be out of date,
which again makes it difficult to understand performance.
2.4.
Whilst the colour coding is easy to read, the use of actual % figures would provide a more
transparent approach to reporting and enable greater understand from the reader’s
perspective.
3.
What suggestions do you have for additional content for 2014/15?
60
1.4
3.1
No suggestions for additional contents, other than that noted in point 7.1 below.
3.2
It is disappointing to note that Trust’s responsiveness to the personal needs of its patients has
not improved as quickly as planned (page 23), neither has the rate of improvement in relation
to Friends & Family results (page 24). It may be useful to explain how the Trust will ‘continue
to focus energy and efforts on improvements to patient outcomes, quality care and patient
experience’.
4.
What other comments or suggestions for improvements would you like to propose?
4.1
Please refer to section 2 above
5.
What would you suggest are the Trust’s priorities for quality improvements for 2015/16?
5.1
To move out of special measures should be the ultimate priority, thus demonstrating the care
provided meets national/legislative requirements.
5.2
Improve the complaints process and provide satisfactory resolutions for complainants.
Demonstrate how learning from complaints is used to bring about service improvement and
how learning from complaints is embedded throughout the Trust (all wards, all sites)
5.3
To clearly demonstrate how patient experience is used to bring about service improvements,
above and beyond ‘I want great care’.
6.
Do you consider that the draft document contains accurate information in relation to NHS
services provided by the Trust?
6.1
As far as it is possible to ascertain the document does contain accurate information although it
is not complete in some places and therefore it is difficult to judge the Trust’s performance
against some criteria.
7.
Do you consider that any other information should be included relevant to the quality of NHS
services provided by the Trust?
7.1
It may be useful to include patient statements on the care provided by the Trust.
Quality Accounts commentary from Healthwatch Lancashire - 18.05.2015
UHMB Quality Account 2014/15:
It is pleasing to note that the Trust’s quality priorities for 2015/16 have been set following consultation
with patients, carers and staff and other stakeholders, including Healthwatch Lancashire and they link
closely to the Care Quality Commission’s (CQC) 5 domains of safe, caring, effective, responsive and
well led.
The Trust has made significant progress against its quality priorities during a busy and challenging
year, as evidenced by data and information included in this report, and it is reassuring that where the
Trust is behind plan actions are already in place to improve performance.
The Trust’s commitment to clinical research and clinical audit is to be commended. Particularly
pleasing to see are improvements being made to the quality of the Trust's services as a result of this
work and the Trust's collaboration with academic institutions such as the University of Lancaster.
Improvements to the Trust’s mortality rate measurements are to be applauded and are very
encouraging, but the latest SHMI mortality measure will need further evaluation when the 2015 data
becomes available (page 21).
Patient Recorded Outcome Measures (PROMS) information is also encouraging, as are actions
planned to improve the response rates for this important data. However, Friends and Family data
(page 24 and page 27) is confusing and would benefit from a clearer explanation.
61
Information regarding readmissions is no doubt indicative of the challenging local health economy and
the Trust's action plan to reduce emergency readmissions, which is led by the Trust’s clinical directors,
is reassuring.
In respect of the Trust's CQC review, Healthwatch Lancashire have been closely involved with this
work and have participated in mock CQC assessments. It is therefore pleasing that progress made to
address areas for improvement has been clearly demonstrated in this Quality Account. It is also
evident from this report, and from our own observations during mock CQC assessments, that the
Trust’s staff are working together to make the necessary changes and improvements to the Trust's
service provision, and are being supported in this by senior managers and the Board of Directors.
However there are some areas where performance has been disappointing eg VTE risk assessments,
but it is reassuring to see that for this issue the Trust is rolling out an electronic assessment tool and is
optimistic that compliance will improve.
Performance in respect of reducing C Diff infections has improved, and actions to support this are
commendable, but it is very disappointing to note the 2 community acquired MRSA infections that
have been attributed to the Trust.
The Trust's delivery of national quality standards is noted, as are the explanations where the
standards were not met. The Trust's improved performance regarding cancer waiting times is very
encouraging.
Data regarding reductions in the percentage of staff participating in mandatory training and
undergoing appraisal requires improvement but it is acknowledged that this has been a very
challenging year in respect of staffing, not only for the Trust, but also in the local and wider national
health economy.
Data on patient safety incidents (page 26 & 35) lacks clarity and would benefit from further explanation
as would data regarding Advancing Quality Indicators. It is pleasing that the Trust had no never events
in 2014/15.
The Trust's performance in the national inpatients survey are noted, as are 'next steps' which should
help the Trust address those areas which require improvement.
Overall the report articulates many improvements and details areas where further work is required.
Thank you for sharing this report with Healthwatch Lancashire and for giving us the opportunity to
feedback and comment.
Quality Accounts commentary from Cumbria Health Scrutiny Committee – 20.05.2015
1.5
The Cumbria Health Scrutiny Committee again welcomes the opportunity to comment on the Trust’s
draft Quality Account for 2014/15, and would like to acknowledge the good working relationship it has
with the Trust.
The document is generally well laid out and reasonably straightforward to understand and enables
Members to explore the Trust’s performance over the year, however to support the lay reader in
reviewing this document it is recommended that further developments are made where possible in this
year’s document, and also in future accounts including;

There was a feeling from members that the length of the document might limit its accessibility.

The structure of the contents page was felt to be a helpful tool in navigating the document.
What follows are comments on specific sections of the draft report where changes are suggested,
either in the form of corrections or requests for further information / clarification:
Page 5 -
‘Performance Against Trust Priorities’ table does not include actual performance data
for 2014/15 only traffic lights. The table should also have the data for previous years
to enable comparison.
62
Page 7 Page 10 Page 11 Page 21 Page 25 -
Page 28 Page 29 Page 36 -
Page 39 -



Evidence of internal pre-consultation on the quality accounts was welcomed by
members.
There needs to be more explanation of the rationale behind the decision to remove
managers from front-line quality inspections and improvement priorities.
It should be made clear how frequently the monitoring committee will report to the
board.
Concern expressed by Members of the Committee on the position of the Trust in
relation to the national average when it comes to all Core Quality Indicators.
Members would like to see the Trust establishing itself as a high achiever in a high
percentile group when it comes to Clostridium Difficile infection prevention. Poor
performance in this area is often an indicator of staff shortages.
A and E must get faster with patients assessed and treated
The table illustrating other quality indicators was felt to be unclear and should be
presented in style and format consistent with those earlier in the report.
Figures highlight issues about communicating with patients, providing clear
information: appropriate instructions on how to treat themselves in the best and most
effective manner, how to give their views on their experience. Complaints should be
handled while patient is on the ward even if it means time with a manager, it could
cease formal complaints. Patients usually just want to be heard above ward level.
Members would like to see the trust state how it intends to reduce falls, not simply
express satisfaction that the position appears to be ‘stable’
Some more general comments on the report which should be considered when finalising the report
There was felt to be a valuable emphasis on ‘quality’ although there was perhaps too much data within
the body of the report.
Ambitions of the Trust should be more directly and effectively communicated to patients.
Discharge if done well and clear communication with patients prioritised readmissions can be
prevented.
Overall, we appreciate the co-operation received and look forward to continuing to work with the Trust
during the coming year to help drive up quality
1.6
Quality Accounts commentary from Lancashire Health Scrutiny Committee - 15.05.2015
The role of the Lancashire Health Scrutiny Committee is to review and scrutinise any matter relating to
the planning, provision and operation of the health service in the area and make reports and
recommendations to NHS bodies as appropriate.
The Committee undertake this responsibility through engagement and discussions with the Trust,
addressing any areas of concern as they arise. It is the intention of the Committee that this
methodology of ensuring that the Trust improve patient safety and deliver the highest quality care to
the residents of Lancashire will continue by having an oversight of how the Trust evidence the
provision of quality and safe services. In addition the Health Scrutiny Committee will seek reassurance
that every effort is being made to ensure; financial stability, reasonable waiting times and the
safeguarding of the most vulnerable.
63
Annex B: Statement
Quality Report
of Directors’ Responsibilities
in respect of the
The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts)
Regulations to prepare Quality Accounts for each financial year.
Monitor has issued guidance to NHS foundation trust boards on the form and content of annual quality reports
(which incorporate the above legal requirements) and on the arrangements that NHS foundation trust boards
should put in place to support the data quality for the preparation of the quality report.
In preparing the quality report, directors are required to take steps to satisfy themselves that:

The content of the Quality Report meets the requirements set out in the NHS Foundation Trust Annual
Reporting Manual 2014/15 and supporting guidance;

The content of the Quality Report is not inconsistent with internal and external sources of information,
including:
o Board minutes and papers for the period 1 April 2014 to 27 May 2015;
o Papers relating to Quality reported to the Board over the period 1 April 2014 to 27 May 2015;
o Feedback from commissioners – NHS Lancashire North Clinical Commissioning Group and NHS
Cumbria Clinical Commissioning Group dated 15/05/2015
o Feedback from Governors dated 22/01/2015; 02/03/2015 and 14/05/2015;
o Feedback from Healthwatch Lancashire and Healthwatch Cumbria organisations dated 18/05/2015
and 18/05/2015;
o Feedback from Cumbria Health Scrutiny Committee – 20/05/2015 and Lancashire Health Scrutiny
Committee – 15/05/2015
o The Trusts Complaints Report published under regulation 18 of the Local Authority Social Services
and NHS Complaints Regulations 2009, dated 20/04/2015;
o The 2014 national patient survey published February 2015;
o The 2014 national staff survey published 24 February 2015;
th
o The Head of Internal Audit’s annual opinion over the Trust’s control environment dated 15 April 2015;
o CQC quality and risk profiles and CQC Intelligent Monitoring Report dated July 2014 and December
2014.

The Quality Report presents a balanced picture of the NHS foundation trust’s performance over the
period covered;
The performance information reported in the Quality Report is reliable and accurate;
There are proper internal controls over the collection and reporting of the measures of performance
included in the Quality Report, and these controls are subject to review to confirm that they are working
effectively in practice;
The data underpinning the measures of performance reported in the Quality Report is robust and reliable,
conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny
and review; and
The Quality Report has been prepared in accordance with Monitor’s annual reporting guidance (which
incorporates the Quality Accounts regulations) published at www.monitor.gov.uk/ annualreportingmanual)
as well as the standards to support data quality for the preparation of the Quality Report (available at
www.monitor.gov.uk/annualreporting manual).




The directors confirm to the best of their knowledge and belief they have complied with the above
requirements in preparing the Quality Report.
By order of the Board.
th
Chairman: Pearse Butler
th
Chief Executive: Jackie Daniel
Date: 27 May 2015
Date: 27 May 2015
64
Annex C: Glossary of Abbreviations And Glossary Of Terms
Table 27 Glossary of Abbreviations and Terms
Abbreviation
Meaning
ACC
Accelerated Clinical Content
ACS
Appropriate Care Score
AQuA
Advancing Quality Alliance (North West)
CDI
Clostridium Difficile Infection
CCG
Clinical Commissioning Group
COPD
Chronic Obstructive Pulmonary Disease
CQC
Care Quality Commission
CQS
Composite Quality Score
DoLS
Deprivation of Liberty Safeguards
CQUIN
Commissioning for Quality and Innovation
DVD
Digital Versatile Disc
FAIR
Find Assess Investigate and Refer target for dementia care
FFT
Friends and Family Test
GP
General Practitioner
GSF
Gold Standard Framework
HSMR
Hospital Standardised Mortality Ratio
HSIC
Health and Social Care Information Centre
KPI
Key Performance Indicators
LoS
Length of Stay
MCA
Mental Capacity Act
MRSA
Methicillin-resistant Staphylococcus Aureus
MSSA
Methicillin-sensitive Staphylococcus Aureus
NICE
National Institute for Health and Care Excellence
NIHR
National Institute of Health Research
PALS
Patient Advice and Liaison Service
PbR
Payment by Results
RAISE
Review, Audit, Inspection Standards
RAMI
Risk Adjusted Mortality Index
SHMI
Summary Hospital Mortality Index
VTE
Venous Thrombo-Embolism
WACs
Women’s and Children’s Services Division
YTD
Year to Date
65
Table 28: Glossary of Terms
Abbreviation
Glossary of meaning
Breach
Failure to meet the standard/target
Cardiac Arrest Cardiac arrest, (also known as cardiopulmonary arrest or circulatory arrest) is the
cessation of normal circulation of the blood due to failure of the heart to contract effectively.
Clinical
Responsible for most healthcare services available within a specific geographical area.
Commissioning
Group
Clostridium
Clostridium Difficile (C. diff) is a bacterium that is present naturally in the gut of around two
Difficile
thirds of children and 3% of adults. C. diff does not cause any problems in healthy people.
However, some antibiotics that are used to treat other health conditions can interfere with the
balance of ‘good’ bacteria in the gut. When this happens, Clostridium Difficile bacteria can
multiply and produce toxins (poisons), which cause illness such as diarrhoea and fever. At
this point, a person is said to be ‘infected’ with C. diff.
Commissioning This is a system introduced in 2009 to make a proportion of healthcare providers’ income
for Quality and conditional on demonstrating improvements in quality and innovation in specified areas of
Innovation
care.
Deprivation of The Deprivation of Liberty Safeguards (DoLS) is part of the Mental Capacity Act 2005. They
Liberty
aim to make sure that people in care homes, hospitals and supported living are looked after
Safeguards
in a way that does not inappropriately restrict their freedom. The safeguards should ensure
(DoLS)
that a care home, hospital or supported living arrangement only deprives someone of their
liberty in a safe and correct way, and that this is only done when it is in the best interests of
the person and there is no other way to look after them.
Harm
An unwanted outcome of care intended to treat a patient.
Hospital
The Hospital Standardised Mortality Ratio (HSMR) A system which compares expected
Standardised
mortality of patients to actual. It is an indicator of healthcare quality that measures whether
Mortality Ratio the death rate at a hospital is higher or lower than you would expect. HSMR compares the
expected rate of death in a hospital with the actual rate of death. Dr Foster looks at those
patients with diagnoses that most commonly result in death for example, heart attacks,
strokes or broken hips. For each group of patients we can work out how often, on average,
across the whole country, patients survive their stay in hospital, and how often they die.
Methicillin
It is a common skin bacterium that is resistant to some antibiotics. Media reports sometimes
Resistant
refer to MRSA as a superbug. An MRSA bacteraemia means the bacteria have infected the
Staphylococcus body through a break in the skin and multiplied, causing symptoms. Staphylococcus Aureus
Aureus (MRSA) (SA) is a type of bacteria. Many people carry SA bacteria without developing an infection.
This is known as being colonised by the bacteria rather than infected. About one in three
people carry SA bacteria in their nose or on the surface of their skin.
Mental
Capacity
(MCA)
The Mental Capacity Act is designed to protect people who can't make decisions for
Act themselves or lack the mental capacity to do so. This could be due to a mental health
condition, a severe learning disability, a brain injury, a stroke or unconsciousness due to an
anaesthetic or sudden accident
National
Institute for
Health and
Care
Excellence
NHS
Outcomes
Framework
Risk Adjusted
Mortality Index
Safety
Thermometer
This is an independent organisation that provides national guidance and standards on the
promotion of good health and the prevention and treatment of ill health.
The NHS Outcomes Framework is structured around five domains, which set out the highlevel national outcomes that the NHS should be aiming to improve. They focus on:
 Domain 1 Preventing people from dying prematurely
 Domain 2 Enhancing quality caring of life for people with long-term conditions
 Domain 3 Helping people to recover from episodes of ill health or following injury;
 Domain 4 Ensuring that people have a positive experience of care; and
 Domain 5 Treating and for people in a safe environment
 Available at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGui
dance
Risk Adjusted Mortality Index – is a measure of the outcomes of care for patients. Risk
Adjusted Mortality compares us to what is expected from the types of cases we manage and
compares us to other similar hospitals in the country.
A point of care survey which is used to record the occurrence of four types of harm (pressure
ulcers, falls, catheter associated urinary tract infection and venous thrombo-embolism).
66
Table 28: Glossary of Terms
Abbreviation
Glossary of meaning
Summary
Summary Hospital Level Mortality Indicator is a system which compares expected mortality of
Hospital Level patients to actual mortality (similar to HSMR) and measures whether mortality associated with
Mortality
hospitalisation was in line with expectations. Deaths within 30/7 discharged from hospital.
Indicator
(SHMI)
The Trust
University Hospitals Morecambe Bay HNS Foundation Trust - A Foundation Trust is part of
the National Health Service in England and has to meet national targets and standards. NHS
Foundation Trust status also gives us greater freedom from central Government control and
new financial flexibility.
Venous
Venous Thrombo-Embolism (VTE) A blood clot forming within a vein. It is the collective term
Thrombofor deep vein thrombosis (DVT) and Pulmonary Embolism (PE). A DVT is a blood clot that
Embolism
forms in a deep vein, usually in the leg or the pelvis. Sometimes the clot breaks off and
travels to the arteries of the lung where it will cause a pulmonary embolism (PE).We can
avoid many VTEs by offering preventative treatment to patients at risk.
VTE
Venous Thromboembolism (VTE) Prophylaxis is preventive treatment given to patients in
Prophylaxis
order to protect them from developing a blood clot that forms in a deep vein.
62 day Cancer
waiting
time
standard
62 day cancer
screening
waiting
time
standard
MRSA Target
Clostridium.
Difficile Target
Monitor
Mortality Rate
Morbidity
Number of patients receiving first definitive treatment for cancer within 62 days following an
urgent GP referral as a percentage of the total number of patients receiving first definitive
treatment for cancer following an urgent GP referral.
Number of patients receiving first definitive treatment for cancer within 62 days referral from
the screening programme as a percentage of the total number of patients receiving first
definitive treatment for cancer following a referral from the screening programme.
Number of patients identified with positive culture for MRSA bacteraemia
Number of patients identified with positive culture for Clostridium Difficile
Monitor was established in 2004 and authorises and regulates NHS Foundation Trusts.
Monitor works to ensure that Foundation Trusts comply with the conditions they signed up to
and that they are well led and financially robust.
Number of deaths
http://www.ic.nhs.uk/statistics-and-data-collections/hospital-care/summary-hospital--levelmortality-indicator-shmi
Morbidity comes from the word morbid, which means “of or relating to disease”
Patient
Reported
Outcome
Scores
PICKER
Institute
The patient reported outcome scores are for (i) groin hernia surgery,(ii) varicose vein
surgery, (iii) hip replacement surgery, and (iv) knee replacement surgery
http://www.ic.nhs.uk/statistics-and-data-collections/hospital-care/patient-reported-outcomemeasures-proms
National Company that undertakes the National Inpatient Survey on behalf of the Trust.
Emergency
readmissions
to
hospital
within 28 days
of discharge
Percentage of
admitted
patients riskassessed for
Venous
ThromboEmbolism
Rate
of
Clostridium
Difficile
http://www.ic.nhs.uk/pubs/hesemergency0910
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH_131
539
http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/ClostridiumDifficile/Epidemiolo
gicalData/MandatorySurveillance/cdiffMandatoryReportingScheme/
The following information provides an overview on how the criteria for measuring this
indicator has been calculated:
 Patients must be in the criteria aged 2 years and above
 Patients must have a positive culture laboratory test result for Clostridium Difficile which
is recognised as a case
 Positive specimen results on the same patient more than 28 days apart are reported as a
67
Table 28: Glossary of Terms
Abbreviation
Glossary of meaning
separate episode
 Positive results identified on the fourth day after admission or later of an admission to the
Trust is defined as a case and the Trust is deemed responsible
Maximum 62 The following information provides an overview on how the criteria for measuring this
days
from indicator has been calculated:
urgent
GP  The indicator is expressed as a percentage of patients receiving their first definitive
referral to first
treatment for cancer within 62 days of an urgent GP referral for suspected cancer;
treatment for  An urgent GP referral is one which has a two week wait from the date that the referral is
all cancers
received to first being seen b y a consultation (see http://www.dh.gov.uk/prod-consumdh/groups/dh-digitalassets/documents/digitalassset/dh-103431.pdf);
 The indicator only includes GP referrals for suspected cancer (i.e. excludes consultant
upgrades and screening referrals and where the priority type of the referral is National
Code 3 – Two week wait);
 The clock start date is defined as the date the referral is received by the Trust; and
 The clock stop date is defined as the date of first definitive cancer treatment as defined in
the NHS Dataset Change Notice. In summary this is the date of the first definitive cancer
treatment given to a patient who is receiving care for a cancer condition or it is the date
that cancer was discounted when the patient was first seen or it is the date that the
patient made the decision to decline all treatment.
Rate of patient http://www.nrls.npsa.nhs.uk/resources/?entryid45=132789
safety
incidents and
percentage
resulting
in
severe harm
or death
Tertiary
Specialist hospital or service
68