Quality
Account
2014/15
Unconditionally registered
with the CQC since April 2010
Healthca r e a t it s ve r y b e st - wit h a p e r so n a l t o uch
Contents
Part 1
Statement on Quality from the Chief Executive............................................2
Quality Account defined ..............................................................................3
Part 2
Quality Priorities for Improvement 2015/16...............................................4-7
Patient Safety............................................................................................5-6
Clinical Effectiveness .................................................................................6-7
Patient Experience........................................................................................7
Commissioning for Quality and Innovation (CQUIN) Indicators.....................8
Statement of Assurance from the Board ......................................................9
Part 3
Review of Quality Performance 2014/15...............................................10-28
Patient Safety........................................................................................10-20
Clinical Effectiveness .............................................................................20-23
Patient Experience.................................................................................23-28
Overview of monthly Board Assurance 2014/15 ...................................29-32
Overview of Quality Improvements .......................................................33-44
Information on Participation in National Clinical Audits and
National Confidential Enquiries.............................................................45-52
Information on Participation in Clinical Research........................................53
Information relating to the registration with the Care
Quality Commission (CQC).........................................................................53
Information on use of CQUIN framework .............................................54-57
Information on the Quality of Data ............................................................58
Key National Priorities 2014/15.............................................................59-60
Core Set of Quality Indicators ...............................................................61-65
Workforce Factors.................................................................................66-67
Involvement and Engagement ..............................................................67-69
Annex 1: Statement on behalf of the Health Scrutiny Committee,
Newcastle Council ...............................................................70-71
Statement on behalf of the Newcastle, Gateshead,
Northumberland and North Tyneside Clinical
Commissioning Groups (CCGs)............................................72-73
Statement on behalf of Healthwatch Newcastle ..................74-77
Annex 2: Statement of Directors’ responsibilities in respect
of the Quality Report ...........................................................78-79
Annex 3: Abbreviations.......................................................................80-82
Annex 4: Glossary of Terms ......................................................................83
Annex 5: Feedback Form..........................................................................84
Quality Account 2014/15 1
Part 1
Statement on Quality from the Chief Executive
During 2014/15 the Newcastle upon Tyne Hospitals
NHS Foundation Trust continued to focus on
delivering the highest quality care and treatment to
our patients and remain one of the leading providers
of quality healthcare spanning secondary, tertiary
and community services for adults and children.
As one of the largest and most successful teaching
hospitals in England we continued to provide a world class
service and place patients at the heart of everything we do.
Arising out of the tireless commitment and dedication of
our staff and volunteers, I remain confident that as a
leading healthcare provider serving local, regional and
national requirements with new procedures, in first class
facilities, to improve patient care is being achieved. This is
underpinned by the principle of delivering safe, high
quality services by the right people in the right place at the
right time and within financial balance.
As Chief Executive I am proud of our achievements and
this Quality Account for 2014/15 serves to demonstrate
our commitment to delivering high quality, cost effective
care. The document describes achievement for last year
and plans for the next year.
Patient safety is an overriding priority and our aim in
2014/15 has been to minimise patient harm, recognising
that when an incident does occur we act and learn
accordingly. This year the Trust have consistently been
reported as delivering harm free care above the national
average of 95%. We have also reported a reduction in the
number of patient falls incidents, in particular falls that
resulted in harm. 2014/15 also saw a reduction in the
number of incidents of patients developing pressure ulcers
and since April 2014 we have not reported any Never
Events. Mortality rates also continue to be reported as the
best in the North East and well below the national average.
All in all we saw more patients in 2014/15 than ever before
and continued to perform well with regard to patient
satisfaction. The results of the Annual Inpatient Survey
2014 serve to highlight so many positive aspects and
overall wellbeing of patient experience and the NHS Friends
& Family Test consistently show that 98% of our inpatients
would recommend the Trust to their friends and family.
The Trust recognises that this high quality service is
delivered by its loyal and dedicated workforce and we
continue to perform well against various national
standards including the Annual Staff Survey and the NHS
Staff Friends & Family Test. Last year we introduced a
Personal Touch Awards Scheme to recognise the
outstanding efforts our staff make every single day to
ensure each patient we see is treated with kindness, care
and compassion.
2 Quality Account 2014/15
A key component of the Trust’s commitment to quality is
being open and honest with our staff, patients and the
public, with published information not simply limited to
good performance. We published lessons learned from
complaints in a “you said, we did” section of the public
website and share examples of recent improvements we
have made as a result of concerns raised by patients, staff
and the public. We have also developed a “Take 2
Minutes” newsletter to report on the feedback we receive
from patients about services.
We continue to develop effective strategic partnership
across health and social care with our clinicians
contributing to policy and clinical practice guidelines by
actively engaging in various National and Local Clinical
Networks and Senates across a range of clinical specialties.
As part of the National institute for Health Research (NIHR)
Clinical Research Network the Trust participate and host
the NIHR where we are responsible for ensuring the
effective delivery of research in the Trusts, primary care
organisations and other qualified NHS providers
throughout the North East and North Cumbria geography.
The Trust also continued to be one of the top recruiters of
patients participating in research studies in England and
are actively involved in projects and activities developed as
part of the nationally acknowledged Shelford Group,
which encompasses ten of the leading teaching hospitals
who have so positively contributed to national decision
making and ultimately benefitted local health economies.
The Quality Account for 2014/15 not only serves to
reaffirm the Trust as an effective, dynamic healthcare
provider as we move forward into 2015/16 but in a good
position to embrace the evolving requirements of the Five
Year Forward View (NHS England) and all this entails.
To the best of my knowledge the information contained in
this document is an accurate reflection of outcome and
achievement.
Sir Leonard Fenwick
Chief Executive
The Newcastle upon Tyne NHS Foundation Trust
1
What is a Quality Account?
Quality Accounts are annual reports to the public from us about
the quality of healthcare services that we provide. They are both
retrospective and forward looking as they look back on the
previous year’s data, explaining our outcomes and, crucially, look
forward to define our priorities for the next year to indicate how
we plan to achieve these and quantify their outcomes.
Quality Account 2014/15 3
Part 2
Quality Priorities for Improvement 2015/16
Following discussion with the Board of Directors, the Council of
Governors, patient representatives, and clinicians, the following
priorities for 2015/16 have been agreed. Consideration has also
been given to feedback received from patients, staff and the
public. Presentations have been provided at various staff groups
with the opportunity to comment on the priority topics and a
feedback form is provided for patients views.
“
“
I felt that I was in very safe hands in the ward and
the staff were always at close hand to help with
any problems
4 Quality Account 2014/15
Patient Safety
Priority 1 - To reduce all forms of healthcare associated
infection (HCAI), we will quantify our success in this by:
• Aiming for the annual number of Methicillin Resistant
Staphylococcus Aureus (MRSA) bacteraemia cases to
be zero
• Reducing hospital acquired infections related to
Clostridium difficile (C.difficile) to be no more than 77
cases in the next year
As well as MRSA and C. difficile, the Trust will continue to
monitor rates of Methicillin-Sensitive Staphylococcus
Aureus (MSSA) and Escherichia coli (E. coli) and
implement strategies to try to reduce the number of
patients acquiring these infections.This indicator will
continue to be reported to the Trust Board, the Infection
Prevention & Control Committee and other relevant
forums.
Priority 2 - The Trust have signed up to the three year
National “Sign up to Safety” Campaign which aims to
save 6000 lives and reduce avoidable harm by 50% and in
doing so have pledged to undertake work in relation to
five patient safety priorities:
1. Deteriorating patient:
• To reduce avoidable harm and death associated
with missed opportunities to detect/instigate initial
management of the deteriorating patient by 50%
by 2018 (Adults)
• To reduce the number of episodes of avoidable
deterioration leading to PICU admission and/or
activation of the resuscitation teams and/or death
by 50% in the North East North Cumbria Region by
2018 (Paediatrics)
2. Medication safety:
• To reduce avoidable harm and death from
medication errors by 50% by 2018
3. Sepsis:
• To improve early detection and initial management
of the severely septic/septic shocked patient by
50% by 2018 (Adults)
• To reduce the number of children treated
inappropriately for sepsis by 50% by 2018.
(Paediatrics)
4. Surgical Safety:
• To have no surgical Never Events.
• To reduce harm associated with post-operative care
of patients undergoing spinal surgery, by 50% by
2018
• To reduce adverse incidents associated with elective
surgery in the diabetic patient by 50% by 2018
• To reduce spinal surgery infection rates to <1% by
2018
5. Obstetrics:
2
• To achieve a 50% reduction in the incidence of
avoidable neonatal hypoxic injury sustained during
childbirth
By signing up to this campaign The Trust is aiming to
promote an open learning culture and promote the
importance of human factors, incident reporting, staff
morale and quality improvement skills across the
workforce. This indicator will be monitored in various ways
including incident reporting, investigation outcomes and
patient and carer feedback. This will be reported quarterly
to the Trust Board via the Clinical Governance and Quality
Committee.
Priority 3 - The delivery of ‘Harm Free Care’ for all
patients is a national and Trust priority. This priority would
be to continue to build on the work undertaken in
2014/15 to prevent avoidable harm, disability or death
from:
• Falls
• Pressure ulcers
Falls
The Trust is consistently reporting below the national acute
Trust average of 6.8 falls/1000 bed days (Trust current
average for 2014/15 is 5.5, April-December 2014
inclusive). The Trust is performing better than 2013/14 and
is currently reporting an average falls/1000 bed days rate
of 5.5 compared to 5.7 for the same period last year.
Furthermore, falls resulting in serious harm (all incidents
graded moderate and above) have reduced by 27%.
Inpatient falls data is analysed continually by the Falls
Prevention Coordinator who looks at data at ward,
directorate and Trust level. Monthly, seasonal variation is
acknowledged and compared to historical data but all
significant increases in incidence at ward or directorate
level are analysed closely to identify any key themes and
learning from incidences. Falls with serious harm are
monitored through a comprehensive Root Cause Analysis
(RCA) process and these are reviewed quarterly to examine
areas of good practice and areas for improvement. The
Trust has committed to a number of work streams to drive
best practice locally and nationally and has been successful
in a bid to the Academic Health Science Network to lead a
regional piece of work to measure the impact of increasing
compliance of utilisation of an evidence based Falls Care
Bundle and once baseline data is established to test some
additional interventions.
Pressure Damage
The Tissue Viability Team continues to work with all Trust
staff to achieve “zero tolerance” to Trust acquired pressure
damage. Several wards have achieved significant numbers
of days “harm free” including three Wards who have been
harm free from pressure damage for over 1 year (Wards
20,40 and 46 at the Royal Victoria Infirmary).
Quality Account 2014/15 5
Patient Safety
The Quality Priorities for 2015/16 in relation to Harm
Free Care are to:
• Maintain and sustain the 20% reduction achieved in
pressure damage in September to December 2014
• Have no deterioration in the falls/1000 bed days rate
achieved in 2014/15 despite an increasing at risk
population of patients
Both areas of this indicator will be monitored through
incident reporting, prevalence audits and investigations.
This will be reported to the Trust Board and the relevant
Trust Groups.
Priority 4 – Human Rights
To include all aspects of Freedom from Exploitation and
Respect for the Person, the Mental Capacity Act (MCA),
Safeguarding and Deprivation of Liberty (DoLS). This will
be achieved by:
• Continuing to build on the existing robust
safeguarding arrangements and focus in particular on:
• Meeting the requirements of the Mental
Capacity Act (MCA), recognising and supporting
those without or with reduced capacity
including application of the Deprivation of
Liberty Standards (DOLs)
• Protecting those at risk of or subject to Domestic
Violence, Sexual Exploitation, or Female Genital
Mutilation
• Ensuring that those with Learning Disability are
recognised, flagged on Trust systems and
appropriate reasonable adjustments provided to
ensure they can access and receive high quality
care. Specific work will be undertaken to review
cancer screening pathways and deaths of
patients with a Learning Disability to identify
improvements and share best practice
• Ensuring staff know how to respond to
concerns and feel supported whilst proceedings
are ongoing
• Re-launching the Regional Deciding Right programme
in 2015/16
• Building on the work achieved in relation to End of Life
Care (EoL) for patients whist in hospital and the
community setting
• Continue to take forward work as outlined in the
Equality Delivery System to ensure equal access and
reduce inequality
This indicator will be monitored through the Trust
safeguarding management structure using results of audit,
assurance work and case reviews which will be examined
and challenged and progress against agreed actions
monitored and reviewed. Regular reports will go to Trust
Board, including updates of the Trust position against the
Neuberger Report and the Newcastle Safeguarding Boards
for Children and Adults.
6 Quality Account 2014/15
Clinical Effectiveness
Priority 5 – Mortality
To monitor mortality indicators with the aim of reducing
avoidable deaths and build on developments achieved in
2014/15.
The Trust shall continue to monitor mortality rates
comparing the number of patients expected to die, given
the severity of their condition, by using national models
against the number of patients who actually die, through
both Summary Hospital Mortality Indictor (SHMI) and
Hospital Standardised Mortality Ratio (HSMR). It will
continue to review reports produced by the North East
Quality Observatory (NEQOS). In addition, the Trust has
continued to focus on reducing avoidable deaths –
consistently achieving the lowest risk adjusted mortality
rates in the region.
The Trust has introduced a new process to understand
whether or not death was a likely outcome for that patient.
Consultants are now asked to conduct a brief case note
review. If it was not an expected death, a multidisciplinary
team of clinical staff are asked to go through the case in
detail and look for any lessons that can be learned. The
Trust moving forward will start to record the outcomes of
all reviews centrally within a new database.
This indicator will be monitored and reported to the Trust
Board and the Clinical Risk Group.
Priority 6 - National Audits and Confidential Enquiries
To ensure that we are helping the gaining of knowledge
across the whole NHS and in turn improving our
knowledge on best practice therefore improving patient
safety, quality of care and experience, we will participate in
all National Audits and Confidential Enquiries that are
applicable to our organisation and when they are available
ensure that we act on the recommendations arising from
the report.
We aim to further develop the Trust’s processes for
implementing the recommendations, where appropriate,
from National Clinical Audit and Confidential Enquiries by
ensuring learning is widely shared across the organisation.
A reporting template will be developed and lead clinicians
for each national clinical audit will be asked to complete
an action plan for any areas of practice which are
identified as being non-compliant with national
requirements. The action plans will be presented to the
Clinical Effectiveness, Audit and Guidelines Committee
and any areas of non-compliance will be monitored on a
six monthly basis. This will then be reported into the
Clinical Governance & Quality Committee.
Priority 7 - NICE Quality Standards (QSTs)
The National Institute for Health and Care Excellence
(NICE) provide a number of different types of guidance
based on the best evidence. NICE quality standards
describe high-priority areas for quality improvement in a
2
Patient Experience
Priority 8 – Patient Experience
The Trust regularly seeks the opinions of its patients and
receives feedback from a number of National Patient
Experience Surveys. Whilst the Trust continues to perform
well in patient experience measures such as the National
Inpatient and Outpatient Surveys it recognises that there is
always the potential for further improvement and is
committed to monitoring and improving the patient
experience. We will continue to build on the developments
in 2014/15 with the Friends and Family Test (FFT) with
further roll out planned in Children’s Services and
Community Services.
defined care or service area. Each standard consists of a
prioritised set of specific, concise and measurable
statements. They draw on existing guidance, which
provides an underpinning, comprehensive set of
recommendations, and are designed to support the
measurement of improvement.
We wish to demonstrate that not only do we take the
concerns of patients and carers seriously, but that our care
matches up to our vision “to be the ‘health service for
Newcastle’ and a leading national healthcare provider”;
and will achieve this through actively seeking views from
the people we serve and the people they love.
We aim, where appropriate, to be compliant with NICE
guidance and strive to ensure that the processes used
within our services are based on the most up to date and
best practice guidance available.
The Francis Report (2013) and the Keogh Report (2013)
both stressed the importance of the patient and carer's
voice. It was the persistence of family members who
brought around the in-depth review and one of the
findings was that if patients and carers had been listened
to, it may well have saved lives.
In 2015/16, three QSTs have been selected to review and
support their implementation across the Trust. These
include:
The results of this indicator will be reported to the Trust
Board and various patient experience committees and
relevant forums.
• QS1 Dementia – this NICE quality standard defines a
high standard of care for patients with dementia. The
Trust have previously implemented a number of new
initiatives and strategies to improve the care patients
receive with dementia and continue to strive to make
further improvements in response to the needs of
patients with cognitive impairment
To make sure a welcoming approach is embedded in
everything that we do, the Trust is to embrace the national
campaign based on the simple but vital courtesy of
introducing yourself. Founded by Dr Kate Granger, a
Consultant in Elderly Care and herself a patient with
terminal cancer, this new scheme was introduced in
January 2015 with over 80 NHS organisations now signed
up. This was officially launched in May 2015 across the
Trust.
• QS66 Intravenous Fluid Therapy in Adults in Hospital –
This quality standard covers the assessment and
management of adults’ intravenous (IV) fluid needs in
hospital. IV fluid therapy is the provision of fluid and/or
electrolytes directly into the vein. This quality standard
does not cover the use of blood or blood products. It
was published in August 2014 and has been selected
because the Trust are committed to patient safety and
wish to progress to full implementation of the standard
This indicator will be reported to the Clinical Governance
& Quality Committee via the Clinical Effectiveness, Audit &
Guidelines Committee.
“
All staff are great, polite,
friendly, helpful and the
ward's facilities made us
feel more at home and
less upsetting about
being in hospital
“
• QS49 Surgical Site Infection – This quality standard
covers the prevention and treatment of surgical site
infection for adults, children and young people
undergoing surgical incisions through the skin, in all
healthcare settings. It was published in October 2013
and is aligned to the Sign up to Safety Campaign
Quality Account 2014/15 7
Commissioning for Quality
and Innovation (CQUIN) Indicators
The Commissioning for Quality and Innovation (CQUIN) payment
framework is designed to support the cultural shift to put quality
at the heart of the NHS. Local CQUIN schemes contain goals for
quality and innovation that have been agreed between the Trust
and the Commissioner. For 2015/16 due to ongoing debate and
negotiations regarding the national payment tariff we are unable
to progress a CQUIN scheme. The Trust will however continue with
all the internal quality improvement projects as outlined in part 2
of this document.
8 Quality Account 2014/15
Statement of assurance from the Board
2
During 2014/15 the Newcastle
upon Tyne Hospitals NHS
Foundation Trust provided
and/or sub-contracted 17
“relevant” health services.
The Newcastle upon Tyne Hospitals NHS Foundation Trust
has reviewed all the data available to them on the quality
of care in all 17 of these “relevant” health services.
The income generated by the relevant health services
reviewed in 2014/15 represents 100 per cent of the total
income generated from the provision of relevant health
services by the Newcastle upon Tyne Hospitals NHS
Foundation Trust for 2014/15.
The Newcastle upon Tyne Hospitals NHS Foundation Trust
aims to put quality at the heart of everything we do and to
constantly strive for improvement by monitoring
effectiveness. High level parameters of quality and safety
have been reported monthly to the Board and Council of
Governors. The Quality Report, reports information under
the headings of Patient Safety, Clinical Effectiveness and
Patient Experience, all of which feature factors relating to
the patient experience. Activity is monitored in respect of
quality priorities and safety indicators by exception and
performance is compared with local and national
standards.
The Trust Complaints Panel is chaired by a Non-Executive
Director of the Trust and reports directly to the Trust Board,
picking up any areas of concern with individual
Directorates as and when necessary.
The monthly Clinical Assurance Tool (CAT) continues to
provide clinical assurance to the Trust Board as an
overview of performance against a wide range of clinical
and environmental measures for each ward and
Directorate. The aim of the CAT is to measure and
demonstrate compliance with the published documents
and national drivers such as High Impact Actions, Saving
Lives as well as providing useful data to support, verify and
offer assurance for external inspectorates.
Feedback and, where necessary, reports on improvement
actions are provided to the Corporate Governance
Committee.
“
Felt safe with compassionate,
kind, professional staff. I was
given expert care by
everyone, from the highest
grade staff, to the lowest
grade. All lovely, caring
people who are dedicated
to their jobs.
“
Leadership walkabouts, coordinated by the Quality and
Effectiveness Lead, involving Executive and Non-Executive
Directors and members of the Medical Director’s and
Nursing and Patient Services Director’s teams have been
regularly conducted in a variety of departments across the
Trust. These are reported to the Corporate Governance
Committee, a standing committee of the Trust Board, and
any actions reported, acted upon and followed up.
Quality Account 2014/15 9
Part 3
Review of Quality Performance 2014/15
The information presented in this Quality Account represents
information which has been monitored over the last 12 months by
the Trust Board, Council of Governors, Clinical Governance &
Quality Committee and the Clinical Policy Group.
The majority of the Account represents information from
all 17 Clinical Directorates presented as total figures for
the Trust. The indicators to be presented and monitored
were selected following discussions with the Trust Board.
They were agreed by the Executive Team and have been
developed over the last 12 months following guidance
from senior clinical staff. The quality priorities for
improvement have been discussed and agreed by the Trust
Board and representatives from the Council of Governors.
The Trust has as intended in 2014/15 consulted more
widely with members of the public and local committees in
ensuring that the indicators presented in this document are
what the public expect to be reported. Comments are still
to be received from Health Scrutiny Committee Newcastle
City Council, Newcastle, Gateshead Northumberland and
North Tyneside Clinical Commissioning Groups (CCGs) and
Healthwatch Newcastle.
Patient Safety
Priority 1 - To reduce all forms of healthcare associated
infection (HCAI), we will quantify our success in this by:
• Aiming for the annual number of Methicillin Resistant
Staphylococcus Aureus (MRSA) bacteraemia cases to
be zero
• Reducing hospital acquired infections related to
Clostridium difficile (C.difficile) to no more than 80
cases in the next year
10 Quality Account 2014/15
As well as MRSA and C. difficile, the Trust monitors rates
of Methicillin-Sensitive Staphylococcus Aureus (MSSA) and
Escherichia coli (E. coli) bacteraemia.
The definition of MRSA is:
Staphylococcus Aureus (S. aureus) is a bacterium that
commonly colonises human skin and mucosa (e.g. inside
the nose) without causing any problems. Although most
healthy people are unaffected by it, it can cause disease,
particularly if the bacteria enters the body, for example
through broken skin or a medical procedure. MRSA is a
form of S. aureus that has developed resistance to more
commonly used antibiotics. MRSA bacteraemia is a blood
stream infection that can lead to life threatening sepsis
which can be fatal if not diagnosed early and treated
effectively.
The definition of C. difficile infection (CDI) is:
C. difficile diarrhoea is a type of infectious diarrhoea
caused by the bacteria Clostridium difficile, a species of
gram-positive spore-forming bacteria. While it can be a
minor part of normal colonic flora, the bacterium causes
disease when competing bacteria in the gut have been
reduced by antibiotic treatment.
The definition of MSSA is:
As stated above for MSSA the only difference between
MRSA and MSSA is the degree of antibiotic resistance:
other than that there is no real difference between them.
The definition of E. coli is:
Escherichia coli (E. coli) bacteria are frequently found in the
intestines of humans and animals. There are many
different types of E. coli, and while some live in the
intestine quite harmlessly, others may cause a variety of
diseases. The bacterium is found in faeces and can survive
in the environment. E. coli bacteria can cause a range of
infections including urinary tract infection, cystitis
(infection of the bladder), and intestinal infection. E. coli
bacteraemia (blood stream infection) may be caused by
primary infections spreading to the blood.
Trust position:
During the period April 2014 to March 2015, there have
been:
• Five MRSA bacteraemia cases attributable to the Trust.
There is a ‘zero tolerance’ approach to MRSA infections
• 73 cases of hospital acquired C. difficile, against an
annual target of 80 cases
• 68 cases of MSSA bacteraemia
• 133 cases of E. coli bacteraemia
3
Table 1: Trust rate MRSA bacteraemia, C. Difficile,
MSSA and E. coli 2010/11-2014/15
Infection
2010/11
2011/12
2012/13
2013/14
2014/15
8
7
4
8
5
150
101
76
75
73
MSSA
bacteraemia
Not
reported
87
75
87
68
E. coli
bacteraemia
Not
reported
142
159
160
133
MRSA
bacteraemia
C. difficile
The exhibits below indicate the position of the Trust as
at the end of March 2015 and the progress made over
time in respect of reducing the incidences of these
hospital acquired infections. The figures are reported to
the Trust Board and Public Health England (PHE) on a
monthly basis.
Exhibit 1: Trust acquired MRSA bacteraemia rates
2010/11 - 2014/15
MRSA bacteraemia
MRSA bacteraemia
9
C. difficile
C. difficile
160
150
8
140
7
7
120
101
6
5
5
76
80
4
4
100
75
73
60
3
40
2
20
1
0
0
2010/11
2011/12
“
2012/13
2013/14
2014/15
2010/11
2011/12
2012/13
2013/14
2014/15
Staff are extremely caring and friendly. I feel
secure and comfortable in their care, also
confident that my treatment is being successful
fills me with positive vibes. Thank you.
“
8
8
Exhibit 2: Trust acquired C. difficile rates
2010/11 - 2014/15
Quality Account 2014/15 11
Exhibit 3: Trust acquired MSSA bacteraemia rates
2011/12 - 2014/15
Exhibit 4: Trust acquired E. coli bacteraemia rates
2011/12 - 2014/15
E. coli bacteraemia
MSSA bacteraemia
MSSA bacteraemia
10
0
87
E. coli bacteraemia
180
160
87
160
90
75
68
70
133
120
60
100
50
80
40
159
142
140
80
60
30
40
20
20
10
0
0
2011/12
2014/15
• Clinical Directors and Directorate Managers now
produce Directorate HCAI action plans, which clearly
identify compliance and progress with the HCAI
Prevention Strategy. These action plans are updated on
a regular basis and the IPC Operational Group provides
feedback when the action plans are submitted
• Antibiotic stewardship is a standing agenda item at
IPCC. Antibiotic champions have been appointed in the
majority of medical specialties to lead on audit work. A
number of the champions attend the Antimicrobial
Steering Group meetings on a regular basis to have
input into the audit process. Pharmacy undertakes
quarterly ward usage audits to demonstrate trends and
will implement an annual Trust-wide prevalence audit
Priority 2 - In accordance with the Safety Thermometer to
prevent avoidable harm, disability or death from:
National target
12 Quality Account 2014/15
April 2014 - March 2015
March
February
January
December
98.00
97.50
97.00
96.50
96.00
95.50
95.00
94.50
94.00
93.50
April
Exhibit 5 provides an update of the Trust’s twelve month
position up to March 2015 with regard to delivering harm
free care. It shows that the Trust has consistently been
above the 95% national target.
Safety Thermometer Harm Free Care
November
Falls
Pressure Ulcers
Catheter related urinary tract infections (UTIs)
Venous thromboembolism (VTE)
Exhibit 5: Trust position of harm free care
April 2014 - March 2015
October
•
•
•
•
2014/15
• The E. coli bacteraemia numbers (post-48 hours) are at
their lowest level since data collection began in
2011/12. Where patients have developed E. coli, the
suspected source of the infection is recorded and
monitored, with particular attention paid to those
patients who had a urinary catheter in place at the
time
September
• HCAI action plans being regularly reviewed by the
Infection Prevention and Control Committee and
Infection Prevention & Control Team. HCAI is a
standing agenda item at the Trust main forums and
Directorate level communication and governance
meetings
• Following each case of MRSA bacteraemia a Rapid
Review and Post Infection Review (PIR) Toolkit are
completed. A Serious Infection Review Meeting (SIRM)
is held and lessons learned are discussed and
implemented. This information is collated in a quarterly
report, which facilitates the sharing of lessons learned
and best practice Trust-wide
• Following each C. difficile case attributed to the Trust, a
root cause analysis (RCA) form is completed and the
results compiled in a database. This information
contributes to the production of the quarterly report. A
SIRM is held where C. difficile is on the death certificate
or where there are clear lessons to be learned (such as
lapses in care). A period of increased incidence (two or
more cases on a ward within 28 days) leads to a MDT
review to discuss the cases
• The Trust has focused on areas where patients are
identified at a higher risk of MSSA which include the
2013/14
Cardiothoracic and Renal Services Directorates. High
risk patients are now identified and treated with
chlorhexidine washes. The Cardiothoracic Directorate
have decreased the numbers of MSSA bacteraemia
from 29 in 2013/14 (33% of the Trust’s cases) to 11 in
2014/15 (16% of the Trust’s cases)
August
There are a number of strategies that the Trust has
implemented to monitor and reduce the number of
HCAIs, these include:
2012/13
July
2013/14
June
2012/13
May
2011/12
“
“
Friendly helpful and sympathetic to
ones needs, and very positive
for me when I wasn't
Falls
The Trust is consistently reporting below the national acute
Trust average of 6.8 falls/1000 bed days (Trust current
average for 2014/15 is 5.5, April-Dec inclusive). The Trust
is performing better than last year and is currently
reporting an average falls/1000 bed days rate of 5.5
compared to 5.7 for the same period last year.
Furthermore, falls resulting in serious harm (all incidents
graded moderate and above) have reduced by 27%.
Inpatient falls data is analysed continually by the Falls
Prevention Coordinator who looks at data at ward,
directorate and Trust level. Monthly, seasonal variation is
acknowledged and compared to historical data but all
significant increases in incidence at ward or directorate
level are analysed closely to identify any key themes and
learning from incidences.
Falls with serious harm are monitored through a
comprehensive Root Cause Analysis (RCA) process and
these are reviewed quarterly to examine areas of good
practice and areas for improvement. The Trust has
committed to a number of work streams to drive best
practice locally and nationally and has been successful in a
bid to the Academic Health Science Network to lead a
regional piece of work to measure the impact of increasing
compliance of utilisation of a evidence based Falls Care
Bundle and once baseline data is established to test some
additional interventions.
The funnel plot below shows the Trust position in relation
to the number of patient falls that result in harm against
the national position reported in the March 2015 Safety
Thermometer prevalence study (* the Trust is represented
as the selected symbol t). This is below the national
average.
Funnel plot 1: Trust position for patient falls that result
in harm in the March 2015 Safety Thermometer
prevalence study
DATIX incident data and Safety Thermometer prevalence
data is used in a monthly quality dashboard that helps
monitor incidents and trends of pressure ulcers to the
Pressure Ulcer Taskforce.
The Tissue Viability Team monitor all pressure ulcers
reported on DATIX and if the information submitted lacks
detail, further clarifications are sought from the clinical
areas to ensure correct classification. Categorisation is not
an exact science and a level of experience is necessary to
validate data.
Definition of category I: Intact skin with non-blanchable
redness or a localised area usually over a bony
prominence. Darkly pigmented skin may not have visible
blanching: its colour may differ from the surrounding area.
The area may be painful, firm, soft, warmer or cooler as
compared to adjacent tissue.
Definition of category II - partial thickness skin loss or
blister. Partial thickness loss of dermis presenting as a
shallow open ulcer with a red pink wound bed, without
slough. May also present as an intact or open/ruptured
serum-filled blister.
Definition of category III: Full thickness skin loss. Full
thickness tissue loss. Subcutaneous fat may be visible but
bone, tendon or muscle is not exposed. Slough may be
present but does not obscure the depth of tissue loss. May
include exposed. Slough may be present but does not
obscure the depth of tissue loss. May include undermining
and tunnelling. The depth of a Category III pressure ulcer
varies by anatomical location.
Definition of category IV: Full thickness tissue loss. Full
thickness tissue loss with exposed bone, tendon or muscle.
Slough or eschar may be present. Often includes
undermining and tunnelling.
Definition of unable to categorise: Full thickness tissue
loss in which actual depth of the ulcer is completely
obscured by slough (yellow, tan, grey, green or brown)
and/or eschar (tan, brown or black) in the wound bed.
Until enough slough and/or eschar are removed to expose
the base of the wound, the true depth cannot be
determined; but it will be either a Category III or IV.
Definition of moisture lesions: Moisture lesions are not
Category II pressure ulcers. These lesions are due to
excessive moisture to the skin (urinary and faecal
incontinence, wound exudate, perspiration).
Funnel plot for falls with harm
30
25
The Trust is also involved in the Safety Thermometer
monthly prevalence study which collects data regarding a
patient’s worst pressure ulcer, which can be old or new
and only includes pressure ulcer of category II and above.
20
15
10
5
Number of patients
NuTH
Acute Hospitals
Upper Control Limit
Lower Control Limit
34000
32000
30000
28000
26000
24000
22000
20000
18000
16000
14000
12000
8000
10000
6000
4000
0
0
2000
Harm per 1000
Pressure Damage
Definition of old and new pressure ulcers: a patient is
defined as developing an old pressure ulcer when they are
admitted with it and a new pressure ulcer when it
developed whilst in our care.
In terms of reducing pressure ulcers, the Trust reported
success in April 2014 when the CQUIN target to sustain a
25% reduction in new pressure ulcers reported on Safety
Thermometer was achieved. A further CQUIN target for
Quality Account 2014/15 13
3
2014/15 was mandated requiring an additional 20%
reduction in new pressure ulcers by September 2014 (this
was achieved) and to sustain this for 6 months.
The Trust achieved and maintained its reduction in
Community Services however only achieved and
maintained it reduction in acute services up to December
2014. From January – March 2015 a 20% reduction was
not maintained but this was during an extremely busy
period which coincided with peak in emergency activity
and patient acuity.
patients/residents. These developments have been coordinated by the Catheter Care Sub-Group and the
Continence Service. These key areas of work have helped
to ensure that within the Trust rates of CAUTI/UTI continue
to remain low.
Two areas were identified for interdisciplinary working
between primary, secondary and tertiary care as part of a
Specialist Care Home Support Team; optimisation for
antibiotic prescribing and adherence to Trust product
formulary. This is being achieved by:
Although disappointing to see the rise in incidents the
level of harm remains reduced. The Tissue Viability Team
continues to work with all Trust staff to achieve “zero
tolerance” to Trust acquired pressure damage. Several
wards have achieved significant numbers of days “harm
free” including three wards who have been harm free
from pressure damage for over 1 year (Ward 20 RVI; Ward
40 RVI and Ward 46 RVI).
The funnel plot below shows the Trust position in relation
to the number of patients that were reported as
developing grade II or above pressure ulcers against the
national position reported in the March 2015 Safety
Thermometer prevalence study (*the Trust is represented
as the selected symbol t). This is below the national
average.
Funnel plot 2: Trust position for patients that were
reported as developing grade II and above pressure ulcers
in the March 2015 Safety Thermometer prevalence study
• Working with a selected group of Care Homes and
GPs; through support with education and training
there has been an increase in the percentage of
antibiotic optimisation for CAUTI/UTI, quarter 4
showing 93%
• Reduction in the incidence of catheterised residents in
a selected group of Care Homes, the national average
of residents with a urinary catheter is 10%, whilst in
Newcastle it is 5.6%; this has been achieved through
specialist nurse assessment, support and education for
Care Homes staff
The funnel plot below shows the Trust position in relation
to the number of patients that developed a CAUTI against
the national position reported in the March 2015 Safety
Thermometer prevalence study (*the Trust is represented
as the selected symbol t). This is below the national
average.
Funnel plot 3: Trust position for the number of patients
that developed a CAUTI in the March 2015 Safety
Thermometer prevalence study
Funnel plot for pressure ulcer prevalence
120
Funnel plot for catheters with UTI
100
35
60
30
Harm per 1000
40
20
25
20
15
10
Lower Control Limit
The work to avoid harm from UTI (Urinary Tract Infection)
as for CAUTI (Catheter Associated Urinary Tract Infection)
has continued with specific focus on interdisciplinary
working between primary, secondary and tertiary care
settings. It is recognised that UTI’s are one of the highest
causes of admission to secondary care, particularly from
Care Homes; therefore work streams to avoid admissions
have been essential.
Several best practice guidelines have either been
developed or implemented within the Trust to help to
achieve harm free care for CAUTI/UTI for
14 Quality Account 2014/15
Acute Hospitals
Upper Control Limit
Lower Control Limit
Venous thromboembolism (VTE)
A venous thromboembolism (VTE) is a blood clot
(thrombus) that forms within a vein. VTE is the collective
name for deep vein thrombosis (DVT) and pulmonary
embolism (PE).
In 2005, a House of Commons Health Committee report
stated that every year in England an estimated 25,000
deaths occur as a result of hospital-acquired VTE. The
government recognises that deaths from hospital blood
clots are preventable and has recommended that all
34000
32000
30000
28000
26000
24000
22000
20000
18000
16000
14000
Number of patients
NuTH
UTI and CAUTI
12000
8000
10000
Acute Hospitals
Upper Control Limit
6000
NuTH
0
4000
Number of patients
5
2000
34000
32000
30000
28000
26000
24000
22000
20000
18000
16000
14000
12000
8000
10000
6000
4000
0
2000
0
0
Harm per 1000
40
80
3
patients admitted to hospital should be assessed for their
risk of developing blood clots and, if necessary, protection
should be provided.
All adult inpatients should have a VTE risk assessment on
admission to hospital, using the clinical criteria of the
national tool. Monthly data is reported to the Department
of Health and the Trust consistently achieved above 95%
in 2014/15.
The funnel plot below shows the Trust position in relation
to the number of patients that have a VTE assessment
undertaken on admission to hospital in the March 2015
Safety Thermometer prevalence study (* the Trust is
represented as the selected symbol t). This is above the
national average.
The RCA process involves both the patient’s lead clinicians
and the Trust lead clinician for VTE. The process facilitates
learning and is used to identify areas for change and to
develop recommendations which deliver safer care for our
patients.
The funnel plot below shows the Trust position in relation
to the number of patients that develop a HAT 2015 (* the
Trust is represented as the selected symbol t). This is
below the national average.
Funnel plot 5: Trust position for patients that were
reported as developing a HAT in the March 2015 Safety
Thermometer prevalence study
Funnel plot for VTE incidence
25
Funnel plot 4: Trust position for patients that had a VTE
assessment undertaken on admission that was reported in
the March 2015 Safety Thermometer prevalence study
34000
32000
30000
28000
26000
24000
22000
20000
18000
16000
14000
400
12000
0
8000
600
10000
5
0
800
6000
10
4000
1000
15
2000
Harm per 1000
Funnel plot for VTE RA
Rate per 1000
20
Number of patients
NuTH
Acute Hospitals
Upper Control Limit
34000
32000
30000
28000
26000
24000
22000
20000
18000
16000
14000
12000
8000
10000
6000
4000
0
2000
0
Number of patients
NuTH
Acute Hospitals
Upper Control Limit
Lower Control Limit
All cases of VTE are identified through diagnostic services,
pathology and bereavement services. They are then
reviewed by the nurse specialist to identifying how many
of these satisfy the definition for a hospital acquired VTE
(HAT). These cases are then subject to a Root Cause
Analysis (RCA) to identify how and why the VTE occurred.
“
Lower Control Limit
“
200
Pleasant, friendly
competent staff, very
reassuring
Quality Account 2014/15 15
Priority 3 - In accordance with the National Patient Safety
Agency (NPSA) Seven Steps to Patient Safety the aim would
be to improve the rates of patient safety incident reporting
and learn from incidents in order to improve patient safety.
During this year the Trust has aimed to encourage staff to
report more patient incidents as according to figures
reported by the National Reporting and Learning System
our reporting rate is much lower than other similar Trusts.
In 2014/15 the Trust reported 14,787 compared to 13,275
in 2013/14. This equates to an 11.4% rise.
Over the last two years, since the Community Directorate
was established there has been a steady increase in the
number of incidents reported per quarter. This is in line
with the rest of the Trust which has achieved a 22%
increase in reporting over the last two years.
A second Trust-wide Safety Culture survey was undertaken
in November – December 2014 some1286 staff responded
which is 30% less than the response rate of 1838 in the
2012 survey. It is acknowledged that the reduction in
response rates may be partly due to the number of surveys
staff have been asked to complete in the previous two
years.
Most staff who completed the survey continue to feel
positive about the attitude of their teams with regard to
patient safety. They stated that they are actively trying to
improve safety, they feel able to raise concerns and their
team works well together.
There are indications that staff feel the safety culture and
attitude across the organisation with regard to patient
safety is improving.
Staff perception regarding the culture of openness and
feedback about errors has improved. Similarly there is a
change in perception regarding a non punitive response to
error with fewer staff feeling that mistakes are held
against them.
Staff perception of Trust management support for patient
safety has improved considerably in 2014 compared with
2012.
Various mechanisms and initiatives have been introduced
in 2014/15 to promote an open and honest reporting and
learning culture including Patient Safety Briefings which
take place at the Royal Victoria Infirmary and Freeman
Hospital each month. This is a forum for sharing lessons
learned from previous patient safety incidents. All staff are
invited to attend and feedback is extremely positive.
Priority 4 - To build on the existing robust safeguarding
arrangement by developing a Trust Strategy which will
outline the longer term priorities and vision for Trust
Safeguarding arrangements. The Strategy will focus
specifically on work related to the Mental Capacity Act
(MCA) and Consent. The achievements within the new
strategy will be monitored throughout 2014/15 to
demonstrate achievement in line with the strategy.
Briefing in a minute
Summary
Key Facts
Risks
What Next?
• All Patients are at risk of
deterioration
• Looking at and talking to our
patient is key to informing us
of how they are doing
• The NEWS provides a safety
net for monitoring our
patients
• Great progress has been
made recently in improving
the process
• Opportunities to detect
deterioration early are
unfortunately still being
missed ➔ resulting in further
deterioration at which point
the early simple effective
interventions may no longer
work and critical care
admission or cardiac arrest
may result
• Each of the 6 Observations
are recorded on average 98%
of the time
• Urine output is commonly not
scored when patients are on
fluid balance charts
• The NEWS score is correct
90% of the time
• Only 1/470 patients triggered
nursing concern March 2015
audit
• A documented timely
response is only seen in 50%
cases
• Failure to escalate to senior
level is both a local and
nationally recognised
common failure
• High risk RED patients
admitted to critical care have
up to 40% mortality.
ORANGE medium risk have
up to 20% mortality
• Up to 40% of cardiac arrests
admitted to critical care may
have been prevented - local
data
• Similar issues in paeds wards
• Missing observations reduces
the chance of detecting
deterioration
• Delayed detection of
deterioration increases chance
of death or critical care
admission and failure of
effective early interventions
• Not escalating to senior
members of the team denies
patients the opportunity of
input into their care from
experiences clinicians
• Once deterioration progresses
to cardiac arrest the chance of
survival is very poor
• The Coroner will expect the
NEWS system has been
followed and failure risks legal
action and potential referral
to GMC
• Wards audit your own
practice - review your charts
identify gaps in monitoring
and issues with escalation
• Develop local plans to address
any gaps
• Is your escalation policy visible
at the nursing station, is it
working, does it need
updating?
• Add Nursing concern if
concerned
• Don’t forget urine output
score if on fluid balance chart
• Have a plan to ensure the
next set of observations is
done on time
• Has everyone been trained?
Use the breeze training
package - use your Outreach
team or critical care
consultants if not sure
• Ensure the responses is
documented
Patient
Safety
Briefing
16 Quality Account 2014/15
An overview to keep, copy and share
Date: 27th April 2015
Presenters: RVI - Phil Laws
Freeman - Annette Richardson
“
All staff from the cleaners to
the head medical staff are
friendly, and approachable,
never made me feel daft when
I asked any questions, always
found time to answer me and
give me honest answers,
always clean and tidy
“
The Trust Safeguarding Strategic Goals were approved by
the Trust Board in May 2014. This included and defined
the strategic priorities within Safeguarding for the next
two years. The details are as follows:
Safeguarding Strategic Goals
The Trust is committed to ensuring it has robust
Safeguarding processes in place so that, once vulnerability
or risk are identified, individuals are protected and
information shared appropriately. The Trust will continue
to review processes in light of case reviews and guidance
from Newcastle Safeguarding Boards (NSB) for Children
and Adults. It will:
• Ensure it meets its statutory duties in relation to Mental
Capacity Act and Deprivation of Liberty Safeguards
• Work with staff across the organisation to effectively
identify and support patients with Learning Disabilities
by providing reasonable adjustments to meet their
individual needs
• Continue to provide a high quality proactive service to
support all staff working with children, young people
and families in order to ensure children, young people
and their families have their needs met and protection
risks identified in a timely way
• Continue to support the work of the NSCB and the
Trust to promote the safety and welfare of young
people living and studying in Newcastle
• Continue to contribute to the statutory health needs of
looked after children and young people
• Explore potential to recruit more Consultant
Paediatricians to the Paediatric Forensic Service
• Ensure learning from child deaths is embedded within
Trust systems
• Recognise that the point of transition from child to
adult services is a time of particular risk for vulnerable
young people and it will ensure that transition is robust
between all safeguarding teams
Work has been ongoing to achieve these goals specific
areas of note are in relation to:
• Meeting statutory duties in relation to Mental Capacity
Act and Deprivation of Liberty Safeguards There has
been an evidenced rise in the number of Deprivation of
Liberty Applications made by the Trust since the
‘Cheshire West’ Supreme Court ruling in March 2014
• Working with staff across the organisation to
effectively identify and support patients with Learning
Disabilities by providing reasonable adjustments to
meet their individual needs. Referrals to the Learning
Disabilities team continue to rise, the team now cover
acute and community settings for children and adults.
Currently the team are conducting a pilot study of
Mortality Reviews on all patients with a learning
disability who passed away whilst in the Trusts’ care
between January- March 2015
• Continuing to provide a high quality proactive service
to support all staff working with children, young
people and families in order to ensure children, young
people and their families have their needs met and
protection risks identified in a timely way. Referrals
have increased in relation to Adult Children and
Maternity safeguarding concerns being raised by staff
across the year
• Continuing to support the work of the NSCB and
NSAB and be active members of both Boards both at
executive and practitioner level
• Recognising that the point of transition from child to
adult services is a time of particular risk for vulnerable
young people and it will ensure that transition is robust
between all safeguarding teams. The NSCB and NSAB
have produced a helpful Transition Protocol which is
now embedded in Trust Safeguarding Policy
In addition, the Trust has recognised the strategic impact
of the increasing age profile and incidence of cognitive
impairment which will increase the age and vulnerability of
the population of Newcastle who require safeguarding.
Changes in birth rates may also impact on Maternity and
Children’s Safeguarding hence the Trust will ensure its
workforce is prepared and aware of these challenges and
their individual responsibilities to safeguard those at risk.
The Trust is committed to maintaining compliance with
national guidance in relation to the safeguarding
competencies of its workforce, and to work jointly with
others in the city to meet this need recognising the
benefits of multi-agency training. The strategic
safeguarding aims related to the Trust workforce have
been taken forward through:
• Ensuring all clinical staff have the appropriate
knowledge and skills to respond to safeguarding
concerns. All adult safeguarding training programmes,
materials and policies have been reviewed to reflect the
implementation of The Care Act (2014)
• Ensuring ongoing communication and supervisory
provision within the Trust so that staff continue to
reflect and learn from safeguarding concerns and
develop practice. A Safeguarding Communication
Forum is now well established where learning from
significant cases is shared and acted upon
• Continuing to raise awareness of MCA/DoLs across
Trust and implement mandatory training for
MCA/DOLs (as relevant to role) A Level 2 e-Learning
package is now available on Breeze incorporating
MCA/DoLs, Adult Safeguarding and Learning
Disabilities, additional work has been undertaken in
relation to MCA in conjunction with the CCG
Quality Account 2014/15 17
3
• Patients >75 admitted as an emergency who are
reported as having: known diagnosis of Dementia or
clinical diagnosis of Delirium, or who have been more
forgetful in the past 12 months
• Patients reported as having had a diagnostic
assessment including investigations
• Patients referred for further diagnostic advice in line
with local pathways agreed with commissioners
• Increased the ability of staff to routinely and selectively
enquire about Domestic Abuse and then respond
appropriately, both in relation to patients and also
recognising that as an employer of 14,000 staff this is
a staff wellbeing responsibility too. The numbers of
Domestic abuse referrals received and made by the
Trust has increased over the year. The Trust also held
a successful Domestic Abuse Conference in November
2014.
All teams have worked to internally review processes,
audit practice and provide information as requested to
support external assurance processes. Through the Trust
safeguarding management structure, results of audit,
assurance work and case reviews will be examined and
challenged and progress against agreed actions monitored
and reviewed. Regular reporting to Trust Board and the
Newcastle Safeguarding Boards for Children and Adults
has been maintained.
Priority 5 - To build on and develop the previous work
undertaken to ensure that patients with a diagnosis of
Dementia receive high quality individualised personal care
provided by a skilled workforce in an environment that
enhances their care and recognises the needs of their
carers.
To date, the Trust has achieved the required national
compliance level of 90% for every month this year for
each of the above areas and can be seen in exhibit 6.
Dementia Care Champions meetings (Nurses and Allied
Health Professionals) were also held throughout the year.
The National Dementia CQUIN Indicator in 2014/15
required the Trust to demonstrate that it had undertaken
monthly audits to test whether carers of people with
dementia feel supported.
Throughout the year questionnaires have been returned
and the following results have been found:
• 100% of staff were available to discuss their
carers/friends care whilst in hospital
• 80% of carers/friends felt that their comments were
acted upon by hospital staff
There is a national mandatory CQUIN target centred
around Dementia care and this includes three areas:
Exhibit 6- Dementia Compliance 2013/14-2014/15
Dementia Assessment Compliance 2013/14 - 2014/15
2013/14
2014/15
National Target
100
98
96
94
92
90
88
86
March
February
January
December
November
October
September
August
July
June
May
April
84
The Trust Dementia Care Steering Group has agreed a number of targets in relation to Dementia Care education and
training and an extensive programme has been undertaken in 2014/15, as per below:
Dementia Training in 2014/15
Number of staff
Dementia
training on
induction
e-learning
dementia
training
Dementia care
training
Barbara’s
story
Post graduate
certificate in
dementia
Post graduate
diploma in
dementia
Best practice
in dementia
care
2,470
120
175
90
5
9
5
18 Quality Account 2014/15
Emerging themes included:
Admission: There was an overall feeling that patients
with dementia are often admitted a number of times
which was usually via the admission suite and then to
various different base wards where they were cared for by
many different staff. All of the carers felt that it would be
beneficial to have consistency in staff. Patients often
deteriorated quite rapidly while in hospital and began to
lose trust in people in authority. They felt that consistency
in the senior medical staff caring for their relative would
be beneficial.
The relatives did talk about a relief when their relative was
admitted to hospital. This was especially so at night where
they knew staff would be looking after them and were not
alone where they could injure themselves.
Hospital stay: All carers felt staff were very supportive
and were good at communicating.
Environment: The carers talked about their relatives
becoming obsessed with time and they suggested that a
dementia clock placed at the bedside could be beneficial.
Staff roles: The carers involved in the focus group felt
that it would be beneficial for each ward to have an
identified Dementia Champion.
Carers also felt that being able to identify staff to speak
to would be beneficial to help enable them to seek out
the correct member of staff to assist them with any
queries they may have. The uniform colours were
explained to the group and it was highlighted that every
ward has a poster displaying key staff members and their
job titles.
Discharge: There were different views regarding
discharge. The majority of carers felt very supported in
relation to discharge, only one carer feeling that when
their relative was medically fit there seemed to be a rush
to get them out to free up a bed.
Information: It was felt that there was a lack of
information when patients were newly diagnosed with
dementia. Relatives often felt alone and did not know
what to say to their relative or how to tell them about the
impact of dementia.
Some relatives spoke about the difficulty in having to
decide that their relative should move from their home
into a nursing home. They felt that there was little
information or direction given regarding which care homes
they should look at.
3
Carers were asked if a standard Dementia Pack should be
provided which would include information on where to
obtain advice, useful contact telephone numbers and an
outline about Dementia and its symptoms. The relatives
felt that it would be good to be given this information on
admission rather than at discharge.
All carers felt that attending the focus group had been
beneficial and felt that by joining this group it had shown
them that they were not alone and there were others in
similar situations. They agreed that it would be beneficial
for regular focus group meetings to be planned next year
and this should be considered.
Overall the carers of patients with Dementia feel
supported. The feedback from the monthly audits and
focus group have provided positive feedback and show
that the Trust is providing support to carers of patients
with Dementia. However the Trust does recognise that
there is always the potential for further improvement and
is committed to continuing to receive feedback and act on
this. A pack is currently being reviewed to give to carers
when their relative is admitted and the Trust are also
reviewing the possibility of providing electronic clocks in
Older People’s Wards.
The Community Response and Rehabilitation Team also
embarked on a further patient experience project to
improve the skills, knowledge and documentation of the
team caring for patients in their home with cognitive
impairment. Caring for people in their own homes with a
cognitive impairment was particularly challenging for the
CRRT. They felt it was essential that they had the
knowledge and skills to feel confident to meet the needs
of people with cognitive impairment as far as is practicable
in the community setting.
The CRRT have now implemented a system which:
• Identifies patients with actual or potential cognitive
impairment early
• Improves early access to specialist mental health
services
• Ensures a patient’s cognition is assessed alongside their
functional and physical function in order to provide a
holistic assessment of the individual
“
Absolutely excellent everything.
You folks saved my life. From the
999 operator to the paramedics to
the surgeons and the nurses &
carers, I couldn't have wished for
better treatment. Thank you.
“
• 100% of carers/friends felt that there was access to the
support they needed whilst their relative was in
hospital
• 80% of carers/friends felt there was written
information available and easy to understand
• 67% of carers/friends felt that this written information
was helpful
• 100% of carers/friends felt included as much as
possible in their relatives care whilst they were in
hospital
A focus group was undertaken in November 2014 where
a total of seven carers attended. The focus group was
chaired by the Nurse Consultant for Older People and the
aim was for carers to share their stories about being a
carer for someone with dementia, what their experience is
when their relative is in hospital and what the Trust could
do to support them.
Quality Account 2014/15 19
• Link with voluntary agencies and organisations to
patients with cognitive impairment
• Ensures Primary Care Practitioners (GPs) are involved in
the decision making processes for patients with
cognitive impairment and their families and carers
• Shares essential and relevant information with GP’s
regarding patients with cognitive impairment
Clinical Effectiveness
Priority 6 - To monitor mortality indicators with the aim of
reducing avoidable deaths and build on developments
achieved in 2013/14.
Over the past 12 months the Trust has continued to
monitor the number of patients that die within our
hospitals and those too who pass away soon after being
discharged from our care. We carefully monitor our
mortality rates comparing the number of patients we
would expect to die, given the severity of their condition,
by using national models against the number of patients
who actually die. We use both the Summary Hospital-level
Mortality Indicator (SHMI) and the Hospital Standardised
Mortality Ratio (HSMR) to help us do this.
The most recently available data shows that our mortality
rates according to SHMI and HSMR are within expected
levels. The exhibits below show how we perform in
comparison to the average for England (exhibit 7) and in
comparison to other providers within the North East
(exhibit 8).
Exhibit 7- SHMI for Newcastle upon Tyne Hospitals (NUTH) Foundation Trust vs National Average for England
SHMI for Newcastle upon Tyne Hospitals (NuTH) Foundation Trust
vs National Average for England
102
NuTH
England Average
100
98
96
SHMI
94
92
90
88
86
Oct 13 - Sept 14
Jul 13 - June 14
Apr 13 - Mar 14
Jan 13 - Dec 13
Oct 12 - Sept 13
Jul 12 - June 13
Apr 12 - Mar 13
Jan 12 - Dec 12
Oct 11 - Sept 12
Jul 11 - June 12
Apr 11 - Mar 12
Jan 11 - Dec 11
Oct 10 - Sept 11
Jul 10 - June 11
Apr 10 - Mar 11
84
Exhibit 8- SHMI vs HSMR. for North East Trusts Oct 2011 to Sep 2014
SHMI vs HSMR for North East Trusts Oct 2011 to Sept 2014
120
117
Source: NEQOS Hospital Mortality Monitoring: Report 24
Data extracted from HED May 2015
113
England
112
112
109
Average SHMI / HSMR
110
109
107
103
Average HSMR
Average SHMI
108
105
104
102
108
107
103
101
100
93
94
90
80
CDD
20 Quality Account 2014/15
North
Tees
South
Tees
Gateshead
South Tyneside
Sunderland
Newcastle
Northumbria
North Cumbria
“
All the staff are
wonderful, supportive,
caring. They really go
the extra mile to care
for you in a way, even
though I want to go
home, I will miss
them.
Exhibit 9- Direct observation compliance rate % September
2013 - November 2014
3
Direct observation overall compliance rate %
96
95.5
95
94.5
94
93.5
93
92.5
92
91.5
“
We are committed to working both within our region and
across the NHS more widely to help progress the national
agenda for reducing avoidable deaths. Over the last 12
months we have participated in several national studies
looking at the links between excess deaths according to
statistics like SHMI and HSMR and avoidable deaths
according to detailed case note reviews. We are also
actively engaged in a regional programme to understand
more about deaths related to patients who have a learning
disability.
November
September
July
May
March
February
January
December
November
October
However to ensure that they we are delivering safe and
effective care right across our services it is important that
we look beneath the headline data. To do this we monitor
the 140 different diagnostic groups that make up SHMI. If
we notice any patterns or increased numbers of deaths in
any areas we ensure that these are fully investigated by
senior clinicians with expertise in that field. The findings
from these reviews are shared so that if there are any
lessons to be learnt they are learnt by all. In addition to
this process we continue to hold traditional Morbidity and
Mortality (M&M) meetings within every department within
the Trust. These are not only important for monitoring the
quality of care delivered to patients who die within our
care but also to assist with the education of our junior
medical staff.
September
91
The Trust has also continued to monitor the response to
patients that trigger a MEWS score of 2 and above and
documented evidence of a plan of care within 60 minutes.
Exhibit 10 shows the Trust position which dipped in May
and November 2014.
Exhibit 10- Documented evidence of a plan of care for
patients triggering a MEWS score of 2 and above
September 2013 - November 2014
% of documented evidence of a plan of care for
patients that trigger a MEWS score of 2 and above
90
80
70
60
50
40
30
20
10
The Trust signed up to a local CQUIN target in 2014/15 to
improve the recognition and response to the deteriorating
patient. The improvement target was focussed on the
requirement to change the existing ‘MEWS’ (Modified
Early Warning Score) to ‘NEWS’ (National Early Warning
Score) to ensure consistency within the region.
The Trust has continued to monitor compliance with the
MEWS charts up to November 2014 and it is good to see
that the recording of observations has stayed above 90%
during this period. This can be seen in exhibit 9.
November
September
July
May
March
February
January
December
November
October
0
September
Priority 7 - To implement the National Early Warning
Score (NEWS) across the Trust to ensure early recognition
of the deteriorating patient. Reporting will include
monitoring of the development of the NEWS chart and
progress with the educational strategy including
compliance with training requirements.
The change over from MEWS to NEWS charts took place
across all adult inpatient wards on the 3rd December
2014. Overall this process went smoothly and feedback
from clinical staff has been positive.
The Trust continues to monitor the implementation of this
change and has organised further audits to monitor
compliance. To continue to improve the early recognition
of a deteriorating patient the Trust has signed up to a
three year “Sign up to Safety” Campaign. This will include
monitoring compliance with the NEWS charts on every
ward to try to reduce:
Quality Account 2014/15 21
Document number if in top or bottom boxes
RESP.
RATE
DATE
DATE
TIME
TIME
≥25
3
≥25
21-24
2
21-24
12-20
Sp02
9-11
≤8
3
≤8
≥94
92-93
2
92-93
≤91
3
≤91
%/L
2
%/L
≥39º
2
≥39º
1
38º
36º
N
NEWS
EWS S
SCORE
CORE MINIMUM
MINIMUM FREQUENCY
FREQUENCY
OF
OF MONITORING
MONITORING
36º
1
0
≤35º
3
≥220
210
3
210
200
3
200
190
1
190
180
1
180
170
170
160
160
150
150
140
140
130
130
120
120
110
110
1
100
BLOOD
PRESSURE
12 hourly observations
Total:
1-4
Total:
5 or more
or
3 in one
parameter
Total:
7
or more
70
70
3
50
≥130
3
≥130
120
2
120
110
110
100
100
1
90
80
80
70
70
60
60
50
•
30
3
COPD
Obesity/ Hypoventilation
Registered nurse to decide if increased
frequency of monitoring and / or escalation
of clinical care is required
•
NEWS responder
•
Response time 30 mins
Sign & date variance box
30
10
8
Urine Output <30ml/hr Y/N
3
Urine Output
7
Y/N
3
Concern
6
TOTAL
TOTAL SCORE
SCORE
5
TOTAL
TOTAL N
NEW
SCORE
EW S
CORE
Initials
XX
seve
Initials
Pain Score
4
Pain Score
3
2
Monitoring Frequency
1
Monitor Freq
News Escalation Plan Y/N n/a
Escal Plan
RN Review Initials
RN Initials
AND Outreach
Response time 10 mins
Time
NEWS Score
Individual Called
Name
Grade
Sign Ward
Staff
PCA continuous oxygen
prescriber/
transcriber
date
4 L/min
28%
10-15 L/min)
35% venturi)
use minimum 02 to achieve target
initial
time
D D MM Y Y Y Y
H H MM
CALLING
OUTREACH
CALLING O
UTREACH
IS
IS NOT
NOT A C
CRITICAL
RITICAL
CARE
C
ARE REFERRAL.
REFERRAL.
Registered nurse assesment
Ward NEWS Responder
Senior Ward NEWS Responder
Consultant
SENIOR
S
ENIOR WARD
WARD
MEDICAL
M
EDICAL STAFF
STAFF
MUST
M
UST DIRECTLY
DIRECTLY
CALL
TEAM
C
ALL IICU
CU T
EAM
Critical
Critical Care
Care
2nd call
call FH
FH
48483
48483 Anaesthetic
Anaesthetic 2nd
FH
48812
48812 GITU
GITU resident
resident FH
2nd call
call FH
FH
48830
48830 Cardiac
Cardiac ICU
ICU 2nd
29999 Critical
Critical Care
Care RVI
RVI
29999
PHYSIOLOGICAL
PHYSIOLOGICAL
P
ARAMETERS
PARAMETERS
3
Respiration
Rate
R
espiration R
ate
≤8
2
≤91
92-93
≤79
80-84
Any
Supplemental
A
ny S
upplemental
Oxygen
O
xygen
1
0
9-11
12-20
1
2
3
21-24
≥25
Date &
Time
Variance
Sign
Temp
Perm
T P
≤35.0
S
Systolic
ystolic B
BP
P
≤90
H
eart R
ate
Heart
Rate
≤40
off
LLevel
evel o
Consciousness
C
onsciousness
≥94
85-87
Yes
Temperature
T
emperature
<30ml/
hr
Scores persistently 7 or above
contact Pain Team
N
Nursing
ursing C
Concern
oncern
Yes
T P
Risk of Hypercapnic
Respiratory Failure
T P
T P
No
91-100
35.135.9
36.038.0
38.138.9
101110
111179
180199
41-50
51-90 91-110
NEW agitation
or confusion
score 3 X X X
U
rine O
utput
Urine
Output
≥88
≥39.0
111129
A
T P
≥200
T P
≥130
T P
V,P,
or U
T P
Patients with established
chronic/ anuric renal failure
score 0
0
No
T P
Confirm with nurse
in charge
NEWS Clinical Response
NEWS Clinical Response
Date
2
4%
24%
% delivery method
other target specify
Senior NEWS responder
•
•
Oxygen
O
xygen
Saturations
S
aturations
9
Alert
V/P/U
2 L/min
target saturation 88-92% (air
Other
3
Additional
Additional
Parameters
Parameters
•
40
Alert
Nursing Concern
Inform registered nurse who must assess
the patient;
target saturation 94-98% (air
National Early Warning Score (NEWS)
Risk of Hypercapnic Respiratory Failure
V/P/U
XX
D
DDMMYYYY
DMMYYYY
Oxygen Prescription (circle target)
Continue routine NEWS monitoring with
every set of observations
Outreach
Outreach
48817
48817 FH
FH
448881
8881
29995
29995 RVI
RVI
223956
3956
worst pain
Level of
Consciousness
•
•
Continuous
monitoring
50
1
Patient i.d.No.
STOP! THINK! Why has my Patient triggered?
90
40
Forename
60
50
Surname
Escalation Policy
Or
3 in two
parameters
80
60
1 hourly observations
90
80
HEART
RATE
4 hourly observations
100
2
90
D
DDMMYYYY
DMMYYYY
CLINICAL RESPONSE
RESPONSE
CLINICAL
3
≥220
Date
D.O.B.
37º
≤35º
Please Affix patient identification label in box below and document date
chart started
Outline Clinical Response to NEWS Triggers
38º
37º
TEMP
NEW SCORE
SCORE
NEW
uses Systolic
Systolic
uses
BP
BP
Please check variance before scoring
1
≥94
Inspired 02
Newcastle Upon Tyne
Hospitals Adult
NEWS Chart
12-20
9-11
Response
Time
Sign NEWS
Responder
Date
Time
NEWS Score
Individual Called
Name
Grade
Sign Ward
Staff
Response
Time
Sign NEWS
Responder
NUTH371
• Unplanned admissions to ITU (Intensive Therapy Unit)
• Cardiopulmonary resuscitations (cardiac arrests)
It was previously agreed that all relevant staff from adult
inpatient wards must either attend the lecture theatre
session or undertake the e-learning programme before the
launch of the NEWS. This excludes paediatric, obstetric,
community, outpatient, nurse specialists, research and
palliative care staff (unless the NEWS is used). A total of
4,309 staff were trained between October and December
2014.
NEWS training became a mandatory requirement on the
2nd January 2015 where all new staff employed in the
Trust must undertake NEWS training on induction.
Between the period January to March 2015 a total of 523
staff have received NEWS training on induction and an
additional 207 staff have undertaken NEWs training.
Priority 8 - The World Health Organisation (WHO) states
that at least half a million deaths per year would be
preventable with effective implementation of the WHO
Surgical Safety Checklist worldwide. In the Trust a new
safe surgery checklist was implemented in 2009 based on
the WHO checklist. The quality priority was to:
• Review and improve the current version of the WHO
checklist which will be achieved by working with
relevant stakeholders
• Monitor compliance with safe surgery policies and
protocols through audit and reporting to the Trust
Clinical Risk Group
22 Quality Account 2014/15
A Surgical Never Events TaskForce undertook an in-depth
review of surgical never events and reported in February
2014. It proposed a strategy of three interlocking elements:
• Standardisation of generic operating department
procedures
• Systematic education and training for staff working in
operating theatre environments
• Harmonising activity to support a safer environment for
patients
As a result of learning from serious incidents and surgical
never events during 2013 the following work has been
undertaken:
• Theatre matrons regularly undertake observational
audits
• There have been changes to the count procedure and
practice which has included a review of appropriate
local policies to ensure they comply with guidance and
ensure all disciplines of staff are aware of their
responsibilities and the implementation of updated
count procedure and count competency
• Transparent plastic swab racks have also been
purchased and whiteboards are always routinely used
for swab counts
A Surgical Safety Checklist Group (SSCG) was established
to oversee the WHO Checklist work. Quarterly audits have
been undertaken using a tool developed by this group.
Audit reports covering practice in the following areas have
been presented to the Clinical Risk Group and the SSCG:
• Theatres, Royal Victoria Infirmary
• Central Operating Theatres, Freeman Hospital
• Cardiothoracic Theatre, Freeman Hospital
The SSCG have reviewed and improved the WHO checklist
which was launched in December 2014. A single Never
Event has been reported this year, in April 2014, compared
with six during 2013-14. Exhibit 11 shows the Trust
position.
Exhibit 11: Trust position in relation to Never Events
Never events at NuTH
Linear (Never events at NuTH)
7
6
5
4
3
2
1
0
2013/14
2014/15
The Never Event reported in April 2014 was a patient with
bilateral cataracts who was admitted for cataract surgery
on the left eye and had the lens appropriate for the left
eye inserted into the right eye.
Moving forward surgical safety has been selected as one
of the key themes in the Sign up to Safety Campaign,
consequently the membership and terms of reference for
the SSCG are under review.
Patient Experience
Priority 9 - Whilst the Trust compares most favourably in
patient experience measures such as the National Inpatient
and Outpatient surveys it recognises that there is always
the potential for further improvement and is committed to
monitoring and improving the patient experience.
In the 2014 Picker Institute National Inpatient Survey the
following has been reported for the Trust:
• A total of 850 questionnaires were sent out to patients
• 826 patients were eligible for the survey
• 426 returned the completed question providing a
response rate of 52% (53% in 2013)
The survey highlighted many positive aspects of the
patient experience including:
• Overall: 92% rated care 7+ out of 10
• Overall: treated with respect and dignity 92%
• Doctors: always had confidence and trust 92%
• Hospital: room or ward was very/fairly clean 100%
• Hospital: toilets and bathrooms were very/fairly clean
98%
• Care: always enough privacy when being examined or
treated 93%
The benchmarking reports will not be published until May
2015 and the Trust will review the findings alongside other
patient experience data such as the results of other surveys
from the CQC National Programme which has included
Children’s, the Emergency Department and Maternity
Service to date, the NHS Friends and Family Test, Trust
complaints and PALS feedback. An action plan will be
developed to address any issues for improvement.
The new and updated Patient, Carer and Public
Involvement Strategy was approved by the Trust Board in
March 2015 and outlines our continuing commitment to
improving the patient experience. In order to monitor our
performance and identify any trends or themes from the
vast amount of qualitative feedback that we receive from
people who use our services, we have developed a
framework for analysing free-text comments using a
content analysis approach.
In the last year we have recorded around 34,000
comments and use these to understand the elements of
the patient experience that matter to patients and identify
changes that can be implemented. For example, a number
of comments are received that tell us that staff don’t
always introduce themselves as a matter of common
courtesy. Once such concern came to us via the Patient
Advice and Liaison Service (PALS). The gentleman wrote:
Only one of the three members of staff caring for my wife
today introduced themselves. This one nurse also smiled
and made my wife feel better during the visit…. My wife
commented on the way home 'I bet a vet makes more
fuss of a dog than they do of a human.'
Our well-established Patient, Carer and Public Involvement
Group brings together Trust staff with others involved in
improving the patient experience, including Healthwatch
Newcastle, PALS, Governors and our Community Advisory
Panel to work together, understand current priorities and
issues and carry out work to make improvements without
duplicating any work. The Group approve the ‘Take 2
minutes… See how we did’ newsletter which outlines the
Trust performance each quarter and publicises some
examples of changes made as a result of patient feedback
and is made available to staff and the public.
The Friends & Family Test (FFT) was introduced in 2013/14
across all adult inpatient wards, people attending the
Emergency Department (ED) and Maternity Services. In
2014/15 it was further rolled out to include all outpatient
and day case areas. Results are published monthly on the
NHS England web site (excludes outpatients and day cases).
A Report published by the North East Quality Observatory
(NEQOS) in April 2015 states that “the combination of a
higher positive recommendation rate and lower proportion
of inpatients not recommending services at Newcastle
Hospitals NHS FT suggests a better than average
experience than across England. This sustained position,
alongside a higher than average response rate is
commendable”. The tables and exhibits on the next page
show the Trust position in comparison to the other North
East Trusts and the leading teaching hospitals in England.
Quality Account 2014/15 23
3
Table 2- Percentage of patients who would recommend the Trust to their Family or Friends –
Inpatient Data September 2014 –March 2015
FFT score
Newcastle
upon Tyne
Hospitals
South Tees
Northumbria
Healthcare
Gateshead
Health
North Tees
and
Hartlepool
South
Tyneside
County
Durham and
Darlington
City Hospitals
Sunderland
North
Cumbria
University
Hospitals
Sep-14
97%
91%
95%
96%
94%
91%
89%
95%
93%
Oct-14
97%
91%
96%
96%
97%
95%
88%
95%
93%
Nov-14
98%
93%
98%
99%
94%
97%
91%
97%
96%
Dec-14
98%
95%
96%
97%
96%
96%
91%
98%
95%
Jan-15
98%
93%
97%
96%
97%
97%
87%
97%
96%
Feb-15
98%
95%
97%
94%
95%
94%
91%
97%
95%
Mar-15
98%
98%
97%
96%
97%
95%
93%
98%
96%
FFT Score
Newcastle
upon Tyne
Hospitals
Guy's and
St Thomas
Cambridge
University
Hospitals
Univ.
Hospitals
Birmingham
University
College
London
Sheffield
Teaching
Hospitals
Oxford
University
Hospitals
King's
College
Hospitals
Imperial
College
Healthcare
Central
Manchester
University
Hospitals
Sep-14
97%
97%
95%
96%
96%
97%
95%
92%
95%
94%
Oct-14
97%
96%
94%
96%
98%
97%
95%
94%
94%
93%
Nov-14
98%
97%
92%
93%
97%
98%
95%
92%
96%
95%
Dec-14
98%
97%
95%
95%
97%
95%
97%
93%
95%
95%
Jan-15
98%
97%
92%
95%
96%
95%
96%
96%
95%
93%
Feb-15
98%
96%
94%
96%
96%
96%
96%
95%
96%
92%
Mar-15
98%
97%
94%
95%
97%
95%
95%
94%
95%
91%
NUTH is top within the cluster of leading teaching hospitals and joint first with Sunderland within the group of local Trusts in March 2015. The exhibits below show the
Trust position in relation to the percentage of patients that would recommend the Trust to their friends or family.
Exhibit 12- In Patient Comparison of FFT Score % Recommended Sep 2014 March 2015 in the North East
100%
98%
Newcastle upon Tyne Hospitals
98%
97%
98%
98%
98%
98%
97%
South Tees
Northumberland Healthcare
96%
Gateshead Health
North Tees and Hartlepool
94%
South Tyneside
92%
County Durham and Darlington
City Hospitals Sunderland
90%
North Cumbria University Hospitals
88%
86%
84%
82%
80%
Sept 2014
Oct 2014
24 Quality Account 2014/15
Nov 2014
Dec 2014
Jan 2015
Feb 2015
Mar 2015
Exhibit 13- In Patient Comparison of FFT Score % Recommended Sep 2014 March 2015 in the leading teaching hospitals
100%
3
Newcastle upon Tyne Hospitals
98%
98%
98%
98%
Guy’s and St Thomas
98%
98%
Cambridge University Hospitals
97%
97%
University Hospitals Birmingham
96%
University College London
Sheffield Teaching Hospitals
94%
Oxford University Hospitals
King’s College Hospitals
92%
Imperial College Healthcare
90%
Central Manchester University Hospitals
88%
86%
Sept 2014
Oct 2014
Nov 2014
Dec 2014
Jan 2015
Feb 2015
Mar 2015
Table 3- Percentage of patients who would recommend the Trust to their Friends or Family Emergency Department (ED) Data September 2014 - February 2015
FFT score
Newcastle
upon Tyne
Hospitals
South Tees
Northumbria
Healthcare
Gateshead
Health
North Tees
and
Hartlepool
South
Tyneside
County
Durham and
Darlington
City Hospitals
Sunderland
North
Cumbria
University
Hospitals
Sep-14
91%
85%
87%
91%
86%
84%
78%
96%
90%
Oct-14
90%
90%
91%
94%
90%
94%
75%
97%
94%
Nov-14
93%
98%
91%
95%
88%
93%
81%
96%
93%
Dec-14
92%
92%
91%
93%
89%
94%
81%
96%
93%
Jan-15
92%
87%
92%
92%
90%
94%
81%
97%
92%
Feb-15
90%
88%
91%
90%
88%
81%
81%
96%
95%
Mar-15
92%
88%
90%
90%
91%
87%
81%
95%
93%
FFT Score
Newcastle
upon Tyne
Hospitals
Guy's and
St Thomas
Cambridge
University
Hospitals
Univ.
Hospitals
Birmingham
University
College
London
Sheffield
Teaching
Hospitals
Oxford
University
Hospitals
King's
College
Hospitals
Imperial
College
Healthcare
Central
Manchester
University
Hospitals
Sep-14
91%
84%
89%
82%
92%
79%
87%
83%
88%
88%
Oct-14
90%
79%
91%
85%
91%
79%
88%
83%
87%
89%
Nov-14
93%
85%
85%
84%
91%
80%
76%
82%
84%
89%
Dec-14
92%
85%
89%
88%
94%
82%
77%
80%
86%
90%
Jan-15
92%
86%
91%
86%
95%
85%
98%
83%
86%
92%
Feb-15
90%
85%
92%
88%
94%
82%
92%
80%
86%
92%
Mar-15
92%
84%
92%
87%
95%
82%
82%
78%
86%
92%
Quality Account 2014/15 25
Table 4- Percentage of patients who would recommend the Trust to their Friends or Family Maternity Data April 2014 - February 2015
Friends & Family Test - Maternity - Question 1 - Antenatal Care
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
CDD
98%
92%
95%
94%
92%
95%
94%
100%
98%
98%
99%
Mar-15
99%
North Tees
100%
92%
100%
100%
97%
93%
98%
100%
93%
100%
97%
100%
South Tees
*
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
Sunderland
97%
93%
96%
96%
99%
96%
91%
98%
93%
95%
97%
96%
Gateshead
100%
100%
100%
100%
100%
94%
67%
100%
100%
100%
100%
100%
North Cumbria
100%
100%
100%
98%
100%
100%
100%
100%
100%
99%
100%
98%
Northumbria
100%
99%
100%
97%
100%
99%
99%
100%
100%
100%
98%
100%
South Tyneside
92%
97%
97%
100%
97%
94%
96%
100%
100%
98%
91%
98%
Newcastle
94%
100%
100%
94%
94%
100%
100%
100%
100%
*
100%
88%
England
94%
94%
94%
94%
94%
95%
95%
96%
96%
95%
95%
95%
North East
90%
95%
97%
97%
96%
96%
95%
100%
98%
92%
98%
98%
North East &
North Cumbria
91%
95%
98%
97%
97%
96%
95%
100%
98%
93%
98%
98%
National High
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
National Low
40%
51%
45%
56%
57%
62%
52%
54%
61%
41%
33%
68%
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
CDD
94%
98%
98%
97%
97%
98%
96%
94%
99%
96%
98%
98%
North Tees
96%
99%
100%
94%
98%
97%
96%
100%
97%
98%
97%
100%
South Tees
89%
80%
81%
72%
88%
93%
91%
95%
88%
88%
88%
100%
Sunderland
95%
96%
91%
96%
96%
100%
99%
99%
99%
100%
99%
99%
Gateshead
100%
100%
98%
96%
99%
100%
98%
99%
98%
100%
89%
99%
North Cumbria
99%
97%
97%
98%
97%
99%
98%
98%
99%
98%
97%
97%
Friends & Family Test - Maternity - Question 2 - Birth
Northumbria
95%
95%
98%
97%
96%
97%
97%
98%
99%
99%
99%
97%
South Tyneside
100%
100%
100%
97%
100%
95%
100%
100%
95%
100%
100%
100%
Newcastle
99%
100%
98%
100%
99%
98%
100%
99%
99%
98%
99%
99%
England
95%
95%
96%
95%
95%
95%
95%
97%
97%
97%
97%
97%
North East
96%
97%
96%
96%
97%
98%
97%
98%
98%
97%
98%
99%
North East &
North Cumbria
96%
97%
96%
96%
97%
99%
98%
98%
98%
98%
98%
98%
National High
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
National Low
50%
65%
62%
59%
66%
56%
72%
81%
80%
83%
67%
79%
Apr-14
May-14
Jun-14
Jul-14
Dec-14
Jan-15
Feb-15
Mar-15
Friends & Family Test - Maternity - Question 3 - Postnatal Ward
Aug-14
Sep-14
Oct-14
Nov-14
CDD
74%
81%
82%
75%
72%
70%
75%
79%
80%
84%
82%
82%
North Tees
95%
97%
100%
92%
100%
94%
96%
97%
100%
96%
100%
100%
South Tees
84%
83%
57%
73%
86%
72%
83%
88%
80%
86%
86%
79%
Sunderland
97%
98%
95%
97%
95%
99%
96%
99%
98%
99%
99%
99%
Gateshead
98%
98%
95%
98%
100%
98%
100%
99%
95%
100%
91%
98%
North Cumbria
99%
97%
97%
98%
97%
99%
98%
98%
99%
98%
97%
97%
Northumbria
95%
95%
95%
98%
97%
97%
97%
99%
99%
99%
99%
97%
South Tyneside
100%
95%
100%
95%
100%
96%
100%
100%
94%
100%
100%
100%
Newcastle
97%
97%
97%
97%
98%
99%
98%
98%
96%
97%
97%
97%
England
92%
92%
93%
92%
91%
91%
91%
93%
93%
93%
93%
93%
North East
92%
93%
91%
92%
93%
92%
92%
94%
93%
95%
93%
93%
North East &
North Cumbria
93%
93%
92%
93%
94%
93%
93%
94%
94%
95%
94%
94%
National High
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
National Low
57%
55%
57%
51%
44%
60%
63%
73%
71%
64%
63%
62%
26 Quality Account 2014/15
Friends & Family Test - Maternity - Question 4 - Postnatal Community Provision
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
CDD
100%
96%
98%
98%
95%
95%
96%
100%
100%
96%
99%
98%
North Tees
95%
94%
93%
100%
95%
97%
100%
92%
100%
94%
100%
100%
South Tees
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
*
Sunderland
98%
95%
100%
95%
98%
99%
98%
99%
100%
92%
100%
100%
Gateshead
100%
100%
98%
100%
100%
100%
100%
100%
100%
100%
100%
100%
North Cumbria
100%
100%
100%
100%
100%
98%
100%
100%
100%
100%
100%
100%
Northumbria
97%
99%
99%
96%
99%
96%
100%
99%
100%
99%
97%
97%
South Tyneside
100%
100%
95%
100%
100%
94%
100%
100%
100%
100%
100%
100%
Newcastle
NA
94%
100%
100%
100%
100%
91%
86%
*
*
100%
100%
England
96%
96%
96%
96%
96%
96%
96%
97%
98%
97%
98%
98%
North East
98%
97%
98%
97%
98%
97%
99%
99%
93%
90%
99%
88%
North East &
North Cumbria
98%
97%
99%
98%
98%
97%
99%
99%
94%
92%
99%
90%
National High
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
National Low
50%
61%
59%
57%
60%
60%
61%
83%
76%
76%
83%
86%
* numbers are not high enough to publish
Outpatient and day case roll out of FFT
in 2014/15
Outpatient implementation:
Prior to the requirement to implement FFT in outpatient
departments a Real Time Patient Feedback (RTPF) project
had commenced. This had already examined the
implementation of patient feedback systems in outpatient
departments. The roll out of FFT into the Outpatient
Departments was incorporated into the Real Time Patient
Feedback kiosks. Currently NHS England do not request
the FFT outpatient or day case data but we can view this
via the RTPF kiosks (see below exhibit September 2014 March 2015).
Day Case Implementation:
All day case areas have been identified throughout the
Trust. For each individual area, postcards have been
introduced which breakdown day case activity to ward or
department level. Day case cards were distributed to all
day case areas during the second week of September this
year and opportunity to participate in FFT is now available
for all day case patients.
Further roll out is planned in 2015/16 to Children’s and
Community Services as well as the introduction of web
and text based solutions to help capture feedback.
The Trust also introduced Real Time Patient Feedback to
community therapy services – Podiatry, Speech and
Exhibit 14- Percentage of patients who would recommend the Trust to their Friends or Family Outpatient Data September 2014- March 2015
92.89
93.31
91.83
93.01
92.50
Sept 2014
Oct 2014
Nov 2014
Dec 2014
Jan 2015
92.26
94.81
100
80
60
40
20
0
Feb 2015
Mar 2015
Quality Account 2014/15 27
3
Language Therapy, and Community Musculoskeletal
Physiotherapy. Initially the services collected feedback via a
paper based process. However later in the year two hand
held devices were piloted. There were difficulties using the
device as it was set up for use by only one member of
staff. It was reported by the member of staff that the
device itself was light, easy to carry around with a good
battery life. Due to the nature of the patient group
utilising the device to complete the questionnaire help was
always required by the podiatrist either to increase the size
of the text to make it easy to read or to help move
patients though to the next page.
Utilising the device necessitated additional clinic time as
clinicians didn’t want to rush patients to complete the
questionnaire.
During 2014/15 it was also planned to introduce and pilot
a child friendly version of the questionnaire to a few
community children’s services, physiotherapy and
occupational therapy. Unfortunately this didn’t take place
as many of the children receive assessment and therapy
within the school setting and would have required support
to complete.
There was also the introduction of the National Friends
and Family test (FFT) to consider with its roll out across
community services from January 2015. Therefore from
January 2015 the Trust focused on introducing the FFT into
the already established questionnaires in Speech and
Language Therapy, Community Podiatry and MSK.
Results are favourable as can be seen in the graph below:
Also in community services the Community Response and
Rehabilitation Team (CRRT), that work in collaboration
with primary care to minimise inappropriate
admissions/readmissions to hospital and long term care,
embarked on a patient experience project in 2014/15. The
team delivers an integrated health and social care model
which centres around realignment and short term support,
particularly for vulnerable people and those with long term
conditions. The service aims to promote independence,
health & wellbeing and to reduce dependence on bed
based care in hospital and long term care homes.
In 2014/15 their project was to improve the experience for
carers who care for those housebound patients. It has
been shown that caring for housebound patients can be
extremely challenging and many carers often feel
forgotten. The CRRT team realised that it is important that
these carers feel supported and are signposted to
appropriate services and support. Therefore in 2014/15 the
CRRT reviewed what they did in relation to identifying and
supporting these carers. They found that this was very
limited and as a result developed and implemented a
discharge summary that includes information about
hidden carers which they share with GPs. Changes made
to the processes have been significant, and now these
carers can be identified to GPs and signposted to the
appropriate services therefore improving their experience.
In community services a ‘Keep Calm and Carry On’
programme was implemented in 2014/15 to improve the
experience for women experiencing mental health
difficulties. Health visitors in the outer West of Newcastle
discovered that maternal depression in their area was
significantly higher than the UK average. To help support
local mums with these problems, the health visitors
undertook a ten week course, working with a
psychologist, to help raise self-esteem and confidence, and
give support on health related topics, as well as parenting,
and managing infant and child behaviour.
The School Health team have also designed an “Open the
doors and take down the walls’ – ‘Pop-up’ interactive
health stalls and displayed them in the school
environment. A ‘Pop-Up’ culture has become popular in
today’s society with banners, posters and interactive
screens increasingly used in shopping malls, restaurants,
and other places.
The Trust recognises the importance of receiving patient
feedback and will retain it as a priority within the Quality
Account. The Trust has been shortlisted as one of five
organisations for patient experience in the National CHKS
Awards (the first time this Award has been presented).
This includes outcomes relating to Patient Related
Outcome Measures (PROMs), FFT and the national survey
responses.
FFT results: “How likely are you to recommend our service / team to friends & family if they needed care?”
the total are as follows.
300
Extremely Likely
Likely
250
Neither Likely or Unlikely
200
Unlikely
Extremely Unlikely
150
Don’t Know
100
50
0
Extremely Likely
28 Quality Account 2014/15
Likely
Neither likely or
Unlikely
Unlikely
Extremely
Unlikely
Don’t
Know
Overview of monthly Board assurance 2014/15
3
This is a representation of the Quality Report data presented to the Trust Board on a monthly basis in consultation with
relevant stakeholders for the year 2014/15. The indicators were selected because of the adverse implications for patient
safety and quality of care should there be any reduction in compliance with the individual elements.
Actual
2013/14
Target
2014/15
Monthly
Actual
Quarter 1 Quarter 2 Quarter 3 Quarter 4
Target
2014/15
Patient Safety
Data source
Standard
Screening MRSA:
electives *
Internal
National
definition
(2009)
100%
100%
100%
100%
100%
100%
100%
100%
Screening MRSA:
emergency *
Internal
National
definition
(2009)
100%
100%
100%
100%
100%
100%
100%
100%
Hand Hygiene audits
(opportunity)
Internal
Local CAT
tool
99.51%
98%
98%
99.37%
99.77%
99.51%
99.50%
99.54%
Hand Hygiene audits
(technique)
Internal
Local CAT
tool
99.36%
98%
98%
99.04%
99.44%
98.69%
99.26%
99.11%
Total number of
patient incidents
reported (Datix)
Internal Datix
Incident reporting
system
Local
Incident
Policy
13,275
Not defined
Not
defined
7
6 (April –
Sep 2014)
7 (0ct 2014)
6.6
6.4
6.6
7.2
6.7
Not
defined
Not
defined
743
690
729
752
2,914
Rate per 100 admissions Internal Datix
of patient incidents
Incident reporting
reported (Datix)
system
Slip, trip and fall patient (Datix)
Internal Datix
Incident reporting
system
National
definition
N/A
6.7
3,023
3,565
3,519
3,748
3,955
14,787
Slip, trip and fall Internal Datix
patient (Datix) per 1,000 Incident reporting
bed days
system
National
definition
5.7
6.8
(National)
6.8
(National)
5.58
5.24
5.39
5.46
5.42
Slip, trip and fall Internal Datix
patient (Datix) per 1,000 Incident reporting
bed days
system
Local (agreed
by Trust
Board)
5.7
5.4 (Trust)
5.4 (Trust)
5.58
5.24
5.39
5.46
5.42
Total number of
CNST claims
Internal Legal
Services
Department
National
NHSLA
definition
195
Not
defined
Not
defined
65
56
54
60
235
Number of radiation
incidents reported
to HSE and CQC
Internal Datix
Incident reporting
system
National
IRMER
definition
31
Not
defined
Not
defined
7
4
4
6
21
Never Event
Internal Datix
Incident reporting
system
National
definition
6
1
0
0
0
1
Inpatients acquiring
pressure damage
Internal Datix
Incident reporting
system
National
650
Not
defined
Not
defined
133
141
166
177
617
Community patients
acquiring pressure
damage
Internal Datix
Incident reporting
system
National
45
Not
defined
Not
defined
0
0
1
1
2
Medication incidents
Internal Datix
Incident reporting
system
Local
1,301
Not
defined
Not
defined
382
430
413
421
1646
General SUI
Internal Datix
Incident reporting
system
Local SUI
Policy
86
100%
Ongoing
17
18
19
16
70
HCAI SUI
Internal Datix
Incident reporting
system
Local SUI
Policy
15
100%
Ongoing
2
3
1
2
8
Internal Datix
Information Governance
Incident reporting
SUI
system
Local SUI
Policy
0
100%
n/a
0
0
0
0
0
Percentage of patient
incidents that
resulted in severe harm
or death
Local
No
Defined
Target
No
Defined
Target
0.89%
1.46%
1.20%
0.99%
1.1%
Internal Datix
Incident reporting
system
0.85%
0
0
Quality Account 2014/15 29
Clinical
Effectiveness
Data source
Integrated
Breast feeding initiation Performance
(Cumulative)
Measures Return
(IPMR)
Target
2014/15
Monthly
Actual
Quarter 1 Quarter 2 Quarter 3 Quarter 4
Target
2014/15
No National
70%
Target
No Target
No Target
68.8%
69.4%
69.7%
70.4%
69.6%
Standard
Actual
2013/14
Breast Feeding 6-8
weeks
Integrated
Performance
Measures Return
(PMR)
National
Standard
45.4%
46%
Quarterly
46.0%
45.9%
46.5%
44.8%
45.8%
Cancelled operations
rescheduled within 28
days
Quarterly Monitoring
Cancelled Operations
Data Set (QMCO)
National
Standard
0.42%
<0.8%
Monthly
0.5%
0.4%
0.3%
0.6%
0.4%
Those not admitted
within 28 days
Quarterly Monitoring
Cancelled Operations
Data Set (QMCO)
National
Standard
1
0
Monthly
0
0
2
2
4
Percentage high risk
TIA cases treated
within 24 hours
Best Practice Tariff
National
Standard
93.2%
60%
Quarterly
100%
93.8%
95.5%
TBC
96.8%
Apr-Dec
Stroke - 80% of people
with stroke to spend at
least 90% of their time
on a stroke unit
Locally Collected
National
Standard
86.2%
80%
Quarterly
89.9%
88.4%
94.6%
TBC
90.8%
Apr-Dec
Choose and Book:
Slot issues
C&B National
Systems & Reports
National
Standard
3.7%
<4%
Quarterly
9.7%
12.2%
14.9%
18.0%
13.7%
NICE guidelines (noncompliant)
Locally Collected
National
57
Not
defined
Not
defined
58
60
63
65
65
Percentage of NICE
guidelines (noncompliant)
Locally Collected
National
Not
available
Not
defined
Not
defined
13.7%
14%
14.5%
14.3%
14.3%
National Confidential
Enquiry into Patient
Outcome and Death
(NCEPOD) (noncompliant)
Locally Collected
National
5
Not
defined
Not
defined
4
3
3
3
3
Standard
Actual
2013/14
Target
2014/15
Monthly
Actual
Quarter 1 Quarter 2 Quarter 3 Quarter 4
Target
2014/15
702
Not
defined
Not
defined
185
196
175
172
728
77.3%
Not
defined
N/A
N/A
N/A
N/A
N/A
N/A
N/A
30% In
patient
(Q4)
20% ED
(Q4)
N/A
40.4%
15.96%
38.4%
13.9%
38.8%
16.2%
40%
10%
N/A
Patient Experience Data source
Number of complaints
received
Local
Internal Datix Incident
Complaints
reporting system
Policy
National Inpatient
Survey
CQC
National
standard
Friends and Family
response rates
(inpatients and A&E)
Locally collected
reported
National
standard
Inconsistencies in data reported in the
2013/14 report:
The 2010/11 rate reported for C.difficile (150) differs
from what was previously reported in the 2013/14
Quality Account (152) because the Trust felt that these
two cases, although specimens were taken pre-72
hours following admission, the cases should be
attributed to the Trust. However, although the Trust
counted these two cases internally as attributable to
the Trust, the national data capture system did not (the
system simply looks at the difference in days between
the admission and specimen date). In order to avoid
confusion the Trust agreed that this should not be
reported in the future, thus ensuring that the Trust
internal figures would always match the nationally
reported figures.
30 Quality Account 2014/15
Patient incident reporting:
In 2013/14 and the first six months of 2014/15 the total
number of all incidents was reported to the Trust Board
along with the rate of patient incidents. In October 2014 it
was agreed that in order to reflect the realignment with
the National Reporting and Learning System (NRLS) and
the national drive to promote an open and learning
organization where patient safety incidents are reported,
then the Board should receive the number of patient
incidents as well as the rate. To also be consistent the
target was readjusted in October 2014 in light of the NRLS
report where the national average for large acute
organisations was 7.2. The Trust Incident reporting system
is also a live database which results in fluctuations in actual
numbers of incidents reported as investigations are
processed through the system.
3
Complaints:
All other data consistent with 2013/14 report.
The Trust complaints reporting system is a live database
resulting in fluctuations in actual numbers of complaints
reported as investigations are processed through the
system. The fluctuations are due to:
Serious Untoward Incidents (SUIs):
• Timing issues – Patient Relations Department (PRD)
reports the number of complaints received to the
Clinical Governance and Risk Department at the end of
each month, but at the end of each month there are
complaints received but not yet registered on the Datix
system which are carried forward into the next month
and with a final adjustment at the end of the last
month of the year, hence the change in total.
• In addition, some complainants will contact us to
withdraw or abandon their complaint having had
second thoughts, and also some Patient Related
Enquiries (anything other than a complaint received
from patients e.g. telephone enquiry about issues re
treatment, waiting times etc which the PRD team will
action and get back to the patient as soon as possible
to advise of the outcome, i.e. general patient enquiries)
can be re-designated as a complaint where full
investigation is felt to be merited, and this can also
alter the figures, after having reported the numbers
each month. Many complaints received at the very end
of March are still work in progress until the end of May
and this can cause further fluctuations.
• Full check and adjustments are run annually to produce
the KO41 statistics for the DOH, and which is the total
figure used for this and for the Trust Annual reports etc.
Serious Untoward Incidents (SUIs) occurring within the
Newcastle upon Tyne Hospitals NHS Foundation Trust are
reported to the Commissioners at the Newcastle and
Gateshead CCG Alliance. After reporting the incident the
Trust is responsible for the investigation and response to
the Commissioners, including the submission of an
investigation report within a defined time scale. The
decision to report is made following consultation between
the Director of Quality & Effectiveness, Medical Director,
Director of Nursing and Patient Services and the Board
Directors and the Chief Executive. SUIs are investigated by
senior members of Trust staff with support from the
Clinical Governance & Risk Department.
Choose and book:
The Trust has to ensure that less than 4% of its Choose
and Book (C&B) bookings result in a slot issue for acute
services on a quarterly basis. The Trust is continually rolling
out services onto C&B, in line with national requirements.
Newcastle Hospitals have one of the highest C&B booking
rates than any other acute Trust in the country and
historically have very low volumes of slot issues.
Although the target has been breached during 2014/15,
the Trust performance is still respectable compared to the
other top 10 highest booking Trusts and the breaches
experienced are a consequence of increasing referrals and
restricted capacity, over which the Trust (like all others in
England) has limited influence at present.
Quality Account 2014/15 31
Complaints
There were 728 written complaints received during the year
ending March 2015 representing a 4% increase over the previous
year. In 2014/15 the rate of complaints per patient contact was
0.33 (0.49 in 2013/14).
The use of the Trust’s website for comments, compliments,
concerns and complaints (4C’s) continues to be well used
with many of the issues raised being dealt with the same
day (94%). Delays and dissatisfaction with clinical
treatment, poor communication and the attitude of staff
remain the three most common reasons for making a
complaint which can have a serious direct impact on a
patient’s view of their experience, even if everything else in
the patient’s care was found to be excellent. There were
also clear emerging themes from a national level, in
respect of the care of elderly people with complex needs
and Dementia, Following the publication of the
government responses (Hard Truths) to the Francis Report,
and Clwyd-Hart Report it is clear that, as a consequence,
the number of complaints about NHS healthcare has again
significantly increased, and this has also been noted at
national level.
The Trust achieved 98% (target 95%) compliance for the
year ending 2014/15 in respect of providing a written
response to the complainant within their individually
negotiated or renegotiated timescale. The Complaints
Panel continues to take the view that responding to
complaints in an open and appropriate way is
fundamental to the long term success of the Trust, and
that resolving patient concerns and learning from what
happened is essential to improve quality in everything that
we do.To ensure this aim was achieved during the year the
Complaints Panel reviewed individual Directorate
performance in not only the quality assurance of
responses, and the satisfaction of the complainant, but
also questioning the learning identified within the
Directorate, especially matters which can be shared across
the Trust. Directorate Teams continue to be held to
account for delivering the actions identified in the
Directorate Action Plans, following the investigation and
response to a complaint, and all outstanding issues are
followed up with either personal intervention by the Chief
Executive, Chair of the Complaints Panel, Medical Director
or Nursing and Patient Services Director as appropriate in
the event of identified weakness in the investigation,
concerns regarding outliers, or failure by a Directorate to
act within the agreed timescale.
When communicating with patients the attitude of some
staff can occasionally be reported as being dismissive or
argumentative. This may be when endeavouring to
diagnose or explain complex and sensitive information
relating to the patient’s care and treatment or when the
staff are themselves under pressure due to the sudden
absence of colleagues affecting their workload, or having
32 Quality Account 2014/15
difficulties in explaining to the patient or relative. A failure
to communicate effectively about care plans or discharge
plans or to keep patients and relatives informed during a
patient’s stay in hospital causes distress to patients and can
be a likely reason for complaints.
Common Themes found:
• Relatives feel communication has been less than
optimal
• Complex explanations and use of medical terminology
or NHS jargon
• Junior staff failure to seek advice from senior staff
when difficulties arise
• Intra professional issues arising from communication at
hand over, or between teams
• Failure to explain complications when they arise
• Not responding with early response to requests for an
informal meeting to provide explanation from medical
staff
Actions taken included:
• Customer Service Training for identified development
of individuals or groups of staff
• Post complaint review of case with all members of staff
involved (individual learning)
• Sharing of best practice with other staff members on
ward to avoid reoccurrence (corporate learning)
• Reinforcing need for effective communication with
family members at all times
• Improvements in handover communications (intraprofessional) to make key staff aware of treatment
considerations and concerns
• Ensuring staff to know when to seek (escalate)
assistance from senior staff, need to manage patients
expectations via improved communications at an early
stage in their pathway
Overview of Quality Improvements:
3
Pages 33-44 give some examples
of other quality improvement
initiatives the Trust have
implemented or been involved in
throughout the year.
Quality Account 2014/15 33
Overview of Quality Improvements
24/7 Consultant Care – Right Place, Right Time
The Royal Victoria Infirmary (RVI) in Newcastle is home to the
Great North Trauma and Emergency Centre - one of the largest
Major Trauma Centres (MTC) in the UK.
As a Level One MTC, our Emergency Care Specialists look
after patients with life-threatening injuries and illnesses
brought in by emergency ambulances and helicopters
from all over the North East and Cumbria. Many come via
our Emergency Department – one of five in the country
providing 24/7 Consultant-led Emergency Care coverage.
Since the Royal Victoria Infirmary became an MTC (one of
only 12 in the UK set up to deal with the most complex
cases for both adults and children), our trauma experts are
now saving an additional 4 to 5 lives each month.
Members of the 24/7 Consultant Emergency Team
on the RVI’s Helipad
34 Quality Account 2014/15
Royal Victoria Infirmary Maternity Unit receives
UNICEF Baby Friendly Award
3
The Region’s busiest Maternity Unit at Newcastle’s RVI – delivering
over 7,000 babies every year – has received full UNICEF Baby
Friendly Initiative Accreditation.
Lynne McDonald, Infant Feeding Co-ordinator at the
Maternity Unit, who has been helping parents to feed
their newborns for 15 years said:
“
We’re thrilled to receive this
accreditation. Breastfeeding helps
to reduce the risk of babies
becoming ill with gastroenteritis
and respiratory infections, and
lowers the risk of conditions such
as asthma, cardiovascular disease
and diabetes developing later in
childhood.
“
Breastfeeding also helps protect
the mother’s health, lowering the
risk of certain types of cancer,
and helping to develop strong
bones in later life. So there are
lots of benefits for both mother
and baby.
“
This award recognises the high standards of care that its
Midwives and other staff provide, to support women in
feeding and bonding with their newborn babies.
The accreditation followed a rigorous assessment of the
RVI's Maternity Unit which included four stages of
assessment over the last four years which ended with a
three day inspection visit to carry out an in-depth review of
services.
Quality Account 2014/15 35
“
A Focus on Learning Disabilities
Supporting individuals with a Learning Disability (LD) is a key
commitment for The Newcastle Hospitals and in particular that
people with LD have equal rights of access to services and
effective treatment. Sometimes, this means making reasonable
adjustments.
Currently, our staff see around 1,100 patients with LD
from the region. We know this is just the tip of the iceberg
and as we further embed systems and processes to
support staff to recognise those with a LD, we expect this
figure to steadily rise.
Recent developments across the organisation include:
• Establishment of a dedicated LD Liaison Nurse
• Flagging of patients with LD on e-record
• Special care pathways including attendance to the
Emergency Department (shortlisted for the Nursing
Times’ Emergency and Critical Care Awards)
• Hospital Passports - a personal document containing
important health needs information
Dr Dominic Slowie, NHS England’s National Clinical
Director for Learning Disabilities praised the universal
approach and ease of access saying: “I think these videos
are great. The fact they are linked to You Tube and using a
QR code can be accessed directly from the patient
appointment letter makes them so user-friendly. I wouldn’t
be surprised if these films set the National Gold Standard
for how patient information should be given.”
The films developed with 'Them Wifies' - a
Newcastle-based community arts organisation which
uses the art to address health inequalities - can be
seen at: www.youtube.com/NewcastleHospitals
The most recent development is a trio of short films
featuring people with LD and their carers, as they come to
hospital to have an x-ray, CT or MRI scan. Dr Clare Scarlett,
a GP in North Tyneside and Clinical Lead for Learning
Disability for both Newcastle CCGs and North Tyneside
CCG explains: “Describing investigations such as CT scans
can be hard. Studies have shown that healthcare
professionals’ explanations are often not so clear as they
intend, and patients will only retain a portion of what is
said in a consultation.
“
People who have a learning disability will have greater difficulty
than most understanding new concepts. Illustrated, easy read text
is very useful to support communication. The use of film offers
additional benefits. “These films are an excellent resource. They are
notable not only for the clarity with which the imaging processes
are explained, visually and verbally, but the excellent quality of the
production. They embody a commitment to accessible
communication of the highest standard using an engaging
medium. I recommend having the link easily accessible.
“
36 Quality Account 2014/15
Balloon release celebrates 100th
congenital adult heart transplant
3
One hundred balloons flew into the sky outside Newcastle’s
Institute of Transplantation to mark a very special centenary
Chris Richardson, a 29 year old from Walker, Newcastle
upon Tyne was born with a congenital heart defect, yet a
heart and lung transplant seven years ago transformed his
life.
Chris explains: “It was really good to release the balloons
and it was quite emotional because it’s a way of thanking
the donors for what they have done. I attached a message
to my balloon which thanked my donor so much for the
transplant, it’s given me the best seven years of my life.
“
The balloon release was a
great way to celebrate the
work that the Freeman
does. I would not be here
today if it wasn’t for the
hospital and its staff.
“
Each balloon was released by someone born with a
complex heart disease, and who would not have been
expected to live into adulthood were it not for the
expertise of the heart specialists at the Freeman Hospital home to the largest centre in the world for this
challenging type of transplantation.
Quality Account 2014/15 37
Top of the Research League
Once again, Newcastle
has topped the national
league table for NHS
research activity. The
number of patients
recruited into clinical
trials last year totalled
over 15,800 - far better
than any other similar
Trusts nationwide.
Clinical research is a vital part of the work of
the NHS, contributing to the drive for better
treatments for all NHS patients and providing
evidence about ‘what works’ so that
treatments for patients can be improved.
In addition, there is research evidence to
show that patients have better outcomes in
hospitals and surgeries that are research
active – even if they don’t actually take part
in a study themselves.
Sir Leonard Fenwick,
Chief Executive explains:
“
This accolade
highlights how
Newcastle Hospitals
remains at the
forefront of research
and innovation in the
UK, providing our
patients with the
opportunity to
participate in the
highest quality
research and
clinical care
“
38 Quality Account 2014/15
Specialist Continence Team wins
British Journal of Nursing Award
3
The Continence Nurse
of the Year Award
recognises the outstanding
efforts of each and every
member of Newcastle’s
Specialist Continence
Team who developed a
special project to help
prevent people in Care
and Residential Homes
having to come into
hospital to be treated for
urinary tract infections
(UTIs). This was focused
around ensuring the UTIs
were prevented in the first
place and the team
continues to be extremely
successful in their efforts.
Congratulations to our Specialist Continence Team who scooped the 2014 British
Journal of Nursing - Continence Nurse of the Year Award
Newcastle Physiotherapist wins
Haemophilia Society Award
David Hopper - a specialist physiotherapist in our Haemophilia
Service - became an official Haemophilia Society 'Buddy' this year
The Haemophilia Society’s award recognises the support
given by friends, family and healthcare professionals to
children with bleeding disorders.
David with two of his nominees and Dick and Dom of
CBBC fame
David Hopper won two awards having been nominated by
patients and a work colleague. David said:
“
People living with bleeding disorders and their
carers often feel isolated and neglected
because many members of the public are still
unaware of the everyday challenges they face.
Our team works on a daily basis to
help make the lives of patients living
with haemophilia easier.
“
Quality Account 2014/15 39
Patients give Newcastle Hospitals
‘highest ever scores’
“
We have had
responses from
more than 22,500
inpatients over the
past year, and to
receive the highest
score in the North
East and Cumbria and the Trust’s
highest ever score indicates that
satisfaction with
our inpatient
services is
on the rise
“
40 Quality Account 2014/15
‘Friends & Family Test’ score for
inpatients was the highest yet!
3
Patients staying in hospital in Newcastle have given a big thumbsup to the services they have received. So much so, that the
Newcastle Hospitals ‘Friends & Family Test’ score for inpatients
was the highest yet!
The national NHS Friends & Family Test asks adult
inpatients and people using the Emergency Departments
and our Maternity Services, one simple question:
North East and Cumbria - and the Trust’s highest ever
score - indicates that satisfaction with our inpatient
services is on the rise.”
‘how likely are you to recommend our ward/department
to your friends and family if they needed similar care?’
As part of the Friends & Family Test, patients are also
encouraged to comment on our services, and we received
over 6,000 comments from April to June 2014. These
indicate that our hospital staff are one of the biggest
influencing factors over whether people are likely to
recommend the Trust to their friends and family.
In the June 2014 Friends & Family Test, over 1,750
inpatients commented on our services when leaving the
RVI, Freeman Hospital, Northern Centre for Cancer Care,
and the Campus for Ageing and Vitality.
The Newcastle Hospitals scored 82 out of a possible score
of minus 100 to 100. This is the highest score for inpatient
services in the North East and Cumbria, and the highest
ever for the Trust.
Helen Lamont, Nursing & Patient Services Director,
explains: ”One of the most important indicators of the
success of our services is how patients feel when they
leave hospital and what they think about the services they
have received. For patients to say ‘yes’, they would
recommend our services to friends and family, is probably
the most compelling endorsement our services can receive.
We have had responses from more than 22,500 inpatients
over the past year, and to receive the highest score in the
One patient commented: “Friendly staff who take pride in
their customer care and professionalism - excellent service.
Patients are treated as individuals, each with their special
needs which are administrated with care and dignity. Most
importantly, staff at all levels listen and understand
concerns. Diagnosis was remarkable and I was thankfully
fast-tracked due to a worsening condition. The ward is a
credit to the NHS.”
The monthly Friends & Family Test results are published on
the NHS Choices and NHS England websites. People can
also access the results from the Newcastle Hospitals
website by searching for ‘Newcastle Hospitals Friends
and Family’.
Quality Account 2014/15 41
Project Choice wins ‘Diversity &
Inclusion in the Workplace’ Award
A project to help young people with learning disabilities gain
valuable skills and work experience, picked up a prestigious
honour at the region’s CIPD People Management Awards.
Lorna Harasymiuk, Project Choice Co-ordinator. “Project
Choice supports the Trust’s commitment to deliver a health
service where equality, diversity and human rights are
embraced in the everyday work of our staff. We are
positive about disability and have made a commitment to
employ, retain and develop staff with disabilities.
Project Choice demonstrates this by enabling young adults
to gain employability skills through work experience, and
helping them prepare for employment.”
Laura receiving her award with one of our young
apprentices
Specialist Nurse wins International Award
Neil Wrightson, Ventricular
Assisted Devices or VAD
Coordinator is a vital member of
the lifesaving heart transplant
team at Newcastle's Freeman
Hospital. Now, he's been
recognised as the best in the
world at what he does, winning
the coveted International VAD
Coordinator of the Year Award.
Neil has been in this role at the region’s Cardiothoracic
Centre for more than seven years looking after patients
with advanced heart failure. For many of these patients,
the VADs keep them alive while they wait for a heart
transplant.
Neil says: “It’s an amazing field of work to be a part of.
With such a terrible shortage of donor organs, we simply
can’t meet the demand for heart transplants.
VADs help us to overcome this and the proof, for me, of
how successful they are, is the fact that I don’t have to
helplessly watch nearly as many people die anymore.
42 Quality Account 2014/15
New Bus Link to Healthcare Just the Ticket
3
Patients and visitors to the Newcastle Hospitals benefit from new
and improved transport links, thanks to a new partnership with
local bus company Arriva North East.
The partnership sees enhanced transport connections from
across Newcastle upon Tyne, Cramlington and South East
Northumberland. Buses bring patients, visitors and staff
direct to the doors of the Freeman Hospital, the Royal
Victoria Infirmary (RVI) in the city centre and the Campus
Transport links for Ageing and Vitality (formerly the
Newcastle General Hospital), where they can benefit from
the Trust's wide range of services.
Transport links include:
• Direct services to the RVI’s Leazes Wing every 30
minutes from Regent Centre and Haymarket
• Direct services to the Freeman Hospital every 30
minutes from Regent Centre
• A 30 minute service, Monday to Saturday (hourly on
evenings and Sundays) between Newcastle Haymarket
and the Freeman Hospital
• Improved access from Ashington, Blyth, Cramlington
and Morpeth with connections at the Regent Centre to
the Freeman Hospital, significantly reducing journey
times from South East Northumberland
The new services all benefit from easily recognisable, low
floor accessible buses with free wifi and improved links
from park and ride available at Regent Centre and Four
Lane Ends.
David Malone, Transport and Travel Advisor for the
Newcastle Hospitals explains: “We put patients at the
heart of everything we do and have listened to comments
from our patients and visitors as to how we can make our
services more easily accessible. We are therefore pleased to
announce our partnership with Arriva North East, which
improves public transport access by providing new services
and better links to our hospitals.”
For timetables and more information visit www.arrivabus.co.uk/north-east
Quality Account 2014/15 43
44 Quality Account 2014/15
Information on participation in National
Clinical Audits and National Confidential Enquiries
During 2014/15, some 40 national clinical audits and 4 national
confidential enquiry reports covered NHS services that the
Newcastle upon Tyne Hospitals NHS Foundation Trust provides.
During that period, the Newcastle upon Tyne Hospitals NHS Foundation Trust participated in 100% national clinical
audits and 100% of the 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 the Newcastle upon Tyne Hospitals NHS Foundation
Trust was eligible to participate in during 2014/15 are as follows:
National Clinical Audits
Acute Coronary Syndrome or Acute Myocardial Infarction
Lung cancer
Adherence to British Society for Clinical Neurophysiology (BSCN)
and Association of Neurophysiological Scientists (ANS) Standards
for Ulnar Neuropathy at Elbow (UNE) testing
National Cardiac Arrest audit
Adult Cardiac Surgery audit
National Comparative Audit of Blood Transfusion
Adult community acquired pneumonia
National Dementia Audit
Adult Critical Care (Case Mix Programme)
National Emergency Laparotomy Audit
Bowel Cancer
National Joint Registry
Cardiac Rhythm Management
National Vascular Registry, including CIA and elements of NVD
Chronic Obstructive Pulmonary Disease
Neonatal Intensive and Special Care
Congenital Heart Disease (Paediatric Cardiac Surgery)
Mental Health - Care in Emergency Department
Coronary Angioplasty
Oesophago-gastric Cancer
Diabetes (Adult) includes National Diabetes Inpatient Audit
Older People - Care in Emergency Department
Diabetes (Paediatrics)
Paediatric Intensive Care
Elective Surgery (National PROMs Programme)
Pleural Procedures
Epilepsy 12 audit (Childhood Epilepsy)
Prostate Cancer
Quality Account 2014/15 45
3
National Clinical Audits
Falls and Fragility Fractures Audit Programme includes National Hip
Fracture database
Pulmonary Hypertension
Fitting Child - Care in Emergency Department
Renal replacement Therapy (Renal Registry)
Head and Neck Oncology
Rheumatoid and Early Inflammatory Arthritis
Heart Failure
Sentinel Stroke National Audit Programme includes SINAP
Inflammatory Bowel Disease
Severe Trauma (Trauma & Research Audit Network)
Intermediate Care
Maternal, Infant and Newborn Clinical Outcome Review
Programme
National Confidential Enquiry
National Confidential Enquiry into Patient Outcome and
Death:Tracheostomy Care
National Confidential Enquiry into Patient Outcome and Death:
Sepsis
National Confidential Enquiry into Patient Outcome and Death:
Gastrointestinal haemorrhage
National Confidential Enquiry into Patient Outcome and Death:
Lower limb amputation
The national clinical audits and national confidential enquiries that the Newcastle upon Tyne Hospitals NHS Foundation
Trust participated in during 2014/15, are as follows:
National Clinical
Audit/National
Confidential Enquiry
Sponsor / Audit
What is the Audit about?
Acute Myocardial
Infarction
National Institute for
Cardiovascular
Outcomes Research
(NICOR)
The Myocardial Ischaemia National Audit Project (MINAP) was
established in 1999 in response to the National Service
Framework (NSF) for Coronary Heart Disease, to examine the
quality of management of heart attacks (Myocardial Infarction)
in hospitals in England and Wales.
Adherence to British
Society for Clinical
Neurophysiology
(BSCN) and
Association of
Neurophysiological
Scientists (ANS)
Standards for Ulnar
Neuropathy at Elbow
(UNE) testing
Association of
Neurophysiological
Scientists (ANS)/British
Society of Clinical
Neurophysiologists
(BSCN)
The audit national standards for ulnar Neuropathy at elbow
testing
Adult Cardiac Surgery
NICOR
This audit looks at heart operations. Details of who undertakes
the operations, the general health of the patients, the nature
and outcome of the operation, particularly mortality rates in
relation to preoperative risk and major complications.
Adult community
acquired pneumonia
British Thoracic Society
(BTC)
This audit addresses the management of patients admitted to
hospital with suspected community acquired pneumonia.
46 Quality Account 2014/15
Trust
participation
in 2014/15
3
3
3
3
National Clinical
Audit/National
Confidential Enquiry
Sponsor / Audit
Trust
participation
in 2014/15
What is the Audit about?
Adult Critical Care
Intensive Care National
Audit and Research
Centre (ICNARC)
The aim of the audit is to improve resuscitation care and patient
outcomes for the UK and Ireland.
Bowel Cancer
(NBOCAP)
Health & Social Care
Information Centre
Colorectal (large bowel) cancer is the most common cancer in
non-smokers and second most common cause of death from
cancer in England and Wales. Each year over 30,000 new cases
are diagnosed, and bowel cancer is registered as the underlying
cause of death in half of this number.
Cardiac Rhythm
Management
NICOR
The audit aims to monitor the use of implantable devices and
interventional procedures for management of cardiac rhythm
disorders in UK hospitals.
Chronic Obstructive
Pulmonary Disease
RCP / BTS / Primary
Care Respiratory
Society / British Lung
Foundation
The audit will bring together primary care, secondary care,
rehabilitation and patient experience.
Congenital Heart
Disease (Paediatric
Cardiac Surgery)
NICOR
The congenital heart disease website profiles every congenital
heart disease centre in the UK, including the number and range
of procedures they carry out and survival rates for the most
common types of treatment.
Coronary Angioplasty
NICOR
This project looks at percutaneous coronary intervention (PCI)
procedures performed in the UK. The audit collects and analyses
data on the nature and outcome of PCI procedures, who
performs them and the general health of patients. The audit
utilises the Central Cardiac Audit Database (CCAD) which has
developed secure data collection, analysis and monitoring tools
and provides a common infrastructure for all the coronary heart
disease audits.
Diabetes (Adult)
Health & Social Care
Information Centre
The National Diabetes Audit is considered to be the largest
annual clinical audit in the world, providing an infrastructure for
the collation, analysis, benchmarking and feedback of local data
across the NHS.
Diabetes (Paediatric)
Royal College of Child
Health and Paediatrics
(RCPH)
The audit covers registrations, complications, care process and
treatment targets.
Elective Surgery
(NationalPROMS
Programme)
Health & Social Care
Information Centre
The audit looks at the change in patients' self-reported health
status for groin hernia surgery, hip replacement, knee
replacement and varicose vein surgery.
Epilepsy 12 (Childhood
Epilepsy)
RCPH
The aim of the audit is to facilitate providers / commissioners
and improve quality of care and contribute to the continuing
improvement of outcomes for children and young people with
seizures and epilepsies and their families.
Falls and Fragility
Fractures Audit
Programme including
National Hip Fracture
database
RCPH
The Falls and Fragility Fracture Audit Programme (FFFAP) is a
national clinical audit run by the Royal College of Physicians
designed to audit the care that patients with fragility fractures
and inpatient falls receive in hospital and to facilitate quality
improvement initiatives.
Fitting Child - Care in
Emergency
Department
College of Emergency
Medicine
The objective of the audit is to identify current performance in
EDs against clinical standards and show the results in
comparison with other departments in order to facilitate quality
improvement. The audit includes patients under 16 years of age
who presented at ED with a febrile or afebrile seizure (actively
fitting or following a fit).
3
3
3
3
3
3
3
3
3
3
3
3
Quality Account 2014/15 47
3
National Clinical
Audit/National
Confidential Enquiry
Sponsor / Audit
What is the Audit about?
Head and Neck
Oncology (DAHNO)
Health & Social Care
Information Centre
The most common sites for head and neck cancer are the larynx
(throat) and oral cavity (mouth). Head and neck cancer
treatment requires a wide range of expertise, and treatment is
usually discussed and agreed by multidisciplinary teams (MDTs).
The aim of this audit is to produce meaningful results that act as
a vehicle to improve delivery of care to patients.
Heart Failure
NICOR
The aim of this project is to improve the quality of care for
patients with heart failure through continual audit and to
support the implementation of the national service framework
for coronary heart disease.
Inflammatory Bowel
Disease
RCP
The UK Inflammatory Bowel Disease (IBD) Audit seeks to
improve the quality and safety of care for IBD patients in
hospitals throughout the UK. It will do this by assessing
individual patient care and service resources and organisation
against the National Service Standards for the care of patients.
Intermediate Care
NHS Benchmarking
Network
The audit covers crisis response, home based intermediate care,
bed based intermediate care and re-ablement.
Lung Cancer
(LUCADA)
Health & Social Care
Information Centre
Lung cancer has the highest mortality rate of all forms of cancer
in the western world and there is evidence that the UK's survival
rates compare poorly with those in the rest of Europe. There is
also evidence that, in the UK, standards of care differ widely.
The audit was set up in response to The NHS Cancer Plan, to
monitor the introduction and effectiveness of cancer services.
National Cardiac
Arrest
ICNARC
The purpose of the audit is to monitor the incidence of, and
outcome from, in-hospital cardiac arrest in the UK and Ireland.
National Comparative
Audit of Blood
Transfusion
NHS Blood and
Transplant (NHS BT)
This was an audit of transfusion in children and adults with
Sickle Cell Disease.
National Dementia
Audit
Royal College of
Psychiatrists
The audit criteria include policies and governance in the hospital
that recognise and support the needs of people with dementia,
elements of comprehensive assessment, involvement of carers,
discharge planning, and identified changes to support needs
during admission.
National Emergency
Laparotomy
Royal College of
Anaesthetists
NELA aims to look at structure, process and outcome measures
for the quality of care received by patients undergoing
emergency laparotomy.
National Joint Registry
National Joint Registry
Centre
The audit covers clinical audit during the previous calendar year
and outcomes including survivorship, mortality and length of
stay.
National Vascular
Registry including CIA
and elements of NVD
RCS
The audit addresses the outcome of surgery for patients who
underwent two types of vascular procedure. The first is an
elective repair of an infra-renal abdominal aortic aneurysm
(AAA). The second is a carotid endarterectomy (CEA).
Neonatal Intensive and
Special Care
BTS
To assess whether babies requiring specialist neonatal care
receive consistent high quality care and identify areas for
improvement in relation to service delivery and the outcomes of
care.
Mental Health - Care
in Emergency
Department
College of Emergency
Medicine
The audit focuses on initial assessment by ED staff, assessment
by mental health staff and the facilities where the patient was
seen.
48 Quality Account 2014/15
Trust
participation
in 2014/15
3
3
3
3
3
3
.3
3
3
3
3
3
3
National Clinical
Audit/National
Confidential Enquiry
Sponsor / Audit
Trust
participation
in 2014/15
What is the Audit about?
Oesophago-gastric
Cancer
Health & Social Care
Information Centre
The oesophago-gastric (stomach) cancer audit aims to examine
the quality of care given to patients and thereby help services to
improve. The audit evaluates the process of care and the
outcomes of treatment for all O-G cancer patients, both curative
and palliative.
Older People - Care in
Emergency
Department
College of Emergency
Medicine
The audit focuses on assessment of cognitive impairment by ED
staff, communication of assessment findings with relevant
services, carers and GPs and documentation of EWS.
Paediatric Intensive
care
PICANet
PICANet was established in 2002 and aims to continually
support the improvement of paediatric intensive care provision
throughout the UK by providing detailed information on
paediatric intensive care activity and outcomes.
Pleural Procedures
British Thoracic Society
The audit addresses the investigation and medical management
of pleural disease in adults.
Prostate Cancer
Clinical Effectiveness
Unit, Royal College of
Surgeons
This first audit covers organizational elements of the service and
whether key diagnostic, staging and therapeutic facilities are
available on site for each provider of prostate cancer services.
Pulmonary
Hypertension
Health and Social Care
information Centre
The Pulmonary Hypertension Audit measures the quality of care,
activity levels, access rates and patient outcomes of pulmonary
hypertension services.
Renal Registry
UK Renal Registry
The Registry contains analyses of data submitted via clinical
information systems relating to direct clinical care and laboratory
permit analyses.
Rheumatoid and Early
Inflammatory Arthritis
British Society of
Rheumatology
The overall aim of the audit is to improve the quality of care
provided by specialist rheumatology services in the management
of early inflammatory arthritis.
Stroke National Audit
Programme
Health & Social Care
Information Centre
The audit collects information about care provided to stroke
patients in first three days of hospital. Data is continuous.
Severe Trauma
Trauma Audit Research
Network (TARN)
TARN is working towards improving emergency health care
systems by collating and analysing trauma care.
Maternal Infant and
Newborn Clinical
Outcome review
Programme
Mothers and Babies Reducing Risk through
Audits and Confidential
Enquiries across the UK
The programme investigates the deaths of women and their
babies during or after childbirth, and also cases where women
and their babies survive serious illness during pregnancy or after
childbirth.
Gastrointestinal
haemorrhage
NCEPOD
To identify the remediable factors in the quality of care provided
to patients who are diagnosed with an upper or lower GIH.
Sepsis
NCEPOD
To examine organisational structures, processes, protocols and
care pathways for sepsis recognition and management in
hospitals from admission through to discharge or death.
Tracheostomy care
NCEPOD
To identify the number of tracheostomies performed annually in
intensive care, explore remediable factors in the care of a patient
undergoing the insertion of a tracheostomy tube and explore
(percutaneous and surgical) tracheostomy related complications
following insertion in operating theatres or critical care complex.
Lower Limb
Amputation
NCEPOD
To review all patients 16 and over admitted for lower limb
amputation including pre-operative, peri-operative and postoperative care.
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Quality Account 2014/15 49
3
The national clinical audits and national confidential enquiries that the Newcastle upon Tyne Hospitals NHS Foundation
Trust participated in, and for which data collection was completed during 2014/15, are listed below alongside the
number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the
terms of that audit or enquiry.
National Clinical Audit/National
Confidential Enquiry
Percentage Data
Completion
Outcome
Acute Myocardial Infarction
100%
Action plan developed
Adherence to British Society for Clinical Neurophysiology
(BSCN) and Association of Neurophysiological Scientists (ANS)
Standards for Ulnar Neuropathy at Elbow (UNE) testing
100%
Compliant
Adult Cardiac Surgery
100%
Compliant
Adult community acquired pneumonia
Data submission
closes 31/05/2015
Publication due October 2015
Adult Critical Care
100%
Compliant
Bowel Cancer (NBOCAP)
100%
Compliant
Cardiac Rhythm Management
100%
Action plan developed
Chronic Obstructive Pulmonary Disease
100%
Action plan developed
Congenital Heart Disease (Paediatric Cardiac Surgery)
Data submission
closes 04/05/2015
N/A
Coronary Angioplasty
100%
Compliant
Diabetes (Adult)
No data collection in
2014/15- deferred
until 2015/16
Action plan currently being developed in
relation to outstanding issues from
previous inpatient audits.
Diabetes (Paediatric)
90%
Compliant
Elective Surgery (National PROMS Programme)
100%
Compliant
Epilepsy 12 (Childhood Epilepsy)
97%
Action plan developed
Falls and Fragility Fractures Audit Programme including National
Hip Fracture database
100%
Action plan developed
Fitting Child - Care in Emergency Department
100%
Publication due July 2015
Head and Neck Oncology (DAHNO)
100%
Compliant
Heart Failure
Data submission
closes 01/06/2015
Publication due October 2015
Inflammatory Bowel Disease
100%
Publication due September 2015
Intermediate Care
100%
Action plan developed
50 Quality Account 2014/15
National Clinical Audit/National
Confidential Enquiry
Percentage Data
Completion
Outcome
Lung Cancer (LUCADA)
100%
Publication due December 2015
National Cardiac Arrest
Adults 70-90% and
Paediatrics 50%
Action plan developed
National Comparative Audit of Blood Transfusion
100%
Publication due December 2015
National Dementia Audit
100%
Action plan developed
National Emergency Laparotomy
100%
Action plan developed
National Joint Registry
100%
Compliant
National Vascular Registry including CIA and elements of NVD
100%
Publication due June 2015
Neonatal Intensive and Special Care
100%
Publication due June 2015
Mental Health - Care in Emergency Department
100%
Publication due July 2015
Oesophago-gastric Cancer
100%
Compliant
Older People - Care in Emergency Department
100%
Publication due July 2015
Paediatric Intensive care
97%
Action plan developed
Pleural Procedures
100%
Publication due July 2015
Prostate Cancer
100%
Compliant
Pulmonary Hypertension
100%
Compliant
Renal Registry
100%
Action plan developed
Rheumatoid and Early Inflammatory Arthritis
100%
Publication due in July 2015
Stroke National Audit Programme
100%
Action plan developed
Severe Trauma
100%
Action plan developed
Maternal Infant and Newborn Clinical Outcome review
Programme
100%
Compliant
Gastrointestinal haemorrhage
100%
Publication due in July 2015
Sepsis
83.3%
Publication due in November 2015
Tracheostomy care
86.5%
Compliant
Lower Limb Amputation
100%
Action plan developed
Quality Account 2014/15 51
3
Lead clinicians for each of the national audits included in
the Quality Account provide the Clinical Governance and
Risk Department with six monthly status positions on the
implementation of each reports finding and this is
discussed at the Clinical Effectiveness, Audit and
Guidelines Committee.
The reports of 44 national clinical audits were reviewed by
the provider in 2014/15 and the Newcastle upon Tyne
Hospitals NHS Foundation Trust intends to take the
following actions to improve the quality of healthcare
provided:
• The Clinical Effectiveness, Audit and Guidelines
Committee receives a quarterly report on the Trust’s
performance in relation to participation in the NICE
programme. On an annual basis the Committee
receives a report on the projects in which the Trust
participates and requires the lead clinician of each audit
programme to identify any potential risk, where there
are concerns action plans will be monitored on a three
monthly basis
• In addition, each Directorate is required to present an
Annual Clinical Audit Report to the Clinical
Effectiveness, Audit and Guidelines Committee
detailing all audit activity undertaken both national and
local. During 2014/15 submission of audit activity had
been enhanced by the establishment of an electronic
online reporting system, the previous year, so that
clinicians can enter their audits directly into the Clinical
Effectiveness Register. This has greatly improved the
pickup rate of clinical audits
• Involvement in National audits is monitored at the
Patient Safety and Quality Reviews where a data pack
is provided that contains audit compliance
• Compliance with National Confidential Enquiries is
reported to the Clinical Governance and Quality
Committee and exceptions subject to detailed scrutiny
and where compliance cannot be achieved this is
evidenced onto the Trust Risk Register and monitored
accordingly
• Non-compliance with recommendations from National
Clinical Audit and National Confidential Enquiries are
considered in the Annual Business Planning process
The reports of 660 local clinical audits were reviewed by
the provider in 2014/15 and the Newcastle upon Tyne
52 Quality Account 2014/15
Hospitals NHS Foundation Trust intends to take the
following action to improve the quality of health care
provided:
• Each Clinical Directorate is required to present an
Annual Clinical Audit Report to the Clinical
Effectiveness, Audit and Guidelines Committee
detailing all audit activity undertaken both national and
local
• Review Directorate Clinical Governance meetings to
ensure national and local audit are presented
An additional 18 audits have been added to the list for
inclusion in 2015/16 Quality Accounts and all 18 audits are
relevant to services provided by the Trust. Some audits had
originally been identified to be included within 2014/15
but had been delayed. The 18 audits include:
• Emergency use of oxygen
• National Comparative blood transfusion – blood
management in scheduled surgery
• National Comparative blood transfusion – Lower GI
bleeding
• National Comparative blood transfusion – blood in
haematology
• Complicated diverticulitis
• National Ophthalmology
• Prescribing Observatory in Mental Health – Substance
misuse and alcohol detoxification
• Prescribing Observatory in Mental Health – Prescribing
for bipolar disorder – sodium valproate
• Prescribing Observatory in Mental Health – ADHD in
children, adolescents and adults
• Procedure sedation in Emergency Department
• UK Cystic Fibrosis Registry (adults)
• UK Cystic Fibrosis Registry (paediatrics)
• Parkinson’s
• Vital Signs in Children in Emergency Department
• VTE risk in lower limb immobilisation in Emergency
Department
• Adult bronchiectasis
• End of Life Care: Care of the dying
• Familial hypercholesterolaemia
Information on participation
in Clinical Research
3
The number of patients receiving relevant health services provided
or sub-contracted by the Newcastle upon Tyne Hospitals NHS
Foundation Trust in 2014/15 that were recruited during that period
to participate in research approved by a research ethics committee
was 15,256 of which 12,493 were UKCRN National Portfolio studies
which equates to 35% of all patients recruited to National Portfolio
studies in the region.
Due to a national reorganization the region has increased in
size to include Cumbria, Darlington and Durham areas;
hence the drop in percentage from last year’s 38% to 35%.
Newcastle in 2014/15 is ranked second in the top league
of sixteen trusts for completing commercial trials to Time
and Target. Also Newcastle is ranked 6th in the top league
of sixteen Trusts for meeting the 70 day benchmark for 1st
patient in a clinical trial.
Information relating to registration
with the Care Quality Commission (CQC)
The Newcastle upon Tyne Hospitals NHS Foundation Trust is
required to register with the Care Quality Commission and its
current registration status is ‘Registered Without Conditions’.
The Newcastle upon Tyne Hospital NHS Foundation Trust is
registered with the CQC to deliver care from five separate
locations and for eleven regulated activities.
The Newcastle upon Tyne Hospitals NHS Foundation Trust
has not participated in any special reviews or investigations
by the CQC during the reporting period.
The Care Quality Commission has not taken enforcement
action against the Newcastle upon Tyne Hospitals NHS
Foundation Trust during 2014/15.
Following the introduction of the Intelligent Monitoring
Reports the Trust has received four reports. These reports
banded the Trust as ‘low risk’ and the Trust received band
5 - 6 during 2014/15.
The Newcastle upon Tyne Hospitals NHS Foundation Trust
is not subject to provider reviews by the CQC.
“
All the staff were welcoming and very
informative about my condition. Felt at ease
and very safe, which is what you need
to feel. Excellent.
“
Quality Account 2014/15 53
Information on the use of the CQUIN framework
A proportion of the Newcastle upon Tyne Hospital NHS Foundation
Trust income in 2014/15 was conditional upon achieving quality
improvement and innovation goals agreed between the Newcastle
upon Tyne Hospitals NHS Foundation Trust and any person or body
they entered into a contract, agreement or arrangement for the
provision of relevant health services, through the Commissioning
for Quality Innovation (CQUIN) payment framework.
The Trust signed up to four national CQUIN indicators, six local acute hospital indicators, four local community indicators,
a local dental and public health indicator and five local specialised indicators. These were chosen because they met with
local and regional strategies or were a continued priority to build on quality improvements achieved in 2013/14.
Further details of the agreed goals for 2014/15 are available on request from the Clinical Governance and Risk
Department at: Quality.Standards@nuth.nhs.uk.
The Trust are still awaiting confirmation from the commissioners regarding achievement in the year.
CQUIN Indicators
Acute CCGs
Status
Description
1. Friends & Family
(7% of CQUIN
contract)
Achieved
1a: 30% of the funding for implementation of the staff FFT across the provider, as specified in the national
guidance, from April 2014.
1b: 15% of the funding for early implementation of the patient FFT, by 1 October 2014.
2: 15% of the funding
Q1: A response rate for Q1 that is at least 15% for A&E services and at least 25% for inpatient services
Q2: A response rate for Q2 that is at least 16.5% for A&E services and at least 26.5% for inpatient services
Q3: A response rate for Q3 that is at least 18% for A&E services and at least 28% for inpatient services
Q4: A response rate for Q4 that is at least 20% for A&E services and at least 30% for inpatient services
3: 40% of the funding for a response rate of 40% (or more) for the month of March 2015 for inpatients
2. NHS Safety
Thermometer to
reduce harm
(7% of CQUIN
contract)
Achieved
Reduction in the prevalence of new pressure ulcers (20% based on achievement of 2013/14 rate)
50% of the funding for a rate of 1.19 at month 6;
50% of the funding to maintain this for the next 6 months (as an average)
3. Dementia and
delirium (6% of
CQUIN contract)
Achieved
3a: 60% of funding for: undertaking case finding for at least 90 per cent of patients aged 75 and over admitted
as an emergency for >72 hours; ensuring that, where patients are identified as potentially having dementia or
delirium, at least 90 per cent are appropriately assessed; and ensuring that, where appropriate, patients with
dementia are referred on to specialist services
3b:10% of funding for ensuring sufficient clinical leadership of dementia within
providers and appropriate training of staff
3. 30% of funding for ensuring carers of people with dementia feel adequately supported
4. End of Life (EoL)
Care Planning –
Implementation of
Neuberger Report
“More Care ,Less
Pathway”(20% of
CQUIN contract)
Achieved
Q1: Baseline to be carried out:
Numbers of nursing staff who have completed on-line NUTH mandatory training in EoL care and a real time
audit of EoL care with audit report and action points
Q2: Production of a report on progress against Neuberger Report targets, with a trust-wide action plan for
changeover from LCP for the remainder of the year including development of modified training materials as LCP
is discontinued
Q3: Real time audit of EoL care and comparison with Q1 results; action plan for learning points.
Q4: Update of progress against action plan for changeover from LCP, including progress on developing new staff
training materials and the numbers of nursing staff who have completed new on-line NUTH mandatory training
in EoL care
54 Quality Account 2014/15
CQUIN Indicators
Acute CCGs
Status
Description
5. Collaborative
Discharge
(15% of CQUIN
contract)
Achieved
Q1: Production of protocol, implementation plans, and specific frail elderly definition/tool in agreement with
Commissioners
Q2: Implementation progress – action plan updated
Q3: Implementation progress – action plan updated
Q4: Audit - % of frail elderly patients with care plans in place to be reported
An audit in Quarter 4 to provide a baseline of the time of discharge from the ward/ department and to identify
possible causes of late in the day discharges.
6. Communications
(10% of CQUIN
contract)
Partially
achieved
6a: To improve the number of OP clinic letters that are communicated to GP’s, from all departments, within 14
days of the OP clinic being attended.
Q1: Development of action plan
Q2: 75%
Q3: 79%
Q4: 82%
6b) To improve the quality and standardisation of communications between secondary and primary care
clinicians following OP appointments, through the introduction of agreed standard templates for OP clinic letters.
The pilot areas will be ENT, Older People’s Medicine and Ophthalmology.
Q1: Development of action plan
Q2: Implementation of pilot
Q3: Audit of pilot to include report and lessons learnt
Q4: Action plan for wider
Implementation and to include identification of options for provision of feedback to primary care on the quality
of referrals to services.
7. Alcohol Related
Attendances
(15% of CQUIN
contract)
Achieved
7a: To increase the recording of alcohol status in A&E, for all patients.
Q1: Action plan for roll out, including training and educational needs analysis, and identification of reporting /
data capture mechanisms (Report)
Q2: Delivery of training and educational aspects to carrying out alcohol assessment, & development of brief
intervention / leaflet
Q3: 70%
Q4: 75%
7b: To increase the proportion of those patients reporting higher risk alcohol consumption (within the areas of
A&E, ENT, Cardiothoracic and Sexual Health) that have received a brief intervention or information leaflet.
Q1: Action plan for roll out, including training and educational needs analysis, and identification of reporting /
data capture mechanisms (Report)
Q2: Delivery of training and educational aspects to carrying out alcohol assessment, & development of brief
intervention / leaflet
Q3: 75%
Q4: 80%
8. Decompensated
Cirrhosis
(10% of CQUIN
contract)
Achieved
Q1: Development of a care bundle and identification and implementation of areas to pilot. Identification of lead
clinician
Q2: Review of pilot and the development of an action plan to roll out across the Trust
Q3: 70% achievement of patients identified with cirrhosis with a care bundle in place in the first 24 hours.
Action plan update and roll out to other areas across the Trust
Q4: Re-audit and achieve 85% performance, or demonstrated improvement on Q3 performance
9. Newcastle Early
Warning Score
(10% of CQUIN
contract)
Achieved
Q1: Development of a NEWS chart with local adaptations and commencement of an educational strategy and
development of an action plan
Q2: Review and update of the action plan, including educational strategy
Q3: 95% of all relevant staff to be compliant with training requirements across the quarter (average).
Update on action plan
Q4: 95% of all relevant staff to be compliant with training requirements during each month in the quarter.
Review of action plan& achievements
CQUIN Indicators
Community CCGs
1. NHS Safety
Thermometer to
reduce harm
(20% of CQUIN
contract)
Status
Achieved
Description
Reduction in the prevalence of new pressure ulcers (20% based on achievement of 2013/14 rate)
50% of the funding for a rate of 0.18 at month 6;
50% of the funding to maintain this for the next 6 months (as an average)
Quality Account 2014/15 55
3
CQUIN Indicators
Community CCGs
Status
Description
2. Carer identification
of hidden carers
(20% of CQUIN
contract)
Achieved
Q1: Development of an action plan that will incorporate the identification of hidden carers and actions
undertaken into the discharge summary to GPs. This will be included in an overall action plan
Q2: Review and update of the action plan,
including the use of the discharge summary and sharing with GPs
Q3: Audit of implementation of the discharge summary and an update on the action plan
Q4: Report on progress with evidence on defined outputs
3. Real Time Patient
Feedback
(20% of CQUIN
contract)
Achieved
Q1: To distribute the Care Measure questionnaire to patients attending the Community Speech and Language
Therapy Service
Q2: The Care Measure will be rolled out to all Community MSK services
Q3: The Care Measure will be rolled out to all Community Podiatry services
Q4: Consideration will be given to rolling the questionnaire out to remaining Community Therapy Services
including community children’s’ services
4. Cognitive
Impairment
(20% of CQUIN
contract)
Achieved
Q1: Development of an action plan that will incorporate the identification of patients with a cognitive
impairment and actions undertaken into the discharge summary to GPs. This will be included in an overall action
plan
Q2: Review and update of the action plan, including the use of the discharge summary and sharing with GPs and
social care
Q3: Audit of implementation of discharge summary and an update on the action plan
Q4: Report on progress with evidence on defined outputs
5. End of Life (EoL)
Care Planning –
Implementation of
Neuberger Report
“More Care ,Less
Pathway”
(20% of CQUIN
contract)
Achieved
As above for acute
CQUIN Indicators
Specialised
Commissioners
Status
Description
1. Friends and Family
(7% of CQUIN
contract)
Achieved
As above for host CCGs.
2. NHS Safety
Thermometer to
reduce harm
(7% of CQUIN
contract)
Achieved
As above for host CCGs (acute)
3. Dementia and
delirium
(7% of CQUIN
contract)
Achieved
As above for host CCGs.
4. Quality Dashboards
(20% of CQUIN
contract)
Achieved
Submit data for each quarter
5. BOAST
(12% of CQUIN
contract)
Achieved
The aim of this indicator is to improve the care patients receive that are admitted with severe open fractures of
the tibia. The British Orthopaedic Association and the British Association of Plastic, Reconstructive and Aesthetic
Surgeons have published BOAST 4 Guidelines.
The BOAST 4 guideline requires:
1. Early identification of severe open fractures of the tibia
2. Joint care from orthopaedic and plastic surgeons
3. Surgical wound debridement and operative fracture stabilisation within 24 hours
4. Definitive soft-tissue cover within 72 hours of injury
Q1: 44%
Q2: 46%
Q3: 48%
Q4: 50%
56 Quality Account 2014/15
CQUIN Indicators
Specialised
Commissioners
Status
Description
6. Haemodialysis
(12% of CQUIN
contract)
Achieved
1. 10% of patients at a particular centre participating in 5 out of 14 tasks relating to their own dialysis
treatment
2. 95% of patients should be asked whether they would like to participate in the tasks relating to their own
dialysis. (5% allows for those patients with whom it is not possible to communicate due to severe physical or
mental disabilities)
7. Perinatal pathology
(12% of CQUIN
contract)
Achieved
1. Total number of completed cases reported by 42 calendar days from date of autopsy to final report
2. Total number of completed cases reported by 56 days from date of autopsy to the final report
Reconciled quarterly.
Q1: 0% payment
Q2: 50% where Q1 (set up) and Q2 (report Q1 and Q2 data) requirements met
Q3: (report Q3 data including incomplete cases from Q1/2) - 25%
Q4: Minimum of 10% improvement in baseline at Q4 (baseline 19%/59% ) - 25%
8. Telemedicine
(12% of CQUIN
contract)
Achieved
Implementation of a telemedicine system for patients with insomnia
Q1: The provider must submit details of the agreed patient cohorts to which this CQUIN will relate, the agreed
clinical criteria for each patient cohort, description of the telemedicine process and details of support to be able
to undertake follow-up of these patients
Q2: The provider must report progress on performance for each individual cohort of patients within this
scheme
At least 10% of patients meet the agreed criteria for insomnia are receiving telemedicine
Q3: The provider must report progress on performance for each individual cohort of patients within this
scheme
At least 15% of patients meet the agreed criteria for insomnia are receiving telemedicine
Q4: The provider must report progress on performance for each individual cohort of patients within this
scheme
A report detailing recommendations on how this initiative may be sustained and/or commissioned in the
following financial year will be included in Q4
At least 20% of patients meet the agreed criteria for insomnia are receiving telemedicine
9. Prosthetics
(12% of CQUIN
contract)
Achieved
All new referrals to be triaged within 4 weeks and offered a MDT within a maximum of 6 weeks of receipt of
referral.
Q1: 82%
Q2: 84%
Q3: 86%
Q4: 90%
CQUIN Indicators
Dental
1. Dental discharge
information
CQUIN Indicators
Public Health
1. Shared assessment
framework between
maternity and
health visiting.
Status
Achieved
Status
Achieved
Description
Develop and implement an information leaflet which patients will receive at time of discharge for all secondary
care dental treatment /admissions /day cases (this only includes patients receiving a general anaesthetic or
intravenous sedation with local anaesthetic)
Q1: baseline assessment of how current information is shared post operatively with patients having dental
treatment
Q2: develop an information leaflet, this will be shared and signed off by the commissioner in year
Q3: Action plan to evidence how these leaflets will be distributed and then the information monitored to show
information leaflets will be distributed
Q4: 100% of all patients to receive an informative leaflet Sample audit carried out by the provider to
evidence that patients have received information leaflets post discharge (10% of patients which equates to 250
patients)
Description
Develop and implement an integrated shared assessment framework to ensure continuous high quality care
between Maternity and Health Visiting Services
1. baseline assessment of how current information is shared across services 2. develop an integrated shared
assessment framework 3. Action plan for implementation including mobilisation 4.100% of women will have
their information routinely shared between community midwives and health visiting at the ante natal and new
birth periods (may include exceptions)
The monetary total for the amount of income in 2014/15 conditional upon achieving quality improvement and innovation goals is £15.107 million, and the
monetary total for the associated payment in 2013/14 was £14.453 million.
Quality Account 2014/15 57
3
Information on the Quality of Data
The Newcastle upon Tyne Hospitals NHS Foundation Trust
submitted records during 2014/15 to the Secondary Uses Service
(SUS) for inclusion in the Hospital Episode Statistics (HES) which are
included in the latest published data (April 2014 – January 2015).
The percentage of records in the published data:
Which included the patients valid NHS number was:
• 99.2% for admitted patient care
• 99.7% for outpatient care
• 97.5% for accident and emergency care
Which included the patients valid General Medical Practice
Code was:
• 100% for admitted patient care
• 100% for outpatient care
• 100% for accident and emergency care
Score for 2014/15 for Information Quality and
Records Management, assessed using the
Information Governance Toolkit
The Newcastle upon Tyne Hospitals NHS Foundation Trust
Information Governance Assessment Report overall score
for 2014/15 is 85% and was graded green (satisfactory).
An action plan to improve this is in place and progress is
being monitored by the Information Governance
Committee.
Clinical Coding Information
The Newcastle upon Tyne Hospitals NHS Foundation Trust
was not subject to the Payment by Results clinical coding
audit during 2014/15 by the Audit Commission due to
significant improvements in previous years.
However our annual Information Governance audit for
diagnosis and treatment coding of inpatient activity
demonstrated the highest level of attainment for
Information Governance purposes of level 3. This level was
attained this for all areas reviewed. Please see table below
for results.
Table 5- levels of attainment of coding of inpatient activity
Levels of Attainment
Area
Level Three
NUTH Score
Primary diagnosis
>=95%
99%
Secondary diagnosis
>=90%
97.94%
Primary procedure
>=95%
95.21%
Secondary procedure
>=90%
96.71%
The Newcastle upon Tyne Hospitals NHS Foundation Trust
will be taking the following actions to improve data
quality:
58 Quality Account 2014/15
• Feedback all areas of error found during the audit to
the coders and reinforce the mandatory comorbidities
and the importance of only recording relevant
conditions to the episode being coded
• Engage with clinicians to maintain a robust
understanding of the term rectal bleeding to ensure
consistency in the code assignment
• Initiate a process in Dermatology for psoriasis patients
to ensure the relevant information is documented in
case notes
• Provide feedback to the Paediatric Team regarding the
importance of documenting a definitive diagnosis and
ensuring all relevant information is included on the
electronic discharge summary
The Newcastle upon Tyne Hospitals NHS Foundation Trust
will be taking the following actions to improve data
quality:
• Review how post natal readmissions are coded
ensuring the clinical coder has access to all the relevant
clinical information
• Liaise closely with clinicians in regards to accurate
clinical documentation in casenotes ensuring any
incorrect information documented is feedback to
relevant clinician
• Ensure all clinical coding errors identified in the audit
are fed back to the relevant clinical coder
The Payment and Tariff Assurance Framework Clinical
Coding Audit undertaken in March 2015 also
demonstrated high quality clinically coded data and out of
the 202 episodes audited only 1.1% resulted in an HRG
change which impacted on payment.
The performance of the Trust compared with the national
average error rate of 7%, measured against the proportion
of episodes changing payment, places it in the top 25% of
best performing Trusts.
Key National Priorities 2014/15
3
The Key National Priorities are performance targets for the NHS
which are determined by the Department of Health and form part
of the CQC Intelligent Monitoring Report. A wide range of
measures are included and the Trust’s performance against the key
national priorities for 2014/15 are detailed in the table below.
Target
Annual
Performance
2014/15
Incidence of Clostridium difficile
No more than 80
73
Incidence of MRSA Bacteraemia
No more than Zero
5
All Cancer Two Week Wait
93%
96.3%
Two Week Wait for Symptomatic Breast Patients (Cancer Not initially Suspected)
93%
96.9%
31-Day (Diagnosis To Treatment) Wait For First Treatment
96%
98.6%
31-Day Wait For Second Or Subsequent Treatment: Surgery
94%
96.8%
31-Day Wait For Second Or Subsequent Treatment: Drug treatment
98%
99.1%
31-Day Wait For Second Or Subsequent Treatment: Radiotherapy
94%
98.9%
62-Day (Urgent GP Referral To Treatment) Wait For First Treatment
85%
87.1% A
No Target
85% (local target)
89.5%
62-Day Wait For First Treatment From Screening Service
90%
96.4%
RTT – Referral to Treatment - Admitted Compliance
90%
89.4%
RTT – Referral to Treatment - Non-Admitted Compliance
95%
94.0%
RTT – Referral to Treatment - Incomplete Compliance
92%
92.7% A
Maximum waiting time of 4 hours in A&E
95%
95.96%
Minimal
1.96%
Cancelled operations – those not admitted within 28 days
Zero
4
Maternity bookings within 12 weeks and 6 days
90%
94.9%
Data completeness: Community Services comprising: Referral to treatment information
>50%
99.3%
Data completeness: Community Services comprising: Referral information
>50%
91.7%
Data completeness: Community Services comprising: Treatment activity information
>50%
97.1%
Compliant
Achieved
Operating and Compliance Framework Target
62-Day Wait For First Treatment from Consultant Upgrade
Late referrals Excluded in Local Target
Delayed Transfers
Certification against compliance with requirements regarding access to health care for
people with learning disabilities
Quality Account 2014/15 59
Failed targets
RTT: Following an increased focus nationally on the 18
weeks targets, additional activity was commissioned across
provider Trusts, between July and November 2014, to treat
long waiting patients. It was recognised by local CCG and
NHS England commissioners that this would adversely
affect the achievement of RTT hence, the deterioration of
admitted and non-admitted compliance in the
corresponding months and consequently the year 2014 –
2015 overall performance
Cancelled operations: Due to the unprecedented level of
emergency demand in 2014/15 and the impact this had
on delivery of elective care, the Trust reported a breach of
the cancelled operation 28 day standard in Quarter 3 and
Quarter 4 of 2014/15
The Trust applies the following criteria to the two
indicators subject to limited assurance:
62-Day (Urgent GP Referral To Treatment) Wait For First
Treatment.
• The indicator is expressed as a percentage of patients
receiving first definitive treatment for cancer within 62
days of an urgent GP referral for suspected cancer
• An urgent GP referral is one which has a two week
wait from date that the referral is received to first being
seen by a consultant
60 Quality Account 2014/15
• 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 that the
referral is received by the Trust
• The clock stop date is the date of first definitive cancer
treatment as defined in the NHS Dataset Set 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
RTT – Referral to Treatment – Incomplete Compliance.
• The indicator is expressed as a percentage of
incomplete pathways within 18 weeks for patients on
incomplete pathways at the end of the period
• The indicator is calculated as the arithmetic average for
the monthly reported performance indicators for April
2014 to March 2015
• The clock start date is defined as the date that the
referral is received by the Trust, meeting the criteria set
out by the DoH guidance
• The indicator includes only referrals for consultant-led
service, and meeting the definition of the service
whereby a consultant retains overall clinical
responsibility for the service, team or treatment
Core set of Quality Indicators
3
Data is compared nationally when available from the NHS Information Centre, otherwise it is compared regionally from
the North East Quality Observatory or stated not available.
Measure
1. The value and
banding of the
summary
hospital-level
mortality
indicator
(“SHMI”) for the
trust
2. The percentage
of patient deaths
with palliative
care coded at
either diagnosis
or specialty level
for the trust
Data Source
Target
NHS Information Band 2
Centre Portal
“as expected”
https://indicato
rs.ic.nhs.uk/web
view/
NHS Information N/A
Centre Portal
https://indicato
rs.ic.nhs.uk/web
view/
2014/15
2013/14
2012/13
Oct 13Sept 14
NUTH
Value:
0.96
July 13June 14
NUTH
Value:
0.95
April 13Mar 14
NUTH
Value:
0.94
Jan 13Dec 13
NUTH
Value:
0.90
Oct 12Sept 13
NUTH
Value:
0.91
July 12 June 13
NUTH
Value:
0.91
Apr 12Mar 13
NUTH
Value:
0.92
Jan 12Dec 12
NUTH
Value:
0.93
Oct 11Sept 12:
NUTH
Value:
0.94
July 11June 12:
NUTH
Value:
0.94
NUTH:
Band 2
NUTH:
Band 2
NUTH:
Band 2
NUTH:
Band 2
NUTH:
Band 2
NUTH:
Band 2
NUTH:
Band 2
NUTH:
Band 2
NUTH:
Band 2
NUTH:
Band 2
National
average:
1.0
National
average:
1.0
National
average:
1.0
National
average:
1.0
National
average:
1.0
National
average:
1.0
National
average:
1.0
National
average:
1.0
National
average:
1.0
National
average:
1.0
Highest
national:
1.20
Highest
national:
1.20
Highest
national:
1.20
Highest
national:
1.18
Highest
national:
1.19
Highest
national:
1.16
Highest
national:
1.17
Highest
national:
1.19
Highest
national:
1.21
Highest
national:
1.26
Lowest
national:
0.61
Lowest
national:
0.54
Lowest
national:
0.54
Lowest
national:
0.62
Lowest
national:
0.63
Lowest
national:
0.63
Lowest
national:
0.65
Lowest
national:
0.70
Lowest
national:
0.68
Lowest
national:
0.71
24.16%
23.9%
23.9%
22.9%
21.1%
19.6%
18.2%
18.4%
19.4%
19%
National
average:
25.3%
National
average:
24.6%
National
average:
23.6%
National
average:
22.0%
National
average:
20.9%
National
average:
20.3%
National
average:
19.9%
National
average:
19.5%
National
average:
19.2%
National
average:
18.6%
Highest
national:
49.4%
Highest
national:
49%
Highest
national:
48.5%
Highest
national:
46.9%
Highest
national:
44.9%
Highest
national:
44.1%
Highest
national:
44%
Highest
national:
42.7%
Highest
national:
43.3%
Highest
national:
46.3%
Lowest
national:
0%
Lowest
national:
0%
Lowest
national:
0%
Lowest
national:
1.3%
Lowest
national:
0%
Lowest
national:
0%
Lowest
national:
0.1%
Lowest
national:
0.1%
Lowest
national:
0.2%
Lowest
national:
0.3%
Measure 1. The value and banding of the summary
hospital-level mortality indicator (“SHMI”) for the
trust.
introduction of a systematic mortality review process has
been implemented to ensure that all deaths in hospital are
subject to a clinician led review.
The Newcastle upon Tyne Hospitals NHS Foundation Trust
considers that this data is as described for the following
reasons: The Trust continues to perform well on mortality
indicators. Mortality reports are regularly presented to the
Trust Board following careful independent interpretation
provided by the North East Quality Observatory (NEQOS).
The Newcastle upon Tyne Hospitals NHS Foundation Trust
has taken the following actions to improve this, and so the
quality of its services by working closely with NEQOS and
the NHS Information Centre to improve understanding of
specific mortality rates. In 2013/14 the Trust have started
to utilise Variable Life Adjusted Displays (VLADs) for some
of the diagnosis groups that make up the SHMI. The
Measure 2. The percentage of patient deaths with
palliative care coded at either diagnosis or specialty
level for the trust.
The Newcastle upon Tyne Hospitals NHS Foundation Trust
considers that this data is as described for the following
reasons: The use of palliative care codes in the Trust has
remained static and aligned to the national average
percentage over recent years. The Newcastle upon Tyne
Hospitals NHS Foundation Trust intends to take the
following actions to improve this indicator, and so the
quality of its services, by involving the Coding team in
routine mortality reviews to ensure accuracy and
consistency of palliative care coding.
Quality Account 2014/15 61
Measure
Data Source
3. The patient reported outcome
measures scores (PROMS) for
groin hernia surgery (average
health gain score)
NHS Information Centre
Portal
http://www.hscic.gov.
uk/proms
4. The patient reported outcome
measures scores (PROMS) for
varicose vein surgery (specific
health gain)
5. The patient reported outcome
measures scores (PROMS) for
hip replacement surgery
(average health gain)
6. The patient reported outcome
measures scores (PROMS) for
knee replacement surgery
(average health gain)
NHS Information Centre
Portal
http://www.hscic.gov.
uk/proms
NHS Information Centre
Portal
http://www.hscic.gov.
uk/proms
NHS Information Centre
Portal
http://www.hscic.gov.
uk/proms
Provisional
2013/14
2012/13
2011/12
2010/11
2009/10
Trust score:
0.07
0.10
0.10
0.08
0.08
National average:
0.09
0.09
0.09
0.09
0.08
Highest national:
0.14
0.15
0.14
0.12
0.14
Lowest national:
0.01
0.01
0.03
0.03
0.01
Trust score:
0.11
0.10
0.10
0.13
0.12
National average:
0.09
0.09
0.10
0.09
0.09
Highest national:
0.15
0.18
0.17
0.14
0.15
Lowest national:
0.02
0.01
0.05
-0.01
0.00
Trust Score
0.43
0.43
0.42
0.42
0.42
National average:
0.44
0.44
0.42
0.41
0.41
Highest national:
0.55
0.54
0.47
0.47
0.48
Lowest national:
0.34
0.32
0.32
0.26
0.29
Trust Score
0.33
0.32
0.31
0.34
0.30
National average:
0.32
0.32
0.30
0.30
0.30
Highest national:
0.42
0.42
0.37
0.38
0.37
Lowest national:
0.22
0.21
0.18
0.20
0.17
Value
Measure 3. The patient reported outcome measures
scores (PROMS) for groin hernia surgery.
The Newcastle upon Tyne Hospitals NHS Foundation Trust
considers that this data is as described for the following
reasons: The Trust continues to report a similar score as the
National average. It is felt that this is because of the low
day case rate for this particular surgery. There is limited
clinical evidence regarding NICE guidance with laparoscopic
groin hernia surgery. The Newcastle upon Tyne Hospitals
NHS Foundation Trust has taken the following actions to
improve this indicator, and so the quality of its services, by
continuing to review the patient pathway.
Measure 4. The patient reported outcome measures
scores (PROMS) for varicose vein surgery.
The Newcastle upon Tyne Hospitals NHS Foundation Trust
considers that this data is as described for the following
reasons: The Trust is above the National average because
it offers all modalities of patient treatment in relation to
varicose veins. The Newcastle upon Tyne Hospitals NHS
Foundation Trust has taken the following actions to
improve this indicator, and so the quality of its services,
by continuing to review the patient pathway.
Measure 5. The patient reported outcome measures
scores (PROMS) for hip replacement surgery.
The Newcastle upon Tyne Hospitals NHS Foundation Trust
considers that this data is as described for the following
reasons: The data shows an increase in PROMS scores to
0.43 from 0.42 over the 12 month period. The Newcastle
upon Tyne Hospitals NHS Trust has an average outcome
for hip replacement surgery as many of the simpler cases
are outsourced to another provider due to current
capacity pressures. This results in more complicated cases
being performed by the Trust and therefore the health
gain increase could be expected to be less, if the simpler
patients were included the Trust believes that the
62 Quality Account 2014/15
increase would be more significant, however it is
important to note that even with a more complex
casemix the Trust still provides an ‘expected’ level of
improvement. The Newcastle upon Tyne Hospitals NHS
Foundation Trust intends to take the following actions to
improve this indicator, and so the quality of its services,
by working with the Specialist Orthopaedic Alliance in
benchmarking best practice for both hip and knee
replacement surgery to identify areas for potential future
improvement.
Measure 6. The patient reported outcome measures
scores (PROMS) for knee replacement surgery.
The Newcastle upon Tyne Hospitals NHS Foundation Trust
considers that this data is as described for the following
reasons: The data shows in increase in PROMS scores to
0.33 from 0.32 over the 12 month period. The Newcastle
upon Tyne Hospitals NHS Foundation Trust provides a
statistically significant (2SD) higher outcome for knee
replacement surgery than the local average. The Trust
believe this signifies the high level of care that the Trust
provide and this is also the case when work is outsourced
to other providers due to capacity issues. The Newcastle
upon Tyne Hospitals NHS Foundation Trust intends to
take the following actions to improve this indicator, and
so the quality of its services, by working with the
Specialist Orthopaedic Alliance in benchmarking best
practice for both hip and knee replacement surgery to
identify areas for potential future improvement.
Measure 7. The percentage of patients aged— (i) 0 to
15; and (ii) 16 or over readmitted.
The last set of data provided by the Health and Social
Care Information Centre covers the period 2011/12 and
was uploaded in December 2013, with the next versions
due ‘early 2016’. The Trust have contacted the Health
and Social Care Information Centre to question the age
Measure
Data Source
7a. Emergency readmissions to
hospital within 28 days of
discharge from hospital:
Children of ages 0-15
NHS Information Centre
Portal
https://indicators.ic.
nhs.uk/webview/
7b. Patient readmitted to hospital NHS Information Centre
Portal
within 28 days of being
https://indicators.ic.
discharged aged 16+
nhs.uk/webview/
Value
2013/14
2012/13
2011/12
2010/11
2009/10
Trust value
Unavailable see Unavailable
below
see below
12.50
11.71
12.25
National average:
Unavailable see Unavailable
below
see below
10.01
10.15
10.18
Highest national:
Unavailable see Unavailable
below
see below
14.94
14.11
15.35
Lowest national:
Unavailable see Unavailable
below
see below
0.00
0.00
0.00
Trust Value
Unavailable see Unavailable
below
see below
11.87
12.45
12.31
National average:
Unavailable see Unavailable
below
see below
11.45
11.43
11.18
Highest national:
Unavailable see Unavailable
below
see below
13.80
14.06
13.30
Lowest national:
Unavailable see Unavailable
below
see below
0.00
0.00
0.00
of the data available and asked when it will next be
updated. The Trust was informed that these indicators
are currently being re-developed as the contract with the
old data supplier has now terminated and they are
looking to bring them in-house.
reasons: Total emergency readmissions in 2014/15 have
increased from 5.6 to 6.1% when compared to last year,
with total numbers increasing from 11,700 to 13,016
(+1,316), although some of this is partially explained by a
significant growth in emergency admissions.
Therefore the Trust has reviewed its own internal data
and used its own methodology of reporting readmissions
within 28 days (without PbR exclusions).
The Newcastle upon Tyne Hospitals NHS Foundation Trust
has taken the following actions to improve this rate, and
the quality of its services, by having a continued focus on
emergency readmissions and updating an action plan to
improve patient outcomes and increase quality.
Furthermore, this is being driven by Directorate level
readmission audits as some readmissions are clinically
indicated and others are unavoidable due to patient
frailty or the inevitable progression of disease. However,
many are preventable if patients receive the right care at
the right place at the right time and it is avoidable
readmissions that are being targeted.
7a. Emergency readmissions to hospital within 28
days of discharge from hospital: Children of ages 0-15
Year
Total
number of
admissions/
spells
Number of
readmissions
(all)
Emergency
readmission
rate (all)
20/11/12
31,548
2,500
7.9
2012/13
31,841
2,454
7.7
2013/14
32,242
2,648
8.2
2014/15
34,561
3,570
10.3
7b. Patient readmitted to hospital within 28 days of
being discharged aged 16+
Year
Total
number of
admissions/
spells
Number of
readmissions
(all)
Emergency
readmission
rate (all)
20/11/12
175,836
9,435
5.4
2012/13
173,270
8,788
5.1
2013/14
177,867
9,052
5.1
2014/15
180,380
9,446
5.2
The Newcastle upon Tyne Hospitals NHS Foundation Trust
considers that this data is as described for the following
The majority of emergency readmissions are admitted via
Internal Medicine and as a Directorate, they account for
the majority share, 4,112 in 2014/15. However, they
showed only a minimal increase in 2014/15 of 76.
Children’s Services is showing a growth in emergency
readmissions, an increase of 2.0% (+828 cases).
However, because they have an ‘open access’ policy for
children with chronic conditions, this would partially
explain the increase. Furthermore, they experienced a
significant growth in emergency demand in 2014/15.
Measure 8. The Trust’s responsiveness to the
personal needs of its patients.
The Newcastle upon Tyne Hospitals NHS Foundation Trust
considers that this data is as described for the following
reasons: The data shows that the trust scores above the
national average. The Newcastle upon Tyne Hospitals NHS
Foundation Trust intends to take the following actions to
improve this indicator, and so the quality of its services, by
continuing to implement processes to capture patient
experience and improve its services.
Quality Account 2014/15 63
3
Measure
Data Source
NHS Information Centre
Portal
https://indicators.ic.
nhs.uk/webview/
8. The trust’s responsiveness to
the personal needs of its
patients
http://www.nhsstaffs
urveys.com/Page/100
6/Latest-Results/
2013-Results/
9. The percentage of staff
employed by, or under contract
to, the trust who would
recommend the trust as a
provider of care to their family
or friends
Value
2013/14
2012/13
2011/12
2010/11
2009/10
Trust percentage
77.3%
74.2%
72.2%
70.5%
70.8%
National average:
68.7%
68.1%
67.4%
67.3%
66.7%
Highest national:
84.2%
84.4%
85%
82.6%
Not available
Lowest national:
54.4%
57.4%
56.5%
56.7%
Not available
2014
2013
2012
2011
Trust percentage
85%
87%
86%
79%
National average:
65%
64%
62%
62%
Highest National:
89%
89%
86%
89%
Lowest national:
38%
40%
35%
33%
Measure 9. The percentage of staff employed by, or
under contract to, the Trust who would recommend
the Trust as a provider of care to their family or
friends.
The Newcastle upon Tyne Hospitals NHS Foundation Trust
considers that this data is as described for the following
reasons: the Trust has not improved on last year’s score but
is well above the National average. The Newcastle upon
Tyne Hospitals NHS Foundation Trust has taken the
following actions to improve this percentage, and so the
quality of its services, by continuing to listen to and act on
all sources of staff feedback.
Measure 10. The percentage of patients that were
admitted to hospital who were risk assessed for
Venous thromboembolism (VTE).
The Newcastle upon Tyne Hospitals NHS Foundation Trust
considers that this data is as described for the following
reasons: The Trust has a robust reporting system in place
and adopts a systematic approach to data quality
improvement. The Newcastle upon Tyne Hospitals NHS
Foundation Trust has taken the following actions to
improve this percentage, and so the quality of its services,
by completion of assessment being electronic to allowing
capture of compliance rates and the implementation of
the Safety Thermometer. The Trust has continued with use
of the electronic reporting system developed in 2014/15 to
assist the process in practice and continues to undertake
root cause analysis (RCA) on patients who develop a
hospital acquired VTE.
Measure
10. The percentage
of patients that
were admitted
to hospital
who were risk
assessed for
Venous
thromboemboli
sm (VTE)
Data
Source
NHS
Information
Centre Portal
2013/14
http://www.e
ngland.nhs.uk
/statistics/stat
istical-workareas/vte/
Q4 2013/14Internal Data
reported to
Unify
Target
2014/15
Measure 11. The rate per 100,000 bed days of cases
of C. difficile infection reported within the trust
amongst patients aged 2 or over.
The Newcastle upon Tyne Hospitals NHS Foundation Trust
considers that this data is as described for the following
reasons: The Trust has a robust reporting system in place
and adopts a systematic approach to data quality
improvement. The Newcastle upon Tyne Hospitals NHS
Foundation Trust has taken the following actions to
improve this rate, and so the quality of its services, by
having a robust strategy that includes the review of all
Trust-apportioned cases to ensure no avoidable cases
occur: completion of root cause analysis (RCA) forms for
all such cases; Antibiotic Champions undertaking regular
audits of Stop and Review including a review of the Policy
and awareness sessions; Quarterly HCAI Report to share
lessons learned and best practice from the RCAs and
Serious Infection Review Meetings. C. difficile awareness
campaigns took place with staff, alongside regular
ongoing hand hygiene and cleanliness audits. Clinical
Directorates have also produced HCAI Action Plans to
demonstrate how lessons learned are shared with all staff
in order to encourage best practice.
Measure 12. The number and rate of patient safety
incidents reported:
The Newcastle upon Tyne Hospitals NHS Foundation Trust
considers that this data is as described for the following
reasons: The Trust take the reporting of incidents very
seriously and have an electronic reporting system (Datix) to
2013/14
Trust
(Target95%)
Q1
Q2
Q3
96.4% 95.8% 95.5%
Q4
Await
Q1
Q2
Q3
95.8% 96.3% 97.4%
Q4
97%
National
average
96.2% 96.2%
96%
Await
95.5% 95.8% 95.7%
96%
Highest
national
100%
100%
100%
100%
100%
Lowest
national
87.2% 86.4% 89.6%
Await
78.8% 81.7% 74.1% 78.9%
64 Quality Account 2014/15
100%
100%
100%
Q1
95%
2012/13
2011/12
Q2
95%
Q2
94%
Q3
Q4
Q1
95.2% 95.4% 95.2%
100%
100%
84.6% 87.9%
Q3
Q4
96.5% 98.2%
Measure
11. The number and
rate per 100,000
bed days of cases
of C.difficile
infection reported
within the trust
amongst patients
aged 2 or over
12. The number and
rate per 100
admissions of
patient safety
incidents reported
Data Source
Target
NHS Information
Centre Portal
http://www.hpa.
org.uk/web/HPA
web&Page&HPA
webAutoList
Name/Page/
1179745282408
Trust number
73
75
76
101
150
Trust Rate
17.06
18.2
15.4
21.4
32.2
National
Average rate
Not available
14.7
17.4
22.2
29.7
Highest
National rate
Not available
37.1
31.2
58.2
71.2
Lowest National
rate
Not available
0
0
0
0
Oct14 Mar15
7703
(Trust
data for
2014/15
14,787)
Apr14 Sept14
7084
Oct13 Mar14
6619
(Trust
data for
2013/14
13,275)
Apr13Sept13
5727
Oct12 Mar13
5138
Ap12 Sept12
4573
Oct11 Mar12
4204
Apr11Sept11
4311
Oct10 Mar11
4259
Apr10 Sept10
3527
Trust Rate
6.95
6.4
5.3
5.4
4.8
4.3
4.1
4.2
4.4
3.4
National
Average
Not available
8.7
8.0
7.7
7.0
6.9
6.5
6.2
6.0
Highest
National
Not available
14.9
12.8
13.7
12.12
10.7
9.22
9.74
10.76
Lowest National
Not available
4.6
4.9
3.2
2.77
0.94
4.14
4.43
3.39
NHS Information
Trust Number
Centre Portal
http://www.nrls.n
psa.nhs.uk/patien
t-safety-data/
organisationpatient-safetyincident-reports/
2014/15
2013/14
13. The number
and
percentage
of patient
safety
incidents
that resulted
in severe
harm or
death
Data
Source
NHS
Information
Centre Portal
http://www.
nrls.npsa.
nhs.uk/
patientsafety-data/
organisation
-patientsafetyincidentreports/
Target
Trust no.
2014/15
2011/12
2010/11
3
Measure 13. The number and percentage of patient
safety incidents that resulted in severe harm or
death:
support this. The Newcastle upon Tyne Hospitals NHS
Foundation Trust has taken the following actions to
improve this number and rate, and so the quality of its
services, by undertaking a campaign to increase awareness
of incident/near miss reporting. The Datix system has
recently been upgraded and changes are being made to
the incident form in order to reduce the time taken to
complete an incident report. Incidents are graded,
analysed and, where required, undergo a root cause
analysis investigation to inform actions, recommendations
and learning. Incident data are reported on a monthly
basis to the Trust Board. Serious incidents are also
reviewed at the Trust Corporate Governance Committee
bimonthly meetings. Analysis of this data is considered by
the Trust Integrated Governance Committee and reported
to the Clinical Risk Group to inform our organisational
learning themes which are reported to the Board.
Improvements have been seen in the last report available
from the NRLS.
Measure
2012/13
The Newcastle upon Tyne Hospitals NHS Foundation Trust
considers that this data is as described for the following
reasons: The Trust takes incidents resulting in severe harm
of death very seriously. The rate of incidents resulting in
severe harm or death is consistent with the national
average. This reflects a culture of reporting incidents which
lead to, or have the potential to, cause serious harm or
death. The Newcastle upon Tyne Hospitals NHS
Foundation Trust has taken the following actions to reduce
this number and rate, and so the quality of its services, by
the Board receiving monthly reports of incidents resulting
in severe harm of death. (The Trust would classify major
and catastrophic as permanent harm or death. This would
include a fracture following a fall if the patient did not
fully recover their normal level of independence.
2013/14
2012/13
2011/12
Oct14 Mar15
Oct14 Mar15
Apr14- Apr14- Oct13- Oct13- Apr13- Apr13- Oct12- Oct12- Apr12- Apr12- Oct11- Oct11- Apr11- Apr11Sept14 Sept14 Mar14 Mar14 Sept13 Sept13 Mar13 Mar13 Sept12 Sept12 Mar12 Mar12 Sept11 Sept11
Severe
Harm
Death
Severe Death Severe Death Severe Death Severe Death Severe Death Severe Death Severe Death
Harm
Harm
Harm
Harm
Harm
Harm
Harm
30
0
18
0
18
0
25
3
35
2
Trust %
Not
available
Not
available
0.4%
0%
0.3%
0%
0.31% 0%
0.56% 0.19% 0.5%
0%
0.6%
0.1%
0.8%
0%
National
average
Not
available
Not
available
0.4%
0.1%
0.3%
0.1%
0.2%
0.1%
0.33% 0.1%
0.4%
0.1%
0.5%
0.1%
0.5%
0.1%
Highest
National
Not
available
Not
available
74.3% 8.6%
0.9%
0.3%
0.8%
0.3%
1.3%
0.28% 1.6%
0.5%
2.6%
0.4%
2%
0.4%
Lowest
National
Not
available
Not
available
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0
29
1
23
0%
In 2014/15 the Trust is now included in a new much larger group of Trusts (140 instead of 30) and one Trust’s data has skewed the highest national results because it has
reported less than a 100 incidents in the 6 months hence the strange high figures. The next highest is 2.3% severe harm and 0.8% for death.
Quality Account 2014/15 65
Workforce Factors
Wellbeing –the tables below provide data on the loss of work days. Table 6 reports on the Trust and Regional position
rate (data taken from the NHS Information Centre) and Table 7 provides an update on the Trust number of staff sick days
lost to industrial injury or illness caused by work.
Table 6: loss of work days (rate)
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
The Newcastle Upon Tyne Hospitals
3.61%
3.48%
3.60%
3.84%
3.57%
3.66%
4.03%
4.16%
4.44%
City Hospitals Sunderland
4.26%
4.44%
4.87%
4.82%
4.78%
5.03%
5.18%
5.49%
5.33%
County Durham and Darlington
4.05%
3.98%
4.16%
4.36%
4.51%
4.50%
4.93%
4.98%
5.20%
Gateshead Health
5.19%
5.21%
4.90%
5.24%
4.95%
4.70%
5.04%
5.49%
5.33%
North Tees and Hartlepool
4.35%
3.83%
4.10%
4.24%
4.40%
4.56%
4.34%
4.76%
5.44%
Northumbria Healthcare
3.58%
3.64%
3.91%
4.33%
4.20%
4.47%
4.63%
4.60%
4.66%
South Tees Hospitals
4.22%
4.02%
4.29%
4.33%
4.52%
4.34%
4.37%
4.59%
4.79%
South Tyneside NHS
5.22%
5.43%
5.30%
5.61%
5.09%
5.26%
5.61%
6.09%
6.47%
England
3.98%
3.79%
3.80%
3.88%
3.81%
3.94%
4.18%
4.24%
4.35%
Table 7: The number of shift staff sick days lost to industrial injury or illness caused by work
Year
Quarter 1
Quarter 2
Quarter 3
Quarter 4
Year Total
2009/2010 no. of days
251
414
581
298
1544
2010/2011 no. of days
118
254
267
366
1005
2011/2012 no. of days
253
299
247
153
952
2012/2013 no. of days
154
138
174
209
675
2013/2014 no. of days
489
331
785
147
1752
2014/2015 no. of days
333
284
178
206
1001
2014 NHS Staff Survey Results Summary
A standard Survey was sent via the internal post to a
random sample of 850 staff from across the Trust in
October 2014. 445 staff participated in the Survey,
equalling a response rate of 53% which is in the highest
20% of acute trusts in England, and was a slight
improvement on 2013; this at a time when nationally
overall the response rate has fallen. It also coincides with
the introduction of the FFT (Staff).
The results are arranged under eight headings – five based
upon the staff pledges from the NHS Constitution plus
two additional themes, work-life balance and your job and
organisation. There are also summary results regarding
background information. The staff engagement score is
calculated using three of the key findings (KF) scores –
staff ability to contribute towards improvements at work,
staff recommendation of the Trust as a place to work or
receive treatment and staff motivation at work. In the Trust
this score was:
66 Quality Account 2014/15
• Overall: rating of staff engagement 3.89 (out of
possible 5).
This score was in the highest (best) 20% compared with
all other acute NewcastleTrusts and the Trust has
maintained the same position as 2013.
The Trust’s top five ranking scores where it compares most
favourably with other acute Trusts were (average for acute
trusts shown in brackets):
• KF24 Staff recommendation of the trust as a place to
work or receive treatment: 4.04 (3.67)
• KF 8 % of staff having well-structured appraisals in last
12 months 47% (38%)
• KF22 % of staff able to contribute towards
improvements at work 74% (68%)
• KF27 % of staff believing the trust provides equal
opportunities for career progression or promotion 92%
(87%)
• KF 3 Work pressure felt by staff (lower the better) 2.90
(3.07)
Of note, the Trust is also categorised in the highest (best),
comparing favourably in % of staff suffering work-related
stress in the last 12 months, staff witnessing potentially
harmful errors, near misses or incidents in the last month,
staff experiencing harassment, bullying or abuse from
patients, relatives, the public or staff in the last 12 months.
The % of staff feeling pressure in the last 3 months to
attend work when feeling unwell has also improved, and
the perceived fairness and effectiveness of incident
reporting procedures is also better than average. This data
relates to individual health and wellbeing and will become
increasingly relevant due to the focus on action to
promote health and wellbeing in the 5YFV.
The Trust’s bottom five ranking scores were (average for
acute trusts shown in brackets): These are the key findings
where the Trust compares least favourably with other
acute trusts in England:
• KF4 Effective team working 3.71 (3.74)
• KF2 % of staff agreeing that their role makes a
difference to patients 89% (91%)
• KF29 % of staff agreeing that feedback from
patients/service users is used to make informed
decisions in their directorate/department 53% (56%)
• KF15 % of staff agreeing they would feel secure raising
concerns about unsafe clinical practice 67% (67%)
• KF13 % of staff reporting errors, near misses or
incidents witnessed in the last month 90% (90%)
Effective team working assesses the extent to which staff
feel they work in a team, team members have shared
objectives, they meet often to discuss the team’s
effectiveness and have to communicate closely to achieve
those objectives. Overall staff experience has been shown
to affect patient care.
Points 3 to 5 are particularly disappointing. Although
‘average’ scores, the results illustrate there is still
significant work to be done with our staff in building
confidence that raising concerns should be part of routine
business of a well-led organisation, that the Trust values
the raising of concerns, and that it wishes to foster an
organisational culture in which staff feel they can safely
raise any concerns. In view of the recently published
Francis ‘Freedom to Speak up Review’ this will continue to
be a priority area in the staff survey action plan.
Where the staff experience has deteriorated was:
• KF10 % of staff receiving health and safety training in
the last 12 months 79% (87%)
• KF27 % of staff believing the trust provides equal
opportunities for career progression or promotion 92%
(96%)
• KF26 % of staff having equality and diversity training
in the last 12 months 71% (80%)
Interestingly for point 2 whilst this represents deterioration
for the Trust compared to 2013, this score remains one of
the top 5 top ranking scores.
Involvement and engagement
Equality Diversity and Human Rights
The information presented in this Quality Account
represents information which has been monitored over the
last 12 months by the Trust Board, Council of Governors,
Clinical Governance and Quality Committee and the
Clinical Policy Group. The majority of the Account
represents information from all 17 Clinical Directorates
presented as total figures for the Trust. The indicators to
be presented and monitored were selected following a
series of discussions with Non-Executive members of the
Trust Board. They were agreed by the Executive team and
have been developed over the last 12 months following
guidance from senior clinical staff. The priorities for
improvement have been discussed and agreed by the Trust
Board, Clinical Governance & Quality Committee, the
Clinical Policy Group and representatives from the Council
of Governors.
Patient Involvement and Engagement activity is monitored
in the Trust via the Patient Experience Steering Group and
Health Equality and Wellbeing Committee. Over 2014-15,
the Patient, Carer and Public Involvement Strategy was
reviewed and refreshed resulting is a new strategy for
2015-17. The strategy includes the commitment to hold a
number of listening events in the local communities in
order to give Directors and other senior staff the
opportunity to hear from members of the public about
their experiences in the Trust and their thoughts on how
we can improve.
In addition, work is continuing to meet the national
requirements for patient experience such as the National
Patient Survey Programme, Patient Reported Outcome
Measures (PROMs) and the NHS Friends and Family Test.
The Friends and Family Test in particular has provided the
Trust with a vast amount of qualitative feedback about our
services and staff. Systems have been developed to analyse
the feedback we receive in order to identify any areas for
improvement and action change.
Over the last year we have listened to the views and
experience of diverse groups of people and individuals
regarding their experiences of healthcare. Through the
Equality, Diversity and Human Rights group we have
reviewed this information along with other local, regional
and national reports. We have used it to revise and further
develop our objectives and action plans. Information about
how we did this can be found on the Trust internet:
http://www.newcastle-hospitals.org.uk/aboutus/equality-and-diversity_equality-deliverysystem.aspx
We have also used the information to equality assess our
policies.
Examples of what people and reports told us and what we
have done are outlined below:
In a survey at Northern Pride in Newcastle 75% of Lesbian,
Gay, Bisexual and Transgender people who have used
Newcastle Hospital Services said they are either likely or
extremely likely to recommend the services to a family
member or friend.
Quality Account 2014/15 67
3
However we know from national reports that LGBT people
still experience difficulties when using NHS Services.
lack of information and appreciation of transgender issues
by health professionals.
We became Stonewall Health Care Champions and
improved our rating from 23rd from 47 entrants this year
to 13th from 39 entrants.
We have incorporated some of the messages they shared
with us into training and a woman with a transgender
history now supports training to newly qualified staff.
Some older people find it hard to hear well in hospital.
On International Men’s Day outreach work was
undertaken in Byker, Newcastle by the ‘Let’s Crack on’
Men’s Health Steering group. Throughout the course of
the day approximately 80 men were spoken to. Although
the workers understand public health some found it
upsetting to witness so much poverty in one place. One
theme that arose from the work was loneliness and people
not knowing about local facilities.
We are undertook a survey with people and staff in the
elderly care wards and have developed an action plan to
raise awareness of the needs of older people who are hard
of hearing with both staff and patients.
Young people said they want clear information about
services and confidential services.
Through the You’re Welcome Accreditation process we
have reviewed children and young people’s services. 17
health services in Newcastle have You’re Welcome status
and an additional 18 working towards the quality mark.
Deaflink told us that some Deaf people are not able to
find out if a British Sign Language Interpreter has been
booked for their appointment.
The Trust worked with the Patient Advice and Liaison
Service so that Deaf people can text them to find out if the
interpreter has been booked.
Self Harm is increasing especially amongst young people.
The Equality, Diversity and Human Rights Working Group
are setting up a subgroup to consider Loneliness; what is
already happening across Newcastle and any actions that
the Trust can take both in inpatient and community
settings to address loneliness.
The Trust contributed to a report on the health of people
from Eastern European communities. The report identified
poorer health and access to services by Roma
communities.
The Health Improvement Service for Ethnic Minorities is
working in partnership with Riverside Community Health
Project to facilitate outreach health-focused work in the
community for example stop smoking support.
An awareness workshop has been held within Equality
and Diversity week to raise awareness of self harm and the
support that is available.
Women identify domestic violence as having significant
impact on their health.
We met the ‘Be You’ Gender Identity group and listened
to the experience of transgender people. They told us
about long waiting times in Mental Health Services and
The Safeguarding Adults Team developed and delivered a
conference on domestic violence which raised awareness
of the issues women faced.
68 Quality Account 2014/15
3
“Excellent care and
friendly staff, make
the experience less
daunting and much
more bearable.
Thank you
“
Quality Account 2014/15 69
Annex 1: Statement on behalf of the
Health Scrutiny Committee
Mrs. Angela O’Brien, Director of Quality and Effectiveness and Miss Elaine Coghill attended the
Health Scrutiny Committee on 14th May 2015 where they outlined and presented the 2014/15
Quality Account. A formal response was received via email on 28th May 2015. All points have
been reviewed and addressed and the document altered accordingly. A formal response was sent
to the Health Scrutiny Committee on 9th June 2015.
Councillor Felicity Mendelson
South Jesmond Ward
37 Queens Road
Newcastle upon Tyne, NE2 2PR
Home phone: 0191 281 8255
Mobile: 07946 412 015
Email:
felicity.mendelson@newcastle.gov.uk
Members’ Services Unit
Phone: 0191 232 8520
Extension: 25044 or 26216
Fax: 0191 211 4959
www.newcastle.gov.uk
Mrs E Coghill
Newcastle upon Tyne Hospitals
NHS Foundation Trust
elaine.coghill@nuth.nhs.uk
Our Ref: QA2015/KC
Dear Elaine
Newcastle upon Tyne Hospitals NHS Foundation Trust, Quality Account 2014/15
Response of Health Scrutiny Committee, Newcastle City Council
As Vice-Chair of the Health Scrutiny Committee, I welcome the opportunity to comment
on your draft Quality Account for 2014/15. Members discussed the draft at their meeting
n 14 May 2015 and this letter provides a summary of the committee’s response.
In general we found that the Quality Account contained a significant amount of detailed
information allowing us to gain a clear picture of the position of the Trust, as a complex
organisation serving many thousands of patients. We do however, consider that as a public
document it is less readable and we suggest that the Trust review this in advance
of the 2015/16 publication, as well as continuing to provide an easy-read version.
Priority 1 Reducing infections
We note that the Trust has given priority to reducing all forms of healthcare associated
infections. We know that these infections can create additional suffering for patients and will
prolong hospital stays, and we therefore welcome this continued focus.
70 Quality Account 2014/15
3
We note that the Quality Account 2013/14 included information from the 2013 staff survey,
which showed that 76% of staff said that hand washing materials are always available. Whilst
this position was higher that the national average it still leaves room for improvement and we are
surprised, given that hand hygiene practices can be a fundamental way of helping to reduce
infections, that the Trust has not reported further on this or set a target in the 2014/15 Quality
Account. In lieu of this information the committee have requested an update on the current
position.
Priority 2 Sign up to Safety
We welcome that the Trust has signed up to the national “sign up to safety” campaign and note
the significant improvement in the number of cases of surgical never events and welcome the
continued focus to having no reported incidents.
Priority 3 Harm free care
We welcome the inclusion of action to reduce falls within this priority. Although the Trust has
established a number of strategies to deal with this and performance by the Trust has
improved compared to previous years, falls remains a significant issue. You will be aware that
the committee held an evidence gathering session on this issue in 2014 and we would
welcome the Trust’s involvement in a follow-up report to committee later this year.
We also note the continued focus on work to avoid harm from urinary tract infections (UTI’s) and
catheter associated UTI’s. Committee is particularly concerned about the level of admissions
from care homes and this may be an area that we return to during the year, to review on going
levels.
Priority 5 Clinical effectiveness, mortality
We note the continued emphasis on working with patients with dementia to ensure they receive
high quality individualised care. We consider that there should be a mandatory requirement for
all staff to complete dementia training to ensure that they have a minimum level of knowledge
and skills to help them better engage with dementia patients; and as a result help to improve
the patient experience of staying in hospital. We look forward to receiving an evaluation of the
impact of this training in 12-months time.
In relation to all the 2014/15 Quality Account priorities we would welcome the opportunity to
receive a progress update during the coming year.
Yours sincerely
Councillor Felicity Mendelson
Vice Chair, Health Scrutiny Committee
Quality Account 2014/15 71
Statement on behalf of the Newcastle, Gateshead,
Northumberland and North Tyneside Clinical
Commissioning Groups (CCGs)
Mrs. Angela O’Brien, Director of Quality and Effectiveness and Miss Elaine Coghill attended the
Newcastle Gateshead, Northumberland and North Tyneside Clinical Commissioning Groups (CCGs)
on 14th May 2015 where they outlined and presented the 2014/15 Quality Account. A formal
response was received via email on 28th May 2015.
Newcastle Gateshead Alliance
Corroborative statement from Newcastle Gateshead, Northumberland and North
Tyneside Clinical Commissioning Groups (CCGs) for Newcastle Upon Tyne
Hospitals NHS Foundation Trust Quality Account 2014/15
NHS Newcastle Gateshead CCG, North Tyneside CCG and Northumberland CCG
welcome the opportunity to review and comment on the Quality Account for
2014/15 and would like to offer the following commentary.
We remain committed to commissioning high quality services from Newcastle
Upon Tyne Hospitals NHS Foundation Trust and take seriously their responsibility to
ensure that patients’ needs are met by the provision of safe, high quality services
and that the views and expectations of patients and the public are listened to and
acted upon.
The CCGs would like to commend the Trust for the improvements that are
demonstrated in the report which cover a wide range of measures relating to
quality, safety and effectiveness. The great majority of the priorities have been met
or bettered; including those related to reduction in healthcare acquired infections,
excellent outcomes on the safety thermometer, and increasing staff input to and
feedback from incident reporting.
The progress in assuring and improving measures relating to safeguarding,
dementia support/training, mortality monitoring and use of NEWS critical patient
safety measure is also commendable; as is the uniform Trust implementation of
the WHO surgical checklist.
It is acknowledged that in one area the Trust did not meet its standard; relating to
MRSA in healthcare acquired infections, but there continues to be a robust review
and action plan to eliminate contributory factors from these.
It is noted that the 95% Referral to Treatment Target was narrowly missed and the
CCGs expect the Trust will continue its focus on this key element of patient
experience.
72 Quality Account 2014/15
3
Newcastle Gateshead Alliance
The CCG’s are looking forward to working with the Trust on the Quality Priorities
identified for 2015/16:
Patient safety - HCAIs, Sign up to patient safety, Harm free care, and DOLs/ MCA
safeguarding.
Effectiveness - mortality reviews, national audits/ confidential enquiries, NICE
quality standards.
Patient experience - National patient experience surveys, Friends & Family test.
Thank you for asking the CCGs to comment on the 2014/15 Quality accounts, we
commend the excellence and caring approach demonstrated in this report.
Dr Neil Morris
Medical Director
Mr Chris Piercy
Executive Director of Nursing Patient Safety and Quality
NHS Newcastle Gateshead Clinical Commissioning Group
28th May 2015
Quality Account 2014/15 73
Statement on behalf of Healthwatch Newcastle
Healthwatch Newcastle did not wish to have a formal presentation of the Quality Account. The
document was sent for review on 28th April with a formal response being received via email on
May 19th 2015. All points have been reviewed and addressed and the document altered
accordingly. A formal response was sent to Newcastle Healthwatch on the 9th June 2015.
Healthwatch Newcastle
Higham House
Higham Place
Newcastle upon Tyne
NE1 8AF
Newcastle
0191 232 7445
www.healthwatchnewcastle.org.uk
Elaine Coghill
The Quality and Effectiveness Team
Clinical Governance and Risk Team
Newcastle upon Tyne Hospitals NHS Foundation Trust
Royal Victoria Infirmary
Queen Victoria Road
Newcastle upon Tyne
NE1 4LP
19 May 2015
Dear Elaine,
Thank you for giving Healthwatch Newcastle the opportunity to comment on the
Newcastle upon Tyne Hospitals NHS foundation Trust’s Quality Account 2014/2015.
This year I have looked at the Quality Account and provided a statement for publication. I
have enclosed this statement.
Yours sincerely
Julie Marshall
Involvement Coordinator
julie@healthwatchnewcastle.org.uk
0191 226 3450
New
74 Quality Account 2014/15
3
Healthwatch Newcastle
Higham House
Higham Place
Newcastle upon Tyne
NE1 8AF
Newcastle
0191 232 7445
www.healthwatchnewcastle.org.uk
Healthwatch Newcastle’s statement for Newcastle upon Tyne
Hospitals NHS Foundation Trust’s Quality Account 2014/2015
Healthwatch Newcastle was pleased to read Newcastle upon Tyne Hospitals (NUTH) NHS
Foundation Trust’s Quality Account 2014/2015 and to learn more about some of its successes
this year. The report is clear and comprehensive but we would advise that where figures
and indicators are used, it is made clear if a higher or lower number is preferable as this
is not always obvious.
Priority 1 – Reduce all forms of Healthcare acquired infection (HCAIs)
We are pleased to see that all forms of HCAIs have reduced in number over the last year,
especially Methicillin Resistant Staphylococcus Aureus (MRSA), Methicillin Sensitive
Staphylococcus Aureus (MSSA) and E.coli which had all increased in the previous year.
Priority 2 – Prevent avoidable harm or death
We are pleased that the Trust continues to perform above the national average for harm
free care and that:
• The Trust continues to perform below the national average for number of falls per
1000 bed days and has also reduced this number further to 5.5 for the period April –
December 2014, which is an improvement on the same period in the previous year
• The Trust was able to achieve a further 20% reduction in pressure damage and
maintain this for a six month period. It is a shame this is unable to be maintained
over the winter months however we recognise that despite the winter pressures, the
Trust still performed better than the national average
• A number of wards have reported a significant number of harm free days and that
three wards have been harm free for over a year. It would be interesting to know
which wards achieved these results. A comment received by Healthwatch Newcastle
also confirms the care taken to minimise pressure damage:
‘…Freeman hospital is fantastic. They really look after my auntie and provide all
the care she needs. They even turn her in bed. Her care home doesn’t do this!’
Ne
• The Trust is below the national average for the number of patients developing a
Catheter Associated Urinary Tract Infection (CAUTI)
Quality Account 2014/15 75
Statement on behalf of Healthwatch Newcastle
We are also pleased to hear of the success of the innovative work with care homes to
reduce the number of catheterised patients to nearly half the national average.
Priority 3 – Patient safety
It is disappointing that incident reporting is lower than the figures for similar trusts,
however it is encouraging that there has been an 11.4% rise in reporting.
We are pleased that the results of the staff survey suggest that staff feel more positive
about the Trust’s culture of reporting and feel that openness and feedback has improved.
Priority 4 – Safeguarding
We are pleased to see the Trust’s continued commitment to safeguarding by the
development of a Trust Strategy. We will continue to follow the Trust’s progress on its
implementation.
Priority 5 - Dementia
We are pleased to see dementia is a key priority and that the Trust has achieved the
national compliance level every month for the reporting period.
We are particularly pleased to read that the results of your recent questionnaire reported
that 100% of carers / friends who responded felt there was access to support and felt
included in their relative / friend’s care. We are also pleased to hear that carers felt the
focus groups they attended were beneficial and that more are being planned.
Priority 8 – Surgical safety checklist
Whilst it is encouraging that the number of surgical never events has reduced significantly
from six in the previous year to one during this reporting period, it is very disappointing
that the figure was not zero. The implementation of the new surgical checklist based on
the WHO best practice guidelines is a positive step and we will follow the Trust’s progress
over the coming year.
Priority 9 – Patient Experience
We are very pleased that patient experience remains a priority for the Trust and that its
importance is recognised.
We are pleased to see NUTH consistently has some of the best results for the Friends and
Family Test (FFT) and performs higher than the national average for inpatient and
maternity services.
We would like to see more information about the other positive work within the Trust
regarding patient experience. For example, more information about the ongoing work of
the Trust’s Patient, Carer and Public Involvement forum and the Trust’s adoption of the
‘Hello, my name is…’ campaign.
76 Quality Account 2014/15
New
The majority of comments that Healthwatch Newcastle receives about health care
services in Newcastle upon Tyne can be themed into four common topics: quality of care,
waiting times, communication / Information and staff attitude. The comments received
about quality of care are mainly positive in nature whilst comments about waiting times,
communication / information and staff attitude are more likely to be negative. In general,
people are very happy with the clinical care they receive in Newcastle upon Tyne but
their patient experience is very heavily determined by the other three ‘associated’, nonclinical factors. This trend is in line with the identified themes of the complaints received
by the Trust over the last year.
Some comments received by Healthwatch Newcastle over the last year are:
‘…Very good - quick diagnosis and treatment…’
‘…Maxillofacial unit RVI excellent…’
‘…Not very good at listening to patients and putting them at ease…’
‘…Eye hospital was very good except for long wait…’
‘…Freeman Hospital in Newcastle has a very good system for deaf patients. They have a
vibrating pager to alert patients of their turn. Very useful…’
Healthwatch Newcastle aims to recognise excellence as well as challenging poor service.
During 2014 we developed our ‘Healthwatch Stars’ award. This gives members of the
public the opportunity to nominate a person or service for excellent patient care. Since
its launch NUTH received two nominations for Healthwatch Star awards. They were
awarded to:
• Donna Sill: Midwife Sonographer, Royal Victoria Infirmary
• Ward 23, Adult trauma orthopaedics, Royal Victoria Infirmary
We look forward to awarding more stars over the coming year.
We are pleased to read about the work undertaken around equality and diversity in
response to feedback from communities. In particular we are very pleased that 17 NUTH
services in Newcastle now have ‘You’re Welcome’ status with a further 18 working
towards accreditation. We are also delighted that the Trust has become a Stonewall
Healthcare Champion and that all newly qualified staff will undergo transgender training.
We wish the Trust every success over the coming year. We will continue to work together
to ensure a high level of patient involvement is maintained into this year and beyond.
Yours sincerely
Bev Bookless
Healthwatch Newcastle Chair
Ne
Rachel Head
Champions’ Support Worker
rachel@healthwatchnewcastle.org.uk
0191 235 7026
Quality Account 2014/15 77
Annex 2: Statement of Directors’ responsibilities
in respect of the Quality Report
The directors are required under the Health Act 2009 and the
National Health Service (Quality Accounts) Regulations 2010 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:
• board minutes and papers for the period April 2014
to March 2015 (No August 2014 Board)
• papers relating to Quality reported to the Board
over the period April 2014 to March 2015 (No
August 2014 Board)
• 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.monitornhsft.gov.uk/annualreportingmanual) as well as the
standards to support data quality for the preparation of
the quality report
The directors confirm to the best of their knowledge and
belief they have complied with the above requirements in
preparing the quality report.
By order of the Board
• feedback from the commissioners dated 28th May
2015
• feedback from governors dated 3rd February 2015
• feedback from Local Healthwatch organisations
dated 19th May 2015
• feedback from Local Overview and Scrutiny
Committee dated 20th May 2015
• the Trust’s complaints report published under
regulation 18 of the Local Authority Social Services
and NHS Complaints Regulations 2009, dated May
2014, August 2014, September 2014, October
2014, November 2014, December 2014, February
2015
• the national patient survey February 2015
• the national staff survey 2014
• the Head of Internal Audit’s annual opinion over the
trust’s control environment dated 26 May 2015
• CQC Intelligent Monitoring Reports 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
78 Quality Account 2014/15
Sir Leonard Fenwick
Chief Executive
28 May 2015
Kingsley
i
l W Smith
S ih
Chairman
3
Quality Account 2014/15 79
Annex 3: Abbreviations
Abbreviations
AAA
Abdominal Aortic Aneurysm
A&E
Accident & Emergency
ANS
Association of Neurophysiological Scientists
BSCN
British Society of Clinical Neurophysiologists
CAT
Clinical Assurance Tool
CAUTI s
Catheter Associated Urinary Tract Infection
CBBC
Children’s BBC
C&B
Choose & Book
CCGs
Clinical Commissioning Groups
C.difficile
Clostridium difficile
CIA
Carotid Interventions Audit
CIPD
Championing better work and working lives
CNST
Clinical Negligence Scheme for Trusts
CQC
Care Quality Commission
CQUIN
Commissioning for Quality and Innovation (CQUIN) payment framework
CRRT
The Community Response and Rehabilitation Team
CT
Computerised tomography
CXR
Chest X-Ray
DAHNO
National Head and Neck Cancer Comparative Audits
Datix
Trust Incident Reporting System
DOH
Department of Health
DoLs
Deprivation of Liberty
DVT
Deep Vein Thrombosis
E.coli
Escherichia coli
ED
Emergency Department
EoL
End of Life
EWS
Early Warning Score
FFFAP
Falls and Fragility Fracture Audit Programme
FFT
Friends & Family Test
FH
Freeman Hospital
FT
Foundation Trust
GP
General Practitioner
GI
Gastrointestinal
GMC
General Medical Council
GNCH
Great North Children's Hospital
HAT
Hospital Acquired Thrombosis
80 Quality Account 2014/15
3
Abbreviations
HCAI
Healthcare Associated Infection
HES
Hospital Episode Statistics
HSE
Health and Safety Executive
HSMR
Hospital Standardised Mortality Ratio
ICNARC
Intensive Care National Audit and Research Centre
IPC
Infection Prevention & Control
IPCC
Infection Prevention & Control Committee
IPMR
Integrated Performance Measures Return
ITU
Intensive Therapy Unit
IV
Intravenous
KF
Key Finding
LD
Learning Disability
LUCADA
National Lung Cancer Audit Database
MEWS
Modified Early Warning Score
MCA
Mental Capacity Act
MDT
Multi-Disciplinary Team
M&M
Morbidity & Mortality
MRI
Magnetic Resonance imaging
MRSA
Methicillin-resistant Staphylococcus Aureus
MSSA
Methicillin-Sensitive Staphyloccus Aureus
MTC
Major Trauma Centre
N/A
Not Applicable
NBOCAP
National Bowel Cancer Audit Programme
NCCC
National Centre for Cancer Care
NCEPOD
National Confidential Enquiries into Patient Outcome & Death
NELA
National Emergency Laparotomy Audit
NEQOS
North East Quality Observatory
NEWS
National Early Warning Score
NHS
National Health Service
NHS BT
National Health Service Blood Transfusion
NICE
National Institute for Health and Clinical Excellence
NICOR
National institute for Clinical Outcome Research
NIHR
National Institute for Health Research
NRLS
National Reporting & Learning System
NPSA
National Patient Safety Agency
NSAB
Newcastle Safeguarding Board for Adults
Quality Account 2014/15 81
Abbreviations
NSAC
Newcastle Safeguarding Board for Children
NSF
National Service Framework
NUTH
Newcastle upon Tyne NHS Foundation Trust
NVD
National Vascular Database
O-G
Oesophago-Gastric
PHE
Public Health England
PICANet
Paediatric Care Intensive Care Audit Network
PICU
Paediatric Intensive Care Unit
PIR
Post Infection Review
PROMs
Patient Reported Outcome Measures
PMR
Performance Measures Returns
QMCO
Quarterly Monitoring Cancelled Operations
QSTs
Quality Standards
RCA
Root Cause Analysis
RCS
Royal College of Surgeons
RCP
Royal College of Physicians
RCPH
Royal College of Paediatric Health
RTPF
Real Time Patient Feedback
RTT
Referral to Treatment Time
RVI
Royal Victoria Infirmary
SHMI
Summary Hospital-level Mortality Indicator
SIRM
Serious Infection Review Meeting
SSCG
Surgical Safety Checklist Group
SUI
Serious Untoward Incident
SUS
Secondary Users Service
TARN
Trauma Audit Research Network
TIA
Transient Ischaemic Attack
UK
United Kingdom
UNICEF
The United Nations Children's Fund
UTI
Urinary tract infection
VAD
Ventricular Assisted Devices
VLAD
Variable Life Adjusted Displays
VTE
Venous thromboembolism
WHO
World Health Organisation
5YFV
Five Year Forward View
82 Quality Account 2014/15
Annex 4: Glossary of Terms
Glossary of Terms
1. CQC
The Care Quality Commission (CQC) is the independent regulator of all health and adult
social care in England. The aim being to make sure better care is provided for everyone,
whether that’s in hospital, in care homes, in people’s own homes, or elsewhere.
2. CQUIN –
Commissioning
for Quality and
Innovation
The CQUIN framework was introduced in April 2009 as a national framework for locally
agreed quality improvement schemes. It enables commissioners to reward excellence by
linking a proportion of English healthcare provider’s income to the achievement of local
quality improvement goals.
3. DATIX
DATIX is an electronic risk management software system which promotes the reporting of
incidents by allowing anyone with access to the Trust Intranet to report directly into the
software on easy-to-use-web pages. The system allows incident forms to be completed
electronically by all staff.
4. HSMR
The Hospital Standardised Mortality Ratio (HSMR) is an indicator of healthcare quality that
measures whether the death rate at a hospital is higher or lower than would be expected.
5. KO41
The reference used by the Department of Health Statistics Branch (HSIC) to refer to the
form used to collect annual information from each Trust about the NHS Written
Complaints received during the year, and which in future will be collected quarterly from
1st April 2015, by HSIC and shared with CQC etc.
7. Monitor
Monitor is the independent regulator of NHS foundation trusts. Established in January
2004 to authorise and regulate NHS foundation trusts it is independent of central
government and directly accountable to Parliament.
8. National Reporting
and Learning System
(NRLS)
The NRLS was established in 2003. The system enables patient safety incident reports to
be submitted to a national database. This data is then analysed to identify hazards, risks
and opportunities to improve the safety of patient care.
9. Near Miss
An unplanned or uncontrolled event, which did not cause injury to persons or damage to
property, but had the potential to do so.
10. Never Event
Never events are serious, largely preventable patient safety incidents that should not
occur if the available preparative measures have been implemented.
10. NHS Safety
Thermometer
The NHS Safety Thermometer is a local improvement tool for measuring, monitoring and
analysing patient harms and “harm free” care. This tool measures four high-volume
patient safety issues (pressure ulcers, falls in care, urinary infection (in patients with a
catheter) and treatment for venousthromboembolism (Pulmonary embolus or deep vein
thrombosis DVT).
11. North East Quality
Since 2009 NEQOS has been providing a quality measurement service to NHS trusts (both
Observatory (NEQOS) providers and commissioners) across the North East region. These are delivered with high
level analytical skills and clinical epidemiological expertise.
12. NPSA
The National Patient Safety Agency leads and contributes to improved, safe patient care
by informing, supporting and influencing the health sector.
12. The Care Act
An act to make provision to reform the law relative to care and support for adults.
12. WHO Surgical Safety
Checklist
A checklist that identifies three phases of an operation, before induction of anaesthesia,
before the incision of skin, before the patient leaves the operating room.
Quality Account 2014/15 83
Annex 5: Feedback Form
We would like to hear your views on our Quality Account.
The Department of Health directs some of the content of
this account i.e. quality measures, that every organisation
must publish.
However, the Newcastle upon Tyne Hospitals NHS
Foundation Trust has an opportunity to publish information
about local quality initiatives. Your feedback will give us an
opportunity to include the initiatives you want to hear
more about. The results of this feedback will contribute to
the development of the Quality Account 2015/16.
An easy read version is available on the Trust website.
Please fill in the feedback form below, tear it off, and
return to us, in the post, at the following address:
The Quality and Effectiveness Team
Clinical Governance and Risk Department,
The Newcastle upon Tyne Hospitals
NHS Foundation Trust,
Queen Victoria Road,
Newcastle upon Tyne,
NE1 4LP
Or alternatively e-mail your comments to:
Quality.Standards@nuth.nhs.uk
Thank you for your time.
Feedback Form (please circle all answers that are applicable to you)
What best describes you: Patient/carer/member of public/staff/other
Did you find the Quality Account easy to read?
Yes
No
Did you find the content easy to understand?
Yes all of it
Most of it
None of it
Did the content make sense to you?
Yes all of it
Most of it
None of it
Did you feel the content was relevant to you?
Yes all of it
Most of it
None of it
Would the content encourage you to use our hospital?
Yes all of it
Most of it
None of it
Did the content increase your confidence in the services we provide?
Yes all of it
Most of it
None of it
Are there any subjects/topics that you would like to see included in next year's Quality Account?
.............................................................................................................................................................................................
.............................................................................................................................................................................................
.............................................................................................................................................................................................
In your Opinion, how could we improve Our Quality Account?
.............................................................................................................................................................................................
.............................................................................................................................................................................................
.............................................................................................................................................................................................
84 Quality Account 2014/15
Freeman Hospital (Headquarters)
High Heaton
Newcastle upon Tyne
NE7 7DN
Telephone: 0191 233 6161
Fax: 0191 213 1968
This information
can be requested
in large print