Quality Accounts 2014-15
PART ONE
Introduction from CEO ------------------------------------------------------------------------ 2
Statement on quality from CEO -------------------------------------------------------------------- 4
PART TWO
Priorities for quality improvement 2015-2016 ---------------------------------------------------- 5
Statements relating to quality of care provided -------------------------------------------------- 9
Prescribed indicators --------------------------------------------------------------------------------- 10
Data quality metrics and processes --------------------------------------------------------------- 17
Clinical coding audit ---------------------------------------------------------------------------- 18
Performance against key national targets 2014-2015 ---------------------------------------- 19
PART THREE
Quality improvement highlights of 2014-2015 -------------------------------------------------- 19
How we did last year against our priorities for quality improvement 2014-2015 ------- 22
Case Study One – Dementia Care ---------------------------------------------------------------- 29
Participation in clinical trials ------------------------------------------------------------------------- 33
Research and development ------------------------------------------------------------------------- 34
CQUINs ----------------------------------------------------------------------------------------------------37
Care Quality Commission ---------------------------------------------------------------------------- 39
Case Study Two – Safer Staffing --------------------------------------------------------------------40
Further review of quality performance 2014-2015 --------------------------------------------- 42
o Transformation ------------------------------------------------------------------------------- 42
o Information, Communication and Technology --------------------------------------- 44
o Electronic Patient Record ----------------------------------------------------------------- 46
o Winter Planning ------------------------------------------------------------------------------ 48
o Discharge Planning ------------------------------------------------------------------------ 51
o Patient Experience -------------------------------------------------------------------------- 52
o Cancer Patient Experience ---------------------------------------------------------------- 56
o Acute Oncology and Malignancy of Undefined Origin Service ------------------- 59
o End of Life Care ------------------------------------------------------------------------------ 61
o Embedding quality through Patient Champions -------------------------------------- 63
o Case Study Three: Our Patient Panel -------------------------------------------------- 63
o Infection prevention and control ---------------------------------------------------------- 66
o Pharmacy – improving medicines management ------------------------------------- 70
o Incident and safety improvement -------------------------------------------------------- 75
o Falls ---------------------------------------------------------------------------------------------- 78
o Pressure ulcers ------------------------------------------------------------------------------ 81
o Stroke Services …………………………………………………………………….. 83
o Family and Women’s Services ------------------------------------------------------------ 84
o Safeguarding adults -------------------------------------------------------------------------- 85
o Safeguarding children ----------------------------------------------------------------------- 87
o Volunteers --------------------------------------------------------------------------------------92
Statements from stakeholders ---------------------------------------------------------------------- 95
Amendments made following stakeholder engagement --------------------------------------- 100
External audit limited assurance report ------------------------------------------------------------ 102
Appendix A: National clinical audits in which the Trust was eligible to participate ------ 103
Glossary of terms ---------------------------------------------------------------------------------------- 108
Quality Account signed audit opinion----------------------------------------------------------------115
1|Page
Introduction from CEO
Our Quality Accounts provide an annual opportunity for everyone to take stock of our
achievements and progress in patient care over the last 12 months and to look forward to
what our ambitions are for the year ahead.
Everything we try to do is based on our values, the desire to build our services around our
patients and service users, their families and carers and our staff who make it all possible.
We also recognise that a great NHS depends on excellent relationships with our healthcare
partners.
Our patients tell us that when we get this right, their care is outstanding. However, if we get it
wrong, through poor communication or a lack of joined-up working, this all adds to delays
and stress which leaves them feeling let-down and frustrated. This is an area we have
worked hard on and is part of the future.
It has been our busiest ever year. As a small District General Hospital we have one of the
busiest emergency departments in England. Not only that, but we have seen far more births,
more cancer care, more urgent operations and more elective care than ever before.
To address these additional pressures, we have been working closely with our health
partners and commissioners to review and improve the service we provide.
We have succeeded in implementing a number of key areas of improvement into our
systems in order to support our teams. Since December 2014, West Essex Clinical
Commissioning Group has been funding a ‘GP at the Front Door’ programme to facilitate
increased streaming from our Emergency Department to more appropriate services. The
CCG is also providing a treating GP to provide additional support for minor injury patients in
ED.
In March 2015, the Trust opened its brand new Surgical Assessment Unit, dedicated GP
assessment and Ambulatory Care environment, resulting in an increase in capacity of 26
beds to support the proposed medical model. From laying the first brick to completion, this
work took just ten weeks – a remarkable achievement.
Reviewing and re-designing our patient pathways – the patient journey - has enabled us to
transform how we deliver services. The result is that we have improved health outcomes
and made the best use of resources, while ensuring that the patients and their needs are at
the forefront. For example, PAHT now offers a straight-to-test service for endoscopy,
allowing GPs to refer patients directly for an endoscopy without the need for the patient to
come in first for an outpatient appointment.
Research and clinical trials continue to be a key focus for the Trust. We participated in 125
local audits during 2014-15, improving patient safety and patient outcomes. A dementia
audit in the Orthopaedics Department, for example, led to a significant increase from 22% to
74% of forms filled in by junior doctors for dementia screening.
The Trust is committed to the adoption of best practice and the drive to innovate. In 2014,
staff from the Princess Alexandra Hospital NHS Trust showcased two of their latest medical
advances at a major international exhibition, with help from Health Enterprise East. The first
innovation was Metasin, a test of the lymph nodes of breast cancer patients which is carried
2|Page
out at the same time they are being operated on. It allows doctors to see whether there are
signs the cancer is at risk of spreading elsewhere via the lymph nodes, enabling their
immediate removal if appropriate. The second is the Trust’s use of digital pathology
enabling quicker and more accurate diagnosis.
In addition to these two areas, the Trust also introduced other major technology advances
for the treatment of cancers. These include the introduction of Intra Operative Radiotherapy
Treatment (IORT) where breast cancer patients receive targeted radiotherapy on the
operating table during surgery, and the use of High Intensity Focused Ultrasound (HIFU) for
the treatment of prostate cancer.
Quality and safety will always be at the heart of everything that we do and in the past year,
we have worked hard to continue to build on our successes and make further improvements
where needed. There has been an 11% increase in incident reporting– regarded as a sign
of an organisation with a strongly-developed safety culture – alongside a reduction in the
severity of incidents. PAHT is in the top 20% of Trusts for reporting incidents and
demonstrates learning and improvement and ensuring that patient experience is premium.
The Trust has remained in the top quartile for the Friends and Family Test for 18 months and
the Achieving Excellence Patient Experience Programme has produced a 50% reduction in
complaints, as well as a significant increase in compliments around the compassion,
empathy and care delivered by our staff.
The Trust remains concerned about the ageing estate and the poor infrastructure,
deteriorating building fabric, equipment and engineering plant, much of which is in need of
urgent replacement or upgrade.
The demand we face for our services is unprecedented and we recognise that major change
is needed to create a hospital that meets local needs in a sustainable and safe way. Early in
2015, therefore, the Trust began engaging with partner organisations to explore how we can
develop a new kind of joined-up health and social care service. The Integrated Care
Programme is a venture into the kind of personalised health and social care that has yet to
be achieved in this country. It could lead to radical changes in the way people look after
their own health, the way they access health and social care services and the way in which
local services are organised, including the possibility of a new integrated care organisation.
The outcome of research into how this would work is due to be concluded by April 2015 and
will be the subject of consultation with wider stakeholders, including patient groups.
The shape of healthcare is changing at a rapid pace and PAHT is determined to lead from
the front, making the best use of resources and ensuring that the care and treatment we
offer our patients is fit for the future. Please read about our achievements and ambitions and
let us know what you think. In the meantime, thank you for your continued support.
Phil Morley
Chief Executive
3|Page
Statement on Quality from CEO
The development of this Quality Account gives staff the ability to look at and think about the
progress made to improve care for patients in 2014/15. It has also provided the Trust with a
chance to decide on, and commit to, further improvements for patients that we will make in
2015/16.
For the public, it is hoped that the Quality Accounts offer a clear and honest overview of the
work undertaken at The Princess Alexandra Hospital NHS Trust, demonstrating the progress
made over the last year. Crucially it also provides everyone at the Trust with a good signpost towards all we have to do over the coming year to improve patient care even more.
I should like to thank all the staff and our volunteers for their input and support in helping us
to progress against our objectives during the year.
I am very pleased that key stakeholders from our local community have had an input into this
Quality Account, providing their ideas and comments. This additional perspective gives me
assurance that we are concentrating on the things that really matter.
The information and data contained in this report has been subject to internal review and
external verification. Therefore, to the best of my knowledge, the information contained
within this document reflects a true and accurate picture of the performance of the Trust.
Phil Morley
Chief Executive
4|Page
Priorities for quality improvement 2015 - 2016
Each year we assess our performance against previous quality priorities and take account of
national reports and emerging themes. This year we have again evaluated our focus for the
coming year and have identified a number of quality indicators for 2015-16.
The following indicators in the table below have been approved by the Board and will form
the basis of all Trust-wide improvements across the year ahead. These priorities are part of
the Trust’s overarching Quality Improvement Strategy which aims to improve outcomes for
patients including our mortality rate which is measured at a national level. The Quality
Improvement Strategy was developed following engagement with staff members from all
disciplines throughout the Trust. This was done via workshops and presentations in
departmental meetings, such as Executive Management Board and the Medical Advisory
Committee. The Strategy aims to:
•
•
•
•
•
Eliminate the level of avoidable and preventable harm to our patients
Improve delivery of palliative care and end of life care
Continue to report incidents; learning how we can improve and embedding change to
ensure that we get care right first time
Develop and implement care pathways, care bundles and embed High Impact
Actions
Participation in NHS England’s Sign up to Safety Campaign which aims to make the
NHS the safest healthcare system in the world.
5|Page
Priorities for quality improvement 2015-2016
1
1.1
Patient Safety
Priorities
What we are trying to
improve
What success will look like
How we will monitor
progress
Deliver harm-free
care
Compliance with best
practice
Eradication of Never Events
Datix
Monthly report
Integrated Performance
Report (IPR)
Serious Clinical Incident
Group (SCIG)
External commissioner
reporting
1.2
1.3
Successful
implementation of
Sepsis 6 Bundle
Timely clinical care of
patients with Sepsis
Successful implementation
of Sepsis 6 Bundle
Through Patient Safety
Quality Committee,
quarterly reporting and
Sign up to Safety
reporting.
Improvement in key
areas identified in our
sign up to Safety
Pledge.
Achievement of outcomes
set out in improvement plan
for each of the priority
areas.
Through Patient Safety
Quality Committee,
quarterly reporting and
Sign up to Safety
reporting.
What we are trying to
improve
What success will look like
How we will monitor
progress
Continue to
enhance the care
people receive at
end of life
Use of DNA CPR use
Eliminate inappropriate
resuscitation or intervention
CQUIN milestones
Continue to
improve the care
received by people
living with
dementia
Early detection and
onward referral
Screening of all admitted
patients aged over 65 (for
their potential dementia
risk) in line with the local
and national CQUIN
Compliance with >90%
patients screened and
referred. Monthly
submission to UNIFY
Sign-up to Safety
Long list derived from
pledge.
Shortlist arrived at
through consultation
sessions with staff.
2
Clinical Outcome
Priorities
2.1
2.2
End of Life plans of care
Early discharge to
preferred place of care
Improvements in ward
environment
6|Page
Roll-out of the
Dementia Champions
schemes
Improved environment for
dementia patients.
Continuation of dementia
champions programme as
part of the dementia
training programme as
required for the local and
national dementia CQUIN.
Compliance with agreed
standards for the
environment for
dementia patients
At least one dementia
champion in each clinical
area.
Implementation of
dementia volunteers
national programme.
2.3
Successful
introduction of
Hospital at Night to
facilitate seamless
and equitable care
24 hours a day
This is a two year
scheme to introduce
and sustain a Hospital
at Night team,
consisting of a group of
multi-professional
individuals with an
agreed range of skills
and competencies to
meet the immediate
needs of patients and
facilitate effective
operational
management of the
Hospital at Night,
optimising patient
safety and minimising
risk.




Reduce avoidable
cardiac arrests
Reduction in the
number of
unplanned
admission and
readmission to ITU
Reduce avoidable
patient harm
incidents
occurring after
8pm and at
weekends
Reduction in the
number of ‘failure
to
rescue’/suboptim
al care’ incidents
3
Patient Experience
Priorities
What we are trying to
improve
What success will look like
3.1
Greater visibility of
Patient Experience
Information at
ward level on
complaints and
compliments.
Information and
transparency for
patients about our
performance at ward
and Health Group level.
Delivering bespoke plans in
place developed in
partnership with patients
and reported back on the 22
Know How We Are Doing
Boards.
Hospital at Night project
team to monitor
progress.
Compliance with local
CQUIN milestones.
How we will monitor
progress
Board and committee
reports.
Process Improvement
workshops.
Clinical Friday audit
programme
7|Page
3.2
3.3
Evidence of
outstanding levels
of patient
satisfaction in the
top 20% of Trusts in
England.
Excellent
communication
skills demonstrated
by medical and
nursing staff.
Improve Patient
Experience survey
results against 2014-15
and national
comparison.
Improved patient
experience through
communication which is
respectful and
empathic.
Ensure all 77 Inpatient
Survey indicators are at
least in the middle 60% or
above with at least three
indicators in the top 20% of
Trusts in England and
Wales.
90% compliance with
training on Level 2
communications skills for all
clinical staff.
Monthly Integrated
Performance Review
Real-time PALS/ patient
feedback.
National survey results.
Staff training statistics.
Complaints and
compliments thematic
analyses.
Real-time feedback.
3.4
Outstanding
complaints
handling process
improvements.
Top ranked complaints
handling processes
nationally.
95% of complaints are
acknowledged within three
working days.
Complaints process
monitoring at committee
level.
95% responded to within an
agreed deadline.
Annual and quarterly
reporting.
Satisfactions levels shown
through survey.
4
What we are trying to
improve
What success will look like
How we will monitor
progress
To create a better
working
environment where
staff morale is
improved and
where all staff have
received
appropriate
workplace training
such as equality
and diversity
training
Score the national
average or above
through staff survey
Progress will be monitored
through monthly surveys
National and local
surveys
4.2
Ensure that the
Trust’s Vision and
Values are
embedded among
the workforce and
are being adhered
to.
Increase number of
staff being trained in
Trust’s Vision and
Values
A rise in the number of staff
receiving training from the
current level of 61% to a
minimum of 70%
Regular reports to the
Board
4.3
To provide the kind
of working
environment and
Staff retention
Reduce voluntary turnover
to 10% or lower
Regular workforce
reports to Performance
4.1
Staff Experience
Priorities
8|Page
career progression
that will encourage
staff to stay at the
Trust long term,
thus providing a
stable and happy
workforce, leading
to better patient
care and
experience.
and Finance Committee
Statements relating to quality of care provided
The Trust provides a range of services to a local population of around 300,000 living in west
Essex and east Hertfordshire. The majority of services are provided from the main hospital
site in Harlow, but local hospitals in Bishop’s Stortford and Epping offer outpatient and
diagnostic services too.
The Trust provides a comprehensive range of general medical and surgical services and has
a busy Emergency Department (101,987 attendances in 2014/15), Intensive Care Unit (10
beds) and Neonatal Unit (16 cots). The current list of service portfolio is outlined below:
Adult Critical Care
Audiology
Breast Screening
Breast Surgery
Cardiology
Chemotherapy
Child Development
Centre
Clinical Haematology
Directory of services CHECK
Diabetic Medicine
High Dependency
Unit
Dietetics
Intensive Care unit
Emergency
Interventional
Department
Radiology
Endocrinology
Maternity
ENT
Medical Oncology
Family Planning
Neonatal Critical
Care
Gastroentorology
Neurology
General Medicine
Obstetrics
Clinical Oncology
General Surgery
Ophthalmology
Community
Midwifery
Day Surgery
Genito-Urinary
Medicine
Geriatric Medicine
Oral Surgery
Dermatology
Gynaecology
Pathology
Patient Appliances
Pre Op Assessments
Radiology
Respiratory Medicine
Rheumatology
Sexual Health
Special Care Baby
Unit
Trauma and
Orthopaedics
Urology
Paediatric Diabetic
Medicine
Paediatrics
During 2014-15 the total revenue was £190.5m. Of this total, £178.7m (94%) related to the
provision of patient care services and £11.8m (6%) related to other operating revenue
including £5.2m for education, training and research.
9|Page
The Trust has a service level agreement in place with subcontract providers for the provision
of services and has regular contact with them to agree levels, type and timescales for patient
treatment.
Prescribed indicators
Below are the core indicators which NHS England has requested be included in the 20142015 Quality Accounts by all NHS Trusts.
12. The Princess Alexandra Hospital NHS Trust considers that this data is as described
having been provided by Dr Foster.
12
Standardised
Hospital Mortality
Indicator
(a) The value
and banding
of the
summary
hospital-level
mortality
indicator
(“SHMI”) for
the trust for
the reporting
period; and
(b) The
percentage
of patient
deaths with
palliative
care coded
at either
diagnosis or
specialty
level for the
trust for the
reporting
period.
Oct ’13 to Sep
‘14
National
average
Highest
score
Lowest
score
Improvement action plan
106.0
100.0
119.82
59.66
Publication of a Trust
Morbidity and Mortality
Strategy.
New Reporting and
Performance process
with a monthly Patient
Quality and Safety
review Panel chaired by
the Chief Nurse, the
Medical Director or the
Chief Executive to hold
individual health groups
accountable for
performance in their
area.
0.38%
0.8%
0.26% (PAH
2.15% (East and
& North
University
Hertfordshire) Hospital of
South
Manchester)
Further training for staff
to understand coding
better.
Better communication
between coders and
doctors.
Introduction of an
escalation process for
coding difficulties.
18. The Princess Alexandra Hospital NHS Trust considers that this data is as described
having been published by the HSCIC.
Patient Reported Outcome Measures
10 | P a g e
PROMs measures health outcomes in patients undergoing hip replacement, knee
replacement, varicose vein and groin hernia surgery in England, based on responses to
questionnaires before and after surgery.
Data available – April 2014 to September 2014.
Figures in brackets represent the national average.
EQ-5D Index (a combination of five key criteria concerning general health)
 12.5% of groin respondents recorded an increase in the EQ-5D Index score following
their operation (49.9%).
 90.90% of hip replacement respondents recorded an increase in their EQ-5D Index
score following their operation (90%).
 92.30% of knee replacement respondents recorded an increase in their EQ-5D Index
score following their operation (82.2%)
 The number of varicose vein questionnaire pairs returned is suppressed due to small
numbers.
EQ VAS (current state of the patients general health marked on a visual analogue scale)
 55.6% of groin hernia respondents recorded an increase in their EQ VAS score
following their operation (38.3%)
 36.4% of hip replacement respondents recorded an increase in their EQ VAS score
following their operation (66.2%)
 41.70% of knee replacement respondents recorded an increase in their EQ VAS
score following their operation (56.7%)
 The number of varicose vein questionnaire pairs returned is suppressed due to small
numbers.
Condition Specific Measures (a series of questions specific to the patients’ condition)
 100% of Oxford Hip Score respondents recorded joint related improvement following
their operation (96.8%)
 92.3% of Oxford Knee Score respondents recorded joint related improvements
following their operation (94.2%)
 The number of varicose vein questionnaire pairs returned is suppressed due to small
numbers.
Participation and Coverage
There were 480 eligible hospital episodes and 378 pre-operative questionnaires returned – a
headline participation rate of 78.8% (76.7%).
Of the 210 post-operative questionnaires sent out, 39 have been returned – a response rate
of 18.6% (25.7%).
11 | P a g e
19. The Princess Alexandra Hospital NHS Trust considers that this data is as described as it
is part of the Integrated Performance Report and audited Trust data.
19
% of
patients
readmitted
within 30
days
Re-admitted to
a hospital which
forms part of the
Trust within 30
days of being
discharged from
a hospital which
forms part of the
trust during the
reporting period.
The % of
patients
aged 0 15:
Feb- Mar
2015 2015
4.41%
9.09%
Nat
Avge
7.70%
Highest
score
17.20%
Lowest
score
4.41%
PAH
Improvement
action Plan



Re-admitted to
a hospital which
forms part of the
Trust within 30
days of being
discharged from
a hospital which
forms part of the
trust during the
reporting period.
The % of
patients
aged 16 or
over:
6.13%
5.80%
8.30%
14.50%
2.50%



Flagging of
patients on readmission
Priority referral to
home team (who
are familiar with
patient and are
able to make the
best plan for the
patient)
Internal
Professional
Standard that
patient should be
seen within 30
minutes of referral
by decision
maker to review if
admission is
needed or if
alternative
method of care is
appropriate
Flagging of patients
on re-admission
Priority referral to
initial team (who
know patient best to
make management
plan)
Internal
Professional
Standard that
patient should be
seen within 30
minutes of referral
by decision maker
to review if
admission is
needed or if
alternative method
of care is
appropriate
12 | P a g e
20. The Princess Alexandra Hospital NHS Trust considers that this data is as described as it
is part of the Integrated Performance Report and audited Trust data.
20
Trust’s responsiveness to
the personal needs of its
patients during the reporting
period.
Ensuring that people have a
positive experience of care.
2013 2014
2014
2015
Nat’l
Av’ge
Highest
score
Lowest
score
Number of PALS cases
resolved
63.7%
20142015
data
awaiting
publication
68.7%
85%
54.4%
21. The Princess Alexandra Hospital NHS Trust considers that this data is
is part of the Integrated Performance Report and audited Trust data.
21
Improvement action
plan
1. To establish a
working group to set
core Customer
Service
communication
standards for the
whole of the Trust
2. To identify the
minimum annual
training and
development
requirements on
communication skills
segmented by
professional group.
3.To tailor how
Conduct and
Capability is
managed through
policy changes
agreed with
workforce leads on
the same minimum
communication
training requirement
4. To revisit the
description of the
communication
standards in current
as
described as it
Values training.
The percentage of staff
employed by, or under contract
to, the trust during the reporting
period who would recommend
the trust as a provider of care to
their family or friends.
Jan to
March
2015
Trust’s
nationally
set target
for this
question
Our
grading
Improvement action plan
Friends and Family Test - staff
3136 staff were sent survey. Out
of these, 896 (28%) responded
73%
67%
Green
Better communications around
survey to ensure more
respondents
13 | P a g e
21.1 The Princess Alexandra Hospital NHS Trust considers that this data is as described as
it is part of the Integrated Performance Report and audited Trust data.
21.1
The
percentage
of patients
who would
recommend
the trust as
a provider
of care to
their family
or friends.
Friends
and Family
Test patients
February
2015 *
March
2015 *
National Average
Other Trusts –
Highest
Improvement
action plan
96%
96%
95%
100%
Communications
standards
working group
has been
established with
minimum
standards for
compliance with
Values,
Standards and
Behaviours
being set across
all Health
Groups.
14 | P a g e
23. The Princess Alexandra Hospital NHS Trust considers that this data is as described as it
is part of the Integrated Performance Report and audited Trust data.
The percentage
of patients who
were admitted to
hospital and who
were risk
assessed for
venous
thromboembolism
For
thethe
year
during
2014-2015,
the
reporting period.
total number of
patients who
were admitted
and assessed for
VTE was 44,294.
Of these a total of
42,747 were
appropriately
assessed for
VTE.
96.51% of
patients were
risk-assessed for
the reporting
period.
NB. Please note
a drop to 80%
compliance in
August 2014 was
due to bedding-in
issues following
the introduction of
the COSMIC
electronic patient
record.
Feb
2015
Mar
2015
National
average
Highest
score
Lowest
score
98.24%
98.47%
96%
100%
Basildon
&
Thurrock
NHS
Hospital
Trust
81%
Cambridge
University
Hospitals
NHS
Foundation
Trust
Improvement action plan
Failsafe check lists reintroduced
at ward level.
VTE risk assessment proforma
updated and launched across
Trust. Patient leaflets available
to all clinical areas.
Audit to check compliance with
giving these out to be
undertaken June 2015.
Patient Safety Thermometer to
include whether prophylaxis
given.
Process for poor compliance
shared with all ward and
departments.
Anticoagulation Nurses
undertaking teaching at ward
level and for all new doctors.
15 | P a g e
24. The Princess Alexandra Hospital NHS Trust considers that this data is as it is part of the
Integrated Performance Report and audited Trust data.
24
The rate per 100,000 bed
days of cases of C.difficile
infection reported within the
trust amongst patients aged
2 or over during the
reporting period.
Feb
2015
24.99
Mar
2015
Highest
Score
for 1 April
2013 to
31 March
2015 *
Lowest
Score
for 1
April
2013
to 31
March
2015 *
Improvement action
plan
30.37
6.9
(Barking,
Havering
and
Redbridge)
37.1
(UCLH)
Continued
responsible use of
antibiotics
Continued thorough
cleaning
Continued hydrogen
peroxide
decontamination
Continue excellent
standards of hand
hygiene
* Latest benchmark data available from NHS Choices
25. The Princess Alexandra Hospital NHS Trust considers that the following data is as
described for these reasons. The data in all columns apart from the final one has been
validated and published by the National Patient Safety Agency. The data in the final column
has been validated and published in the latest National Reporting and Learning System
report.
The PAHT has taken the following actions to improve its scores and hence the quality of its
services, by continuing to train all clinical staff in Root Cause Analysis and holding regular
workshops and events around Being Open and Duty of Candour.
25
The number and,
where available,
rate of patient
safety incidents
reported within
the trust during
the reporting
period, and the
number and
percentage of
such patient
safety incidents
that resulted in
severe harm or
death.
Number of
Serious
Incidents
and
incidents
resulting in
death
Serious
Incident
National
Average
Serious
Incident
Trust
Average
Incidents
resulting in
death.
National
average
Incidents
resulting in
death.
PAH
average
Incident
reporting rate
1 April
2014 to 30
Sep 2014
1 April
2014 to
30 Sep
2014
1 April
2014 to
30 Sep
2014
1 April
2014 to 30
Sep 2014
1 April 2014
to 30 Sep
2014
1 April to 30
Sep 2014
16 | P a g e
12 Severe
Incidents.
No deaths.
0.4%
0.4%
0.1%
0.0%
37.16
incidents per
1,000 bed
days
Statement on Relevance of Data Quality
The Princess Alexandra Hospital NHS Trust continues to progress improvements in data
quality:
 An Electronic Patient Record (EPR) system to replace the Trust’s existing technology
was implemented during July 2014.
 Regular reporting on data quality issues to the Information Governance Steering
Group via the Trust’s weekly Operational EPR Group, the Performance and Finance
Committee and Board of Directors.
 Continue clinical validation of medical records coding to ensure accuracy of data for
national and local benchmarking.
 The use of data quality risk registers to manage data quality risks/issues and monitor
the actions the Trust takes to mitigate those risks.
 Development of the weekly Data Quality dashboard to support monitoring and
operational resolution of data quality issues.
Data quality, metrics and processes
NHS Number and General Medical Practice Code Validity
The Princess Alexandra Hospital NHS Trust submitted records during 2014/15 to the
Secondary Users Service for inclusion in the Hospital Episode Statistics, which are included
in the latest published data. The percentage of records in the published data:
Which included the patient’s valid NHS number was: Which included the patient’s valid NHS
number was:
 99.1% for admitted care 99.1%
 99.4% for outpatient care 99.4%
 96.7% for accident and emergency care
Which included the patient’s valid General Medical Practice Code was:
 100% for admitted patient care 100%
 100% for outpatient care 100%
 100% for accident and emergency care 100%
Information Governance Toolkit attainment levels The Trust’s Information Governance
Assessment Report overall score for 2014-15 (V12) was 68%, and was graded red. The
business case for appointment of an Information Asset Management Coordinator/Information Governance Officer to support improvements in this area. was
approved by the Executive Management Board on 14 April 2015. Taking the recruitment
period into account, it is anticipated the Trust will be able to evidence IGT level 2
17 | P a g e
compliance by the end of January 2016, by having a robust plan of actions in place to
substantiate the increase in scores.
Clinical Coding Audit
PAH was subject to a payment by results Clinical Coding audit in 2014/15. This was
undertaken by Capita on behalf of Monitor. The areas covered by the audit were Maternity
and Trauma and Orthopaedic inpatient.
The error rates reported at the time for diagnosis and procedure coding were:
During the year the Trust implemented a new patient administration (July 2014) which
adversely impacted on the data quality and subsequently the clinical coding audit outcomes.
NZ – MATERNITY
Accuracy:
Primary Diagnosis = 89%
Primary Diagnosis
Primary Procedure
Primary Procedure = 97.1%
Number of primary diagnoses
100
%
Number of primary diagnoses incorrect
11
11.0
Number of primary procedures
35
%
Number of primary procedures incorrect
1
2.9
HA – TRAUMA & ORTHOPAEDICS
Accuracy: Primary Diagnosis = 94%
Primary Diagnosis
Primary Procedure
Primary Procedure = 77.2%
Number of primary diagnoses
100
%
Number of primary diagnoses incorrect
6
6.0
Number of primary procedures
57
Number of primary procedures incorrect
13
22.8
18 | P a g e
Performance against key national priorities
2014-2015
Target
PAH Achievement
Emergency 4 hour standard
95%
88.01% YTD
Emergency four hour standard
90%
Not available
90%
Not Available
Threshold of
16 cases
0 cases
16
Referral to Treatment (RTT) Admitted
RTT Non-Admitted
C-Diff
Meticillin-Resistant
Aureus (MRSA)
Clostridium difficile Staphylococcus
(C-Diff)
Cancer: two week wait
from referral to date
first seen, comprising:
All cancers: 31-day wait
for second or
subsequent treatment,
comprising:
All cancers: 62-day wait
for first treatment,
comprising:
all cancers
for
symptomatic breast
patients (cancer not initially
suspected)
Surgery
Anti-cancer drug
treatments
1
Zero
tolerance
93%
98.2% M12
93%
99.0% M12
94%
100% M12
98%
93.3% M12
85%
89% M12
90%
100% M12
96%
99.1% M12
95%
98.24% M12
100%
94.55% YTD
100%
96.61% YTD
From urgent GP RTT
From consultant screening
service referral
All Cancers: 31-day wait from diagnosis to first
treatment
VTE Screening
Elective MRSA Screening
Non Elective MRSA Screening
Quality improvement highlights of 2014-2015
There has been an 11% increase in incident reporting during the year compared with
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2013/14 figures. As always, our aim is to increase the overall level of reporting as this helps
us to identify where things are not working as they should. It provides us with the
opportunity to investigate incidents to find root causes so that learning and improvements
can take place thereby decreasing the severity of reported incidents.
The Trust commissioned external training for staff in Being Open and Root Cause Analysis
(RCA) investigation techniques. The total number of staff trained in Being Open/ Duty of
Candour now stands at 110 while those trained in RCA techniques now stands at 79.
Feedback received from staff for these sessions were positive. Additionally, there have
been three Sharing the Learning sessions during the reporting year. Further details are in
the report under the section Incidents and Safety Improvements.
Dementia care has been a strong focus during 2014-15. Although we have not yet achieved
100% compliance with all clinical staff having completed an awareness session, to date
nearly 1,200 staff have either attended a face-to-face session or undertaken the session via
e-learning. Special sessions have been held for medical staff – giving them a more
clinically-focused understanding of the issues surrounding dementia management.
The Dementia Champions programme has seen the first cohort qualify and the second
cohort progress to near completion of their programme. The Champions programme runs for
six months and is designed to give the candidates an enhanced understanding of dementia
so that they can lead and “champion” dementia care in their areas.
Other milestones in the past year include the recruitment of a dementia volunteer to spend
time with patients, the hosting of “Dementia Friends” sessions for the Alzheimer’s Society;
provision of reminiscence boxes on all ward areas and compliance for the first time with all
requirements of the dementia Commissioning for Quality and Innovation (CQUIN) for the first
time.
It has been a very successful year for the Trust’s Family and Friends Test with over 40% of
those eligible rating their care across Maternity, Outpatient, Inpatient and Emergency
Department Services. This equates in 2014-15 to over 20,000 people rating their care in the
last year and the results are changing the way we deliver services including changes to the
times partners are available to expectant women and improving information about the role of
senior staff.
The goal for 2015-2016 continues to be zero-tolerance of hospital-acquired, avoidable
pressure ulcers. The percentage of pressure ulcers deemed ‘avoidable’ following scrutiny
panel was 23% and the number of ‘unavoidable’ was 69%. The explicit aim of the Trust was
to eliminate avoidable pressure ulcers. The total number of pressure ulcers declared as
‘hospital-acquired’ is slightly higher than 2013-14 but the severity continues to reduce.
Staff within the Trust have continued to work tirelessly to ensure a clear downward trend in
the number of hospital-acquired pressure ulcers, grade 2, 3 and 4 in 2014-15. There have
been no grade 4 pressure ulcers since November 2013. There have been no avoidable
grade 4 pressure ulcers since September 2013.
In the coming year, the Nutrition Nurse and Tissue Viability Specialist Nurses (TVNs) will
lead the Agents for Nutrition and Tissue Viability (ANTs) training programme with a further
20 | P a g e
two cohorts each of both registered nurses and healthcare support workers, thereby helping
to provide specialist cover on each shift and on every ward.
The TVNs will continue to work collaboratively with community colleagues to help educate
on the ways of preventing pressure ulcers, as well as to standardise care across the locality.
In August 2014 the Department of Health published The Hospital Food Standards Panel’s
report on standards for food and drink in NHS hospitals. The Trust has now developed a
Food and Drink Strategy to ensure delivery of the five recommended standards as well as
CQC regulations standards and NICE Quality standards. The Trust’s Nutrition and
Hydration Policy is now in place after it was ratified by the Trust Policy Group.
We have improved the support for patients with Learning Disabilities and their carers and
have also signed up to the East of England ‘HELPS’ initiative. We were shortlisted for a HSJ
award for ’Acute Sector Innovation’ for our work with patients and carers. In 2015, we will be
working on a Vulnerable Patient Study Day and running some epilepsy awareness courses.
We are also hoping to recruit a Learning Disability Assistant.
In the following sections we go into more detail about the work that is being done, the
challenges we face and the hurdles we have overcome as well as the areas still requiring
work.
21 | P a g e
How we did last year against our priorities for quality
improvement 2014-2015
Each year we assess our performance against previous quality priorities and take account of
national reports and emerging themes. Last year we evaluated our focus for the coming year
and identified a number of quality indicators for 2014/15.
Below is full information on how we did on each of the indicators –in the form of a grid listing
our specific targets.
How we did against each quality improvement priority 2014-2015
1
1.1
Patient Safety
Continue to improve
care and prevention of
pressure ulcers
What we are
trying to
improve
What success
will look like
How we will
monitor
progress
Reduce
avoidable
hospital
acquired
pressure ulcers
Zero avoidable
cases
Datix.
Monthly report.
Integrated
Performance
Report (IPR).
Serious Clinical
Incident Group
How we did
Achieved
Zero grade 4 hospital
acquired, avoidable,
pressure ulcers since
September 2013
22 | P a g e
Patient Safety
continued
1.2
Improve VTE
assessments
What we are
trying to
improve
All adult
patients receive
an assessment
What success
will look like
100%
compliance
(SCIG).
External
commissioner
reporting.
23% of hospital
acquired grade 2 and
3 pressure ulcers in
2014/ 15 were
deemed avoidable.
This is down from 31%
in 2013-14
How we will
monitor
progress
Datix.
Monthly report.
IPR.
SCIG.
External
commissioner
reporting.
How we did
Partially achieved
Compliance in the
coding of patient notes
has been maintained
at 98% since
September 2014 - this
evidence is on the
monthly SPQRG
Report that goes to
the Commissioners
The 2% noncompliance will be
investigated by the
appropriate health
group.
1.3
1.4
Reduce hospital
acquired avoidable VTE
events
Reduce harm from falls
Number of
HATs reduced
compared to
2013/14
CQUIN
achievement
Reduce
severity of falls
No
severe/death
cases
Datix.
Monthly report.
IPR.
SCIG.
External
commissioner
reporting.
Datix.
Monthly report.
IPR.
SCIG.
External
commissioner
reporting.
Achieved
No hospital-acquired
thromboembolisms
since April 2014.
Not achieved
2013-14: 0 deaths
2014-15: 1 death
There has been a
significant increase in
incidents classified as
severe during 201415. 6 incidents
recorded in 2014-2015
compared with 1
reported in 2013-2014
There has been a 40%
increase in NO harm
falls in 2014-15
compared to 20132014.(632 v 451)
1.5
Improve recognition of
the deteriorating patient
Ensure all
patients who
deteriorate are
identified and
treated in a
timely manner.
No SIs for
deteriorating
patients
Datix.
Monthly report.
IPR.
SCIG.
External
commissioner
reporting.
Not achieved
There were 103
suboptimal Datix
cases for deteriorating
patients between April
2014 and March 2015.
There has been a
23 | P a g e
Patient
1.6
Reduce medication
errors
What we are
trying to
improve
Prescribing
accuracy
What success
will look like
Improved
reporting and
reduced
severity of
incidents
How we will
monitor
progress
Datix.
Medicines
management
governance.
significant increase in
Critical Care Outreach
Team referrals
peaking at between
170 and 180 for the
last few months of
2014-2015, compared
to just 80 in 20132014
How we did
Not achieved
A total of 493 incidents
were reported in 20142015 compared to 390
in 2013-2014. Despite
this improvement in
reporting levels, these
are still only around
one quarter of those
being reported at
similar-sized Trusts.
Minor and moderate
severity has
increased, but there
have been no major,
severe or deaths
reported in the last
year.
To improve the current
situation we will be
appointing a
medication safety
pharmacist. The
Clinical Governance
Department will report
medication incidents
to the Medicines,
Management and
Incidents Committee
for monthly review.
2
Clinical Outcomes
What we are
trying to
improve
What success
will look like
How we will
monitor
progress
How we did
Ensure all End
of Life patients
have a DNR
and /or End of
Life
plan/Preferred
Priority for Care
(PPC) in place
following
discussion with
the family.
Increase in
compliance.
Inclusion on
EPR.
Trust data
Partially achieved
2.1
Improve end of life care
A total of 523 patients
were referred to the
specialist palliative
care team 1415. Thirty
three had a prior PPC
/ End of Life care plan.
In 371 cases, a PPC /
End of Life care plan
was initiated following
discussion with the
family. However, the
remaining patients
were too unwell, had
no capacity, no next-of
24 | P a g e
kin or declined to
discuss PPC / End of
Life care planning.
DNACPR is included
on Discharge
Summary.
Clinical Outcomes
Continued
2.1
Improve end of life care
continued
2.2
Improve care for
dementia/vulnerable
patients
What we are
trying to
improve
What success
will look like
How we will
monitor
progress
How we did
An audit of eight
wards showed 75% of
patient records had
been assessed and
correctly completed for
DNACPR (Do Not
Attempt Coronary
Pulmonary
Resuscitation).
Awareness
through training
and dementia
competency.
Increase in
compliance.
Reduced
complaints.
Increase in
training figures.
Increase
compliments.
Improvement in
Carers Survey
results.
Not achieved
No data available on
dementia- related
complaints or
compliments. Trying
to establish why and
what is being done to
rectify this AB
Training: The training
programme has
“rolled” over from
2013-14 to 2014-15.
The total number of
clinical staff who have
received basic
dementia awareness
training is 79% (62%
for medical staff)
against a target of
100% to be achieved
by October 2014.
There has been a
decrease in the
number of returned
carer surveys (down
from 29 to 22)
2.3
Improve quality of
discharge
Ensure all
patients have a
co-ordinated,
safe discharge.
Evidence of
discharge
planning
Reduced
complaints.
Increase
compliments.
Improvement in
In-Patients
Survey results.
Partially achieved
Reduction from 6.55%
of patients having a
delay to their transfer
of care in 2013-2014
to 5.25% for 20142015
An increase in the
number of transfers of
care by 1pm from
18% in 2013-14 to
25 | P a g e
34% in 2014-15.
Quality of Discharge
continued
2.3
What we are
trying to
improve
What success
will look like
How we will
monitor
progress
Continued
How we did
Increased the
proportion of patient
transfers of care
taking place at
weekends to 25%
Recent improvement
work on two pilot
wards has delivered:
88% of patients’
transfers of care within
12 hours of being
declared medically fit
by the clinical team
Increase in weekend
transfers of care to
37%
Reduction in Length of
Stay from 12.3 days to
8.1 days on one ward
and from 12 days to
10 on another
3
3.1
Patient Experience
Improve overall patient
satisfaction as
measured by national
surveys
Improve survey
results against
2013/14 and
national
comparison.
Improve net
promoter score.
Ensure all
indicators are in
the middle 60%
or above.
Monthly IPR.
Real-time
patient
feedback.
National survey
results.
Partially achieved
The National Inpatient
Survey shows that the
Trust has improved in
two of the five areas
where concerns were
raised.
Question 70 on being
given information
about how to complain
where we are in the
middle 60% and
Question 26 regarding
doctors speaking in
front of patients as if
they are not there.
58 of 68 questions
show the Trust to be
similar to other Trust
nationally with a score
in the middle 60% of
Trusts nationally.
The Trust has
recorded a score in
the lowest 20% on 6
26 | P a g e
questions relating to
leaving hospital, 2 on
doctors, 1 on being
admitted and 1 on
information about
condition and
treatment.
Patient Experience
continued
3.1
Improve overall patient
satisfaction as
measured by national
surveys
3.2
Implement training to
ensure all staff adheres
to Trust values at all
times.
What we are
trying to
improve
What success
will look like
How we will
monitor
progress
How we did
The net promoter
score, also known as
the Friends and
Family Test has not
improved this year.
The sampling rate has
improved significantly
with most months
showing a 40%
sampling rate in
Inpatient Services and
above 20%
consistently for
Outpatients,
Emergency Medicine
and Maternity
Services.
Patient
experience.
Staff
compliance of
standards.
100%
compliance for
all staff training.
Staff training
statistics.
Complaints.
Compliments.
Real-time
feedback.
Partially achieved
A total of 2,056 or
66.2% of staff have
been trained in Values
Standards and
Behaviours by the end
of April 2015 - a
33.8% shortfall.
Although 100%
compliance has not
been achieved there is
clearer evidence from
complaints data that
the areas of
improvement we have
been seeking to
achieve are beginning
to become visible, in
particular the National
Inpatient Survey
shows doctor
communication may
be improving and
medical care as a
theme in complaints
has now fallen out of
the top 3 complaint
themes for the first
time in years, with a
consistent reduction
over time.
3.3
Staff will always
communicate with,
inform and respect the
Partnership
with patients
and families.
Improved
patient
satisfaction
Improved net
promoter score.
Complaints.
Partially achieved
27 | P a g e
patient and/or carers.
Patient Experience
continued
What we are
trying to
improve
results.
Compliments.
Real-time
feedback.
What success
will look like
How we will
monitor
progress
Complaints have fallen
from 389 to 379 and
real time feedback has
increased from 2192
to 2510 PALS
concerns resolved
respectively this year
3.3
3.4
The Friends and
Family test (F&F or
Net Promoter Score)
shows evidence of a
fall in overall
satisfaction and so this
objective as measured
by the F&F test has
not been achieved.
How we did
Patients, families and/or
carers will always know
who is in charge of their
care.
All patients and
families being
made aware of
who is in
charge of the
care.
100%
compliance.
Clear
introductions
and
documented
named carer in
charge.
Audits.
Patient survey
results.
Complaints.
Partially achieved
Patient communication
boards have been
introduced at every
bedside.
A small fall in
complaints overall,
from 389 to 379, a
significant increase in
PALS resolutions and
a fall in compliments
recorded present a
mixed response to this
question. A more
detailed analysis of
the number of
complaints with a
communication theme
over the last two years
shows that in 2013-14
287 contained a
communication theme
and in 2014-15 263
contained a
communication theme.
No significant
improvement is in
evidence here, but
some small changes
may be occurring
when taken with
evidence from other
areas of work.
4
4.1
4.2
Staff Experience
Staff recommendation
of the Trust as a place
to work or receive
treatment.
Maintain or
improve the
scale summary
score
Maintain an
above average
score for 2014
Percentage of staff
appraised in the last 12
months.
Increase the
number of staff
who feel they
Maintain a
positive result
and sit within
Quarterly friends
and family test
results.
Partially achieved
Above average score
for place to receive
treatment but below
average score as a
place to work.
Monthly reports
of appraisal
figures.
Not achieved
28 | P a g e
Staff experience
continued
4.3
Percentage of staff
having equality and
diversity training in the
last 12 months.
have had a
meaningful
appraisal.
the best 20% of
Trusts
What we are
trying to
improve
Increase to the
national
average
number of staff
having equality
and diversity
training in the
last 12 months
What success
will look like
Achieve the
national
average in the
staff survey
34% of staff
(compared to 43% last
year) said they had a
meaningful appraisal
compared to a
national average of
38%
How we will
monitor
progress
Monthly reports
on training
figures.
How we did
Partially achieved
59% of staff report
having equality and
diversity training – an
increase of 6% on
2013 results. The
national average
benchmark is 63%.
Case Study One – Dementia Care
Much progress has been made during the past year into screening and caring for patients
with dementia. Our headline successes include:









Continuing awareness training for all clinical staff
Commencement of Dementia Champions programme
Recruitment of a dementia volunteer
Hosting “Dementia Friends” sessions for the Alzheimer’s Society
Provision of reminiscence boxes on all ward areas
Meeting all requirements of the Dementia Commissioning for Quality and Innovation
(CQUIN) for the first time
Introduction of the “This is me” tool across all clinical areas
Continuation of Carer Survey
Continuation of the successful CQUIN fellows programme
The Dementia CQUIN is divided into three sections with the following targets:
1. Find Assess Refer
a) 90% of patients aged 65 years or older admitted as an emergency to be asked the
case-finding question.
b) 90% of patients answering positively to the case-finding question, having diagnostic
assessment.
c) 90% of patients having a positive diagnostic assessment referred in line with agreed
local pathways.
2. Clinical Leadership
 Named lead clinician
 Agreed training plan in place
3. Supporting carers
 Undertake monthly Carer Surveys
29 | P a g e

Present the findings of the Carer Surveys to the Trust Board twice in each financial
year.
1. Find Assess Refer
Despite an intensive programme, the Trust struggled to meet the 90% requirement in each
of the Find Assess Refer criteria throughout 2014-15. It was hoped that the introduction of
the new COSMIC patient administration system would improve compliance as the dementia
screening fields were made mandatory. Eventually, in October 2014 the Trust was able to
confirm the following figures:
a) 92.92%
b) 100%
c) 90.2%
Unfortunately, in November, December and January 2015 the figures relating to section a)
have significantly dropped again. This has been due to technological and other issues which
we have been working hard to resolve. Unfortunately, end-of-year data shows that the 90%
criteria has still not been met in all sections.
Clinical Leadership
The Trust has a named clinical lead for dementia – Dr Alice Dain, Consultant for Care of the
Elderly. As part of the agreed training programme, the Trust made a commitment to ensure
that all clinical staff has undergone an awareness session by the end of October 2014. By
April 2015, 79% of staff had attended a session, with 62% of medical staff having undergone
training. Although these figures are below trajectory, 79% is a significant achievement,
equating to 1,182 staff.
2. Supporting Carers
The Carer Survey has been harder to implement fully than initially expected. The survey is
meant to be given to carers during their relatives’ stay or on discharge. A pre-paid envelope
is supplied so that it may be taken away and completed at a later date. It is also available on
line via the Survey Monkey system. The ward staff have not been distributing the surveys as
expected and, to date, no one has completed it via Survey Monkey. Since April 2014, 614
patients with a confirmed diagnosis of dementia have been admitted to PAH. During this
period, only 13 completed surveys have been returned. It is impossible to determine what
the response rate is, as the ward staff do not keep a record of who has been given a survey.
Planned improvements
It is imperative that the numbers of returned surveys is increased as not only is it a CQUIN
requirement, but the Trust uses the responses to gauge performance and determine when
and where improvements need to be made. A number of initiatives have been introduced to
try to improve the response rate. Two of the CQUIN clinical fellows have taken this on as
their project and have been undertaking “rounds” in order to distribute the surveys.
The Patient Panel did initially help with the distribution and completion of the surveys by
attending the wards during visiting hours and helping carers to complete them. However,
this was not sustainable and the Panel is currently looking at how they can assist in more
practicable ways. An article about the importance of completing the surveys is to be placed
30 | P a g e
in the local newspapers. Various posters explaining the importance of the surveys have also
been placed around the Trust.
Training
In many ways, the Trust has made considerable progress with dementia care during 201415. Although we have not yet achieved 100% compliance with all clinical staff having
completed an awareness session, to date nearly 1,200 staff have either attended a face-toface session or undertaken the session via e-learning. Special sessions have been held for
medical staff – giving them a more clinically-focused understanding of the issues
surrounding dementia management.
The Dementia Champions programme has seen the first cohort qualify and the second
cohort progress to near completion of their programme. The Champions programme runs for
six months and is designed to give the candidates an enhanced understanding of dementia
so that they can lead and “champion” dementia care in their areas. The programme consists
of three study days but the candidates must also complete clinical competencies, undertake
e-learning modules, introduce a dementia-focused project into their work area and pass a
short written assessment. The first cohort saw nine members of staff qualify with six
members of staff in the second cohort.
During March 2015, the Trust ran the first “Dementia Virtual Tour”. The aim of this externallyled session was to give staff a greater understanding of dementia from the sufferer’s
perspective using a structured sensitivity approach. It is hoped that such an understanding
will help staff to improve their dementia care.
Working with our partners
The Trust has built strong relationships with external partners. One of the foremost of these
is the local Alzheimer’s Society branch. The branch manager is a member of the
Dementia/Delirium steering board and the Trust has hosted several successful “Dementia
Friends” sessions for the Society. The Society regularly holds information stands in the main
hospital foyer and these are very successful. Joint sessions were also held during the
national dementia awareness week in 2014.
The Trust also works closely with the local community and mental health trusts and a lot of
co-ordinated work has been undertaken, looking at admission pathways and discharges –
the aim being to improve the whole experience for people with dementia.
The Trust remains an active member of the Harlow “Dementia Friendly Communities”
initiative.
The Trust has also recruited a very active volunteer. This volunteer has considerable
personal experience with dementia care and attends the Trust one day per week to work
with patients who have dementia.
She mainly sits with people who may be anxious or demonstrating disturbed behaviour and
talks to them or reads with them. Evidence shows that people with dementia may get very
bored while in hospital and by having someone just sit and talk or read with them can be
very beneficial. She is also trained as a Mealtime Buddy and can feed or assist people who
need a little extra time and attention. In addition she teaches on the Dementia Champions
programme and the Agents for Nutrition and Tissue Viability (ANTs) programme.
31 | P a g e
Her contribution has been invaluable and the wards where she is based feel that her being
present does make a considerable difference to some of the patients.
Getting to know our patients
The Trust has continued to embed the use of the “This is me” tool across all clinical areas.
This is a simple tool which is completed by the patient or carer with the staff and can be
used for care planning or handovers for example. The aim of the tool is to get to know about
the person behind the dementia – very often knowing the patient well, their likes, dislikes and
things that are important to them can make it much easier to provide high-quality patientfocused care.
Each ward area has been provided with a reminiscence box. The boxes are full of various
items which can be used to help patients look into the past. Patients with dementia mainly
recall past events better than recent ones and the items in the boxes can help to reassure
and relax patients. The League of Friends kindly donated money to enable us to purchase
“memory jogger” photos and the Trust has been very fortunate that various local businesses
such as ASDA, Tesco, and M&S have very kindly donated items to put in the boxes.
In addition, M&S made the dementia charity at Princess Alexandra Hospital (PAH) its staff
charity of the year and they have provided money to help us purchase various items to
benefit patients with dementia. The support of all of the local community is invaluable.
The Trust has an active steering board composed of colleagues from a variety of disciplines
across the Trust and also external stakeholders such as social care, mental health,
Alzheimer’s Society and the Patient Panel. The board now meets on a quarterly basis and
continues to oversee the implementation and efficacy of the Trust’s dementia strategy.
The coming year
During 2015/16 the Trust will continue to ensure that all clinical staff receives awareness
sessions on dementia. This will include new starters. In addition the aim is to provide
awareness training to non-clinical front line staff who may come into contact with people with
dementia, for example receptionists. The Alzheimer’s Society has kindly offered to assist
with this process.
Following the success of the Dementia Virtual Tour in March 2015, we aim to bid for funding
for several senior staff members to attend “train the trainer” sessions so that the initiative can
be extended to as many staff as possible.
The current volunteer, (and any others who may be recruited), will be further involved in
providing training for Trust staff.
During 2015-16, the aim is to recruit more volunteers to work with our patients who have
dementia.
During 2015-16, at least one further cohort of Dementia Champions will commence – with
the lessons learnt from the two previous cohorts being incorporated into a revised
programme. The aim over, the next few years is to have as many champions as possible
and at least one on every ward and every clinical area.
The Trust has secured funding for four wards to be part of the Quality Mark programme. This
programme, run by the Royal College of Psychiatrists, is a quality improvement programme
32 | P a g e
for wards and it aims to promote excellence in the care of all older people in general hospital
wards.
The Trust is considering producing a business case to employ a Dementia Nurse Specialist.
The aim during 2015/16 is to add an alert to COSMIC to enable patients with dementia to be
recognised by all staff when they are admitted or are on any elective pathway. This is similar
to the alerts currently used for patients with learning disabilities which has proved very
successful.
During 2015-16 the Trust will aim to undertake the national “dementia friendly hospitals”
assessment. This self-assessment looks at all aspects of the provision of dementia care but
particularly focusses on environmental issues. The self-assessment is a large undertaking
but has proven in other hospitals to be an extremely valuable way of focussing on
environmental issues and how they can directly impact on high quality dementia care.
Participation in clinical trials
The Trust participated in 125 local audits during 2014-15, improving patient safety and
patient outcomes, including:
Dementia screening in the Orthopaedic Department
This audit led to a leap from 22% to 74% of forms filled in by the on-call FY2 doctor for
dementia screening.
Post Myocardial Infarction Patients
Posters displayed and cardiac rehab packs provided to patients as a result of the audit, and
following re-audit 70% of patients – an increase from 25% - were known to be receiving the
correct information.
Diagnosis of Pulmonary Embolism and DVT in Orthopaedic Patients
This audit recommends implementing stricter vetting of CT pulmonary angiogram (CTPA).
As a result of this audit a new protocol is being developed which is expected to results in the
reduction of unnecessary CTPAs.
During 2014-15, 44 national clinical audits and four national confidential enquiries covered
relevant health services that The Princess Alexandra Hospital NHS Trust provides.
During that period, The Princess Alexandra Hospital NHS Trust participated in 77% of
national clinical audits and 100% of 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 Trust was
eligible to participate and/or participated in during 2014-15 are detailed in appendix A.
The national clinical audits and national confidential enquiries that the Trust participated in,
and for which data collection was completed during 2014-15 are listed in appendix A along
with 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.
The reports of 11 local clinical audits were reviewed by the provider in 2014-15 and the Trust
intends to take action to improve the quality of healthcare provided.
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Participation in clinical research
The number of patients receiving NHS services provided or sub-contracted by The Princess
Alexandra Hospital NHS Trust in 2014-15 that were recruited during that period to participate
in research approved by a research ethics committee was 402.
Research and Development
Research in the NHS is performed in order to gauge the efficacy and the safety of new,
innovative treatments and medicines. At the beginning of 2014-15 it was agreed, with the
North Thames Clinical Research Network, that the Trust would recruit a target of 359
patients into National Institute for Health Research (NIHR) portfolio adopted trials. In January
2015 the Trust reached the agreed target and, following further recruitment of patients into
trials, exceeded this initial figure by 43 with 402 patients benefiting from participation in
research. Recruitment will continue until the third week in April. This work has helped to
achieve the government’s objective that every patient has the opportunity to participate in
research. We have participated in clinical trials where the success of the new treatment has
led to the unblinding of the trial patients and the effective treatment being offered to those on
the control arm of the trial.
When attending hospital for various clinics and treatments, every patient should be
encouraged to ask if there is a research study suitable for their condition.
Recruitment per Speciality
Speciality
Cancer
Cardiology
Children
Dermatology
Diabetes
Gastroenterology
Ophthalmology
Orthopaedic – Non-Portfolio
Rheumatology
Stroke
Surgical
Vascular
Recruitment
49
51
10
37
47
26
9
15
37
5
72
10
34 | P a g e
Recruitment by Speciality
Recruitment
3%
Cancer
13%
Cardiology
Children
20%
Dermatology
14%
1%
Diabetes
Gastroenterology
Ophthalmology
10%
3%
10%
4%
2%
Orthopaedic – Non-Portfolio
Rheumatology
Stroke
7%
13%
Surgical
Vascular
Key Performance Indicators
(KPIs)
During 2014-15 PAHT set 4 specific KPIs in line with the High Level Objectives set by the
National Institute for Health Research.
The 4 KPIs we agreed are:




Increase the Trust’s recruitment of patients in trials target by 5% from previous year
Increase the Trust’s commercial studies by 25%
To meet the NIHR 70 day benchmark and delivery of trials to time to target
PPI’s (Patient Public Involvement) “Every patient has the opportunity to participate in
research”
The Princess Alexandra Hospital NHS Trust have fulfilled all research KPI’s for 2014/2015
and continue to promote research, ensuring that every patient knows about potential
research concerning their condition.
Good news stories
The Princess Alexandra Hospital NHS Trust were:1. The top recruiter in the Streamline L Study - Streamlining Staging of Lung Cancer
with Whole Body MRI.
2. The top recruiter across the UK in the Act-Move Study on 3 separate occasions –
Giving Tocilizumab by Injection in Patients with Rheumatoid Arthritis.
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3. Involved in the Intermittent Compression Sleeves used as part of the CLOTS 3 trial
are currently in use in pilot sites (including PAHT) and should be available soon for
general use – a good example of translational research in action.
4. The top recruiter in the UK for the BSRBR Study - Register of anti-tnf treated
patients and prospective surveillance study for adverse events
5. The top 10 for recruitment in the Pressure-2 Study - Pressure RElieving Support
SUrfaces: a Randomised Evaluation II
6. Are on the steering group to develop the new Local Portfolio Management System
(LPMS) for the National Institute for Health Research (NIHR).
7. The top recruiting Trust across the North Thames Clinical Research Network In
November, 2014 with Dr Roberto Verdolini entering a total of 40 patients into trials.
8. The top recruiters in the UK for The East Study.
9. One in six cancer patients were offered the opportunity to participate in research.
10. The target for opening commercial trials in the Trust has been achieved with 8
commercial trials approved to date.
11. There are currently 8 commercial trials and 39 academic trials active across the
Trust.
R&D Approvals
(Research Studies)
Study
Name
Bacchus
Dare
East
Emmace-4
Focus - 4
Genetics of
Anky
Spondylitis
Intense
Brief Description
Speciality
A Phase II, Multicentre, Open-label,
Randomised Study of Neoadjuvant
Chemotherapy and Bevacizumab in
Patients with MRI defined High-Risk
Cancer of the Rectum
This research study is a community-wide
collaboration between patients and
professionals to provide a platform to
enable further study into the causes and
complications of diabetes. It will combine
clinical, laboratory, molecular and
genetic information to improve our
understanding of Type 1, Type 2 and
other forms of diabetes and their
associated complications.
Early treatment of Atrial fibrillation for
Stroke prevention Trial
Evaluation of the Methods and
Management of Acute Coronary Events
Molecular selection of therapy in
colorectal cancer
A research study to identify the key
genetic effects of Ankylosing Spondylitis
Cancer
Commercial or
Academic
Non-Commercial
Diabetes
Non-Commercial
Stroke
Non-Commercial
Cardiology
Non-Commercial
Cancer
Non-Commercial
Rheumatology
Non-Commercial
Real world effectiveness of lixisenatide
and other intensification therapy in the
management of type 2 diabetic patients
uncontrolled with basal insulin
Diabetes
Commercial
36 | P a g e
Larcs/Sti
McCave
Safari
Signature
Targit B
The Janus
1 Study
Tulip
Snap
Fertility
Issues
UK All 2011
Bridging
the Age
Gap
Association between LARCs and
Chlamydia infection
A phase ii, multi-centre, randomized,
double-blind study to evaluate the
efficacy and safety of ro5520985 plus
folfox versus bevacizumab plus folfox in
patients with previously untreated
metastatic colorectal cancer
A phase IV, prospective, open label,
uncontrolled, European study in patients
with neovascular age-related macular
degeneration (nAMD), evaluating the
efficacy and safety of switching from
intravitreal aflibercept to ranibizumab 05.
mg
Secukinumab In patients with moderate
to severe active, chronic plaque psoriasis
who have failed on TNFα antaGoNists: A
clinical Trial EvalUating Treatment
REsults
Sexual Health
Targeted intraoperative radiotherapy for
breast cancer in patients in whom
external beam radiation is not possible.
A Randomized, Double-Blind, Phase 3
Study of the JAK1/2 Inhibitor, Ruxolitinib
or Placebo in Combination With
Capecitabine in Subjects With Advanced
or Metastatic Adenocarcinoma of the
Pancreas Who Have Failed or
AreIntolerant to First-Line Chemotherapy
Use of Intravitreal JETREA® in Clinical
Practice: A European Prospective Drug
Utilisation Study
A national survey of patient reported
outcome after anaesthesia
Questionnaire development on attitudes
and beliefs surrounding the fertility
issues of young women with breast
cancer
National Randomised Trial for Children
and Young Adults with Acute
Lymphoblastic Leukaemia and
Lymphoma 2011
Improving Outcomes for Older Women
Cancer
Non-Portfolio
Non-Commercial
Commercial
Ophthalmology
Commercial
Dermatology
Commercial
Cancer
Non Commercial
Cancer
Commercial
Ophthalmology
Commercial
Surgical
Non-Commercial
Cancer
Non-Commercial
Cancer
Non-Commercial
Cancer
Non-Commercial
CQUINs
A proportion of the Trust’s income is conditional on achieving quality improvement and
innovation goals agreed between The Princess Alexandra Hospital NHS Trust (PAHT) and
any person or body they entered into a contract, agreement or arrangement with for the
37 | P a g e
provision of NHS services, through the Commissioning for Quality and Innovation (CQUIN)
payment framework.
The 2015/16 guidance setting out the Commissioning for Quality and Innovation (CQUIN)
schemes confirms the value of the schemes will be up to 2.5% of Actual Annual Contract
Value, as defined in the 2015/16 NHS Standard Contract. 2015/16 is seen as an
evolutionary year for CQUINs; offering an opportunity to consolidate efforts on national goals
from the previous year’s schemes whilst also shifting the focus on to new national goals.
This is in line with the 5 year forward view of promoting well-being and preventing ill-health.
National/
Local
National
Indicator
Elements
%
weighting
10%
Financial
value
£360
Sepsis
National
Acute
Kidney
Injury (AKI)
Screen all those patients for whom
sepsis screening is appropriate.
Rapidly initiate intravenous antibiotics,
within 1 hour of presentation, for those
patients who have suspected severe
sepsis, Red Flag Sepsis or septic
shock.
To improve the follow up and recovery
for individuals who have sustained
AKI, reducing the risks of
readmission.
Re-establish medication for other long
term conditions and improve follow up
of episodes of AKI which is associated
with increased cardiovascular risk in
the long term.
10%
£360
National
Dementia
Support the identification of patients
with dementia and delirium, alone and
in combination alongside other
medical conditions. Promote prompt
referral, follow up, and effective
communication between providers
and general practice, through the
introduction of a care plan on
discharge; after the patient is
discharged from the hospital following
an episode of emergency unplanned
care.
10%
£360
National
Urgent
Emergency
Care
Reducing the proportion of avoidable
emergency admissions to hospital for
a disease specific group.
20%
£720
Local
Integrated
workforce
strategy
Work with colleagues across the
whole local health economy to ensure
that there is an integrated strategy for
the delivery of an effective and flexible
workforce. Opportunities for staff to
rotate across acute and community
providers depending upon the
workload requirements.
16.5%
£594
38 | P a g e
Local
Motivational
Interviewing
Supporting patients with long-term
conditions (diabetes and chronic
obstructive pulmonary disease;
COPD) to self-manage their condition,
using motivational interviewing/health
coaching to promote behaviour
change.
Local
Hospital at
Night
Strengthen the systems of clinical 12%
handover from day-time to night-time,
optimising the skills and availability of
staff working at night to ensure the
safety of patients through seamless
care delivery.
£432
Local
End of Life
discharge
liaison post
A new post to facilitate work with
colleagues in health and social care
outside the hospital to ensure that
people who, whilst in hospital are
identified as at the end of their life are
supported to achieve their preferred
place of care without delay.
£324
Specialist
Commissioning
Group
TBC
Total potential value
12.5%
9%
£450
£3,597
Care Quality Commission
The Trust is registered with the Care Quality Commission (CQC) and its current status is
‘registered without condition’. The CQC has not taken enforcement action against the Trust
during 2014-15.
The Trust has recently removed Keats House as a registered location, with the services that
are still in place forming part of the Trust’s registration. The Trust’s Statement of Purpose
reflects this change and is published on the Trust website.
In September 2014, the CQC set out their new operating model which is underpinned by the
new fundamental standards, to be introduced in April 2015. Using Intelligent Monitoring built
on a set of indicators that relate to the five key questions they ask of all services – are they
safe, effective, caring, responsive and well-led - the CQC combines information from a wide
range of data sources to decide when, where and what to inspect. Analysing a range of
Trust information including patient experience, staff experience and patient outcomes, the
CQC create a priority banding. The priority banding puts Trusts into one of six bands, with
an extra category to reflect that a Trust has recently been inspected. At the time of writing
this report the Trust is at banding two with one being the highest priority for inspection; the
last CQC inspection took place in July 2013 and the next is due to start on Monday 20 July
2015.
During 2014-15, the Trust has reviewed its monitoring process to bring it into line with the
CQC’s new operating model and the fundamental standards. To promote and embed this
39 | P a g e
within the Trust, the post of Head of Quality Compliance has been introduced to support a
programme of continual improvement.
Case Study Two: Safer Staffing
In November 2013, the National Quality Board which brings together the different parts of
the NHS system with responsibilities for quality worked with the Chief Nursing Officer for
England to publish a guide to nursing, midwifery and care staffing capacity and capability.
This was followed in March 2014 by clear guidance and milestones from the Chief Nursing
Officer for NHS England and the Chief Inspector of Hospitals for the delivery of Hard Truths
commitments associated with publishing staffing data regarding nursing, midwifery and care
staff.

The Trust Board is actively involved in agreeing staffing establishments, considering
the impact of other factors, such as cost improvement programmes upon staffing.
They have received and examined monthly reports on staffing capacity and capability
linked to trends identified through quality indicators and clinical outcome measures.

The Trust Board discussed a nursing skill-mix review in May 2014 which
recommended a financial investment to increase the number of registered nurses on
duty at night time. A nurse recruitment plan is in place - see Nursing and Midwifery
Recruitment section below for further detail.

Information about nurses, midwives and care staff deployed for each shift, compared
to what has been planned, is displayed at ward/department level.

The Trust publishes staffing fill rates (actual versus planned) in hours on the NHS
Choices website; submitting monthly data via UNIFY since June 2014.

The Trust has invested in electronic software to facilitate the capture of patient
dependency and acuity, linked to staffing levels. The data will support six monthly
nursing skill-mix reviews and meets the guidance published by NICE in July 2014. It
is expected that all of the wards will be using the Safe Care module by April 2015.

In September 2014 the Trust strengthened the process for escalating concerns
related to safe staffing levels. The escalation process is supported by “red flag”
safety trigger pocket- size prompt cards for registered nurses in line with the NICE
safe staffing guidance.
Nursing and Midwifery recruitment
The Chief Nurse presented a review of nurse staffing skill-mix to The Trust Board in
May 2014; the review built upon the work that started in the previous year, identifying
the need for further financial investment in nursing over the next 18 months to
facilitate increased registered nurses on duty at night time.
Our aim for midwifery is to achieve a 1:30 midwife to birth ratio in line with the
national expectation. This challenging goal continues to be proactively pursued.
40 | P a g e
A range of recruitment approaches are in place to address vacancies including:




Providing opportunities for all nurses in training at local universities to take up
permanent employment with the Trust on qualifying. The Chief Nurse meets
with the students throughout the three year training programme, working with
them to ensure that they receive the best possible training experience and
begin to build an affinity with the organisation.
National and local advertisements inviting nurses, midwives and health care
support workers to attend open days held at weekends. The candidates are
taken on a tour of the hospital, hear presentations from the many different
clinical teams and participate in a selection interview and assessment
process.
Recruitment from the EU; the Trust has been recruiting cohorts of nurses
from Portugal, Madeira and Ireland since 2013.
Discussion with the Local Education Training Board (LETB) to pursue the
provision of shortened courses for registered nurses wishing to undertake
midwifery or children’s nursing qualifications.
41 | P a g e
Further review of quality performance 2014-2015
Transformation
The Transformation programme is designed to deliver the overall improvements over a three
to five year period and to be explicitly aligned to the Trust’s strategic goals and priorities.
The initiatives associated with each of the work streams are subjected to the Trust’s
established quality impact risk assessments process led by the Medical Director and the
Chief Nurse, who ensure the highest standards of quality including safety, effectiveness and
patient experience are maintained.
The objectives of the Transformation programme are to deliver the following outcomes:





Excellent safety and outcomes for patients: benchmarked against the best
Excellent patient and carers experience: delivering personalised care
Excellent operational performance: meeting regulatory and national operating
standards
Excellent value: improving efficiency, productivity and reducing costs
Excellent morale, staff engagement and organisational health: ensuring we are fit for
the future
The guiding principles are:





Improving patient safety and quality
Early involvement of clinicians in the decision making process
Clinical leadership of key projects
Combine better health outcomes with productivity
Sustainability
42 | P a g e

System alignment
Key work streams underlying achievement of efficiency savings target
The total efficiency savings target for this year and the next four years is £9.7m (2014/15)
and £11.4m (2015/16), followed by £8.1m and £8.3m, respectively.
The Transformation programme comprises 11 principal work streams as follows:
Key Work streams
Length of stay and bed capacity
Theatres Productivity
Outpatients Productivity
Quality Improvement
and Outcome
Objective and Scope
Reduce operational pressures, reduce use of
escalation beds, and facilitate penalty reductions.
To deliver a clinically sustainable and financially
viable non-elective pathway to ensure we can
increase and manage our bed capacity more
effectively; reducing backlogs across and along the
pathway and reducing the financial penalties
incurred.
Reduce surgery cancellations, improve timings and
capacity.
Improve in-session and capacity utilisation to
reduce wastage and ensure that theatres have the
capacity to treat an increased number of patients,
reducing waiting times and saving avoidable
additional costs.
Improve clinic utilisation, attendances and nonattendance rates.
Increased capacity to see more patients more
efficiently and reduce waiting times and avoidable
additional costs.
•
•
•
•
Right Care, Right Time, Right Place
Improved patient outcomes
Reduction of length of stay
Improved patient experience
•
improved patient experience and theatre
utilisation
•
Improved team performance and staff well
being
•
Improved access – Delivery of 18 week
standard and to reduce cancelled
operations.
•
Improved clinic utilisation
•
Deliver 18 week standard
•
Improved booking and scheduling process
•
Improved patient satisfaction
•
Reduction in clinic cancellations
•
Improved patient safety through timely
distribution of clinic letters, more
appropriate procedure locations
•
Reduction in unnecessary follow up
appointments to improve access for
patients
•
Reduction in costs of unnecessary
additional clinics
More efficient management of clinical rotas to
ensure better patient care and investment in
frontline services
Medical Productivity
Match workforce capacity and demand closely.
Introduce electronic roster system.
Temporary Staff - Direct
Engagement
Changing contracting arrangements for agency
staff to reduce costs.
The savings can be invested in improving quality
of care.
Procurement and Supply Chain
Opportunities
Initiatives to transition from a transactional
reactionary buying operation to a strategic
procurement function.
Better procurement to reduce wastage. Savings
can be invested in improving quality of care.
Other Income Opportunities
including Contract and
Commercial
Including working with CCG colleagues to
repatriate activity back into area and maximising
the use of Best Practice Tariffs.
Salary sacrifice schemes
Provide staff benefits such as IT equipment
Repatriation of services locally will enhance
patient access and experience.
The Best Practice Tariffs Programme indicate
that the policy is delivering real improvements in
the quality of care that patients receive. We will
further expand this to cover:
•
Promoting better management of long
term conditions to reduce the risk of
avoidable hospital admissions.
•
Delivering care in appropriate settings.
Improvement in staff morale and satisfaction.
New service developments to provide better care
to patients at a local level.
Optimised Pharmacy
To reduce amount of waste and to reduce
variation with the dispensing of clinical pharmacy
services.
Reduce or eliminate drug errors.
Contain or reduce costs of patients treating
patients at inpatients
43 | P a g e
Strategic Options
Developing and executing strategic changes that
will put the Trust in a clinically, operationally and
financially sustainable position
Ensuring we continue to provide long-term
sustainable high quality services for the local
population
Information, Communication and Technology
The past year has been an exceptionally busy one for the ICT Department and reflects the
many improvements we have been able to make in Infrastructure and in turn to our service
delivery. The volume of work also reflects the pace of change in the Trust at large, and the
IT service continues to be an agile partner in the wider transformation agenda, including the
many moves to service reconfiguration throughout the year.
Despite the amount of system change throughout the year, the aggregate availability of our
systems was 98.74%. As part of our ‘continual service improvement’ ethos, we have
updated and improved many of our internal processes including incident management,
problem management, change management and the starters’ and leavers’ process in
conjunction with Workforce.
Over the past 12 months we have added to the service in support of the Electronic Patient
Records system (EPR) and other additions to our service catalogue by increasing the roles
within the team in order to give the best support possible to the Trust. This has included
transferring the Patient Administration System (PAS) team to create a new Application
Support team in May 2014. This has allowed for expert support on the use of our key clinical
and administrative systems. We have also taken over responsibility for leading Information
Governance at the Trust. We are also in the process of taking on Telecommunications for
the Trust which will include the Trust’s Switchboard operations.
Above and beyond our day-to-day service we have been supporting the largest Trust
programme, EPR (see next section for more detail). This has meant providing infrastructure,
process design, contract management, service level management, service design, 24-hoursa-day support and intensive support for our users in the run-up to, and after, go-live as the
organisation starts to fully engage in this new way of working.
Among the many other projects launched or completed in the last year were:






Upgrading all clinical PCs (1200) to Windows 7 for EPR go-live with a view to whole
Trust completion by summer 2015.
Provision of over 200 tablet devices to support near patient data viewing and
recording
Implementation of an Enterprise Management Tool to facilitate service delivery and
management of the complex infrastructure.
Tidying up the network at St Margaret’s Hospital to deliver a reliable and responsive
service
Deploying Mobile Device Management solutions to Trust mobile devices and Bring
Your Own Device (BYOD).
Re-procurement and project management of the Radiology PACS and migration of
all of the Trust radiology images from the NHS Central Data Store (~1.2 million
studies).
Rolling out wireless network access across the site.
44 | P a g e


Implementing Uninterruptable Power Supply (UPS) and air-conditioning in Computer
Room B to ensure higher availability and better experience to our users.
Facilitating a paperless Board.
There are a number of projects that will support integrated care, the Trust transformation and
the NHS ‘Digital First’ initiatives that are currently in-flight. IT continues to play a key role in
the following projects:









Electronic Document Management as part of the NHS-funded Safer Hospitals, Safer
Wards (SHSW) initiative.
Clinician and Patient portal as part of the NHS funded SHSW initiative.
Pathology system upgrade to V11, which represents a high risk to the Trust as the
system has not been upgraded for several years, is unstable and a point of failure for
all of our pathology information.
E-prescribing and Medications Management - this has the potential to significantly
improve patient safety and efficiency in how we care in the hospital.
Med iSOFT Ophthalmology system installation.
Migration of Prism Cardiology system to Solos to facilitate central reporting
requirements
Pharmacy prescription tracker.
Single Sign- On, which will increase the amount of time to care for our clinicians.
Migration to new NHS Registration Authority system.
While there has been huge progress in the past year, use of the new EPR system, COSMIC,
has drawn attention to significant issues with the Trust’s legacy data, Referral to Treatment
(RTT) pathways and general process compliance throughout the hospital. Separate
projects have been initiated to improve data quality and RTT pathway issues. Operational
departments are expected to deal with process compliance issues; these issues are
highlighted to them by the EPR and Data Quality teams.
We are looking to re-structure the IT department to take into consideration the
requirements arising from the deployment of the EPR solution. As the Trust moves towards
a paperless environment, it is vital that we have the support required by our workforce to
ensure they are productive and that we are able to play an active and effective role in other
Transformation objectives.
Plans for 2015-2016
As well as the projects already underway, including those identified in the Capital Planning
Group for IT for 2015/16, there are a number of areas of service improvement planned in IT.
We have begun to bring Telecoms into the IT department. This will provide resilience of
support and provision for all of our telephony for the Trust. In the future, we will look to move
the existing analogue telephony into digital, Voice Over IP, utilising our existing digital
networks and services.
We will create a Vendor Neutral Archive that will provide a central repository for all digital
images, accessible to clinicians at point-of-care, where currently there are silos of images
which are stored in non-resilient methods and thus presents a risk to the Trust.
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IT will deliver the EPR programme that aims to establish a single digital medical record and
make it available to clinicians and patients within the Trust and across the community.
Funding from the SHSW programme will enable the Trust to achieve its vision of improved
ambulatory care in the home and to leverage its investment in digital records to deliver direct
benefits to patients and clinicians within the Trust and in the wider health community.
During the coming year, the IT Department also plans to:
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Align projects underway with Business As Usual (BAU) requirements to ensure that
systems can be supported safely
Continue to implement initiatives to support Department of Health’s remit of ‘Digital
First’, and ‘Power of Information’, which will require NHS providers to assure plans
are in place to meet the objectives of a digital NHS by 2018
Continue staff training to embrace digital working
Consolidate virtualisation of storage of our data utilising Hyper-V technology
Consolidate small Structured Query Language (SQL) databases to reduce licensing
costs
Facilitate further rollout of mobile devices for near-patient recording
Support for the NHS Nursing Technology Fund
Centralise application support of key applications
Create a ‘Unified Communications’ strategy to ensure that the Trust benefits from
digital communications to improve care and decrease costs.
Electronic Patient Record
The Electronic Patient Record (EPR) programme, COSMIC, which launched in July 2014 is
a 10 year effort to replace ageing IT systems at the Trust while delivering clinical
improvements and operational efficiencies. COSMIC is an essential element for PAH to
realise the goals and mandates established by the government for electronic working in the
NHS. Cambio Healthcare Systems is the provider of our core EPR software.
The IT Strategy includes the Paperless Hospital and Care Record Integration projects
(funded in part by the NHS Technology fund) and the Order Communications Upgrade
project.
By implementing this first phase of EPR, the hospital made a major operational and
administrative change, by turning on a new system for integrated Patient Administration
System (PAS), Emergency Care, Maternity and Outpatients in July of 2014. The system was
implemented without impact to the four hour waiting targets or a reduction in clinics.
The Trust made a successful bid for £2.8m in technology funding. This award requires
matching funds for the Trust which were committed in November 2014. This award will fund
two projects, Paperless Hospital and Care Record Integration.
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Our plans for 2015- 2016
Our plans for 2015-2016 include:
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Continued development of EPR through monthly releases, addressing issues and
improving the usability of the product.
Through upgrading the Pathology system, that also serves as the Trust Order
Communications system, we plan to implement an integrated Order Communications
system using COSMIC.
We will procure a replacement Theatres Management System as this will be out of
contract in 2016.
We will procure a Clinical and Patient Portal that will further move toward the goal of
a paperless NHS, provide patient information for clinicians from all of our systems
and start to involve patients in the management of their care.
We will procure an electronic document management system that will further digitise
our current paper records and provide clinical noting and associated workflow to
improve the experience of clinicians and make clinical practice more efficient and
effective.
We will procure a medicines management system that will improve safety and
efficiency across the hospital by replacing current paper and manual prescribing for
general medicine management and special chemotherapy prescribing.
We will deliver point-of-care information and technology solutions to assist our
nursing colleagues with the care they provide, including on the ward and when
working remotely.
Our programme aims to establish a single digital medical record and make it available to
clinicians and patients within the Trust and across the community. The information to form
that record will be drawn from the Trust’s EPR, external sources and paper files. In order to
deliver these aims, the project will select and implement both a Clinical and Patient portal
and an Electronic Document Management (EDM) solution, including the scanning of active
medical records and creating clinical forms, charts and associated workflow. Our use of the
single digital medical record will provide a toolset for storing, managing and organising
documents, including those that originate in paper form as well as electronically. It will
transform current Trust and wider clinical practice and lead to the following benefits:
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For patients - access to their up-to-date medical records anytime, anywhere, with
secure electronic access to shared documents, images, results and messages,
resulting in increased involvement in their care. This will improve their ability to
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manage their own health, participate in their care and treatment, and lead to
improved outcomes.
For Trust clinicians - access to a full digital record, whenever and wherever they
need it, improved communication between the various healthcare professionals
involved with a patient, and better, more open and informed relationships with
patients and their GPs.
For the Trust as a whole - improved efficiency through a reduction in storage,
transportation and management costs, and the elimination of paper records and,
specifically, significant cash-releasing savings through the release of medical
records and administrative staff and the ability to release prime hospital estate for
direct patient care.
For all - the improved patient care and confidence in the patient experience as a
whole arising from the ability of patients and carers, GPs, other providers and
commissioners to be able to interact electronically with the Trust.
The project is the logical next component of our draft Information Management and
Technology strategy.
Winter planning
The Trust has been working hard to mitigate the increased pressures on our ED service,
particularly over the past winter. Our own situation is a reflection of the national picture
which has seen emergency admissions increase by 47% in the last 15 years. In the past
year we have seen 101987 ED attendances with 24969 patients being admitted (update at
year-end).
Below, we outline some of the challenges the Trust is facing and the specific steps we are
taking to address these in collaboration with our local health partners. You can read more
about the measures we are taking in the Trust’s Quality Accounts.
Emergency Department context
The National Emergency Access Target (NEAT) requires the Emergency Department (ED)
to treat, admit or discharge, 95% of attending patients within four hours. PAHT performance
has fallen below this standard, and also the Trust’s agreed trajectory for this financial year
201415. The key reasons can be seen within two areas; external pressures and internal
pressures:
External pressures
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Primary care services in the local area have also struggled to deal with the increase
in demand despite having robust plans in place.
An increase in ambulance conveyances saw a 9.6% rise between December 2013
and December 2014 (see figure one – to be updated). A recent audit demonstrated
that the west Essex locality has seen a significant increase in attendees by
ambulance when compared to similar periods last year.
Out-of-area ambulance conveyances to PAH where the nearest hospital is not
considered to be PAH. This was recorded at 15.5% for November 2014.
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24% of the Trusts adult ED attendances are over 75. This patient group has a higher
rate of admission due to complex needs and exacerbation of longer term conditions.
Delayed transfers of care remain above 3.5% threshold – to be updated at end of
year.
Increase in ambulance conveyances from 2013 -14 against 2014 - 15
Figure 1
Internal pressures
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Mismatch of ED demand and capacity specifically relating to patients conveyed by
ambulance resulting in delayed handovers and overcrowding in ED
Increase in patient acuity as demonstrated through recent audits completed at PAHT
Closure of Assessment areas due to building works and the opening of escalation
beds, impacting on demand within ED
Delays in patient discharges
Delayed transfers of care
Increased patient admissions to hospital
Reduction in capacity of Ambulatory Care Unit due to building works
Continued use of escalation capacity to maintain patient safety
Review of our Emergency Department
PAHT has recognised the pressures on the Emergency Department (ED) and has been
working in close partnership with our Clinical Commissioning Groups (CCGs), National Trust
Development Authority (NTDA) and a specialist Emergency and Urgent Care Intensive
Support Team (ECIST) to provide a detailed review and recommendations to enhance our
overall ED performance.
The ECIST report focused on two main areas, the Emergency Department and Assessment
areas and Operational centre and specialist services in the Trust. The recommendations
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from this review have been implemented and are being reviewed by the Trust and its primary
care partners, as well as within our local system resilience group. The Trust was
commended for a number of initiatives specifically the Ambulatory Care Service and has
been asked to support other Trusts in developing this service.
As part of the above work, we have succeeded in implementing a number of key areas of
improvement into our systems during this period of peak pressure in order to support our
teams.
Figure 2
Figure 2 demonstrates the number of initiatives we have put in place working closely with
our CCGs to ensure people choose the right service they require i.e. GP, pharmacy care,
NHS 111.
From 8 December 2014, West Essex CCG has been funding a ‘GP at the Front Door’
programme to facilitate increased streaming from ED to more appropriate services. They are
also providing a treating GP to provide additional support for minor services in ED.
The Trust has piloted the Rapid Assessment and Treatment model (RAT) for all ambulance
arrivals to support ‘early senior review’.
To support the recommendations of the ECIST report the Trust has embarked on a Capital
Programme that saw the creation of a Surgical Assessment Unit, dedicated GP assessment
and Ambulatory Care environment, resulting in an increase in capacity of 26 beds to support
the proposed medical model. These areas became operational from mid-March 2015.
To support the flow of patients through the emergency patient pathways, the system has
invested in increased support staff with the introduction of patient journey navigators, senior
floor-walkers and an increase in HALO (Hospital and Ambulance Liaison Officer) operating
hours. It is envisaged that this investment will support frontline staff to ensure the high level
of patient safety and the delivery of the four hour standard.
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The Trust is working in collaboration with health and social care teams to develop a model of
care that will see patients who require a further period of assessment, taking place in their
usual place of residence rather than in an acute setting. This will support improved accuracy
of assessment as patients will not be affected by environmental factors, resulting, it is hoped
in a reduction in associated delay.
The Trust runs a rolling recruitment programme for nurses (see Nursing and Midwifery
Recruitment page 40) and is actively recruiting for consultants within ED and our Emergency
Assessment Unit (EAU).
Despite this level of increased pressure, we have continued to strive to deliver the best
possible experience to patients who attend our hospital as an emergency. The clinical
teams remain vigilant in taking every action possible to improve the service we provide our
patients. With the support of a number of important stakeholders, the Trust has gained
valuable insight into areas that can be improved and has used System Resilience Group
Funding 2014-15 to implement the improvements. The Trust launched its new internal
Urgent Care Improvement programme in February 2015 under the banner “ Every Minute
Matters” - another strong example of our clinicians leading on improvements to our hospital
With the benefit of strong clinical leadership and thanks to our dedicated teams, we are
confident that the Trust can transform the delivery of urgent care and ensure sustainable,
quality and safe care for all our patients.
Discharge planning
In January 2015, the Trust developed and refreshed the key recovery and action plans and
launched the new programme “Every minute matters” to support a return to delivering
better patient experience across the emergency pathway.
Effective Transfer planning should ensure that patients are transferred from the acute
hospital when the acute phase of their clinical condition has been resolved. This requires
careful planning and synchronisation of activities both internally in the Trust and externally
by health and social partners to deliver a safe discharge. The transition of care from an
acute setting is supported by the transfer of treatment information provided to GPs or other
key stakeholders at the point of discharge and should be timely, accurate and relevant.
Any delays in transfer pose an increased risk to patient safety and impact directly on the
availability of capacity to manage new patients requiring an acute episode of care. The
increased pressures on acute hospital capacity means that there is an increased need to be
able to effectively plan and discharge patients to their own home or other setting of care
across the whole week and not just Monday to Friday to ensure that capacity is maintained
within the whole system
The current arrangements which aim to steer patients through their clinical journey from
admission through to discharge from hospital and beyond, can be less than seamless.
Delays are often caused by the requirement to negotiate between different agencies and
organisational entities, or the need to grapple with relatively complex discharge issues
requiring effective working between different professional groups.
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In 2014-15 the Trust engaged with system partners to undertake a number of key
improvements, these included:
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Development and pilot of “Home to Assess model” with integrated workforce
Development of the Transfer of Care summary
Implementation of transitional care concept to support the assessment of patients ongoing care needs in a more appropriate environment
Engagement in the system wide 100 day challenge work programme
Implementation of education and validation of Continuing Health Care nurse
specialist roles to support a reduction in process time for 14 days to 48 hours.
Patient Experience
The Trust has made huge progress in engaging local people and transforming patient
experience in the last few years, but we know we still have a huge amount to do. Over 2,000
staff have been through the new Values, Standards and Behaviours training. The number of
compliments we receive are now consistently high, with an average of over 100 compliments
per month ten times higher than just a few years ago.
Complaints numbers have remained consistent with 2013-14 at under 400, a drop from two
years ago in 2011-12 when 665 were reported, however this now needs to translate into
service improvement with patients
We deal with around 230 patient contacts per month all of which we aim to turn around
within 48 hours.
A powerful patient voice of growing importance can be found in the Trust’s Patient Panel led
by Chair, Ann Nutt, and Vice Chair, John Woods, with the group now embedded in decision
making bodies, working with the Board.
Around 2,000 votes are cast every single month, with consistently positive feedback on
services and where comments are critical, immediate feedback is provided to the service, so
that changes can be implemented.
Valuing patients and staff
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Over 2,000 people have been through the new Values, Standards and Behaviours
training.
We designed this in partnership with 400 patients, families, carers and staff.
Staff feedback on the training has been very positive, with some trainers leading the
organisation, championing the values by presenting to their own staff and then to
many others throughout the organisation.
The number of compliments we receive are now consistently high, with an average
of over 100 compliments per month, whereas a few years ago before this was around
60 per month, and sometimes as low as 13.
PALS: solving your problems at the point of care
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We deal with a phenomenal number of patient concerns, around 230 per month,
which is more than 10 a day, all of which we aim to turn around within 48 hours. In
the last year we successfully resolved 2,510 PALS concerns.
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Complaints
Complaints are a key performance and quality metric for the Trust particularly following the
Francis Inquiry Findings, the Clwyd Hart Report and the historic high levels of complaints at
The Princess Alexandra Hospital NHS Trust, all of which have pointed to the need for an
improved capacity to listen to the voice of patients, families and carers. The Trust has
invested significant energy and resources in reforming policy and processes to enable
patient centred practice by immediately offering a meeting to complainants, pursuing point of
care resolution, revising recording processes and appointing priority areas around empathic
listening, effective facilitation and leadership of change at a local level. As a result, from a
time when we were receiving 665 complaints per year in 2011-12, last year we received 379.
Complaints Themes by Quarter
The 379 complaints cases received in 2014-15 are evidence of a continuing reduction in
complaints overall and some improvement in our ability to manage quality.
Expectations of medical care fell gradually as a theme throughout 2014-15 and this was one
of the most striking trends visible in the data. By the end of the year, medical care failed to
feature in the top three complaint themes. The green line marked by a triangle shows the
pattern of movement downward which appears to be a trend which has been visible since
September of last year.
The Trusts’ goals through 2015-16 are to develop high quality evidence of action and
learning from complaints from all health groups as they are now set and to embed the
findings of the Clwyd Report in working practices.
Partnerships for improvement
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The Trust is committed to improving partnership working and engagement with
patients and their families and has made huge strides in engaging the community in
its work with 14 patient groups now in place.
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A powerful patient voice of growing importance can be found in the Trust’s Patient
Panel led by Chair, Ann Nutt, and Vice Chair, John Woods, with the group now
embedded in decision-making bodies, working with the Board
New partnerships with local voluntary and community groups which will work jointly to
meet the needs of local communities and support long term funding models for
statutory and voluntary co-production.
A recent audit found the Trust’s 14 patient groups have over 150 patient members,
supported by Clinical Nurse Specialists in a wide range of specialties, from stoma care and
bowel disease to diabetes, stroke and a variety of cancers, shaping what we do. We commit
to building on this work and transforming patient care, by re-shaping our pathways around
patients, families and carers.
Our vision of an integrated care organisation is one where patients’ families and carers are
at the heart of everything we do, so challenge us to do better and we pledge to respond in a
way which is built on our partnership with you.
CQUIN Outcome
The Friends and Family – a national measure - is the indicator used by West Essex Clinical
Commissioning Group to assess the Trust. The Princess Alexandra Hospital NHS Trust has
achieved 100% CQUIN compliance for patient experience for the last two years. Every
month over five and a half million people rate their care through the Friends and Family Test
across the whole of the NHS England and Wales. Over one year, that is 66 million ratings of
NHS care.
In the case of the Trust, around 2000 votes are cast every single month, with consistently
positive feedback on services and where comments are critical, immediate feedback
provided to the service, so that changes can be implemented.
While we achieved great success in many areas, there is more work to be done with
the following:
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The Trust aimed for 100% compliance with Values, Standards and Behaviours
training by March 2015, but appears to be on track for 85% compliance.
The Trust wished to see a significant fall in complaints over the year but appears to
have achieved only a small drop over the last two years.
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National surveys
With regard to the Inpatient Survey the Trust has been working hard to eliminate the key
areas of concern raised by patients around poor communication by doctors in 2014-15.
The Trust has fallen back somewhat compared to the previous year but continues to
demonstrate improvements in the quality of its communication and information provided.
This has included new, higher quality patient information published throughout 2014-15 on
Leaving Hospital, on Critical Care, on Patient Experience, Having a Procedure and many
other areas.
Despite these changes, 2014-15 was a year of significant operational pressure and the
evidence has clearly emerged in the National Survey of the parts of the patient experience
where this has negatively impacted. The ten questions where we performed in the lowest
20% of Trusts nationally were:
There were two areas of improvement and these included complaints processes and
doctors’ communication, specifically:
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Evidence found in the National Emergency Department Survey 2014 is consistent with that
described from the National Inpatient Survey, with one area of performance in the top 20%
nationally on the pace of initial assessment:
In all other respects the key issues remain the same, with poor communication in two areas
and processes relating to transfers of care back home or into the community demonstrably
deficient in comparison to other Trusts nationally.
The specific questions where we performed worse than other Trusts included: knowing who
to contact if you were worried about your condition or treatment after you left; when a patient
could resume usual activities; one member of staff saying one thing and another saying
something different and finally doctors and nurses not spending enough time listening to
what patients had to say.
The Trust will be implementing a number of actions to address the challenges raised by the
evidence from the National Surveys in 2014-15 and this includes the following actions:
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Developing a Communication Customer Care Standard with compulsory training for
all staff
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Health Group leaders to develop and present improvement plans to Quality and
Safety Committee, with regular review of evidence of progress.
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We are working with the NESTA to recruit 100 young volunteers in 2015-16 to assist
patients leaving hospital as well as those with dementia
Cancer patient experience
A total of 153 Trusts took part in this year’s survey which involved adults over the age of 16
and which was conducted between 1 September and 30 November 2013.
We sent 481 surveys to Princess Alexandra Hospital patients and 272 were completed and
returned, representing a response rate of 62%, just 2% lower than the national figures.
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PAH has had one of the most significant improvements in performance across the North
East London sector in the last year. A total of 86% of patients who responded rated
their care as excellent or very good, which is an improvement since last year.
There was a statistically significant improvement on 11 questions (out of 70 in total),
since 2010, and significant improvement on three questions in the last year.
For PAH, 23 questions had scores in the lowest 20% of all Trust scores across the
country as opposed to 27 last year, and five questions fell into the best 20% of all Trust
scores compared to 3 last year.
There is still room for improvement as 19 questions still have scores lower than 70%
which is the same as last year.
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The results overall represents an improvement in the last two years of 26% for the Trust.
However, we are not complacent and are very aware that more work and training of staff
needs to be completed and that the Cancer Patient Experience Survey must remain high on
our agenda.
The results overall represents an improvement in the last two years of 26% for the Trust.
However, we are not complacent and are very aware that more work and training of staff
needs to be completed and that the Cancer Patient Experience Survey must remain high on
our agenda.
Tumour Group
Breast
Colorectal/Lower Gastrointestinal
Lung
Prostate
Brain/Central Nervous System
Gynaecological
Haematological
Head and Neck
Sarcoma
Skin
Upper Gastrointestinal
Urological
Other
Number of respondents
72
44
16
19
0
7
55
2
0
0
15
19
23
Where we did well
The Trust made significant progress from last year’s results in the following questions:
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Where we need to improve further:
Q6. Staff gave explanation of purpose of test(s)
Q9. Given complete explanation of test results in understandable way
Q11. Patient told they could bring a friend when first told they had cancer
Q12. Patient told sensitively that they had cancer
Q13. Patient completely understood the explanation of what was wrong
Q15. Patient given a choice of different types of treatment
Q16. Patient’s views definitely taken into account by doctors and nurses
discussing treatment
Q17. Possible side effects explained in a understandable way
Q18. Patient given written information about side effects
Q19. Patient definitely told about treatment side effects that could affect them
in the future
Q20.Patients definitely involved in decisions about which treatment.
Q23 The CNS definitely listened carefully the last time spoken to.
Q40 Patient’s family definitely had opportunity to talk to doctor
Q41 Got understandable answers to important questions all/most of the time
Q43 Nurses did not talk in front of patients as if they were not there
Q47 All staff asked patient what name they preferred to be called by
Q50 Patient was able to discuss worries or fears with staff
Q54 Staff told patients who to contact if worried post discharge
Q55 family definitely given enough care from health and social services
Q64 Practice staff definitely did everything to support the patient
Hospital and community staff always worked well
Better communication still remains one of the key areas of concern for patients, whether this
relates to their experience of being informed of their diagnosis, or being made aware that
they are very welcome to bring family or friends for support to their outpatient appointments.
The results showed that patients want to feel more involved in the decisions regarding their
treatment. They want to understand what is happening to them. This covers all areas from
tests, procedures and surgery, through to having the results explained in a way they can
understand. Being given time to ask questions was another area which patients felt was
extremely important and work is in progress to give longer appointment times to patients to
enable this to take place
“You Said, We Did” is a programme of work which focuses on being as responsive as
possible to the opinions of patients and their relatives and to demonstrate our commitment to
making changes based on that feedback.
As part of that programme, the Trust’s dedicated Patient Experience team has been involved
in arranging various “In Your Shoes” events where patients are invited to meet staff to talk
through concerns about their care. It is an opportunity for them to spend unhurried time with
us, detailing issues they may have so that we can learn from these and continue to improve
the care we offer. We are also nationally recognised for having one of the highest “Friends
and Family” survey ratings.
All the nurses in the Trust have signed up to the Trust’s Values, Standards and Behaviours
which are entail being respectful, caring, responsible and committed. The majority of staff
working within Cancer Services have undertaken specific training in this area and are
monitored to ensure they adhere to these commitments.
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Training has also been made available for staff to develop in areas where improvement is
still needed. These include Breaking Bad News workshops for doctors, End-of-Life training
for all staff and the opportunity for all to attend Cancer Educational study days. Clinical
Nurse Specialists are also introducing holistic needs assessments for all patients who would
like to complete one. This helps us to look at every aspect of patient care and ensure these
are included when a patient’s care pathway is being discussed at diagnosis and during their
care with us and in the future planning in primary care.
We are undertaking local surveys to see whether this has improved the patient experience,
as well as offering patients access to telephone clinics, instead of attending appointments at
the hospital. There are certain specialities which run clinics at the local hospice which
enables patients to meet with their Clinical Nurse Specialist or key worker, as well as locallyrun support groups.
We are continually striving to use different approaches in order to make further
improvements for the benefit of all our cancer patients and their families.
Acute Oncology and Malignancy of Undefined Origin Service
The role of the Acute Oncology (AOS) and Malignancy of Undefined Origin Service (MUOS)
is:
 To provide specialist advice and support for medical and nursing staff in the
management of the acutely unwell oncology patient
 To facilitate the appropriate triage of patients to avoid unnecessary admission
 To improve patient outcomes and reduce length of stay by facilitating timely and
appropriate investigation and to fast-track outpatient clinics
 To facilitate improved access to palliative care and oncology services
 To improve the patient experience by providing information and support
The AOS is intended for acute problems and will see and advise on patients presenting with:
 Complications resulting from their cancer treatment
 Complications resulting from the cancer itself
 A new malignancy of undefined origin (MUO)
The key areas of improvement in the past financial year include:
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The appointment of one full-time Clinical Nurse Specialist (CNS) and one part-time
associate CNS in September 2014 to work alongside the Acute Oncology Consultant
The introduction of a structured daily acute oncology handover
The development of a formal referral process using trust email and referral form on
intranet
Improved communication with the visiting oncologists and Clinical Nurse Specialists
via a daily email update
Improved communication with ward teams, palliative care teams and community and
hospice teams
Implementation of the weekly MUO Multi-Disciplinary team meeting which is also
attended by the Palliative Care team
Completion of a Sepsis audit (results pending)
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Completion of a three month Metastatic Spinal Cord Compression (MSCC) audit
(results pending)
Regular patient satisfaction questionnaires about the chemotherapy patient helpline
As PAH does not have an oncology ward, the AOS aims to provide support and advice to
both patients, families and staff on how to manage those patients who are admitted with
complications in their cancer treatment, whether from the cancer itself or from a new
malignancy of undefined origin. The AOS receives around 60 new referrals each month.
An increasing number of patients presenting to PAH as an emergency are being treated at
tertiary centres; the AOS has improved liaison with these centres to ensure patients are
receiving the appropriate management. The AOS has worked hard to improve links with the
community services including the local hospices, and recognises the importance of
collaborative working. Many oncology patients also require palliative care input and the AOS
now meets on a weekly basis with the hospital palliative care team in order to improve
communication and ensure patients are seen by the most appropriate specialist.
The recruitment of a full time Clinical Nurse Specialist and a part-time Associate Specialist
Nurse has enabled there to be more structure within the service, including an improved
referral process, improved data collection and audit, and service development. The specialist
nurses are now able to act as key workers to those patients with a diagnosis of MUO,
providing support and information and co-ordinating the often complicated pathway for these
patients.
Where further improvement is needed
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Currently the AOS is unable to provide a service out-of-hours
The AOS service currently has only one Consultant (who also has other
responsibilities within the Trust) which means that cover is required for annual leave
More space is required in the Outpatients Department and in Ambulatory Care to
review and assess patients who are urgent, but may not need admission, as well as
newly-diagnosed MUO patients
The current cancer patient advice line is provided by North Middlesex Hospital and
patient feedback indicates patients are not receiving adequate support and advice
out-of-hours
Plans for 2015/16
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Implementation of the UK Oncology Nursing Society (UKONS) 24 hour triage tool
Review admission pathways for oncology patients
Develop further links with GPs and community services
Development of Trust-specific guidelines for the acute oncology patient
Update and re-introduce the neutropenia sepsis policy
Update and re-introduce the MSCC policy
Develop Trust guidelines for the management of the MUO patient
To provide regular acute oncology teaching sessions for ward staff
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The UKONS 24 hour triage tool is used by many Trusts in order to provide a 24-hour advice
line for cancer patients undergoing treatment. The AOS is planning to implement this tool
over the next few months; the tool will improve patient safety and care by ensuring that they
receive a robust, reliable assessment every time they contact the helpline for advice. It will
ensure patient assessments are of a consistent quality and that patients requiring urgent
assessment are identified and that action is taken. It will also identify and reassure those
patients who are at lower risk and may safely be managed at home, to avoid unnecessary
attendance.
For those patients who do require admission, the AOS plans to work with the acute teams in
order to develop specific admission pathways and avoid delays in assessment and
treatment. The AOS also aims to develop further links with GPs and the community to
support and advise on patient management and avoid unnecessary admission.
AOS plans to develop Trust guidelines for the management of the acute oncology patient, in
order to standardise care and provide guidance and support for ward teams. Neutropenic
sepsis also known as ‘blood poisoning’ involves serious potentially life-threatening infection
which can develop when a patient’s immune system is low following chemotherapy
treatment. MSCC is a condition whereby cancer has spread to the bones in the spine which
can put pressure on the spinal cord and cause pain and problems with sensation and
mobility; both of these conditions require urgent attention and although there are policies
within the Trust, the AOS team plans to update these and re-introduce them to staff to
ensure patients are treated quickly and appropriately.
One of the key roles of the AOS is to ensure frontline staff are equipped to manage the
acutely unwell oncology patient. The AOS team plans to initiate regular teaching sessions for
emergency and ward staff to ensure knowledge and skills are up to date and evidencebased.
End of Life care
End-of-life training has been extended to a growing number of staff in the past year. All new
clinical staff undergo a three hour-long training session during their induction following the
successful completion of the 2013-2014 End of Life CQUIN which involved training all
clinical staff who have regular contact with End of Life patients. We identified that some
doctors do not attend, so they are encouraged by the training department to complete the elearning module. Up to the end of April 2015, 447 new staff (97% of a possible total) had
completed the training.
The non-clinical training continues with 186 out of 206 staff completing the training. This
equates to 90% surpassing the CQUIN target of 90% by end of March 2015.
Our two Clinical Nurse Specialists have collaborated with a colleague in Medical Education
and been granted funding by Health Education East of England to have monthly End of Life
training using the simulation manikin in Parndon Hall. The training began with a pilot on the
13 March 2015 where various scenarios were tested out ahead of monthly sessions
beginning in 2015.
Specialist palliative care staffing
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A senior consultant has been allocated two sessions per week for specialist palliative care in
her job plan. In addition to the two sessions being worked already by a medicine consultant
from St Clare Hospice who has an honorary contract with PAHT, it means we can offer four
sessions per week to patients.
The Clinical Nurse Specialists (CNSs) are in the process of formulating a business case to
support two further sessions per week of consultant cover. This is in response to the written
offer from St Clare Hospice of two consultant sessions from April 2015. The hospice has
also offered to provide an out-of-hours on-call service with consultant cover; we are
investigating the cost this would entail and preparing to write a separate business case to
support this.
We are also in the process of submitting an expression of interest to Macmillan Cancer who
are offering funding for two years on the understanding there are plans for a business case
for the funding to be continued by the Trust when the two years are completed.
The team has seen a rise in referrals since we increased the number of staff undergoing End
of Life training. Please see Figure 1 below.
Figure 1
New patient referrals 2014 - 2015
Quarter 1
Quarter 2
Quarter 3
Quarter 4
Numbers of new patient referrals
108
130
137
148
2014 - 2015 CQUIN
The Trust is achieving patients’ wishes for their place of death (PPD), in the majority of
cases. Where we do not achieve a patient’s PPD, it is due to the following issues:
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The patient rapidly deteriorates and is too poorly to move.
There are no hospice beds available
Patients are still being actively treated - sometimes at the patient’s request –
but at other times the plan of care needs reviewing.
2015 - 2016 CQUIN
There is on-going discussion with the CCG about a CQUIN centring around discharge
planning for end of life patients with the aim of improving achieving patients PPD.
End of Life champions
Their introduction remains a goal which may develop further following the simulation training
outlined above.
Dementia team collaboration
The Palliative Care team helps to train the Dementia Champions and are also part of the
dementia steering group.
While much progress has been made, one of the issues we wish to address in the coming
year is the priority for side rooms for dying patients. Currently this is based on an isolation
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priority list where ‘palliative care’ is listed as number 13. We need to find a way to increase
the number of side rooms available or create capacity elsewhere in order to afford such
patients greater dignity and privacy.
Embedding quality through patient champions
The past year has seen the commencement of the Dementia Champions’ programme and
the scheduling of further work with our already-established Learning Disabilities Champions.
In February 2013, the Trust introduced Learning Disabilities Champions. The volunteer
champions underwent a full study day to prepare them for this role. As this is a highly
specialised area, the aim during 2014 was to provide further update training and support.
However, due to the Learning Disabilities Nurse Specialist being on maternity leave during
2014,no further work was undertaken with the Champions.
Our plans for 2015-2016 include:
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At least one further cohort of Dementia Champions to start the programme.
The Learning Disabilities Champions programme to be re-introduced.
The third cohort of Dementia Champions will commence the training programme during 2015
with a date to be confirmed. The aim is to evaluate the programme in response to feedback
from the first two cohorts, making amendments where necessary. This is a significant piece
of work, requiring detailed feedback from previous participants. We estimate that we should
complete this work in time for the next programme of training to start in September 2015.
The Learning Disabilities Nurse Specialist has now returned from maternity leave. One of
her top priorities for 2015 is to re-launch the Learning Disabilities Champions programme
and this will include study sessions and on-going support and development.
Case Study Three: Our Patient Panel
In July 2013, Princess Alexandra Hospital re-launched its Patient Panel with a team of
people who had recent experience as a patient or carer. During the past year, the Panel has
taken on further projects and continues to build its reputation as a critical, but constructive,
friend to the Trust.
The purpose of the Patient Panel is to make sure that the patient voice is heard in all areas
of the hospital, especially in the decision-making process. The Chief Nurse talks about the
values Respectful, Responsible, Caring and Committed: part of the Panel’s work is to
ensure that staff adheres to these values. However, its role is not only to find fault, but also
to highlight the very good work done within PAH. The Panel does not deal with patient
complaints, which are handled by the Trust’s Patient Advice and Liaison Service team
(PALS).
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Achievements in 2014 - 2015
Delays in the discharge process were seen as a major issue, with all members of the Panel
having had personal experience of this. The Patient Panel therefore set up a task group of
its members to look into what was causing the delays and has provided feedback to the
Trust Board on the main factors. It is also working with Healthwatch Essex who is carrying
out research into the discharge process. PAH has volunteered to be one of the pilot
hospitals. The Patient Panel has a representative on the ‘100 Day Challenge’ which has
brought together staff from PAH, St Margaret’s and Herts and Essex Hospitals along with
Social Services and other agencies to seek, within 100 days, radical ways to reduce
pressure in our Emergency Department, by improving discharge practices.
Pharmacy
Not having the correct medication ready for a patient is the reason for many delays in
discharge and the Patient Panel has focused on rectifying this by working closely with
Pharmacy staff. The Chief Pharmacist attended one of the Patient Panel meetings and this
resulted in members being invited to the Pharmacy in July 2014 to see how they work,
where the delays occur and to see the creative solutions staff have initiated to eliminate
some of the problems. This also identified that it was a combination of small issues that led
to delays, which were not always exclusively the fault of Pharmacy staff. The Patient Panel’s
report of the visit to the Pharmacy particularly noted the delays in sending TTA’s (To Take
Aways - medication for patients awaiting discharge) to Pharmacy was a serious cause of
delays in discharge, and this has been taken up by the 100 Day Challenge.
Food
Over the past year, a Patient Panel representative has spent a considerable amount of time
at meetings and on the wards talking to patients and staff about the food that is served.
They asked questions such as: ‘Is this the food you would want your mother to eat?’, they
looked at portion size, temperature and protective mealtimes which enable patients to enjoy
their food without being disturbed with trips to X-ray, Pathology or by doctors rounds, for
example.
Website
One of the Patient Panel with an IT background dedicated time to creating a new web page
for the Patient Panel. The page was up and running by August 2014 and has made it easier
for the public to find information, read the reports on the work they are doing and information
about how others can become involved.
Visit: Patient Panel information page
Reporting
The Chair of the Patient Panel has regular meetings with the Chief Nurse and the Chairman
of the Board to discuss their reports, findings and suggestions. The Patient Panel currently
has members sitting on 12 different committees and has received requests to join more.
They use these to give feedback about their work with patients and families using the Trust’s
facilities.
The coming year
The Panel will continue its work improving the surroundings and conditions that patients and
their families experience while at Princess Alexandra Hospital.
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Following an interview with the family of a lady who died of cancer, the Panel raised
concerns about the need for a ‘quiet room’- somewhere relatives can go at night, make a
cup of tea and relax in between sitting with their loved ones. Although the Trust is
supportive, lack of space and costs were both raised as issues. As a result, in March 2015,
the chair of the Patient Panel did a tour of the hospital site with the Head of Estates to
identify any suitable rooms and found two. Approaches are now being made to The League
of Friends and local businesses to help refurbish at least one. The family who alerted the
Panel to this issue has volunteered to work with the Patient Panel and hospital on this
project and have also become members of the Panel.
The Panel held its second annual conference in February 2015 at the Harlow Leisurezone
which was attended by more than 55 members of the public as well as many representatives
from voluntary organisations and the Patient Panel. The conference raised a number of key
issues especially around Integrated Care. Although the presenters said that the voluntary
sector was part of the planning, very few people in the room were aware of the Integrated
Care Project and its effect on the way services will be delivered. The Patient Panel agreed to
organise a half-day seminar in partnership with the hospital and West Essex CCG.
Carers issues were also a key area for attendees and the Patient Panel will be picking this
up in the coming year.
The Panel has also been rotating its committee meetings between morning, afternoons and
evenings to ensure maximum accessibility to people who use Princess Alexandra Hospital.
We are holding a seminar in April/May 2015 for the public, voluntary organisations and
professionals on the significant changes that are happening in the Emergency Department.
This will be a great opportunity for ED staff to talk to people, hear their feedback and explain
the benefits to the community of these changes.
We have been involved with Essex County Council’s Health Overview and Scrutiny
Committee looking at complaints. This meeting involve Chairs from the other hospitals in
Essex. This was the first opportunity we had to meet colleagues from the other hospitals and
PAH Patient Panel suggested that we meet at least twice a year to share good and bad
practice and how we can support each other. PAH will host a meeting in the summer and
Essex Healthwatch has offered to support this initiative.
Partnership working
Student nurse ambassadors have evolved from our first open meeting and are being
supported by Anglia Ruskin University. One student nurse told us why they value the
project: “We are discussing with our university Anglia Ruskin to see how we can relay all the
information we gain, back to other students and give new students an insight into things we
do not learn as part of our course. There are plans being made for how we can develop our
roles further, we look forward to putting it all into place and making a difference to patient
experience”.
We have made good contacts with the West Essex Clinical Commissioning Group and look
to make more links with the many voluntary health groups in our community.
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Volunteers
As a result of this winter’s capacity issues in the Trust’s ED, the Panel wrote a paper
recommending the use of volunteers when demand outstrips capacity. This was endorsed by
the Board as well as ED staff and training for volunteers started in February 2015. Following
a visit to ED when PAH was on Black Alert, it was obvious that the volunteers needed to be
knowledgeable about the layout of the department and hospital, be able to advise relatives
on where out-of-hours pharmacies are situated, as well as local restaurants and hotels, and
are able to provide limited refreshment when the canteen is closed to both relatives and
staff.
Transport
Work has been continuing during the past year with senior staff from the hospital, local
authorities and the local bus provider to improve transport links to the hospital. This is
progressing very well and a decision is hoped for in the autumn
Copies of the Panel’s first annual report as well as their reports on the Discharge Lounge;
Pharmacy and Social Care and the discharge process, are available by clicking on Patient
Panel reports
Infection Prevention and Control
Due to its commitment to patient safety and infection prevention and control, The Princess
Alexandra NHS Trust has continued to see year-on-year improvements with most
Healthcare Associated Infections (HCAI) indicators. Good infection prevention and control
measures in clinical practice are essential to provide a safe environment for our patients,
and this ethos is embedded in everyday patient care. At the Princess Alexandra Hospital
(PAH), infection prevention and control is a top priority for the Trust, supported by the Board,
and is at the centre of patient care. All staff of all grades in the organisation are fully
engaged and committed to providing a safe, harm-free environment for our patients.
Our performance in 2014-2015
The Department of Health has set national targets for each NHS Trust in regards to MRSA
bacteraemia and Clostridium Difficile (C. difficile) infections. Trusts are set individual
trajectories annually
C.difficile
The Trust’s infection prevention and control strategy continues to meet the C.difficile target set
for us, and nationally we have performed extremely well, leading us to have one of the lowest
targets set for C.difficile across the country, in recognition of our sustained low rates of C.difficile
disease. The threshold for 2014 - 2015 was set at 16. It is confirmed that the Trust achieved
its trajectory for 2014-2015, ending the year on 16 cases of C.difficile reported on the national
HCAI data capture system. However, in terms of contractual purposes, only 15 cases were
recorded; this was following the successful removal of one case at the North Essex Quality
Collaborative Serious Incident and Never Event Panel (Appeals Panel). The panel were in
agreement that there were no lapses of care in the Trust that contributed to the patient acquiring
C.difficile
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The graph on page 68 demonstrates the cumulative total of C. difficile from 1st April 2014 – 31st
March 2015. All cases, including hospital attributable (post) cases and community attributable
(pre) are shown.
Cumulative C-diff cases – 1st April 2014 – 31st March 2015
40
post 72 hr
35
30
25
pre 72 hr
20
15
10
5
0
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
The following demonstrate the steps we have in place to prevent the occurrence of C.difficile
cases.
Current mitigation

The SIGHT model.
S – suspect/assess. For this we would use an algorithm or PT assess tool.
I – Isolate. All patient with C.difficile must be isolated.
G – Gloves/aprons. Protective equipment must be worn around the patient.
H – Hand washing with soap and water.
T – Test. A toxin test must be done.
Our safeguards include:
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Antimicrobial stewardship. Antibiotic ward rounds with Antibiotic
Pharmacist/Consultant Microbiologist and the antimicrobial audits/antibiotic app.
Teaching and educating (statutory, mandatory and grand rounds), including
educating staff on the updated Algorithm and Patient Assessment Tool for collecting
stool specimens (micro-teaching sessions)
Hydrogen Peroxide Vaporiser for the decontamination of the environment.
Root Cause Analysis of all cases (shared learning) and Scrutiny Appeals Panel
(CCG).
Mock CQC Inspection Programme.
Audit – audit of compliance of stool sampling/use of the Algorithm and the Patient
Assessment Tool; Monthly Hand Hygiene Audits
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Proposed future mitigation
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Ongoing training and education (including more robust Link Practitioner programme
to encourage ‘champions’ for each area).
Focus on lapses (if any identified) in quality of care provided and continue to work
with clinical staff to improve care. The Commissioner will continue to exercise
discretion in decided whether individual cases should be counted towards, or be
removed from trajectory.
Ongoing antimicrobial stewardship.
Ongoing ‘shared learning’ at monthly CCG Scrutiny Panel.
Review of existing Root Cause Analysis tool to incorporate all factors in NHS
guidance C.Difficile checklist (developed by PHE CDI ‘Lapse in Care’ sub group).
Microbiology/IPC joint ward rounds for review of C.difficile cases.
MRSA bacteraemia
In July 2014, the Trust had its first case of MRSA bacteraemia since July 2012. This represents
a period of two years without an MRSA bacteraemia. We take each case seriously and
investigate it thoroughly as we are very proud of our performance in controlling healthcareassociated infections; the Trust has been one of the top performing Trusts with regard to our
MRSA bacteraemia rates.
The root cause analysis of the case of MRSA bacteraemia in July 2014 identified that
preventative steps to avoid MRSA infection such as identifying a previously known MRSA
positive patient had not occurred. This is a rare event at PAH. A number of learning points were
identified and an action plan was developed. A task and finish group was immediately set up, to
enable the actions to be implemented. The action plan and remedial work was presented to the
Quality and Safety Committee as well as at other forums and committees, to ensure shared
learning across the organisation. Whilst it was extremely disappointing to have had a patient
develop a MRSA bacteraemia at PAH, the work that has been implemented as a result of this
has been important in re-enforcing the multiple steps in place to prevent future infection with
MRSA.
The graph below shows total numbers of Trust attributable (post) and non-Trust attributable
cases of MRSA bacteraemia this year.
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The following demonstrate the steps we have in place to prevent the occurrence of MRSA
cases.
Current mitigation
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Mandatory MRSA screening
All inpatients prescribed decolonisation (topical skin wash) for duration of admission
All known positive patients prescribed MRSA decolonisation (full MRSA protocol)
Protocol for high risk patients (as per criteria on MRSA care pathway) is provided in
pre-assessment
Antimicrobial policy/stewardship, including app in place
Use of Chloraprep for skin decontamination
Documentation tools for patients with invasive devices, e.g. Body Map Tool, Visual
Infusion Phlebitis (VIP) scores
Audit; monthly hand hygiene audits in place; MRSA Screening and Management
Audit (bi-annual)
Isolation of patients (where possible)
Training and education for all grades of staff Trust-wide
Ring-fenced surgical ward (no patients with history of MRSA or other infections can
be admitted)
Surveillance of MRSA transmissions, including RCA meetings
Mock CQC inspection programme
Proposed mitigation

Future implementation of extension sets for lines and cannulation packs to reduce
risk (IPC Team, Outreach, Clinical Skills and Procurement teams working together to
bring in – pilots have been undertaken in some areas).
 Implement additional high impact intervention (DOH Saving Lives) audit tools for
invasive devices (Trust-wide) including peripheral line care (from April 2015) – this
will be implemented in a phased process.
 Revision of MRSA policy (by June 2015)
Ongoing work to improve compliance with documentation of body maps.
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Pharmacy – improving medicines management
Medicines are the most common intervention in medical care. The costs of medicines
amount to around 10% of NHS expenditure. A Cochrane review “Interventions for enhancing
medication adherence” concluded that improving how and when medicines are taken could
have a far greater impact on clinical outcomes than an improvement in treatments. However,
it has been variously estimated that between a half and third of all medicines prescribed for
long-term conditions are not taken as recommended, and wider than this the costs of nonadherence are both personal and economic. The economic costs are not limited to wasted
medicines but also include the knock-on costs arising from increased demands for health
and social care as health deteriorates.
The national drivers for Medicines Optimisation also recognise that support for effective use
of medicines spans all sectors of health and social care. There are significant gains to be
made financially for all partners in healthcare if medicines are well managed and patients
adhere to treatments. To achieve these benefits, there needs to be a significant
enhancement of the traditional function of the Pharmacy team to incorporate a more patient
facing role working as part of the Consultant led teams.
In compliance with the Royal Pharmaceutical Society’s professional standards for hospital
pharmacy services, TDA medicines optimisation and pharmaceutical services framework
and Mazars Medicine Management external audit, medicines management at Princess
Alexandra Hospital has improved remarkably during the last 12 months.
Some of the key achievements within this period are as follows: Clinical Pharmacy
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We have continued to consolidate and build on the improvement work we have been
doing which earned very positive feedback from Helen Gordon, Chief Executive of The
Royal Pharmaceutical Society (RPS) during a visit at the end of 2013. Helen was highly
impressed by the Trust, in particular the team work among the staff and leadership within
the Pharmacy Department and across the organisation in managing medicines
A monthly report on TTA performance is sent to each healthcare group. This provides
information on the number of TTAs received 24 hours in the advance of patient’s
discharge and the number of TTAs prescribed on the day of discharge. This is set up as
a measure of improving patient safety, experience and discharge. A TTA performance
report is also provided to the Medicine Management and Incident Committee (MMIC)
and to medical advisory committee (MAC) and is discussed at the daily bed meeting to
monitor improvement in discharging of patients on time.
During dispensing of TTAs, on average 76% of TTA’s are turned around within 2 hours
against a Trust standard of 70%. This helps to ensure a good patient experience and
helps the Trust to efficiently manage its beds
EPR validation of formulary medicines to DMD codes has been completed and ready for
the implementation of electronic prescribing module. Matching of formulary medicines to
DMD codes will become mandatory in the next few years and the trust already achieved
this standard before the deadline.
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Consolidation of a Trust Medicine Management and Incident Committee (MMIC) and
development of Medicines Management Action Plan
Consolidation of a West Essex Health Economy Medicines and Therapeutics Committee
(WEHEMTC) to ensure a joint formulary across the whole health economy
Production of a quarterly CDLin report to demonstrate how the Trust manages controlled
drugs appropriately and sharing the learning from CD incidents across the organisation.
Pharmacy Transformation Programme
The following has been achieved as part of the Trust pharmacy transformation programme: Introduction of outpatient dispensing from the Pharmacy Department to
improve patient experience and reduce medicines wastage
 Collection of prescription charges across the Trust for patients that need to
pay for their prescriptions in line with DOH standards. Comprehensive drug
usage review of medicines such as anaesthetic agents and parenteral
nutrition for patient safety and cost effective use of medicines across the
organisation.
 Undertaken a comprehensive review of homecare services for medication
supply and associated documentation as part of the pharmacy transformation
programme to ensure appropriate governance and cost recovery from
commissioner.
Medication safety
The following has been achieved as part of the medication safety programme:
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Deliveries of Medicine Management training sessions including safe prescribing,
antibiotic management and anticoagulant management to clinical staff are led by
pharmacy department. Prescribing assessments are completed by junior doctors and
feedback is given. Introduction of prescribing training and assessment for non-medical
prescribers are also provided to ensure safe prescribing.
The pharmacy department were part of the ‘sharing the learning’ event within the Trust to
promote medication safety. This was organised in line with the patient safety and quality
department.
Regular medication safety clinical pharmacy audit to ensure appropriate usage and
storage of medicines across the organisation
Launch of a new inpatient drug chart to improve patient safety and support clinicians
when prescribing and administering medicines
A business case has been written for the upgrade of out-of-date equipment and the
automated dispensing robot to improve patient safety and pharmacy efficiency
Medicines Policy has been reviewed and submitted to MMIC for approval in January
2015
Introduction of medication error reports to MMIC by healthcare groups to help to ensure
learning takes place within their healthcare group and across the organisation.
Improvement in the time lapse between ordering and delivery of medicines, especially for
out-of-hours admissions to improve patient safety by reducing missed doses
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Plan for the next 12-36 months
Medicines Management at Princess Alexandra Hospital has made significant progress in the
last year but there is still much to do to improve compliance with medicine management
standards. The priorities requiring immediate action over the next 12-36 months are: Medicine Optimisation
A review of Medicines Management action plan to identify gaps in relation to TDA’s
Medicines Optimisation Framework Tools and implementation of Royal Pharmaceutical
Society hospital standards is to take place.
Following a visit of the chief pharmacist of the TDA to the Trust in June 2014 he identified
that medicines optimisation and pharmacy services currently have a relatively low profile
within the organisation. He recommended that the trust board consider how it assures itself
that the use of medicines within the organisation is optimised. He identified that the
pharmacy estate and IT would benefit from modernisation as many of the fixtures and
fittings, particularly the aseptic preparation area, are nearing the end of their useful life. He
also suggested that the reporting line for the chief pharmacist should be directly to Trust
board level to increase the profile of medicine optimisation in line with Trust strategy.
Medication Safety to Improve Patient Experience and Reduce Patient harm
The most recent NRLS report showed that PAH was in the top 25% of Trusts for reporting
incidents with a reporting rate of 9.01 incidents per 100 admissions, however of the incidents
reported 6.5% were medication incidents. This is much lower than the average for other
Trusts which are 11%. This indicates that whilst PAH is good at reporting incidents it is not
good at reporting medication incidents or sharing lesson learnt locally and outside the
organisation. There is a risk that the Trust will not learn and improve medication practice if
problems are not known about
Following an MHRA alert it was recommended that the Trust appoint a Medication Safety
Officer (MSO).
The establishment of a MSO is integral to improving medication error incident reporting and
learning within the Trust. One of the MSOs’ key roles is to promote the safe use of
medicines across the organisation and be the main expert in this area to understand the
impact of medication errors on patient care and involvement of staff. In addition to improving
the quality of reporting, the MSO will serve as the essential link between the identification
and implementation of (local and national) medication safety initiatives and the daily
operations to improve patient safety with the use of medicines.
Examples of patient safety work to be done for 2015/16 include:

The Chief Pharmacist has been working with the Chief Medical Officer to introduce key
performance indicators dashboard for each healthcare group for TTA and antibiotic
management. The dashboard will be managed by each healthcare group. This will help
to improve patient experience, patient safety, TTA performance and the management of
antibiotics. Implementation of these KPIs and medicines prescribing training for all
doctors should help reduce TTAs prescribing errors by at least 10% from 72% to 62%.
Production of a register for unlicensed drugs detailing indications for use, dosage,
frequency, course length and approved prescribers
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Improve transfer of medication between healthcare settings and wards to prevent loss,
missed doses and re-dispensing of medication
Continue to update the Trust formulary including assurance that NICE approved drugs
have been included on the formulary
Look at pre-packs for admitting wards and development of policy for implementing
discharge using TTA packs and use of pre-printed prescriptions to speed up discharge of
elective patients.
Improvement in attendance at the MMIC and WEHEMTC to ensure that medication
safety has a higher profile within the organisation and across the whole health economy
Capital, Equipment and IT
The Trust needs to invest in the following:For over a decade the external Quality Control Auditor, East of England has been auditing
the aseptic preparation facility at our Trust. Since their first inspection in 2001, they have
been highlighting that the current facility does not meet the current standards for the
preparation of sterile medicines. The most recent audit assessment of the Technical
Services Unit (TSU) categorised the facility as a ‘major deficiency’. There are significant
risks to staff, patient safety and this has been highlighted on the risk register. In addition the
unit is working significantly over capacity at 110% against a MHRA standard of 70-80%
which increases the risk to patient safety. Following publication of the audit results the lead
specialist pharmacist for quality assurance in East of England recommended to the Chief
Executive that the Trust pursue the building of a new unit as a matter of urgency.
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Upgrade of automated dispensing system and out-of-date equipment especially within
TSU
Improvement in the level of Information Technology (IT) – via either an update of current
facilities or additional support to increase efficiency
Installation of a new pharmacy computer system to improve financial reporting and help
manage the drug budget
To promote temperature monitoring in medication storage areas across the Trust to
ensure medication is stored at the correct temperature and investment is made in
temperature regulation where deficiencies are identified to meet MHRA standards.
To promote electronic medication cupboards across the Trust to comply with the Mazars
medicine management external audit for reconciliation of medication stock at ward level
Review of Pharmacy Service Provision and Performance
An initial review by Chief Pharmacist took place when she started in post 2 years ago. She
identified some significant opportunities to utilise the skills of a full pharmacy workforce to
improve medicines safety and make significant savings in medicines use.
In the summer of 2014 an initial review was commissioned again by Princess Alexandra
Hospital by external consultants to undertake Clinical Workforce review of Allied Health
Professionals. The Pharmacy Department was reviewed as part of that project. Against this
finding the pharmacy report suggested that the Trust needed to review its focus on
medicines management and pharmacy services to look at a comprehensive strategy
73 | P a g e
(including investments in new technology) to support the Trust to deliver its overall strategic
aims.
As part of this approach the current pharmacy workforce should be reviewed to look at the
skill mix to ensure the balance of skills is right to deliver the service strategy. The overall
impact of such an approach would be to support the Trust to make better use of medicines,
resulting in significant savings to the Trust, not just in medicines costs but also in reducing
harm and the potential for readmissions
The pharmacy review will help establish the role of the pharmacy service in implementing
organisational strategic vision. This will include consultation on seven day service and to
ensure we have specialist pharmacists for directorates such as clinical service lead
pharmacists for Intensive Care unit and Women & Family services especially paediatrics
pharmacist as recommended by external oncology peer review.
The following is to be undertaken as part of the pharmacy service review and performance
management:




To undertake a patient and service user satisfaction survey. This will enable the
pharmacy department to review its current service provision and ensure patient and staff
engagement is achieved, leading to implementation of 7 days working.
To increase awareness across the organisation of pharmacy performance and the
impact of other departments on pharmacy workload. This will include the performance
already recorded on the pharmacy dashboard i.e. TTA and outpatient turnaround times,
clinical pharmacy intervention recording and medicine reconciliations undertaken by
pharmacy staff. This data will also be used as evidence to support compliance with CQC
medicines management and patient satisfaction.
To display the pharmacy department’s achievements especially the dashboard targets
on the notice board to all pharmacy staff as a way of appreciating their contribution and
monitoring improvement.
To improve the number of TTA’s turned around within 2 hours by 10%. This will improve
patient experience and reduce medication errors and will be managed by healthcare
groups through the introduction of a TTA dashboard.
As part of sharing good practice nationally the pharmacy department has been accepted
to present at the clinical pharmacy congress in April 2015. This presentation reflects the
introduction of pharmacy bedside TTAs dispensers to improve the timeliness, patient’s
experience and safety of patient discharge.
Pharmacy Transformation Programme
The pharmacy review will help with the implementation of directorate pharmacists to ensure
we have the appropriate knowledge for clinical pharmacy and skills for more detailed
reporting to directorates and for the Trust to manage its resources most effectively.
To implement new pharmacy stock control system that will allow more detailed reporting to
the Directorates and the Trust. This is part of the pharmacy efficiency project as part of the
Trust’s Transformation programme.
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The appropriate transfer of information from existing IT systems to EPR and implementation
of the medicine management module of EPR to ensure electronic prescribing across the
trust is required.
The following areas are part of the pharmacy transformation programme for 2015/16:



Homecare VAT savings to be agreed with the commissioners.
To complete drug usage review as stated in pharmacy transformation project for high
use medicines to reduce wastage and cost effective use of medicines.
Introduction of a TTA dashboard managed by each healthcare group with TTA’s
prescribed at least 24 hours before discharge to speed up discharge and improve
patient’s experience.
Expansion of dispensing for discharge on admission, use of patients own drugs (POD)
and self-administration of medicines (SAM) to cover the rest of the hospital with the
introduction of medicine management matron. This will also allow the development of a
common standard to reduce interruptions during drug rounds to help prevent medication
errors.
When implementing SAM functioning of patient medication bedside lockers will be
checked and a programme of upgrade of medicine cupboards across the Trust to comply
with British standards.
Education and Training
To introduce mandatory medicine management training for all clinical staff to ensure safe
prescribing and administering of medicines to reduce harm to all patients.
All medical and Non-medical prescriber staff that prescribe medication to receive prescribing
training and competency assessment
The Trust does not currently have a formal process for the management of prescribing
errors. This will need to be introduced in conjunction with the Chief Medical Officer to ensure
there is a consistent approach to the management of prescribing errors
Summary
In summary to ensure that these developments occur, the Pharmacy Department will
undergo pharmacy review and will requires a programme of investment in staff and
resources, including information technology to enable the work to be carried out. This has
been evident through the Royal Pharmaceutical Society professional standards for hospital
pharmacy services, TDA medicines optimisation and pharmaceutical services framework
and Workforce Benchmark by South East England Clinical Pharmacy Services.
Incident and Safety Improvement
A patient safety incident or adverse incident is defined as ‘any unintended or unexpected
incident which could have, or did lead to, harm for one or more patients receiving NHS
funded care’. This includes all terms such as adverse incidents, adverse events and near
misses (NPSA).
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For the reporting period 1 April 2014 to 31 March 2015, a total of 8,529 incidents were
reported on the Trust’s Datix incident management system as having occurred in PAH, an
increase in incident reporting compared with 7,414 over the same period last year, with a
decrease in severity of incidents reported. This represents an 11% increase. An increase in
incident reporting is viewed as an indicator of a good and effective safety culture as it allows
the Trust to identify and address any areas requiring improvement.
The majority of incidents reported were no harm incidents (5,802) representing 68% of the
total incidents for this period. Approximately 93% of reported incidents during this period
were a combination of no harm (5,802) or minor harm (2,113).
All these incidents are reported to the National Reporting and Learning System (NRLS) now
part of NHS England to enable learning and comparison with similar sized organisations to
occur.
Serious Incident Themes and Trends
There are currently 140 PAH serious incidents (SIs) on the Department of Health’s Strategic
Executive Information System (StEIS), for the reporting period 1 April 2014 to 31 March
2015. This excludes SIs that have been de-escalated as there were no care or service
delivery problems or were found not to meet the SI threshold with the emergence of further
information.
This is a reduction in numbers compared with 229 SIs in the same period last year although
with similar themes. This is due to an increasing focus on safety by the organisation and the
vigilance of staff.
Although incident reporting has increased overall, seen as a sign of a positive safety culture,
the severity of reported incidents has decreased. It should be noted, however, that direct
comparisons and conclusions across periods should be drawn with caution.
The most frequently reported SIs during this reporting period are pressure ulcers (82), with the
numbers reported including both avoidable and unavoidable events, falls (15) and
suboptimal care of the deteriorating patient (9). There are ongoing safety initiatives focused
on the themes.
Never Events
There were two reported Never Events in 2014-15. These occurred in July 2014 and a
comprehensive Root Cause Analysis (RCA) investigation involving external partners took
place and improvements have and are being made. There have been unannounced and
announced visits by external partners to the unit where it occurred.
Some of the changes made include:




Introduction of new or revised documentation (checklist and notes) and laminated
memory joggers
Introduction of a new induction/orientation pack to support bank and agency staff
Simulation training based to enhance team working among staff.
Embedding ‘Pause for Gauze’ and strengthening use of WHO surgical count
checklist
All identified actions on both reports have been completed and audits of continue.
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Sharing the Learning (STL) Events
The Trust’s central Patient Safety & Quality Team working with relevant experts have held
three successful STL events during the reporting year.



Focus on Being open and Duty of Candour (28 April to 2 May 2014)
Focus on Medication safety (15 to 19 September 2014)
Focus on Safeguarding vulnerable people (9 to 13 February 2015)
The Focus on Being open and Duty of Candour STL event opened with an official launch on
Monday 28 April 2014 by the Chief Nurse, Professor Nancy Fontaine. The launch was well
attended by staff and there were a series of presentations and road shows by the Quality &
safety team over the course of the week. A total of 208 staff members attended the Duty of
Candour / Sharing the Learning event
The Duty of Candour posters designed and printed by the central PSQ Team can be seen
placed in different areas across the Trust, reinforcing the Trust’s commitment to
transparency and candour.
The second event, STL Focus on Medication Safety took place from 15 to 19 September
2014. There were presentations and workshops that reviewed error causation, sample errors
and other areas of medication safety. This will be added to the planner and repeated in the
future.
The final STL event for the year focused on Safeguarding Vulnerable individuals. The wellattended event provided staff with opportunities to review recent SIs and share learning from
them with a view to preventing any recurrence.
Being Open and Root Cause Analysis (RCA) Investigation Skills Training
The Trust identified the need to increase the numbers of staff trained and skilled in
conducting RCA investigations as well as ensuring that staff are supported in having Being
Open/ Duty of Candour conversations with patients and families when things go wrong. For
Being Open sessions, in addition to the six previously held in January and February 2014
(with 64 staff trained), further Gold and Senior Clinical Counsellor Sessions took place
between October and December 2014 bringing the total number of staff trained to 110. Two
further RCA sessions took place in September and November 2014 bringing total staff
trained to 79 (40 previously). Feedback received from staff for these sessions were positive.
Safety Culture
A baseline assessment of Safety Culture took place from December 2013 to January 2014.
A repeat survey took place from February to May 2015. Analysis of findings is in progress
and the report and recommendations due to be finalised in June 2015 will contribute to
establishing forthcoming improvements in safety.
Next Steps
As part of its recently-launched Quality Improvement Strategy, (see page 5), the Trust will
commit to holding at least two Sharing the Learning events in 2015-16. There will be an
increased focus on improving medication error reporting as this has been identified as an
area requiring further efforts so we can accurately benchmark with our peers. In addition, the
Trust will roll out its new Governance Software to help with monitoring the Care Quality
77 | P a g e
Commission’s Fundamental Standards, NICE guidance and Quality Standards as well as
Risk Management. The detailed list of priorities for quality improvement is in the relevant
section of the Quality Account.
Falls
Measures identified below have been put into place to maximise patient safety, improve
patient care and to reduce the overall number of falls. Patients who have fallen while in
hospital and are considered high-risk are entered onto the Safeguarding Situation Report.









A full-time Falls Prevention Lead (FPL) has been in post during 2014-2015
Most wards have purchased their own falls prevention equipment, for example
bed/chair sensors, crash mats and non-slip socks from their budget. The Trust has
purchased an additional 10 low rise beds (MMO) which are suitable for use with Duo
II pressure mattresses
There was a successful study day for all ward Falls Champions in October 2014
facilitated by the FPL. All Champions are being supported to lead on falls prevention
on their ward
All patients who have fallen are reviewed by a Matron and wherever possible by the
FPL who will ensure that correct procedures have been followed and remedial
actions put into place. Falls teaching continues for the Health Care Support Worker
Programme, Clinical Update, Preceptorship and FY1 induction
The FPL continues to network with fellow falls leads across Essex and Hertfordshire.
Topics include scoping of services, networking and Sharing the Learning
The Falls Project Group continues to meet monthly, where issues, concerns or trends
around inpatient falls are discussed and action plans are agreed. The Falls Project
Group’s Terms of Reference have been reviewed and updated. A Falls Prevention
Leaflet for patients and/or their carers has received final corporate approval and is
now available for printing and dissemination
A review of the Datix recording process has taken place between the FPL and
Patient Safety and Quality team. The Datix recording form for falls has now been
simplified to encourage a more accurate coding of the incident
Falls with moderate harm as well as serious harm are being discussed at Scrutiny
Panel
A Close Observation Pool was established: this pool comprises regular NHS
Professionals staff who have undergone further training, including dementia, learning
disabilities and falls. The aim (during the pilot trial) is that they will work on Friday,
Saturday and Sunday nights and will be allocated to work only with patients who
require close observation
Further work needs to be done to address the following issues:


There are still some wards hiring equipment on a needs-only basis
An audit of compliance with falls risk assessment tools has taken place during
Clinical Friday. The results show particular inconsistencies in the completion of the
falls care plan. The correct use of these assessment forms is now included during
Preceptorship training and one-to-one sessions on the ward. Unfortunately, the falls
project group is struggling with attendance numbers, especially at a senior nursing
level
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
The Close Observation Pool was not as successful as initially planned
Below are the areas where we will be focusing our energies during 2015-2016 in order to
consolidate the successes we have had so far in reducing fall numbers:









Falls and bed rails risk assessments are to be included on COSMIC. This will ensure
that they are readily available and form part of the patient’s electronic record
The Trust’s Slips, Trips and Falls Policy has been updated and presented to the
Trust Policies Committee for ratification .
The Manual Handling Lead is working with the FPL and the Chairman of the Falls
Project Group to design a business case for the purchase of recliner chairs for all
wards, due to the high cost of hiring this equipment
PS&Q team are looking at ways of ensuring that any learning from these incidents is
shared across the Trust
There are plans for regular Vulnerable Adults Study Days which will include training
updates on falls prevention.
Re-launch of Close Observation Pool.
Further work to be undertaken with the Falls Champions including clinical support
and development.
Continued promotion of increased incident reporting
Recruitment of a new Falls Prevention Lead following the departure of the current
lead in January 2015.
The Trust needs to develop a more robust method of ensuring that lessons learned from
incidents is widely shared and embedded across all areas of the Trust. The PS&Q team
have been tasked to develop a robust method of disseminating learning.
The first of the newly devised Vulnerable Patients study days (which will include falls
prevention) will be held during 2015/16 as part of the Trust’s review of all mandatory and
statutory training requirements. All clinical staff will be required to attend this session on a
three yearly basis.
The Close Observation Pool, which is made up of a small group of NHS Professionals, will
be re-launched during 2015. Their role is, following training in falls, epilepsy etc., to provide
close observation to patients who need it. The initial pilot launch identified issues to be
resolved and these will be included when the project is re-launched. Use of the close
observation pool will improve the quality of care given to patients who require close
observation.
Increased incident reporting rates are vital if the Trust is to be able to properly review all falls
related incidents and identify thematic areas for improvements. Although the rate of incident
reporting has increased more work needs to be undertaken by the falls prevention lead and
all unit matrons.
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Table 3 – Falls by Severity at PAH
Date
No
harm
Minor
Moderate
Severe
Death
Total
Apr 2014
36
35
1
2
0
74
May 2014
36
53
1
0
0
90
June 2014
45
43
1
1
0
90
Jul 2014
63
37
2
0
0
102
Aug 2014
50
19
1
1
0
71
Sept 2014
45
25
2
1
0
73
Oct 2014
50
32
2
0
0
84
Nov 2014
60
32
4
0
0
96
Dec 2014
60
37
0
0
0
97
Jan 2015
68
51
2
0
1
122
Feb 2015
62
45
1
0
0
108
March
58
27
6
1
0
92
Total falls
1,099
Scrutiny panel decision on falls
April 2014 – January 2015
4
14
Panel decision
Avoidable
Unavoidable
Two further falls are currently waiting to be discussed at scrutiny panel
Total falls
Death
2014-15
2013-14
1*
0
Severe
6
1
Moderate
23
27
Minor
436
552
No
harm
634
451
Total
1100
1031
* A post-mortem report is outstanding. It is not yet clear if this death is directly attributable to
the fall.
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Pressure ulcers
The goal for 2015-2016 continues to be zero-tolerance of hospital-acquired, avoidable
pressure ulcers. Staff within the Trust have continued to work tirelessly to ensure a clear
downward trend in the number of hospital acquired, avoidable, pressure ulcers, grade 2, 3
and 4 in 2014-15. See Figure 1.
Figure 1
April 2014 to March 2015 avoidable/unavoidable for Trust
Avoidable
Unavoidable
18
Linear
(Avoidable)
16
14
12
10
8
6
4
2
0
Apr 2014
May 2014
Jun 2014
Jul 2014
Aug 2014
Sep 2014
Oct 2014
Nov 2014
Dec 2014
Jan 2015
Feb 2015
Mar 2015
Please note that not all the pressure ulcers for March 15 have been presented at Scrutiny
Panel. There have been no grade 4 pressure ulcers since November 2013. There have
been no avoidable grade 4 pressure ulcers since October 2013.
The total numbers of hospital acquired pressure ulcers for 2014/15 are shown in figure 2
81 | P a g e
Figure 2.
Pressure Ulcers by reported date and grade April 2014 to March 2015
April 2014
10
Hospital
Acquired GRADE
3
8
May 2014
14
4
18
June 2014
7
2
9
July 2014
9
7
16
August 2014
7
2
9
September
2014
8
10
18
October 2014
8
6
14
November 2014
1
7
8
December 2014
10
12
22
January 2015
11
13
24
February 2015
10
2
12
March 2015
4
16
20
Totals:
99
89
188
Hospital Acquired
GRADE 2
Total
18
The total number of pressure ulcers declared as ‘hospital-acquired’ was 188 in 2014-15
which is 23% lower than 245 in the year 2013-14. In addition the severity continues to
reduce; there have been no grade 4’s and most of the grade 3 pressure ulcers are small
areas of ‘deep tissue injury’ (DTI) and many of these fade or are reabsorbed with no break in
the integrity of the skin.
From January 2015 the Tissue Viability Specialist Nurses (TVNs) have been keeping data
about grade 3, DTI, pressure ulcers and will follow up these patients until the patient is
discharged. They will de-escalate any of those declared as grade 3 which do not develop
into true pressure ulcers. It is the view of the TVNs that the grading tool introduced in 2012
by the Midlands and East Strategic Health Authority (SHA), and still in place today, results in
serious over-reporting of grade 3s. In our opinion these sometimes tiny areas of deep tissue
injury are not serious incidents in the same way that a grade 3 pressure ulcer with full
thickness and dermal loss, is.
The percentage of pressure ulcers deemed ‘avoidable’ following scrutiny panel is currently
28% and the number of ‘unavoidable’ is 72%. The explicit aim of the Trust remains to
eliminate avoidable pressure ulcers.
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The two part time Tissue Viability Specialist Nurses have presented posters on the
improvements and success in reducing avoidable pressure ulcers by 70% over 24 months
(2013-2014) at both the prestigious ‘Patient Safety Congress’ and at a ‘Wounds UK’
conference. They have also been co-authors of a second paper ‘Avoidable pressure ulcer
rates in six acute Trusts’ (Downie et al, 2014), and a follow-up paper to ‘Are 95% of hospital
acquired pressure ulcers avoidable?’ (Downie et al, 2013)
The TVNs led a study day, in October 2014, for community nurses working in nursing
homes, community practices, the private sector and community hospitals. It was wellevaluated by those attending although turnout was lower than hoped.
What’s next?
In the coming year, the Nutrition Nurse and TVNs will lead the Agents for Nutrition and
Tissue Viability (ANTs) training programme with a further two cohorts each of both registered
nurses and healthcare support workers, thereby helping to provide specialist cover on each
shift and on every ward.
The ANT programme continues to develop according to clinical and educational needs. For
example in 2014, Stoma Care and Continence Care Clinical Nurse Specialists were invited
to give teaching sessions for each cohort.
In 2015 the TVNs will continue to work collaboratively with community colleagues to help
educate on the ways of preventing pressure ulcers, as well as to standardise care across the
locality.
Stroke Services
During 2014-15 the Princess Alexandra Hospital has seen and treated around 389 stroke
patients predominantly in its acute stroke unit, staffed by a team of specialist therapists and
nurses. We carried out brain imaging on the vast majority of these patients and
administered thrombolysis (clot busting drug) to 35 of them. In January 2015 a new Early
Supported Discharge service in Hertfordshire was launched which our team at Princess
Alexandra Hospital have been utilising to facilitate safe discharges home. In the clinical
audit results published this month as part of the Stroke Sentinel National Audit Programme,
Princess Alexandra Hospital demonstrated excellent performance in the area of speech and
language therapy, scoring in category A.
However, in other areas performance has been poor, shown in our monthly reports on key
metrics such as direct admission to stroke unit within four hours. There has been recent
recruitment to a few key posts within the stroke service and these individuals are now
working hard with the team and the rest of the hospital to drive forward improvement in these
areas. There is a recovery plan in place with a focus on improving performance.
Alongside this a stroke review in the East of England has identified that continue provision of
hyperacute stroke services (including thrombolysis) is unlikely to be sustainable due to the
relatively low number of patients and staffing required to provide the service. We have been
working alongside commissioners in West Essex (West Essex CCG) and East Hertfordshire
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(East & North Herts CCG) to investigate different models of care for the benefit of patients.
Once the proposals are further developed there will be full patient engagement prior to
implementation.
Family and Women’s Services
In 2014 the Trust was successful again in winning a Department of Health bid for £266,000
to improve the environment for women and their families. Three clinical rooms that had been
used for offices over a number of years were converted back into modern and improved
clinical rooms with ensuite facilities in each room.
Three other single rooms were upgraded and modernised with one offering ensuite facilities
too. The two bathrooms on the postnatal ward were upgraded and modernised with showers
and a bath. The Bereavement Room has become a bereavement suite with upgraded,
comfortable seating.
The number of births at PAHT continued to see services stretched to maximum capacity.
The highest number of births in any one month was 421 in October 2014. In January 2015
24.1% of all PAH births were in the Birthing Unit, making it the most successful month since
it opened.
In January 2014, the Trust appointed two Obstetrics and Gynaecology Consultants, one of
whom is a Foetal Medicine Consultant, allowing the department to undertake their own
amniocentesis and Chorionic Villi Sampling (CVS) for any antenatal women wishing to find
out if their baby has a chromosomal condition, such as Down syndrome.
Following the successful recruitment of sonographers, the maternity department was able to
bring back in-house all first trimester screening. This was a really positive step for the Trust,
resulting in a higher quality service, with better follow-through care for women enabling them
to see a substantive member of staff with in-depth knowledge of the Trust.
Midwifery recruitment remained a focus throughout this year too. All of the Trust’s ten
student midwives signed permanent contracts upon qualification. There have also been two
successful recruitment days, as well as a recruitment visit to Ireland which resulted in our
being able to maintain our midwife to birth ratio at 1:31. Further active recruitment by the
Women and Family Health Group is planned to sustain this 1:31 ratio and work will also be
done to recruit to neonatal and paediatric nurses.
The new Paediatric Emergency Department opened in September. This is a new modern
department with separate entrance and dedicated space. We have also appointed a new
Paediatric Consultant who will be supporting neonates. Two additional Paediatric
Consultants were appointed before year-end.
There were two never events within the department in the past year. These were followed
by various unannounced visits between July and December 2014 by the CQC.
In
December 2014 there was a joint quality assurance visit attended by representatives from
West Essex and East and North Herts CCGs’ Quality teams. The visit comprised a tabletop review of actions in place following the two never events, and an associated visit to the
clinical service area.
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The visit report concluded that there was overall a strong impression of multi-disciplinary
teams working together to improve services, and of taking ownership of the lessons
identified in the investigations from the Never Events.
There was a clear link between the positive work described in the panel review and the
feedback reported directly from the Clinical area review and discussion with mothers and
staff which provided assurance regarding lessons learned and changes in practice being
embedded.
Safeguarding Adults
In 2014/2015 the Safeguarding Adults Lead Nurse worked hard to continue to raise the
profile and agenda of Safeguarding Adults.
Key areas of improvement over the last year are:











A continued increase in completion of mental capacity assessments for adult
patients; this can be contributed to increased awareness and training across the
organisation
The Trust has seen an increase in the Deprivation of Liberty Safeguards (DoLS)
applications (table 1), primarily due to increased awareness in this area, specifically
since the Supreme Court ruling in March 2014
The continued collaborative approach to delivering level 1 training for adults and
children safeguarding in partnership across the team
Continued partnership working with the supervisory body for DoLS to ensure the
Trust meets the requirements for applications
Level 2 training delivered to the Trust Board on safeguarding adults and children
Successful consolidation of the ‘DAISY’ project for the Emergency Department
introduced in November 2013, to support disclosure of domestic abuse and provide
an on-going plan of care
NICE guidance in relation to domestic abuse was issued in February 2014. Owing to
the introduction of the DAISY project and Safer Places, the Trust is virtually
compliant on all the relevant criteria within this guidance. The only outstanding area
is to demonstrate working in partnership to support the perpetrators of abuse, which
does not sit within the gift of the Trust
Development of a joint adult and children’s safeguarding post introduced in August
2014 to support both Lead Nurses and have a sustainable solution long term
The Trust is now represented at all regional and local fora for safeguarding adults.
Receiving adequate assurance for safeguarding children and adults following internal
audit in 2013
Since the Launch of EPR, all safeguarding adult cases are flagged as vulnerable,
with advice of whom to contact for more information
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2011/2012
2012/2013
2013/2014
2014/2015
Number of DOLS completed
21
38
83
197
Number of SetSaf completed by
PAH
104
107
99
120
Number of SetSaf against PAH
21
15
23
28
Number of MCA’s completed
75
183
198
159
Percentage of Level 1 Adult
Safeguarding Training completed
61%
87%
95%
93%
Safeguarding Adults activity
Since the Supreme Court ruling DOLS applications have increased nationally and this is
reflected in the in figure 2 on page 86.
Figure 2
Applications of Deprivations of Liberty Safeguards 2014
Year
Jan
Fe
b
Mar
Apri
l
May
Jun
e
Jul
y
Aug
2013
2014
1
9
6
7
4
4
4
11
8
12
7
21
5
22
8
13
Sept
13
14
Oc
t
No
v
De
c
5
19
6
21
7
16
Prior to the ruling there was a clear process for all applications and staff were engaged with
this, which has meant we have been in a positive position compared to other acute Trusts
who have had difficulty in engaging/ and developing clinical staff in making applications.
This process remains in place for Trust staff to follow and will be reviewed once guidance is
given from the National Task and Finish Group.
Future plans





The PREVENT agenda has been initiated and the training cascade has been
planned. Currently, the Trust has five trained PREVENT facilitators. The Trust policy
was ratified at the beginning of February 2015. Training has now begun to be rolled
out across the Trust as part of the statutory-mandatory training programme
Continue with the DAISY project for domestic abuse and from April 2015 all staff will
receive training as part of their mandatory training.
Pilot key areas within the Trust on DoLS process to raise the agenda and increase
staff knowledge in this area as it is likely more of our patients will meet this criteria
since the Supreme Court ruling.
Review the Trust process once Guidance is given from the National Task and Finish
Group.
“Sharing The Learning Event on Safeguarding Adults and Children” to identify key
themes on Safeguarding within the Trust , and raise the profile on the Safeguarding
Agenda
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Safeguarding Children
The key areas of improvement that we have seen in 2014-2015 include: The Safeguarding
Children team continue to raise the profile of safeguarding children across the Trust. In
2014, the uptake for Safeguarding Children Level 1 training continued to achieve the target
of 95% as set by the WECCG in every month, apart from August and December 2014 where
there were high levels of annual leave and considerable clinical pressures within the Trust
(Figure 1).
Figure 1: Safeguarding Children Level 1 Training 2014 - 15
96%
96%
96%
96%
96%
95%
94%
94%
94%
94%
94%
The uptake for Level 2 training is variable from month to month with compliance between 91
and 95% (Figure 2).
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Figure 2: Safeguarding Children Level 2 Training 2014 - 15
95%
95%
95%
94%
92%
91%
92%
92%
92%
92%
92%
91%
In June 2014 the decision was made to widen the inclusion of practitioners who required
Level 3 training. This added an additional 94 members of staff who required Level 3 training,
thereby lowering the Trust’s compliance level to 79%. The Safeguarding Children Team
implemented further Level 3 training sessions and are currently achieving between 91 and
95% compliance (Figure 3).
Figure 3: Safeguarding Children Level 3 Training 2014 - 15
89%
93%
90%
91%
95%
95%
93%
91%
92%
92%
86%
79%
There continues to be a significant number of cases brought to the attention of the
Safeguarding Children team for overview and information sharing. The month of May 2014
was the team’s most demanding with 120 consultations being raised
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Figure 4: Safeguarding Children Consultations 2014 - 14
120
115
106
87
92
77
71
68
60
50
47
25
The Trust is required to undertake child protection medical examinations within 24 hours of
the request by either social care or the child abuse investigation team within Essex police. In
100% of the cases, the Trust has been able to achieve this. The number of child protection
medical examinations continues to fluctuate from month to month with a significant peak in
September 2014 of 11 medical examinations (Figure 5). The Trust is also required to provide
the referrer with a comprehensive child protection medical report within 72 hours of
undertaking the medical examination. There was a serious incident raised in July 2014
where this did not happen in three cases. This was addressed as part of the Trust’s incident
reporting mechanisms and an action plan was initiated. Since July 2014, the Trust continues
to be compliant with submitting a medical report within 72 hours.
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Figure 5: Child Protection Medical Examinations 2014 - 15
11
7
5
5
5
4
3
1
3
3
1
0
The number of referrals to social care continue to be relatively low (Figure 6). However,
given the number of safeguarding consultations that are undertaken (Figure 4) the
Safeguarding Children team can provide assurance that appropriate cases are being
referred to social care.
Figure 6: Safeguarding Referrals to Social Care 2014 - 15
15
11
6
6
6
5
4
3
3
2
2
2
90 | P a g e
Since the launch of COSMIC, all children who are subject to a child protection plan are
flagged.
The Trust is represented by the Safeguarding Children’s team at the Partner Agency Review
Group, Local Operational Group Meeting, Multi Agency Risk Assessment Conference, Stay
Safe and the Children’s Partnership Group.
The coming year





The Trust is currently unable to deliver adequate safeguarding children supervision
across the organisation due to a lack of suitably-qualified staff to facilitate the
supervision sessions. The Trust is working closely with the CCG to secure places on
an appropriate course for key members of staff. Additionally, the designated nurse for
WECCG is supporting the named professionals in providing safeguarding supervision
across the Trust.
A ‘Sharing the Learning’ event on safeguarding adults and children will take place in
February 2015 to raise the profile of safeguarding within the Trust.
The Trust has re-designed how its mandatory training will be delivered across the
Trust. The impact on safeguarding children is that the face- to-face sessions will now
be delivered three times a year rather than just annually. The duration of the taught
sessions will be increased in line with 2014 intercollegiate guidance for safeguarding
children.
There has been a significant number of serious incidents in relation to safeguarding
children over the past 12 months. The Safeguarding Children team has developed an
integrated action plan to address the issues raised and the Trust is working towards
compliance on all of the action points.
The Named Nurse for Safeguarding Children will be leaving the post in April 2015. A
succession plan has been developed with the Chief Nurse to ensure continuity of the
service until a substantive post holder can be recruited.
Pain Recording
The Acute Pain Team is committed to the delivery of adequate and timely pain relief to
patients and believes that this is an essential component of good quality care. All patients
have the right to care that promotes comfort and minimises pain.
The standardised pain score implemented in 2014 is now on the National Early Warning
Score (NEWS) observation chart and at the time of launch teaching in the assessment of
patients with pain using this pain scale was undertaken on all wards.
The patient leaflets / sheets are out for peer review with an expectation that they will be in
Same Day Admissions Unit for patients to read prior to their surgery.
Together with the Royal College of Nursing the Acute Pain Sister has developed three
leaflets regarding pain for those patients who have learning difficulties or dementia. These
leaflets will be launched at the RCN Congress in Bournemouth, June 2015.
91 | P a g e
The main aim for of the Acute Pain team in the coming year is to improve the overall
management of acute pain across the Trust and to reduce incidents, poor patient feedback
and complaints.
The main improvement we will be undertaking in 2015-16 will be an increase in service
provision, with the recruitment of a second Acute Pain Nurse. Working a six day week will
enable Friday elective patients to be reviewed and by extending our hours, an afternoon pain
round will be undertaken. We will also be offering training sessions on a regular basis to
improve and enhance the skill and knowledge of frontline clinical staff in undertaking regular
pain assessment and implementing appropriate pain-relieving strategies. To ensure that this
training is available to all staff, an online teaching pack is currently under development.
All policies and guidelines regarding pain management will be reviewed during 2015-16 and
where necessary we will develop new policies and guidelines, along with relevant
competencies.
The Acute Pain Champion initiative will be reviewed and re-launched during 2015-16 with
the intention of having a ‘Champion’ in every clinical area.
The Acute Pain Team will continue to benchmark with local and comparable organisations
nationally.
Volunteers
Over the last year we have strived to ensure we recognise our volunteer’s contributions to
the Trust and that we demonstrate good practice with regards to involving volunteers and
any voluntary services which are based within the Trust.
A formal volunteer recruitment process has been put in place which includes informal
interviews, references, and DBS checks. We have also developed a Volunteer Induction
Training session which currently takes place every two months. The training session covers
manual handling, fire awareness, infection control, safeguarding adults & children and
information governance. We have also recently included a section on the Trust Values,
Standards and Behaviours.
A volunteer-friendly atmosphere has been created by recruiting a Voluntary Services
Manager which allows volunteers to have a nominated person to deal with any queries or
issues, or just to make sure things are running smoothly.
New voluntary roles have been developed based on volunteers’ skills and the needs of
individual departments. This has led to volunteers being recruited in areas that have been
unable to utilise volunteers for quite some time, including Maternity, and Dolphin Ward. The
number of volunteers in the Trust has now reached approximately 130 with a constant
stream of applications coming in.
We are looking forward to further developing the role of volunteers throughout the coming
year. We have identified a need for Emergency Department fast response volunteers and
are aiming to work alongside the Patient Panel to ensure best practice with regards to
recruiting volunteers for this role. We aim to recruit a team of locally based volunteers who
92 | P a g e
will be fully trained and contactable in an emergency situation to support waiting patients and
staff in the Emergency Department.
We have also been encouraged by the success of our mealtime buddy scheme which
utilises trained volunteers to support patients during mealtimes. Most of our current mealtime
buddies are members of staff who volunteer during their lunch time or after work but we are
now recruiting externally for the role. Our first training session for external volunteers took
place at the beginning of January and we are hoping to deliver this every two months.
We have recruited a fully trained dementia volunteer who is proving to be invaluable and she
has a wealth of knowledge due to her own experiences as a carer. We are hoping to
increase our recruitment of dementia volunteers over the next year so that we are able to
provide an extra dimension of support for our patients with dementia.
This year, we have introduced a Volunteer Award as part of the Trust’s Achieving Excellence
Awards for staff. This will be given to recognise the outstanding contribution of volunteers
within the Trust. We hope to continue moving onwards and upwards with our volunteers and
are extremely grateful for all they do to support patients and staff at PAH.
93 | P a g e
Statement of Director’s Responsibilities in
Respect of the Quality Accounts
The directors are required under the Health Act 2009, National Health Service (Quality
Accounts) Regulations 2010 and National Health Service (Quality Account) Amendment
Regulation 2011 to prepare Quality Accounts for each financial year.
The Department of Health has issued guidance on the form and content or annual Quality
Accounts which incorporates the above legal requirements.
In preparing the Quality Accounts, directors are required to take steps to satisfy themselves
that:




The Quality Accounts presents a balanced picture of the Trust’s performance over
the reporting period.
The performance information reported in the Quality Accounts is reliable and
accurate.
There are proper internal controls over the collection and reporting of the measures
of performance included in the Quality Accounts, 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
Accounts are robust and reliable, conform to specified data quality standards and
prescribed definitions, is subject to appropriate scrutiny and review. The Quality
Accounts have been prepared in accordance with Department of Health guidance.
The directors confirm that, to the best of their knowledge and belief, they have complied with
the above requirements in preparing the Quality Accounts.
By order of the Board
Douglas Smallwood
Chairman
Phil Morley
CEO
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Statements from Stakeholders
East and North Herts Clinical Commissioning Group’s Response to the Quality
Account provided by Princess Alexandra Hospital NHS Trust
East and North Herts CCG (ENHCCG) has reviewed the information provided by
Princess Alexandra Hospital NHS Trust (PAH) and we believe this is a true reflection
of the Trust’s performance during 2014/15, based on the data submitted during the
year as part of the on-going quality monitoring process.
During 2014/15 ENHCCG has met regularly with both the host commissioner, West
Essex CCG (WECCG), and PAH to review progress in relation to quality
improvement initiatives.
The Trust has clearly identified within its Quality Account where progress has been
made and where further improvements are still needed.
Firstly ENHCCG would like to acknowledge the Trust’s performance in relation to
infection prevention and control, ending the year equalling the challenging nationally
set ceiling of 16 cases of c-difficile. ENHCCG also acknowledges the positive
improvement in the number of incidents reported by the Trust, demonstrating an
open safety culture.
Whilst ENHCCG recognises the Trust’s focus in relation to patient experience and
engagement, and improvement in the cancer patient experience survey results, the
2014 national inpatient survey results are disappointing with deterioration in a
number of key questions. Significant focus is required to improve the experience of
patients during 2015/16.
During 20141/5 PAH has failed to achieve a number of key performance metrics
relating to A&E and stroke services. The CCG acknowledges the actions being taken
to make the required improvements in these areas, and on-going progress will
continue to be monitored closely. Performance in national cancer metrics has been
disappointing during 2014/15, however ENHCCG notes the improved performance in
April 2015.
In July 2014 PAH introduced a new Electronic Patient Record system and this has
identified a number of data quality and process issues within the Trust, as well as
causing significant disruption to Trust reporting. ENHCCG notes the work being
undertaken to resolve these issues, and the Trust’s focus on Information,
Communication and Technology for the coming year.
The Trust’s 2015/16 Quality Priorities demonstrate the commitment to further
improve the quality of care provided to patients and improve staff experience.
ENHCCG is also pleased to see the on-going focus on eliminating avoidable
pressure ulcers and reducing falls during 2015/16.
Overall we acknowledge the improvements made during 2014/15; however
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ENHCCG wishes to see significant focus and drive to ensure on-going
improvements in the quality of services delivered to patients, particularly in relation to
stroke services and patient experience.
ENCCG looks forward to working with and supporting PAH in further developing and
monitoring the quality of services it provides for patients. We hope the Trust finds
these comments helpful and we look forward to continuous improvement in 2015/16.
Lesley Watts
Chief Executive
East & North Herts CCG
May 2015
2014/15
Statement of Endorsement, West Essex Clinical Commissioning Group
As host commissioners for The Princess Alexandra NHS Trust (PAH) we would like to thank
you for sharing the Quality Account. We have been involved in reviewing the content of the
Account, and feel that it accurately reflects the quality, safety and effectiveness of services
provided in the last year.
The Trusts active engagement with patients and their families has resulted in developments
to services and a reduced numbers of complaints.
The Trust has a positive safety culture; this is demonstrated by the increased number of
reported clinical incidents. This demonstrates staffs willingness to report incidents and that
the Trust investigates in order to learn and reduce risk for the future.
We would like to take this opportunity to commend the Trust on its commitment to
continuously improving quality by using the feedback from patients to support staff through
the values, standards and behaviours programme. This in turn has benefitted patients,
families and carers.
The Trust has continued to develop services and responded tirelessly to patients needs
through some difficult periods.
The Quality Accounts for 2014/15 demonstrate the progress the Trust has made during the
past year. The Trust’s continues to focus on providing hospital care that is; respectful,
caring, responsible and committed. This is positive for patients and staff alike.
The priorities and performance illustrated within the Account for this year and last year
accurately reflect and support both national and local priorities. West Essex Clinical
Commissioning Group is pleased to endorse and support the publication of this Account.
Jane Kinniburgh
Director of Nursing & Quality
West Essex Clinical Commissioning
96 | P a g e
Statement from Healthwatch Essex
Healthwatch Essex is an independent organisation with a vision to be a voice for the people
of Essex, helping to shape and improve local health and social care services. We believe
that people who use health and social care services and their lived experience should be at
the heart of the NHS and social care services.
We recognise that Quality Account reports are an important way for local NHS services to
report on what services are working well, as well as where there may be scope for
improvements. The quality of services is measured by looking at patient safety, the
effectiveness of treatments that patients receive and patient experience of care. We
welcome the opportunity to provide a critical, but constructive, perspective on the Quality
Accounts for PAH, and we will comment where we believe we have evidence – grounded in
people’s voice and lived experience – that is relevant to the quality of services delivered by
PAH.
In the Quality Account, PAH recognises that it has been difficult and busy year for the
services it offers. However, the Trust has also begun to experience financial difficulties in
2014-15 – a fact which it has in common with many other acute Trusts. This coincides with
other common factors that are placing an additional burden on the Trust’s resources, such
as bed capacity and high demand for services. It is important to remain vigilant to the impact
this could have on patient and carer experience at PAH.
The Trust has a Patient Panel which ensures that the patient voice is heard in all areas of
the hospital, and has an active and dynamic patient experience team. The Trust’s Friends
and Family Tests show an above average performance around patient experience. However,
there is inconsistency with regards to other indicators of patient experience. For example, in
the CQC national inpatient survey, PAH scored average compared to other Trusts except for
the sections on waiting to get a bed on a ward, doctors and leaving hospital, which they
scored worse. PAH has recorded a score in the lowest 20% on 6 questions relating to
leaving hospital, and 2 on doctors, 1 on being admitted and 1 on information about condition
and treatment. In the National Cancer patient experience survey, a total of 86% of patients
who responded rated their care as excellent or very good. The results overall represent an
improvement for the Trust over the last two years. In addition, the Achieving Excellence
Patient Experience Programme has reduced the number of complaints, as well as
significantly increasing the number of compliments.
In the Account, PAH outlines the actions being taken to help further improve the experience
of patients. These actions include plans to improve the information patients receive about
performance, improve the Patient Experience survey results against 2014-15, and a more
timely response to complaints handling. Healthwatch Essex supports the Trust in these
endeavours, but would encourage the Trust to think about how other methods can be used
to capture qualitative insights of people’s lived experiences of care, and to use this to
continue to drive improvement. We are pleased to be working with PAH on a major research
project looking at the lived experience of hospital discharge, for example.
Healthwatch Essex believes that lived experience should be at the heart of services, and
believes that listening to the voice and lived experience of patients, service users, carers,
and the wider community, is a vital component of providing good quality care. We will
continue to support the work of PAH in this regard.
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Statement on Quality Accounts from Patient Panel
The Princess Alexandra Hospital Trust - Patient Panel welcomes the opportunity to provide
this statement on PAHT’s Quality Accounts.
We confirm that we have reviewed the information contained within the Account and in our
opinion it is accurate in relation to the services provided.
We believe that the Account represent a fair, representative and balanced overview of the
quality of care at PAHT.
The Patient Panel acknowledges the huge amount of work that is reflected in this document,
the Patient Panel has found The Princess Alexandra Hospital Trust willing to engage, listen
and respond positively to recommendations from the Panel during the year.
We have taken particular interest of the identified priorities for improvement and how this
work will enable real focus on improving the quality and safety of health services for the
community served.
The Patient Panel will be committed to working with the Trust to ensure a focus is kept on
areas that are important to patients and will monitor the Trusts quality improvements
throughout 2015/16.
The Patient Panel will continue to monitor the care people receive at end of life; discharge
process and timescales and the complaints procedures
The Quality Accounts 2014-15 have been reviewed at the Patient Panel monthly meeting in
May. It was recorded in the minutes that all members in attendance agreed with the above
statement.
Chair,
Patient Panel
Healthwatch Hertfordshire’s response to Princess Alexandra Hospital NHS Trust
(PAHT) Quality Account 2015
Healthwatch Hertfordshire thanks PAHT for the opportunity to comment on their Quality
Account. This is a detailed report of the quality performance of the Trust and the plans for
2015/2016. Priorities for the coming year and the impact of last year’s priorities are clearly
set out. Some elements of the 2014/2015 priorities are carried forward for further
development.
We are pleased to see that improvements to the care received by people living with
dementia and enhancing the care people receive at the end-of-life are continuing. The recent
Health Ombudsman’s report has highlighted concerns over the poor provision for end-of-life
98 | P a g e
care so it is good to see that the work completed last year has meant that PAH is achieving
patients’ wishes on their preferred place of death in most cases.
Much has been achieved for patients living with dementia but the trust recognises there is
more to do. PAHT has made good progress with staff training and involving community and
voluntary organisations to achieve a more dementia friendly hospital. Plans to increase the
amount of surveys completed by carers is welcomed.
The Patient Panel at PAHT is ensuring that the patient voice is included and valued when
changes are taking place at the hospital; it highlights areas for improvement and supports
the hospital in practical ways. As a significant amount of patients from east Hertfordshire use
PAHT services, Healthwatch Hertfordshire would welcome a more regular dialogue with
senior personnel to raise any concerns and give feedback on work that we are undertaking.
However we were pleased to participate in the Patient Led Assessment of the Care
Environment (PLACE) for the first time this year.
PAHT has obviously had to cope (like many hospitals) with an increase in demand on its
services. It has experienced ‘one of the busiest Emergency Departments in England’, ‘far
more births’, ‘more cancer care’ for example but it has implemented some new systems such
as the new Surgical Assessment Unit, dedicated GP assessment and Ambulatory Care
environment (opened in March 2015) to increase capacity and improve the patient
experience. We look forward to seeing the impact of these initiatives.
Staffing levels in some wards are an issue. There is also a shortage of IT specialists which
could impact on the safety of documents and images and the roll out of the ‘paperless’
hospital. We also note that PAHT is due for a Care Quality Commission (CQC) inspection in
July 2015 and that the trust has dropped into the CQC Band 2 rating (higher risk).
The Trust should be congratulated for their medical advances work that they have
showcased at an international exhibition and the introduction of other major technological
advances for the treatment of cancers. Encouraging patients to take part in clinical trials and
research has also been successful.
Healthwatch Hertfordshire values its relationship with PAHT and would very much like to
further this by a planned range of involvement activities in 2015/16 to ensure Hertfordshire
residents are well represented.
Michael Downing, Chairman Healthwatch Hertfordshire, May 2015
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Amendments made following stakeholder
engagement
Thank you to our CCGs, Healthwatch Essex and Herts and the Patient Panel for their
feedback.
The following amends were received and have been made to the Account.
General
- Ordering of the sections within the Quality Account be reviewed to bring it in line with
the national guidance (eg 15/16 priorities should be in part 2, with review of 14/15
performance in part 3)
- Remove repetition in some areas
Specific feedback, including any inaccuracies;
- P14, participation in national audits, clinical trials and research is positive, however
examples of how clinical research has improved patient care at the Trust should be
included
- P20, the table for 15/16 CQUINS includes the previous year’s CQUINs currently
- P21, In relation to data quality there is no mention of the data reporting issues
associated with EPR
- P22, the nationally required statement regarding IG toolkit attainment levels has been
included. However as the status is red we would expect an explanation of how this
will be improved during 15/16
- P33-37, please could it be clearly stated for each of the quality priorities whether this
has been achieved, partially achieved or not achieved during 14/15.
- P42 states the ICT department remains understaffed with a skills shortage which is
impacting on day to day tasks. This is really concerning, and it needs to be clear how
this will be addressed.
- P45, the November data states 15.5% for out of area ambulance conveyances. An
element of this increase had been accounted for in the Activity & Finance plans for
ENHCCG, our own figures would suggest an 8% increase over and above what was
planned for.
- P67, Serious Incident section refers to theme/ trends and learning however no
specific actions taken as a result of SIs have been included. Other than pressure
ulcers no themes have been included.
- P68, further information could be provided regarding the never events
- P75, further detail regarding maternity services could be included, for example the
positive quality visit from the CCGs following the never events.
- P77, it states 198 MCAs have been completed during 2013/14. Whilst this is an
increase the numbers still seem really low. It would be helpful to understand whether
this metric relates to all MCAs and how it is calculated?
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-
P81, there is reference to inadequate safeguarding children supervision. It would be
helpful to include the specific data around this.
P86-90, we note that there are a number of 15/16 priorities to be confirmed. All
metrics must be clearly measurable, with clear targets detailed within the report.
Information CCG would like to see included;
- Stroke data is currently not included. This is a key area for the Trust and should
performance should be included in the final Quality Account.
- A section on complaints including numbers, themes/ trends and learning needs to be
included within the Quality Account. Compliments should also be included
- Complaints handling should also be included for 2014/15
- Reference to other ways in which patient experience is captures eg NHS Choices
should also be included with examples of feedback received (positive and negative).
- P50 references the cancer patient survey. The national patient surveys for A&E and
inpatients should also be included in the Quality Account.
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External audit limited assurance report
Grant Thornton
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Appendix A
National clinical Audits in which the Trust was eligible to participate
Subject
Participated Cases
Indicated or
Required
Peri and Neonatal
Cases
Submitted
% Cases
Submitted
Comment
Neonatal
intensive and
special care
(NNAP)
Yes
All
463
100%
Quarterly clinics are currently
being arranged in order to follow
up 2 year olds who have been in
NICU.
Yes
All Cases
24
75%
Action plan in place:-
Children
Epilepsy 12 –
Royal College of
Paediatrics and
Child Health.
Appointment of consultant
paediatrician with special
interest in Neurology/Epilepsy to
be appointed by summer 2015.
Business case currently being
developed to appoint an
Epilepsy Nurse Specialist.
Paediatric
Intensive Care
(PICANet)
Paediatric
Cardiac Surgery
(NICOR
Congenital
Heart Disease
Audit)
Not
applicable
to the Trust
Not
applicable
to the Trust
Diabetes (RCPH
National
Paediatric
Diabetes Audit)
Maternal Infant &
Newborn
Programme
(MBRRACE-UK)
Yes
All cases
All Cases
100%
Yes
All maternal
deaths and
stillbirths.
All Cases
100%
Cardiac Arrest
(Nat Cardiac
Arrest Audit)
Yes
All Adult inhospital
Cardiac
Arrest
All Cases
100%
Information received quarterly,
and shared appropriately.
Action Planning meetings taking
place.
Adult Critical
Care (ICNARC
Yes
All Cases
All
100%
Year on year data collection,
involving various agencies to
As a direct result of data
submitted in the 2011-12 report
an improved complete care
package is in place.
Lessons learned continue to be
highlighted to staff through
monthly newsletters and ward
meetings.
Acute Care
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CMPD)
Initial
Assessment of
the fitting Child
(College of
Emergency
Medicine)
Mental Health
(College of
Emergency
Medicine)
Yes
All Cases
Yes
All Cases
National
Emergency
Laparotomy Audit
(NELA)
Yes
All patients
over 18 years
having a
general
surgical
emergency
laparotomy
Non-Invasive
Ventilation –
adults
Adult Community
Acquired
Pneumonia
Pleural
Procedures
improve services. Key findings
shared with team as and when
reports received.
Information not yet available,
data collection completed
January, 2015. National Report
due for publication May 2015
Therefore will be reported in
Quality Accounts for 2015/16
Information not yet available,
data collection due for
completion February, 2015.
National Report due for
publication June 2015
Therefore will be reported in
Quality Accounts for 2015/16
Actions/outcomes not available
until the National Report is
published later in 2015. Will be
reported in Quality Accounts for
2015/16.
39
53
Information not provided
Yes
All Cases
Data entry closes May 2015
Will be reported in Quality
Accounts for 2015/16.
Information not provided
Long Terms Conditions
National Diabetes
Audit (NDA)
Yes
All Cases
349
100%
Action Plan in Progress
National Diabetes
Inpatient Audit
(NaDIA)
Yes
All Cases
37
100%
Action Plan in Progress
National Diabetes
in Pregnancy
(NPID)
COPD (RCP)
Yes
All Cases
9
36%
Yes
All Cases
83
77%
National
Inflammatory
Bowel Disease
Yes
All Cases
Some patients would not
consent to participate. Awaiting
results.
The national report was received
in October, 2014 and an action
plan is currently being
developed
Action Plan in place due for
completion July 2015
Yes
All Cases
Older People
Older People
(College of
Emergency
Information not yet available,
data collection due for
completion February, 2015.
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Medicine)
National Audit of
Dementia
Yes
National Report due for
publication June 2015 therefore
will be reported in Quality
Accounts for 2015/16
Information not yet available,
data collection due for
completion March 2015.
Therefore will be reported in
Quality Accounts for 2015/16
Minimum of
40 cases with
diagnosis or
current
history of
dementia
Elective Procedures
Hip, knee and
ankle
replacement (Nat
Joint Registry)
Yes
All Cases
All Cases
100%
Information from the registry
database published annually
outlining a league table for these
areas of surgery. This
information is used to help
improve patient safety and
monitor the results of joint
replacement surgery.
Information helps to find out
which are the best performing
artificial joints and the most
effective types of surgery.
Participation up by 1% so far
this year.
Elective Surgery
(Nat PROMs
Programme) Hips
Elective Surgery
(Nat PROMs
Programme)
Knees
Elective Surgery
(Nat PROMs
Programme)
Hernia
Elective Surgery
(Nat PROMs
Programme)
Varicose Veins
Yes
All Cases
200 to date
82.9%
Yes
All Cases
227 to date
88.4%
Participation up by 7.1% so far
this year.
Yes
All Cases
71 to date
55%
Participation up by 17.3% so far
this year.
Yes
Cases
35 to date
55.7%
Participation up by 17.8% so far
this year.
National Vascular
Registry
Yes
All cases
100%
Carotid Endarectomy = 59
AAA repair = 112
Intra-Thoracic
Transplantation
(NHSBT UK
Transplant
Registry)
Coronary
Angioplasty
(NICOR Adult
Cardiac
Interventions
audit)
CABG and
Not
applicable to
the Trust
Not
applicable to
the Trust
Not
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valvular surgery
(Adult cardiac
surgery audit)
Applicable to
the Trust
Cardiovascular Disease
Acute Myocardial
Infarction & Other
ACS (MINAP)
Yes
All ACS + MI
Patients
Actual
Data completion May 2015, will
be reported in Quality Accounts
for 2015/16
Heart Failure
(Heart Failure
Audit)
Yes
ongoing
Data completion due June,
2015, will be reported in the
Quality Account for 2015/2016
Sentinel Stroke
National Audit
Programme
(SSNAP)
Yes
100 based on
requirement
for previous
year
All cases
Cardiac
Arrhythmia
(Cardiac Rhythm
Management
Audit)
Pulmonary
Hypertension
No
447
100%
New ICP introduced, evaluated
and in use.
Electronic referral system
introduced for TIA clinic.
All
Actual
Data completion due end of
March, 2015, will be reported in
2015/2016 Quality Account.
Not
Applicable to
the Trust
Data presented from designated
centres, this Trust is not one of
them.
Renal Disease
Renal
Replacement
Therapy (Renal
Registry)
Renal
Transplantation
(NHSBT UK
Transplant
Registry)
Not
applicable to
the Trust
Not
applicable to
the Trust
Cancer
Lung Cancer
(National Lung
Cancer Audit)
Bowel Cancer
(National Bowel
Cancer Audit
Programme)
Head & Neck
Cancer (DAHNO)
Oesophagogastric Cancer
(NAOG Cancer
Audit)
National Prostate
Cancer Audit
Yes
113
170
150%
Action Plan in place and to be
implemented during 2015
Yes
All Cases
142
100%
Information not received
Yes
All Cases
19
100%
Information not received
Yes
51
46
90.1%
Continually updated Cancer
Plan in place.
Yes
All Cases
203
100%
Recommended pathway has
been implemented. Introduction
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of multiparametic MRI in the
pathway.
Trauma
Falls & Fragility
Fracture Audit
Programme
(FFFAP)
Yes
372
100
372%
Monthly hip fracture evaluation
meetings
Standard Operating Procedure
to fast track patients from A&E.
Communication event increasing
awareness and compliance with
recommendations of audit
report.
Severe Trauma
(TARN)
Yes
314
366
86%
Data completion due end March
2015, will be reported in Quality
Account for 2015/2016
Blood Transfusion
National
Comparative
audit – 2014
Audit of
transfusion in
children and
adults with Sickle
Cell Disease
Yes
All Cases
Data collection due for
st
completion 31 March, 2015, will
be reported in Quality Accounts
for 2015/16
National Confidential Enquiries in which the Trust was eligible to participate
Subject
Principal
Auditor
Participated
Tracheostomy
Care
Lower Limb
Dr Saha
Mr Refson /
Mr Abidia
Dr Dutta
Dr S Gupta
Sepsis
Gastro-intestinal
Cases
Submitted
% Cases
Submitted
Yes
Cases
Indicated
or
Required
2
2
100%
Yes
5
5
100%
Yes
Yes
5
5
5
5
100%
100%
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Glossary of terms
Ambulatory Care
A personal health care consultation, treatment, or intervention using advanced medical technology or
procedures delivered on an outpatient basis.
Amniocentesis
Amniocentesis is a diagnostic test carried out during pregnancy.
Antimicrobial stewardship
A coordinated intervention designed to improve and measure the appropriate use of antimicrobials by
promoting the selection of the optimal antimicrobial drug regimen, dose, duration of therapy, and route
of administration.
Agents for Nutrition and Tissue Viability (ANTS)
ANTS identify skin issues patients may have and ensure that those at risk are getting all the right food
that they need for their skin to remain healthy and thus avoid the danger of pressure sores
developing.
Appraisals
An act of assessing something or someone.
Audiology
The branch of science and medicine concerned with the sense of hearing
Avoidable
See unavoidable
Board Rounds
Visits to clinical areas of the Hospital by a Director and Non-Executive Director to assess compliance
and gather patient feedback.
Cardiology
The branch of medicine that deals with diseases and abnormalities of the heart.
Chemotherapy
The treatment of disease by the use of chemical substances, especially the treatment of cancer by
cytotoxic and other drugs.
Chloraprep
A type of antiseptic.
Chorionic Villi Sampling (CVS)
Chorionic villus sampling (CVS) is a prenatal test in which a sample of chorionic villi is removed from
the placenta for testing.
Clostridium Difficile (C.Difficile)
Clostridium difficile, also known as C. difficile, or C. diff, is a type of bacterial infection that can affect
the digestive system.
Clinical Audits
A process aimed to improve quality of patient care and outcomes through systematic review of care
against explicit criteria and the implementation of change.
Clinical Commissioning Group (CCG)
NHS organisations set up by the Health and Social Care Act 2012 to organise the delivery of NHS
services in England.
Clinical Nurse Specialist (CNS)
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A nurse who has advanced knowledge and competence in a particular area of nursing practice.
Clinical Pathway
Care placed in an appropriate time frame, written and agreed by a multidisciplinary team.
COSMIC
The Electronic Patient Record system we have in place at PAHT. See Electronic Patient Record.
Compliance
The action or fact of complying with a wish or command.
COPD
Chronic obstructive pulmonary disease (COPD) is the name for a collection of lung diseases including
chronic bronchitis, emphysema and chronic obstructive airways disease.
CPD
Continuing Professional Development is defined as the education of physicians following completion
of formal training.
CPR
Cardiopulmonary arrest means that a person’s heart and breathing has stopped. When this happens
it is sometimes possible to restart their heart and breathing with this emergency treatment.
CQC
The Care Quality Commission is the independent regulator of all health and social care services in
England.
CQUIN
Commissioning for Quality and Innovation is a system introduced in 2009 to make a proportion of
healthcare providers’ income conditional on demonstrating improvements in quality and innovation in
specified areas of care.
DAISY project
A hospital based advocacy service offering advice and support for both staff and patients, male and
female, who are victims of domestic abuse
Datix
Supplier of patient safety incidents healthcare software and risk management software systems for
incident reporting and adverse events.
Dementia Champions
A group of staff who have had specific training in dementia care. Their aim is to make other
colleagues more understanding of why a patient may be more challenging and encourages them to
tailor therapies accordingly.
Deprivation of Liberty Safeguards (DoLS)
Part of the Mental Capacity Act 2005, DoLS aim to make sure that people in care homes, hospitals
and supported living are looked after in a way that does not inappropriately restrict their freedom.
Dermatology
The branch of medicine concerned with the diagnosis and treatment of skin disorders.
DNA
Did not attend (in this instance in the context of a missed hospital appointment).
DNR/DNAR
A do-not-resuscitate and do not attempt resuscitation order tells medical professionals not to perform
CPR. This means that doctors, nurses and emergency medical personnel will not attempt emergency
CPR if the patient's breathing or heartbeat stops.
Duty of Candour/Being Open
A process of apologising to patients and/or their carers when things go wrong, and communicating
with them in an open and honest manner.
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End of Life (EOL)
End of life care includes palliative care to control pain and other symptoms and offers psychological,
social and spiritual support.
Endocrinology
The branch of physiology and medicine concerned with endocrine glands and hormones.
Electronic Patient Record (EPR)
A series of software applications bringing together key clinical and administrative data in one place.
Friends and Family Test (FFT)
Test aimed at providing a simple headline metric which, when combined with follow-up questions, is a
tool to ensure transparency, celebrate success and galvanise improved patient experience. It asks
“How likely are you to recommend our [ward/A&E department/maternity service] to friends and family
if they needed similar care or treatment?” with answers on a scale of extremely likely to extremely
unlikely.
Gastroenterology
The branch of medicine which deals with disorders of the stomach and intestines.
Genito-Urinary
The brand of medicine relating to the genital and urinary organs.
Gynaecology
The branch of physiology and medicine which deals with the functions and diseases specific to
women and girls, especially those affecting the reproductive system.
Haematology
The branch of medicine involving study and treatment of the blood.
Hard Truths
Associated with publishing staffing data regarding nursing, midwifery and care staff levels.
Healthcare Associated Infections (HCAI)
Infections that are acquired as a result of health care. The burden of healthcare-associated infections
has mainly been in hospitals where more serious infections are seen.
Hospital Standardised Mortality Ratio (HSMR)
Calculation used to monitor death rates in a trust.
Integrated Performance Report (IPR)
A monthly report including all aspects of the Trust’s performance, including quality measures.
LCP
The Liverpool Care Pathway for the Dying Patient (LCP) is a UK care pathway covering palliative care
options for patients in the final days or hours of life. It was developed to help doctors and nurses
provide quality end-of-life care.
League of Friends
A group of volunteers who help at The Princess Alexandra Hospital NHS Trust.
Malignancy
The state or presence of a malignant tumour; cancer.
Mealtime Buddies
A group of volunteers who help feed patients during mealtimes in Princess Alexandra Hospital.
MCA
The Mental Capacity Act is designed to protect people who can't make decisions for themselves or
lack the mental capacity to do so.
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Medicines and Healthcare Products Regulatory Agency (MHRA)
The MHRA determine whether a product falls within the definition of a medicine – 'medicinal product'
or a medical device and provides information on whether a product is a medicine or a medical device
or not
Meticillin-Resistant Staphylococcus Aureus (MRSA)
Type of bacterial infection.
Mitigation
The action of reducing the severity, seriousness, or painfulness of something.
Malignant spinal cord compression (MSCC)
When cancer grows in, or near, the spine and presses on the spinal cord and nerves.
National Early Warning Score (NEWS)
A simple system in which a score is allocated to physiological measurements already undertaken
when patients present to, or are being monitored in hospital. Six simple physiological parameters form
the basis of the scoring system:
a) respiratory rate
b) oxygen saturations
c) temperature
d) systolic blood pressure
e) pulse rate
f) level of consciousness
Neonatal
New born children.
Net Promoter Score (NPS)
Result based on the following question; 'How likely it is that you would recommend our company to a
friend or colleague?'
Neurology
The branch of medicine or biology that deals with the anatomy, functions, and organic disorders of
nerves and the nervous system.
Neutropenic Sepsis Policy
The guidance surrounding the development neutropenia. Neutropenia relates to a patient with an
abnormally low number of neutrophil granulocytes (a type of white blood cell) in the blood.
Never Events
Serious, largely preventable, patient safety incidents that should not occur if the available preventative
measures have been implemented.
NHS Safety Thermometre
This provides a ‘temperature check’ on harm that can be used alongside other measures of harm to
measure local and system progress in providing a care environment free of harm for our patients.
NICE
The National Institute for Health and Care Excellence provides guidance which supports healthcare
professionals and others to make sure that the care they provide is of the best possible quality and
offers the best value for money.
Obstetrics
The branch of medicine that deals with the care of women during pregnancy, childbirth, and the
recuperative period following delivery.
Oncology
The study and treatment of cancer and tumours.
Ophthalmology
The study of the structure, functions, and diseases of the eye.
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Orthopaedic
The branch of medicine that deals with the prevention and correction of injuries or disorders of the
skeletal system and associated muscles, joints, and ligaments.
Picture archiving and communications system (PACS)
A medical imaging technology that provides storage and convenient access to images from multiple
sources.
Paediatrics
The specialty of medical science concerned with the physical, mental and social health of children
from birth to young adulthood.
Palliative Care
An approach that improves the quality of life of patients and their families facing the problem
associated with life-threatening illness, through the prevention and relief of suffering by means of
early identification and impeccable assessment and treatment of pain and other problems, physical,
psychosocial and spiritual.
Pathology
The scientific study of the nature of disease and its causes, processes, development, and
consequences.
Patient Advice and Liaison Service (PALS)
Service offering confidential advice, support and information on health-related matters. Provides a
point of contact for patients, their families and their carers.
Patient Panel
A group of volunteers who represent patients, families and carers of The Princess Alexandra Hospital
NHS Trust.
Patient Safety Thermometer
The NHS Safety Thermometer is a local improvement tool for measuring, monitoring and analysing
patient harms and 'harm free' care.
Post Myocardial Infarction
Commonly known as a heart attack.
Preceptorship
A period of practical training for a student or novice under the supervision of an expert.
Preferred Priorities of Care (PPC)
Document used to plan an individual’s future end of life care. Includes thoughts and feelings about the
patient’s illness, what is happening, preferences and priorities for future care and where the individual
would like to be cared for in the future.
Pulmonary Embolism (PE)
A sudden blockage in a lung artery.
Radiology
The branch of medicine that deals with the use of radioactive substances in diagnosis and treatment
of disease.
Respiratory
The act of breathing.
Rheumatology
The study and treatment of arthritis, autoimmune diseases, pain disorders affecting joints, and
osteoporosis.
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Root Cause Analysis (RCA)
The method of problem solving that tries to identify the root causes of faults or problems with the goal
of preventing a recurrence.
Safeguarding
Protection or defence that ensures safety.
Serious Clinical Incident Group (SCIG)
A formal review of serious incidents which may need external reporting.
Serious Incidents (SIs)
An unexpected or unplanned event that caused harm or had the potential to cause harm to a patient,
member of staff, student, visitor or contractor.
Service Level Agreement
A contract between a service provider and a customer.
Stakeholders
A stakeholder is anyone with an interest in a business. Stakeholders are individuals, groups or
organisations that are affected by the activity of the business. They include: Owners who are
interested in how much profit the business makes.
Summary Hospital-level Mortality Indicator (SHMI)
Ratio between the actual number of patients who die following treatment at the trust and the number
that would be expected to die, on the basis of average England figures given the characteristics of the
patients treated there.
Senior House Officer (SHO)
Junior doctor undergoing training within a certain speciality.
Triage
A process for sorting injured people into groups based on their need for or likely benefit from
immediate medical treatment.
Unavoidable
Used when an individual has been affected even though the:
 condition and risk has been evaluated
 goals and recognised standards of practice that are consistent with individual needs had been
implemented
 impact of these interventions had been monitored, evaluated and recorded
 approached had been revised as appropriate
Term usually used in relation to cases of hospital acquired infections, pressure ulcers and falls.
Urology
The study of urinary organs in females and the urinary and sex organs in males.
Venous Thromboembolism (VTE)
Collective name for deep vein thrombosis (DVT) and pulmonary embolism.
WHO
World Health Organisation
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