Gateshead Health NHS Foundation Trust
Quality Account
2014/15
1
Contents
1.
Achievements in Quality in 2014/15
4
Statement on Quality from the Chief Executive
5
2.
Priorities for Improvement
2.1
Reporting back on our progress in 2014/15
2.2
Our Quality Priorities for Improvement in 2015/16
2.3
Statements of Assurance from the Board
2.4
Mandated Core Quality Indicators
7
7
25
37
57
3.
Review of quality performance
3.1
Patient Safety
3.2
Clinical Effectiveness
3.3
Patient Experience
3.4
Focus on Staff
3.5
Quality overview - performance of Trust against selected indicators
3.6
National targets and regulatory requirements
68
68
76
81
91
96
109
4.
Feedback on our 2014/15 Quality Account
111
Annex: Statement of directors’ responsibilities in respect of the quality account
115
Glossary of Terms
117
Appendix A:
Participation in National Clinical Audits and National Confidential Enquiries
122
Appendix B:
Independent Auditor’s Report to the Board of Governors of Gateshead
Health NHS Foundation Trust on the Quality Report
126
2
What is a Quality Account?
Since 2009 as part of the movement across the NHS to be open and transparent about the quality of
services provided to the public, all NHS hospitals must publish a Quality Account (Health Act 2009). Staff
at the hospital can use the Quality Account to assess the quality of their care. The public and patients
can also view quality across NHS organisations by viewing the Quality Accounts on the NHS Choices
website: www.nhs.uk
The dual functions of a Quality Account are to:
Summarise our performance and improvements against the quality priorities and objectives we
set ourselves for 2014/15
Outline the quality priorities and objectives we set ourselves going forward for 2015/16
Review of 2014/15
quality information
Set out quality priorities
for 2015/16
LOOK BACK
LOOK FORWARD
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1. Achievements in Quality in 2014/15
We have remained a Care
Quality Commission Band 6
Hospital this year
Finalist in CHKS Top Hospitals
Award (Excellence in A&E )
Head of Infection Prevention
and Control was nominated and
awarded the prestigious
‘Brendon Moore Award’ by the
Infection Prevention Society
Maternity services retain top
rating from Care Quality
Commission
Recognised at the 2014 Nursing
Times Awards with finalist in
The Nurse of the Year category
We attained the North East
Better Health at Work Gold
Award
Recognised at the 2014 Nursing
Times Awards with finalist in the
Rising Star category
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Statement on Quality from the Chief Executive
It is my pleasure to introduce to you the sixth Quality Account to be published by Gateshead Health NHS
Foundation Trust. Despite the many challenges facing the health and social care economy, in the context
of national pressures, sustaining high quality and safe care remains central to our values and our
approach to service delivery on a daily basis.
I am therefore pleased to report that the Quality Account for 2014/15 once again reflects another
excellent year for the Trust in our pursuit of high quality and safe care for everyone that uses our
services. Our staff are to be commended for their continuing dedication, commitment and passion to
provide and continuously improve the care we deliver to patients and their families. This is
demonstrated through our retention of the Care Quality Commission (CQC) band 6 rating throughout
2014/15, making us one of the safest and best performing hospitals in the country.
The CQC also undertook a multi-agency review of health services for Looked After Children and
Safeguarding in Gateshead in October 2014. Their report was very complimentary about our services
and found examples of good practice within our A&E and maternity services.
Our new Emergency Care Centre opened in January 2015 providing one point of access for all medical,
surgical and paediatric emergencies. It also includes a short stay ward, frailty assessment area and
integrated diagnostic and support services. Walk in services for central Gateshead have also been
integrated into the emergency services located in the new Centre. This represents a significant
improvement in facilities for the local population supported by state of the art technology and design.
The Trust has also been recognised by CHKS as a finalist for the CHKS Top Hospitals Award for Excellence
in A&E. Recognition of this nature is clearly a very welcome confirmation of our continued efforts to
drive up the quality, safety and effectiveness of the care we provide.
We have also opened a new £12 million Pathology Centre following reconfiguration of pathology
services for the South of Tyne and relocating these in the new centre at the Trust. This provides
enhanced diagnostic and screening services for patients.
Feedback from our patients shows us that the Trust continues to provide a positive patient experience
with an average of 96% of inpatients saying that they would definitely recommend the hospital to family
and friends. 88% of patients that completed the 2014 NHS inpatient survey would rate the care provided
at 7/10 or above (Picker Institute, 2014) and 96% of inpatients in our local Trust survey say that our staff
are caring and compassionate.
We have regularly monitored our improvement plans during 2014/15 through our Patient, Quality, Risk
and Safety Committee and the Trust Board. In addition to the examples detailed above, the Quality
Account for 2014/15 reflects the excellent progress we have made against our priorities for the year:
Examples
Continued improvement in reducing missed doses of critical medicines;
Significant improvements in developing our ‘Dementia Friendly’ hospital
Expanding our 15 steps challenge programme of work
Mortality
5
Whilst we have made significant progress in some key areas over the past year we are not complacent
and recognise that we can always do better. We will therefore continue our quality journey through the
delivery of our SafeCare Strategy 2014/17 that sets out how we will continue to deliver improvements
over the next two years, alongside our six key priorities reflected in our Quality Account for 2014/15:
Clinical Effectiveness
Reducing avoidable hospital deaths, including focusing on recognition and management of Sepsis
Implement the ‘Saving Babies Lives’ Campaign
Patient Safety
Continue to reduce harmful in hospital falls
Continue to improve medication safety
Implement the ‘ThinkSafe’ project
Patient Experience
Implement the ‘Family Voices’ project at end of life
We hope that you will enjoy reading about the many examples of the improvement work that teams
across the organisation are pursuing and will see that we strive to provide excellent care which meets
the high standards that our patients deserve. We want the Trust to continue to be the health care
provider that patients trust to provide those highest standards of care - and the organisation that staff
have pride in and where they are willing always to give of their best.
I can confirm that on behalf of the Board of Gateshead Health NHS Foundation Trust that to the best of
my knowledge the information presented in the Quality Account is accurate.
Signed:
Mr I D Renwick, Chief Executive
Date: 5 June 2015
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2. Priorities for Improvement
2.1 Reporting back on our progress in 2014/15
In our 2013/14 Quality Account we identified six quality improvement priorities that we would
concentrate on in 2014/15. This section focuses on the progress we have made against these.
KEY:
We achieved our aims
We partially achieved our aims or significantly improved our processes to enable future
improvement
We did not achieve our aims
Priority 1:
Priority 2:
Priority 3:
Priority 4:
Priority 5:
Priority 6:
Continue to focus on reducing avoidable deaths in hospital
Continue to improve the care of patients living with a diagnosis of Dementia and creating
a Dementia friendly hospital
Reduce inpatient falls that cause harm to patients
Continue to reduce omitted doses of critical medicines
Implement ‘Open and Honest Care: Driving Improvement ’
Continue to embed the 15 Steps Challenge
Clinical Effectiveness
Priority 1: Continue to focus on reducing avoidable deaths in
hospital
What did we say we would do?
We will aim to achieve a year on year reduction in mortality utilising the crude mortality rate, the
Hospital Standardised Mortality Ratio (HSMR) and the Summary Hospital-level Mortality Indicator
(SHMI). Our aim is to achieve lower than expected or as expected SHMI banding and by the end of 2015
achieve a SHMI of 0.99 or below.
Explanation of how mortality is measured:
Like many other Trusts, the Trust uses an independent organisation called Dr Foster to monitor its
Hospital Standardised Mortality Ratio. The Hospital Standardised Mortality Ratio (HSMR) compares the
expected rate of death in a hospital with the actual rate of death and allows us to assess the Trusts
performance on a range of clinical conditions, such as patients with conditions that most commonly
result in death for example, heart attacks and strokes.
7
The Summary Hospital-level Mortality Indicator (SHMI) is similar to the HSMR but this takes into
consideration out of hospital deaths that have occurred within 30 days of discharge from hospital. The
SHMI whilst calculating a score places each Trust into one of three bands for mortality rating.
Table illustrating how the risk adjusted scores are interpreted:
Interpretation of score
HSMR value
Deaths as predicted
100
SHMI band
‘as expected’
More deaths than predicted
Score greater than 100
‘high’
Less deaths than predicted
Score less than 100
‘low’
Crude mortality rate is a measure of the number of deaths which does not include an adjustment for risk
factors as in the HSMR. The crude rate is the percentage of deaths that have occurred out of all hospital
spells (stays).
Did we achieve it?
Yes we did
The Summary Hospital-level Mortality Indicator (SHMI) reports mortality at a trust level across the NHS
in England and is regarded as the national standard for monitoring of mortality. The main development
in measuring mortality that the SHMI takes into account is patient deaths outside of hospital within 30
days of discharge from hospital. Previous indicators have focused purely on in hospital deaths. The
SHMI is produced quarterly with the first publication made in October 2011. The SHMI categorises
trusts into one of three groups based on the Trust SHMI calculation; low, as expected and high. For all
of the SHMI calculations since October 2011, death rates (mortality) for the Trust are described as being
‘as expected’.
8
One of the key advantages to using Dr Foster is the in-depth information around mortality and the
ability to see the data that underpins many of the publications related to hospital death rates allowing
the Trust to realise opportunities for learning and improve patient care.
The latest 2014/15 position available as at December 2014 is showing the HSMR at Gateshead as being
higher than the previous year. The Trust’s target of achieving a year on year reduction at this stage is
not being achieved, however as this is not a full year’s data there is still a possibility that a reduction
could be realised. The likelihood of this occurring is increased given the numbers of deaths from
internal data sources show in hospital deaths reducing month on month from December 2014 to March
2015. This can only be confirmed once the data is processed by Dr Foster but the signs are
encouraging.
In support of the Trust’s current mortality position the recent publications from the CQC in their
Intelligent Monitoring Reports do not highlight the Trust as having higher than expected death rates
which is further supported by the reduction in crude mortality and a maintained level of performance
using the national Summary Hospital-level Mortality Indicator (SHMI).
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Encouragingly a reduction in crude mortality was observed in 2014/15 from the previous year. The
pattern demonstrated for crude death rates shows a downward trend with the exception of a slight
increase in 2012/13. The Crude mortality rate has reduced from 3.23% in 2008/09 to 1.78% in 2014/15
representing a 44.9% reduction overall
How did we achieve it?
We have continued to implement our mortality reduction strategy to assist us in reducing avoidable
mortality. The strategy focuses on three areas for change recognised to be important to reducing inhospital mortality:
1. Leadership - The organisation has the data, reporting and leadership skills it needs to manage and
improve standardised mortality
We have reviewed the provision of information and data the Board receives related to mortality
to ensure its usefulness in informing decision making.
We have continued to review and refresh our mortality governance arrangements to ensure that
these are embedded in the organisation. Our aim is that leaders at all levels of the organisation
and in all clinical areas are continuously and actively engaged in activities to reduce avoidable
mortality.
We have worked with other Trusts in the region to share knowledge, learning and develop
discrete pieces of work to help us understand where improvements can be made. Some of this
has involved external peer review of deaths. This has provided very useful feedback highlighting
some very positive areas such as excellent standards of nursing care, communication and
documentation. It also highlighted areas for further exploration that we were able to follow up.
We held a Mortality Symposium ‘Dying to Know’ in November which was a great success with
over 50 internal and external delegates attending. We were lucky to secure Dr Helen Hogan as
our keynote speaker. Dr Hogan was the lead researcher in a detailed study of hospital deaths in
England. The symposium comprised presentations focusing on understanding mortality
10
indicators, what we have learned from mortality reviews at Gateshead, and workshops covering
understanding clinical coding and practical sessions on undertaking mortality reviews.
2. Improving Clinical Care and pathways- provide safe, evidence based care
To deliver care that is safer, more effective, and that provides a better experience for patients some of
our focus has been on the following areas:
Clinical Review of deaths
Timely recognition and treatment of sepsis
Rescuing the deteriorating patient
Clinical Review of Deaths
We have strengthened our processes related to review of deaths across the Trust to ensure that
all services are included and that feedback and emergent learning is shared through the
Mortality and Morbidity Steering group. In order to further support this learning culture we are
in the process of developing a mortality database to assist clinical teams by simplifying the
process of mortality review and to provide the administrative support needed for subsequent
sharing of learning.
We have reviewed and refreshed the documentation that is used for the review mortality. This
now incorporates codes that help us record the quality of clinical care and key areas where
action must be taken.
Based on our review of deaths the Mortality and Morbidity Steering Group have set clinical
priorities and commissioned reviews of clinical care where there has been potential for
improvement. We have also carried out some focused work on reviewing the care of patients
with specific conditions where our mortality data has appeared higher than expected. One
example of this relates to improvements to our Non-Invasive Ventilation (NIV) service. As a
consequence of learning from the review of deaths the service has undergone significant
development following a successful business case in 2013. Additional nurses have been
appointed aiming to run a 24/7 service to improve the care for Acute Exacerbations of Chronic
Obstructive Pulmonary Disease (AECOPD). The service is now seeing and assessing 100 patients
per month, with an average of 30 patients per month starting treatment with Non-Invasive
Ventilation, compared to 7 before the change in service. This is being achieved within one hour
in 100% of patients in line with BTS guideline recommendations. Our data indicates that NIV is
successful in 76% of patients, an improvement on 66% in 2012. Our COPD patients treated with
NIV now match trial mortality rates (11% in-patient mortality) and all cause in-patient mortality
matches other large cohorts within the literature (33%, previously being 40% in 2012).
Timely recognition and treatment of sepsis
Considerable work has been undertaken to improve our recognition and treatment of patients
with sepsis. This is discussed in detail on page 30.
Rescuing the deteriorating patient
Timely recognition and response to the deteriorating patient is a key factor in reducing avoidable
mortality. The Trust was successful in securing funding for VitalPAC an electronic patient
observation system through the national Nurse Technology Fund at the beginning of 2014.
Electronic observations via VitalPAC have now been rolled out across all inpatient wards. Next
steps will be to implement ‘Closing the Loop’ a message, response and logging system that will
11
help ensure that patients with high and critical Early Warning Scores receive prompt attention
from clinicians, whilst enabling a balance between, between safety and appropriate clinical
judgement. This will be followed by the introduction of systems for assessing patient risk of
developing VTE, dementia and alcohol related illness and nutritional deficiencies.
3. Documentation and Informatics - patient documentation and coding is accurate, includes all relevant
clinical information and is used effectively to improve care
We have undertaken a programme of audits related to clinical coding. Some of these have
involved assessing the quality of clinical documentation in relation to how it supports the clinical
coding process. Where need for improvement was identified, this was fed back to clinical teams
and clinical coders.
The clinical coding manager is a member of the regional coding managers group. Part of the
focus of these meetings is to discuss mortality, and how clinical coding links to a Trusts
performance. Managers share areas of best practice that have been established within their
own Trusts and this is fed back through the Mortality Steering Group to gain the views of clinical
teams.
The clinical coding manager is also involved in the development of the mortality database to
ensure the system facilitates an increased level of real time validation of coding. This will
highlight any areas that may require further investigation or education of the clinical coders or
clinicians.
Our work on reducing avoidable mortality will continue in 2015/16.
Priority 2: Continue to improve the care of patients living with a
diagnosis of Dementia and creating a Dementia friendly
hospital
What did we say we would do?
We will further establish and implement the work programmes of the four newly established
dementia work streams:
1. Delivering CQUIN indicators that focus on improving dementia and delirium care,
including sustained improvement in: Finding people with dementia, Assessing and
investigating their symptoms and Referring for support (FAIR).
2. Education and Training
3. Dementia Environment
4. Nutrition
We will continue our programme of environmental audits within the Queen Elizabeth Hospital
Based on these environmental audits we will further develop our environmental action plan via the
Dementia Environment work stream
Roll out the ‘Forget me Not’ programme including the use of specific
identification bands
‘Barbara’s Story’ session to be accessed by all staff within the Trust.
Also further develop Level I and II dementia training within the Trust
Continue to undertake carers and users satisfaction surveys
Undertake a review of our dementia and delirium care pathways
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Did we achieve it?
Yes we did
How did we achieve it?
Dementia is a significant challenge and key priority for the NHS with an estimated 25% of acute beds
occupied by people with dementia. Hospital care for people with dementia has become an area of
particular concern. We set ourselves a challenge in the 2013/14 Quality Account to meet the
requirements of becoming a dementia friendly hospital by 2016, ensuring that patients with a dementia
are provided with the best possible care that meets their specific needs. We have undertaken a great
deal of work this year, beginning to implement our Dementia Strategy 2014-2017 and to further develop
the four dementia work streams.
Delivering Commissioning for Quality and Innovation (CQUIN) indicators:
This work stream has provided the Trust with assurance against the delivery of the dementia CQUIN,
implementation of the dementia strategy and highlights any gaps against quality standards.
We have consistently achieved above our target of 90% ensuring patients over 75 who have dementia or
delirium are identified, and referred on to the appropriate clinicians for high quality care both during
and following admission for themselves and their carer’s.
The feedback received from our relatives and carers satisfaction questionnaires has been extremely
positive, examples include:
“Every member of staff on the
Cragside Unit have been
excellent by providing care as
well as supporting me and my
family very well.”
“Ward 23 has been a very
good ward and I could gladly
recommend it to anyone. The
staff have been very helpful.”
Quality standards relating to dementia are reviewed and assurance provided by the Mental Health
SafeCare group. Currently one quality standard remains incomplete; (carers of people with dementia
are offered an assessment of emotional, psychological and social needs and, if accepted, receive tailored
interventions identified by a care plan to address those needs). Unprecedented front line service
pressures this winter period have impacted on this standard being met; however a plan is in place to
address this with a time frame for completion of May 2015.
Next Steps
The compliance work stream will continue to monitor delivery of the dementia CQUIN targets.
Registration for the National Audit of Dementia opened in January 2015 and the Trust has registered to
take part in this valuable process. The audit will commence in May, and will cover a survey, carer
experience, and staff questionnaire. Progress will be reported through the Steering Group.
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Education and training:
In December 2013 the Trust made Dementia Training mandatory for all of its employees and this is
being delivered through the Barbara’s Story programme. Barbara’s Story (1 & 2) is now delivered on
day two of Corporate Trust Induction for all new starters, and this has helped us to reach more staff and
offer them this excellent training opportunity which will benefit our patients.
The roll out of the ‘Forget Me Not’ flower has been adopted by the Trust as part of our commitment to
improve the care of patients with dementia or cognitive impairment within the hospital setting. Blue
wristbands have been purchased for this group of patients so staff will be able to identify discreetly
those patients that require additional assistance whilst in hospital. This roll out is due to be evaluated in
April 2015.
Next Steps
Increasing take up of dementia training from 71% to 95% remains the key priority for the education
work stream; although it is acknowledged continued staffing pressures over the extended winter period
have made this difficult. Barbara’s Story also has further films, and a training needs analysis needs to be
done across the organisation to identify which staff groups require this enhanced level of training.
Improving the dementia environment:
The Trust continues to use the University of Stirling Dementia Environmental Design audit toolkit as a
gold standard for dementia friendly design.
In 2013 the Trust were successful in the bid for monies from the Department of Health for improving the
environment of care for people with dementia and received a grant of almost £160,000 to undertake
work on three schemes within the Trust. This included:
Dementia friendly outpatient facilities
A gym at Woodside Younger Persons Dementia Day Care Service
An outdoor space at Cragside Court conducive to therapeutic dementia care
These estates projects have been completed, with the work at Cragside Court receiving positive local
press attention.
Environmental improvements have been made on Ward 23, including dementia friendly signage and
lighting throughout, timber effect flooring, as well as contrasting finish to patient handrails/doors.
Dementia friendly signage has also been commissioned for the new Emergency Care Centre along with
timber effect flooring throughout, service doors painted the same colour as walls, and providing
contrasting toilet seats.
Following a recent Clinical Commissioning Group assurance visit to Cragside Court and Sunniside Unit,
our two older person’s mental health wards, a suggestion was raised to consider the layout and
environment of the units with respect to the uniform and ‘institutionalised’ feel of day rooms. Although
infection prevention & control and the function of an assessment unit need to be considered, new
furniture has been ordered with a more ‘homely’ feel. Cragside Court have also recently began the
development of ‘Dementia Cafes’ to provide additional carer support, and the introduction of memory
boxes for patients with dementias to identify their own rooms via personally recognisable visual cues.
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Next Steps
The environmental work stream has suggested further areas for roll out of dementia friendly
environment; Wards 24, 25, Outpatient X-ray, Rheumatology, Ellison Unit, and Bensham Hospital. The
work stream was also identifying issues raised with the functionality of sinks, taps, and call buttons on
Cragside Court.
Improving nutrition:
Patients with dementia are at particular risk of malnourishment or dehydration. Specialist cutlery,
coloured crockery and smaller plates have been introduced on to wards, with evidence to suggest this
encourages patients to eat and drink. The nutritional team continues to work with catering to provide
more food options on to the wards, as well as finger and fortified foods to maximise calorie intake for
those patients who may otherwise become malnourished. Snack boxes have also been introduced for
patients with dementia who may find sitting to eat meals difficult if restless or wandering.
The nutrition team continues to work with the Malnutrition Task Force; a national Department of Health
funded initiative to encourage healthy nutritional intake for older people at risk of malnutrition. With
the Task Force, Ward 23 hosted an ‘afternoon tea,’ to raise awareness of healthy nutritional intake for
patients, staff and visitors to the ward. This was not limited to only patients on Ward 23 with the ward
sister arranging for dementia patients and staff across the Trust to attend.
Next Steps
As well as feedback on the quality of food, future objectives include a survey on possible improvements
to the meal time experience as a whole. For example the benefit of protected meal times, and the
potential to use volunteer ‘dining companions’ to remind and encourage patients with dementia to eat.
Ward 23 have also identified with colleagues from South Tees NHS FT the opportunity to explore the use
of Psychology undergraduates to work as ‘therapeutic volunteers.’ These volunteers would maintain
their own learning objectives from working with patients with dementia, whilst providing therapeutic
activity support and supporting with the encouragement and assistance needed at mealtimes.
We will continue our work to continue to improve this important area of patient care.
Patient Safety
Priority 3: Reduce inpatient falls that cause harm to patients
What did we say we would do?
Reduce the rate of harmful falls from a rate of 2.40/1,000 bed days in 2013/14 to 2.0/1,000 bed days or
below by March 2017. We set ourselves an annual target of 2.25/1,000 bed days by March 2015.
Measuring falls as a rate per 1,000 bed days helps us to take into account the fluctuations in the number
of patients admitted to hospital rather than just the number of patients who have fallen. This gives us a
more accurate picture when comparing our performance over time.
Did we achieve this?
Our rate of harmful falls this year is 2.57/1,000 bed days. We are disappointed to report that we have
not been able to reduce the rate of harmful falls further and meet our target. There has however, been
a slight reduction in the percentage of moderate and serious harm falls this year.
15
How did we achieve it?
We have worked very hard to try to reduce harmful falls and have developed and implemented the
following improvement strategies.
In April 2014 we launched our falls reduction strategy (2014- 2017) focussing on leadership and front
line actions to help to steer us to achieve our falls reduction target over the next three years.
We held a trust-wide SafeCare event in July 2014 called ‘Falls Free Friday’.
The focus of this event was to get staff to think
about what strategies they need to put into place
to achieve being ‘falls free’ the following Friday.
By having the strategies in place to prevent falls
that Friday the strategies would be in place to
prevent falls every day.
AND EVERY DAY
FALLS
FREE
FRIDAY
This day was also an opportunity to offer support
and education to front line staff about falls
prevention strategies, promote new falls
prevention patient information leaflets, share
information on medication that may have an
effect on patients falling and remind staff to
use previously implemented tools such as falling
stars and slip resistant socks. We also distributed small cards to be
used as an aide memoire for what to consider for patients
to help prevent falls.
THINK:
Footwear
Environment
Personal
equipment
Medication
In addition we have:
Developed a new multifactorial assessment tool to replace the existing falls numerical risk tool.
Recent guidance suggested that such numerical risk assessment tools may not be sensitive or
specific enough for local use and advised that a multifactorial assessment is undertaken to
identify the patient’s individual risk factors for falling in hospital that can be treated, improved or
managed during their stay.
Focussed on ensuring that when a patient has fallen they receive the relevant care, further
assessment and rehabilitation. This is referred to as the post falls care bundle. This information
helps us to understand why patients fall so we can learn from this and try to prevent harmful
falls in the future. We have audited this practice monthly throughout the year and have
consistently achieved the target set for us by our commissioners
Updated the falls prevention information leaflets for both patients and families
Clinical Lead Sisters champion the falls prevention work
Changes were made to the DATIX system to ensure we are capturing appropriate information to
help us improve falls care
Continued to utilise improvement tools such falling stars & slip resistant socks
We aim to reduce avoidable harm and therefore the Trust has an on-going commitment to reviewing
and understanding why patients fall within our care by undertaking a root cause analysis on all falls of
moderate harm or above. Whilst considerable work has already been undertaken in reducing harm from
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falls within the Trust we have just completed the first year in our three year falls reduction strategy and
are committed to making further improvements.
Priority 4: Continue to reduce omitted doses of critical medicines
What did we say we would do?
Continue to measure the number of missed doses of Intra-venous (IV) Antimicrobial medications and
medications for Parkinson’s disease to ensure we sustain the improvements made in 2013/14 and
where possible further improve on this.
In addition:
Focus on improving missed doses of Tinzaparin. Tinzaparin is an anti-clotting medicine given by
injection to help prevent the development of deep vein thrombosis (when a clot forms in a deep vein
within the leg) or pulmonary embolism (a blood clot that has come away from its original site and
becomes lodged in one of the lungs). Whilst currently 95% of patients receive their prescribed doses of
this medicine we aim to further improve on this in 2014/15 to at least 98% by March 2015.
Focus on ensuring that patients in our care receive their Insulin on time. Insulin is a hormone that is an
important part of diabetes treatment. The main job of Insulin is to keep the level of sugar in the
bloodstream within a normal range. Our medication storage audits show us that Insulin is often not
stored appropriately, ordered in excess leading to waste, and is not always immediately available for the
patient when required.
We will:
Increase the use of patients own supply of Insulin
Improve the storage of Insulin in ward areas
Improve the timeliness of administration of Insulin
Reduce the amount of Insulin wasted due to excessive ordering
Did we achieve this?
Yes we did
How did we achieve it?
In 2013/14 we succeeded in reducing the number of missed doses of critical medicines from 11% to
2.5%. This year we continued to monitor these by undertaking a monthly audit. The table of results
below shows that we have been able to sustain this improvement.
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Percentage of Omitted doses of Parkinsons disease medicines
12
10
8
6
4
2
0
We also said we would further improve on the number of missed doses of Tinzaparin. By March 2014,
95% of patient received their prescribed doses of Tinzaparin. We set ourselves a target of at least 98%
by March 2015. We have continued to audit this on a monthly basis and the table below shows how we
have further reduced the number of missed doses of Tinzaparin achieving our target of at least 98% by
March 2015.
Percentage of Tinzaparin doses missed each month
6
percentage
5
4
3
2
1
Mar-15
Feb-15
Jan-15
Dec-14
Nov-14
Oct-14
Sep-14
Aug-14
Jul-14
Jun-14
May-14
Apr-14
Mar-14
Feb-14
Jan-14
0
We said we would ensure that where possible patients are able to administer their own Insulin,
observed by a nurse, and that storage and use of Insulin preparations is improved to reduce waste
We undertook a baseline audit on several wards to understand the value of Insulin that was being
wasted due to inappropriate storage. This initial audit showed that £400 of Insulin was destroyed either
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because it was stored inappropriately or patient’s own Insulin had not been given back to the patient on
discharge. Then once a month we visited the wards to undertake further measurement to evaluate if:Patients who require Insulin are able to, they are asked to administer their own Insulin
If patients bring their own Insulin into hospital
Our regular visits to the wards over the year have highlighted that nursing staff encourage patients to
maintain their independence and if they are able, support them to administer their own Insulin whilst
they are in hospital.
2014/15
Where
patients are
able they are
encouraged to
administer
their own
insulin
May
June
July
Aug
100%
100%
100%
100%
Sept
100%
Oct
Nov
Dec
Jan
Feb
March
100%
100%
100%
100%
100%
100%
Our monthly audit of wasted Insulin has demonstrated that we struggled in the first few months to
ensure that all Insulin was correctly stored and that any patient’s own Insulin was returned to them on
discharge (see table below). However, this has improved over the year as staff now give Insulin
appropriately to the patient on discharge and are storing it correctly. In addition, patients who are able
to, also bring their own Insulin into hospital on admission.
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Insulin is stored
correctly and
patient’s own
insulin is
returned to
them on
discharge
The table below demonstrates how we have successfully reduced the amount of wasted Insulin.
Value of Patient Own and Ward Stock insulin wasted
Value of Insulin wasted
£250.00
£200.00
£150.00
£100.00
Ward
Patients own
£50.00
£-
19
To achieve these very positive improvements in medication safety we have used the following
strategies:
We held a medication safety awareness trust wide SafeCare event in September 2014
We have provided wards with appropriate return to pharmacy medication storage containers
We have continually given feedback on results via the clinical leads forum and identified and
celebrated areas of success.
Awareness of the value of Insulin wasted has been raised at medicine management mandatory
training
Labelling of Insulin products at the point of dispensing has been improved by pharmacy staff
giving to ward staff valuable information about storage of Insulin, on the ward.
Provided wards with a flow chart to display on how to store Insulin correctly, and reminded staff
to return Insulin to the patient on discharge
Priority 5: Implement ‘Open and Honest Care: Driving Improvement’
What did we say we would do?
The Trust is committed to making more information available about the
quality of our care. We said we would publish a set of patient outcomes;
patient experience and staff experience measures so that patients and the
public can see how we are performing in these areas.
Did we achieve it?
Yes we did
How did we achieve it?
Every month we have published our ‘Open and Honest’ report via the Trust
intranet and internet: http://www.qegateshead.nhs.uk/openandhonestcare
The information provided in the monthly report includes the following:
The Safety Thermometer result- The Safety Thermometer looks at four harms: pressure ulcers,
falls, blood clots and urine infections for those patients who have a urinary catheter in place. This
helps us to understand where we need to make improvements. Our safety thermometer results
for this year can be seen on pages 70 – 84.
Information on healthcare associated infections- We published the number of Meticillin –
Resistant Staphylococcus Aureus (MRSA) and Clostridium Difficile (C. Diff) infections we had each
month plus the improvement targets and results for the year to date.
Pressure ulcers grade 2 and above- They are sometimes known as bedsores. They can be
classified into four grades, with one being the least severe and four being the most severe. We
have published the number of pressure ulcers graded 2-4 that were acquired during hospital
stays. So we can know if we are improving even if the number of patients we are caring for goes
up or down, we also calculate an average called 'rate per 1,000 occupied bed days'. This allows
us to compare our improvement over time, but cannot be used to compare us with other
hospitals, as their staff may report pressure ulcers in different ways, and their patients may be
more or less vulnerable to developing pressure ulcers than our patients. We have also reported
our rate of pressure ulcers grade 2-4 per 1,000 occupies bed days.
20
Falls causing moderate harm and above- this measure includes all falls in the hospital that
resulted in injury, categorised as moderate, severe or death, regardless of cause. As with
pressure ulcers we also calculated an average called 'rate per 1,000 occupied bed days' for falls.
Information on staff experience- Every month we published our Trust level results after asking
our ward teams e.g. nurses, doctors, domestics, housekeepers, porters, physiotherapists,
dieticians and pharmacists the following three questions:
I would recommend this ward/unit as a place to work
I would recommend the standard of care on this ward/unit to a friend or relative if they
needed treatment
I am satisfied with the quality of care I give to patients, carers and their families
Staff chose from the following responses for each question:
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
The tables below highlight the responses from our staff for the three questions for each month from
April 2014 to March 2015.
Q1. I would recommend this ward / department as a place to
work.
100%
80%
60%
40%
20%
0%
Strongly Agree & Agree
Neither agree nor disagree
Disagree & Strongly Disagree
Q2. I would recommend the standard of care on this ward /
department to a friend or relative if they needed treatment.
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Strongly Agree & Agree
Neither agree nor disagree
Disagree & Strongly Disagree
21
Q3. I am satisfied with the quality of care I give to the service,
patients, carers and their families.
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Strongly Agree & Agree
Neither agree nor disagree
Disagree & Strongly Disagree
Information on patient experience- the Friends & Family Test results for inpatients and A&E. The Friends
and Family Test is a single question survey which asks patients after discharge from wards and A&E
whether they would recommend the service they have received to friends and family who need similar
treatment or care. The response generates a score. We published our monthly inpatient and A&E score
and the number of patients who have responded.
We also published the Trust level results of our monthly in-patient survey and the number of
patients who have responded.
A patient story- each month we have published a patient story with the purpose of seeing care
through the eyes of the patient or family member and told in their own words. The stories have
been used to share positive experiences or those where improvement needs to be made. The
following are examples of a patient story comment.
“I would like to thank everyone on Ward 22 for the care that my mother received
during the last few days of her life between 14th and 17th February 2015. From
her arrival at A+E the staff ensured that she was treated throughout with extreme
professionalism and dignity.
I was allowed to stay with her in her final hours and all of the staff on Ward 22
were absolutely brilliant throughout. You never like to think about a parent's
death even though it is sometimes inevitable. If you have someone on Ward 22
and you are reading this to seek reassurance, please be reassured, your loved one
is being cared by some of the loveliest people you will ever meet. In the 30 hours
that I sat with my mum the staff showed the same care for all of the patients in
their care. I am certain that they will do the same for your loved one.
I have chosen to remain anonymous only to preserve my mother's dignity.”
An improvement story- these describe what the Trust has learnt from reviewing the quality of
our services and what improvements we are making. The following example demonstrates how
we have made improvements based on feedback received from patients.
22
Following a call from Mrs T to the PALS department the Ward Matron met with Mr and Mrs T to
hear their concerns. This discussion revealed that he was concerned that he was not improving,
was still immobile and unclear of his plan of care. Mrs T was also concerned about her husband’s
low mood and possible factor in poor compliance with physiotherapy for rehabilitation. A meeting
was arranged with the Matron, Consultant and PALS to agree a forward plan of Mr T’s care. With
the involvement of Tissue Viability Nurse and Physiotherapist a full reassessment of care was
undertaken in collaboration with Mr T. A duty of candour was initiated with Mr T and his wife in
view of his pressure ulcer deterioration to grade 4 and RCA completed. Due to Mr T’s deteriorating
pressure ulcer he was unable to have full physiotherapy for rehabilitation and ultimately increased
the length of his admission to hospital.
Following Root cause analysis investigation, the following actions were agreed to make
improvements to practice:
• Flexible visiting times were agreed with the family to support their needs.
• Weekly review and updates to plan of care involved Mr T and his wife
• Staff to monitor Mr T’s mood and ensure medication administered
• Pressure Ulcer prevention re-energised with the ward team
Senior nursing teams were responsible for ensuring completion of weekly risk scores
and triggers acted upon accordingly.
Daily assessment for patients at risk of or who have pressure ulcers to detect pressure
ulcers earlier
Improve written documentation
Improve communication at handover of shift
Ensure non- compliance of treatment by patients is captured in the daily care record.
• Staff to continue to practice shared decision making
Monitoring of practice is important to ensure improvements implemented are sustained therefore;
practice on this ward has been monitored regularly by Sister and Matron. This was last undertaken
in May 2014 and this identified that care reflects compliance with the improvements agreed.
23
Patient Experience
Priority 6: Continue to embed the 15 Steps Challenge
What did we say we would do?
Continue to undertake a programme of 15 steps challenge visits. We will expand this to include
inpatient areas where children are cared for. We will also develop our programme to include outpatient
and day case areas.
Did we achieve this?
Yes we did
How did we achieve it?
Our 15 steps challenge teams consisting of one non-executive director of the Trust Board, one member
of non-clinical staff and a patient representative have continued to undertake a programme of 15 steps
challenges visits this year. They have made 34 visits between April 2014 and March 2015 and have
covered a range of areas including inpatient wards, day case areas, outpatient clinics, children’s services,
maternity services and mental health wards. The table below highlights the areas we have visited this
year.
Month
April 2014
May 2014
June 2014
July 2014
August 2014
September 2014
October 2014
November 2014
December 2014
January 2015
February 2015
March 2015
Areas visited
Ward 14, Ward 2 & Ward 22
PODs (day case surgery ward) & Ward 4
Ward 24, ENT Clinic, Jubilee Day Unit, Ward 3 & Postnatal Ward
Emergency Admission Unit, Special Care Baby Unit & Pregnancy Assessment
Unit
Ward 20 (children’s ward), Paediatric Emergency Assessment Unit &
Children's Outpatients Department
Sunniside unit & Cragside court unit (both Mental Health wards)
Nuclear medicine (medical physics), Chemotherapy Day Unit, Accident &
Emergency & X-ray department
St Bedes Unit (palliative care ward)
Ward 23 (dual care ward)
Physiotherapy Department, Orthotics Department, Colposcopy clinic
MRI Department & Breast screening unit
Endoscopy Unit, CT Department & Pre-assessment unit
Critical Care Department, Ultrasound & urology departments
Local recommendations for change are fed back to the staff in the clinical areas immediately following
the visit. The majority of feedback has been positive however, a number of themes have been identified
across the Trust which are being addressed corporately. These are:
•
Patient information was left visible on the computers on wheels- a SafeCare
Practice Bulletin was developed and distributed to highlight best practice with
staff around patient confidentiality and information governance.
Best
24
•
Lack of information in respect of who is who in the clinical areas- a board depicting who wears
which uniforms has been developed.
•
Direction signage around the hospital can be confusing- a new colour coded signage is currently
being implemented across the Trust
2.2 Our Quality Priorities for Improvement in 2015/16
Our new SafeCare Strategy 2014/17 aims to deliver a programme of work that will reduce harm and
avoidable mortality, improve our patients’ experience and make the care that we give to our patients
reliable and grounded in the foundations of evidence based care. We have set six key priorities for
quality improvement for 2015/16 and these are linked to patient safety, effectiveness of care and
patient experience.
We have established our priorities for improvement in 2015/16 through the following:
Consultation with our staff through a variety of established forums and meetings.
Governor engagement
Discussions with our Patient Panel, Carers Group and Patient, Public & Carer Involvement &
Experience Group
25
Discussions with commissioners and alignment to our CQUIN scheme
SafeCare plans and identified priorities of our clinical services
Internal and external data sources and reports including: Care Quality Commission standards,
recommendations from national reviews into the quality and safety of patient care within the
NHS, local and external clinical audits and analysis of complaints and incident reports.
Progress against existing quality improvement priorities
Alignment with our SafeCare Strategy 2014/17 and Trust objectives
Following Trust Board consideration of our analysis our six corporate priority areas for quality
improvement are:
Priority 1:
Priority 2:
Priority 3:
Priority 4:
Priority 5:
Priority 6:
Reduce avoidable hospital deaths, including focusing on recognition and management of
Sepsis
Implement the ‘Saving Babies Lives’ Campaign
Continue to reduce harmful in hospital falls
Continue to improve medication safety
Implement the ‘ThinkSafe’ project
Implement the ‘Family Voices’ project at end of life
Last year’s priorities of Dementia, implementing Open & Honest Care- Driving Improvements and the 15
Steps Challenge will remain areas of high importance for the Trust and this work is embedded in our
quality improvement and reporting framework. We will continue to drive and monitor progress in these
key areas. Our Council of Governors and Board of Directors are particularly keen to ensure that progress
is maintained.
26
Clinical Effectiveness
Priority 1:
Reducing avoidable hospital deaths focusing on recognition and
management of Sepsis
We will continue to implement our mortality reduction strategy and programme of work over 2015/16.
We will continue to aim to achieve a year on year reduction in mortality utilising the crude mortality
rate, the Hospital Standardised Mortality Ratio (HSMR) and the Summary Hospital-level Mortality
Indicator (SHMI). Our aim is to achieve a lower than expected or as expected SHMI banding.
In 2015/16 a key focus will be improving our recognition and management of patients with sepsis. The
UK Sepsis Trust (2013) defines Sepsis as a “life threatening condition that arises when the /body’s
response to an infection injures its own tissues and organs. Sepsis leads to shock, multiple organ failure
and death especially if not recognised early and treated promptly.”
The documented incidence of Sepsis worldwide is 1.8 million deaths annually however it is suggested
that the real figure is higher due to low recognition and diagnosis. Even using the lowest mortality rate
of 35% for people without comorbidities this would equate to 37,000 deaths in the UK per year (Davies,
2001). The graph below illustrates the rate of mortality for sepsis nationally compared to other causes of
death. Improving outcomes of patients with sepsis has been recognised nationally as being vitally
important. In recognition of this identification and early treatment of sepsis has been identified as a
national NHS England Commissioning for Quality and Innovation (CQUIN) indicator.
Source: Sepsis, ICNARC data 2006
Sepsis is almost unique among acute conditions in that it affects all age groups and presents in any
clinical area and health setting. However, Sepsis can easily be treated through timely recognition and
intervention in the form of the sepsis six care bundle. Nursing and medical staff should work together to
ensure that this bundle be initiated immediately on diagnosis or suspicion of severe sepsis. The Sepsis
Six should be completed within one hour of initial identification.
27
The Sepsis Six Care Bundle
What will we do?
We will improve our performance in relation to the recognition and timely treatment of patients
presenting with sepsis.
How will we do it?
Undertake a baseline assessment of clinical knowledge and practice
We will provide a programme of education sessions for front line clinical staff
We will develop a communication strategy to raise staff awareness of our improvement
campaign
We will promote the use of national screening tools to enable us to better recognise patients
with Sepsis and measure our performance through case review
We will work to improve our performance in relation to the timely implementation of the sepsis
six care bundle and measure this through case review
We will take part in a regional patient safety collaborative where we will work with other Trusts
to share knowledge and learning that will drive improvements in patient care.
We will share our performance and any learning from the ward to the Board and with external
partners.
How will we measure it?
We will utilise clinical audit in the form of case reviews of patient care
28
How will we monitor and report it?
Quarterly to the Mortality and Morbidity Steering Group
Monthly to the Quality Outcomes Meeting
Twice yearly to SafeCare Council.
Yearly to PQRS
Yearly to the Board of Directors
Priority 2:
Implement the ‘Saving Babies Lives’ Campaign
Stillbirth, death of a newborn baby or the birth of a baby with brain injury are life-change events that
affect women and their families for many years.
Current estimates for the UK suggest that around 500 babies a year die or are left severely disabled, not
because they are born too soon, too small, or have a congenital abnormalities, but because something
goes wrong during their labour. The NHS has made it a priority to reduce stillbirth rates in the NHS
Business Plan 2014-15. Reducing deaths in babies and young children: specifically neonatal mortality
and still birth is also a key NHS indicator in the NHS Outcomes Framework. A National care bundle for
reduction in stillbirths and neonatal deaths, which will reduce variations in care pathways, has been
recommended which focuses on key interventions which are evidence based to improve Public Health
outcomes. The focused elements in the care bundle are;
1. Reducing smoking in pregnancy by carrying out a Carbon Monoxide (CO) test at booking to
identify smokers (or those exposed to tobacco smoke) and referring to stop smoking
service/specialist as appropriate.
2. Identification and surveillance of pregnancies with fetal growth restriction.
3. Raising awareness amongst pregnant women of the importance of detecting and reporting
reduced fetal movement (RFM), and ensuring providers have protocols in place, based on best
available evidence, to manage these women.
4. Effective fetal monitoring during labour
What will we do?
We will implement the NHS England care bundle initiative which will run alongside Royal College of
Obstetricians & Gynaecologists (RCOG) ‘Each Baby Counts’ project to reduce the number of stillbirths,
early neonatal deaths and brain injuries in the UK as a result of incidents occurring during labour. We
have set ourselves an ambitious target to reduce still births by 50% annually and to reduce the number
of infants born with birth related injuries by 69%.
How will we do it?
We will implement the NHS England Care Bundle key elements. More specifically we plan to:
Implement robust smoking cessation interventions
Implement and initiate staff training for Customised Growth Charts-identification and
surveillance of vulnerable babies
Work with the regional strategic clinic network to develop and implement patient information
leaflets regarding fetal movements. This is a very important intervention to ensure that we ‘Ask,
Assess, Act, Advise’
RCOG Small for Gestational Age guidelines to be integrated into practice and guidelines
Review capacity for ultra sound scanning in view of proposed increased surveillance
Implement a standardised and assessed measurement of fundal height for all clinical staff
29
Implement a CTG Assessment and training programme for all clinical staff
Implement Peer review of all stillbirths and neonatal deaths
Audit all stillbirth and neonatal deaths as part of maternity risk and governance and report on
the maternity dashboard.
Each case will be reviewed internally and will be peer reviewed. This is already done by regional
RMSO but will report to the RCOG with ‘Each baby counts’ reporting framework. The Perinatal
Institute will audit all customised growth charts and produce reports.
Report cases and results of local serious incident investigation to RCOG ‘Each baby counts’
project. A dedicated team at RCOG will analyse the data sent in by all Trusts in order to identify
avoidable factors in the cases and share lessons learned and develop action plans for local
implementation.
How will we measure it?
We will measure compliance against the bundle of care.
How will we monitor and report it?
Compliance with the bundle results will be utilised to monitor and report progress at maternity
SafeCare meetings
Quarterly to the Mortality and Morbidity Steering Group.
Twice yearly to the SafeCare Council
Yearly to PQRS
Yearly to the Board of Directors
Patient Safety
Priority 3:
Continue to reduce harmful in hospital falls
We set ourselves an ambitious target of reducing harmful falls from 2.40 – 2.0 per 1,000 bed days by
March 2017. We then broke this down further into annual targets to achieve:
Reduced to 2.25 per 1000 bed days by March 2015
Reduced to 2.15 per 1000 bed days by March 2016
Reduced to 2.0 per 1000 bed days by March 2017.
Although we have made some progress in delivering our reducing harmful falls strategy in 2013/14, we
are disappointed that we did not achieve the annual target we set ourselves of reducing harmful falls
from 2.40 to 2.25 per 1000 bed days by March 2015.
We still have improvements to make to achieve the targets we set ourselves and we are committed to
review and understand why patients fall within our care. Whilst considerable work has already been
undertaken in reducing harmful falls, it continues to be an area where we are determined to drive
further improvement. This important area of patient safety remains a Trust priority.
What will we do?
We will review our performance collected via the incident reporting system over the last 12
months to identify any areas for focussed education or targeted improvement work.
We will continue to implement our three year falls reduction strategy and aim to reduce the rate
of harmful falls to 2.25 or less, the target we were unable to achieve in 2014/15.
30
We will focus on the effective and safe handover of patients at nursing staff shift changes to
ensure patients falls prevention needs and treatment plans are clear
We will continue our education programme and awareness sessions for staff, patients and
visitors about falls prevention strategies. We will commence this with a falls out and about trustwide SafeCare session on 1st April 2015 called April ‘Falls’ Day.
How will we do it?
We will continue to embed the new multifactorial falls assessment tool in clinical practice to
ensure all patients receive this on admission and it is reviewed when appropriate.
We will implement a chart to monitor when a falls sensor alarm is in place, it is switched on and
working.
We will continue to monitor where patients fall to identify potential trends and implement
strategies to address this.
We will continue to ensure that all patients receive the post fall care bundle.
We will continue to undertake root cause analysis on all patients who fall and sustain moderate
harm or above and share lessons learned.
We will continue to ensure that our four basic measures for preventing falls are in place:
1. Ask patients on admission if they have fallen recently
2. Avoid unnecessary hypnotic and sedative medicines
3. Ensure patients have appropriate footwear
4. Ensure call bells are in easy reach
We will ensure all healthcare professionals dealing with patients known to be at risk of falling
develop and maintain basic professional competence in falls assessment and prevention.
We will ensure written information on the prevention of falls is given to all patients and carers.
We will ensure health problems that could increase a patient’s risk of falling are considered.
We will ensure we maintain adequate levels of falls alarms available to patients in the Trust.
We will ensure the right level of training and support is available to allow clinical teams to lead
falls prevention improvements.
We will revisit the use of improvement tools such as Safety Cross, Falling Star and Ward
Mapping.
We will review the Situation, Background, Assessment and Recommendations tool (SBAR) to
ensure all patients at risk of falling are identified.
How will we measure it?
We will continue to use Datix reports to monitor the incidence of falls on a monthly basis
We will ensure any learning and actions from root cause analysis are actioned and implemented
How will we monitor and report it?
Monthly to the Strategic Falls Group
Twice yearly to SafeCare Council
Yearly to PQRS
Yearly to the Board of Directors
31
Priority 4:
Improve patient safety by improving the use of Patient’s Own
Drugs.
Medicines remain the most common therapeutic intervention in healthcare, and therefore it is essential
that individual patients and society gets as much value out of them as possible, that they are used safely
and resources are used wisely and effectively.
The current community medicines campaign, My Medicines, My Health,
encourages patients to ‘value’ their medicines and to take them in the
right way and at the right time to stay healthy. In addition, patients are
being urged to use a green medicine bag to keep their medicines together
and to use it to take them into hospital if they are admitted.
It is important that, as an acute healthcare provider, we facilitate the use
of a patient’s own drugs when brought in from home. Currently, patient’s
own drugs make up around 30% of the medicines supplied at discharge.
What will we do?
The increased use of patient’s owns drugs within the hospital have many
advantages for the patient, the Trust and the wider health economy:
•
•
•
•
•
•
Improved drug history
Decreased missed doses
More rapid discharge
Discharge with familiar medicines
Less waste
Decreased costs
We carried out a baseline audit in December 2014 which showed that 31% of patients used their own
medications whilst in hospital and were discharged back home with them where appropriate. We will
increase the usage of Patient’s Own Drugs within the hospital from 31% to at least 50 % by the end
March 2016.
How will we do it?
Medicines management at the interface with the community and within the hospital is complex. There
are many processes that have to be right in order for the management of patients own drugs, in
particular, to be successful. A key component of this process is the safe and secure storage of a
patient’s own medicines - on admission, as the patient moves through the system and then when the
patient is ultimately discharged.
32
Currently, the storage of patient’s own medicines is not of a uniform quality across all wards in the
organisation due to problems with the lockers used to store these medicines.
We intend to review the storage lockers for patient’s own drugs across the organisation and resolve any
identified problems so that the improved use of these medicines is fully facilitated.
In addition, following this work we will be promoting the benefits of patient’s own drugs to ward
medical and nursing staff to improve their usage across the organisation.
How will we measure it?
Each month, we will undertake an audit of how many Patients Own Drugs (PODS) are being used on
sixteen in-patient wards. This will be done by reviewing a number of patients on the wards, to see how
many regular medicines (prescribed prior to admission) they are prescribed on their medication charts,
and of these how many we are using the patient’s own drugs to administer. This will be converted to a
percentage which can be compared to the baseline data to track the increase in use. This will be
recorded at ward level and Trust level.
How will we monitor and report it?
Quarterly to the Medicines Governance Group
Twice a year to SafeCare Council
Yearly to PQRS
Year to the Board of Directors
Priority 5:
Implementing the ‘ThinkSAFE’ project
Improving patient safety is a worldwide imperative. About 10% of hospital patients are harmed, leading
to many approaches to improving safety, including international emphasis on patient involvement. In
the UK, active involvement of patients and families for safer healthcare is a key recommendation of the
recent patient safety reports such as the Francis, Keogh and Berwick reports. Both staff and patients
recognise patient safety benefits from having patients routinely involved in their care.
A research programme, based at Newcastle University,
has worked extensively with patients, relatives and
healthcare staff to develop ‘ThinkSAFE’, a user-informed,
robust approach to supporting patient and family
involvement in improving in-patient safety. There are
four components to ThinkSAFE: a patient safety video; a
patient-held Logbook containing a number of tools to
facilitate patient and professional interactions; the
sharing of information, ‘Talk Time’ – dedicated time to
discuss queries and concerns with staff; and a theory and
evidence-based educational session for staff.
Hence,
ThinkSAFE addresses the needs of both service-user and frontline healthcare staff. A pilot study showed
that the approach is acceptable and feasible and that it can improve patient safety and positively
influences both patient and healthcare professional interactional behaviours.
33
What will we do?
We will join the 2nd phase of this research project along with four other Trusts in the region to develop
an implementation package, including a detailed user-guide and implementation toolkit which ultimately
will become freely accessible to other NHS Trusts and patients.
How will we do it?
We plan initially to implement the ThinkSAFE initiative with patients who undergo orthopaedic surgery.
The initiative will however include involving two groups of staff, one, in the pre-assessment clinic at the
beginning of the patient’s journey and the other, the orthopaedic ward.
The project plan includes:
Quarter 1
Identifying a patient group and project team to lead on the ThinkSAFE initiative
Develop an action plan with the national programme manager
Using professional and patient feedback, contribute to the development of monitoring tools, a
dedicated website and refinement of existing tools and resources from 1st pilot.
Quarter 2
Finalise ThinkSAFE materials and resources
Set up and deliver training sessions for staff groups involved in project
Confirm a robust action plan for starting the test phase
Quarter 3
Start test period with active implementation of ThinkSAFE
Monitor and evaluate implementation from staff and patients
Quarter 4
Final amendments to implementation package and resources to be made from staff and patient
feedback
Consider how/ or what adaptations are required so that ThinkSAFE can be utilised with other
patient groups
Plan the next group of patients for implementation of ThinkSAFE.
How will we measure it?
We will monitor our compliance against the University’s quarterly milestones agreed prior to
commencing the project.
How will we monitor and report it?
Bi-monthly at board to board performance meeting
Twice yearly to SafeCare Council
Yearly to PQRS
Yearly to the Board of Directors
34
Patient Experience
Priority 6:
End of Life Care – implementing the ‘Family Voices’ project
Communication in the last hours to days of life can be very difficult in hospital. A ‘Family’s Voice’ diary,
to help families communicate with healthcare staff at this crucial and sensitive time, is being tested
through a research project. The diary is an innovative tool for the acute hospital setting that promotes
communication between families and clinical staff in real-time by the dying patient’s bedside. It can
contribute to a “good death” for patients through the engagement of their family and carers. It also
provides real-time feedback of the quality of care as experienced by family and carers of dying patients.
What will we do?
We will implement this initiative in St Bede’s, our palliative care ward, and ward 11 with the aim of:
Improving communication between family/friends and the ward team.
Give friends/ family a ‘voice’ on behalf of the patient
Provide real-time feedback to all staff every time they review the patient
How will we do it?
We will ensure that families do not feel any anxiety about the diary at this crucial time. We will also
ensure that families are made aware that the diary does not replace verbal communication and this is
still encouraged. The diary contains questions in relation to any difficulties when families and friends are
in hospital, being treated in a sensitive manner and with dignity, or anything further that could have
been done to help. It is also important that families know that any negative comments made within the
diary will not impact on the quality of care and also that they can discontinue the use of the diary at any
time.
We will implement the initiative by:
Delivering an awareness and education session to all relevant staff participating in the project.
Using the project information booklet to obtain consent from families to participate in this
project.
Ensuring families are aware participation is not compulsory however; those patients and families
who agree to participate will be asked to complete the diary once per day or as often as they
wish.
Reviewing the diary regularly to identify and resolve any issues that need to be addressed.
Ensuring when the episode of care is over, the diary is forwarded to the researcher for analysis.
How will we measure it?
Once the episode of care is over, the diary will be sent off to the researcher. Any data will be recorded
and analysed so that we can see if the diary is helpful to families and friends in various clinical settings. It
is also expected to show a snapshot of the care provided on each ward for dying patients. We will
receive feedback from the researcher in the form of a report, we will share lessons learned and improve
practice where necessary.
35
How will we report it?
Quarterly to the End of Life Steering Group
Twice yearly to SafeCare Council
Yearly to PQRS
Yearly to the Board of Directors
36
2.3 Statements of Assurance from the Board
During 2014/15 the Gateshead Health NHS Foundation Trust provided and/or sub-contracted 32
relevant health services. The Gateshead Health NHS Foundation Trust has reviewed all the data available
to them on the quality of care in 32 of these relevant health services. The income generated by the
relevant health services reviewed in 2014/15 represents 100% of the total income generated from the
provision of relevant health services by Gateshead Health NHS Foundation Trust for 2014/15.
Participation in clinical audit
During 2014/15, 33 national clinical audits and five national confidential enquiries covered relevant
health services that Gateshead Health NHS Foundation Trust provides.
During that period Gateshead Health NHS Foundation Trust participated in 100% of national clinical
audits and 100% of national confidential enquiries which it was eligible to participate in.
The national clinical audits and national confidential enquiries that Gateshead Health NHS Foundation
Trust was eligible to participate in during 2014/15 are listed in Appendix A. This also gives details of the
National Audits that the Trust was not eligible to take part in.
The national clinical audits and national confidential enquiries that Gateshead Health NHS Foundation
Trust participated in during 2014/15 are listed in Appendix A.
The national clinical audits and national confidential enquiries that Gateshead Health NHS Foundation
Trust participated in, and for which data collection was completed, during 2014/15, are listed in
Appendix A alongside the number of cases submitted to each audit or enquiry as a percentage of the
number of registered cases required by the terms of that audit or enquiry.
The Trust utilises clinical audit as a process to embed clinical quality at all levels in the organisation and
create a culture that is committed to learning and continuous organisational development. Learning
from clinical audit activity is shared throughout the organisation from Ward to the Board.
The reports of 14 national clinical audits were reviewed by the provider in 2014/15 and Gateshead
Health NHS Foundation Trust intends to take the following actions to improve the quality of healthcare
provided:
National Clinical
Audit
National
Comparative Audit –
The Use of Anti D
Immunoglobulin
Prophylaxis.
Priority for Improvement
This is a national comparative audit. Anti D is administered to RhD negative
pregnant ladies at various stages of the pregnancy, in order to minimise the
development of maternal anti D which could compromise future
pregnancies. The data was collected from ladies booked in during September
2012, expecting to deliver their baby in 2013. There has been a delay in the
publication of these results, hence only reviewing them during 2014/15. The
results demonstrated that at the Trust 100% of the routine antenatal Anti-D
Immunoglobulin Prophylaxis was given at the correct time and dosage, 100%
of post-delivery dosages were given. Nationally 95.8% of potentially
sensitising events (an event when a pregnant women who is rhesus negative
blood type suffers any form of trauma/bleeding in the abdomen which cause
the maternal blood cross over with the fetal blood) were recorded as having
37
been treated with Anti-D, although 3.7% did not get the correct dose and only
79% received the Anti-D dose within target of 3 days of the event. 58% of the
RhD negative pregnant women had documented that consent had been given
prior to administration of Anti-D, 39% received an information leaflet.
Sentinel Stroke
National Audit
Programme (SSNAP)
The following actions have been identified in order to improve this service:
Actions:
• Circulate results of the audit to all relevant staff
• Transfusion to consider supplying Anti-D to improve the traceability of the
product
• Review and update Anti-D patient information leaflets
This is a national audit of stroke patient care in England. The data is collected
prospectively about the patient’s admission and hospital stay until their
discharge. Subsequently, the stroke data is used to look at mortality up to 30
days post discharge. The mortality data is adjusted for case mix, thereby
providing a unique advantage over the Dr Foster data.
There is now strong evidence from SSNAP that mortality on stroke units is
directly linked to the numbers of trained nurses on the ward.
Due to the nature of stroke care, this involves a number of specialties working
as an interdisciplinary team. There are areas of good practice at the Trust.
However, there is room for improvement across a number of areas. These
areas have been highlighted in the past.
The following actions for improvement have been identified:
National Care of the
Dying audit 2014
Actions:
• Develop seven day working in therapy services in line with national
standards and to resource adequate therapy levels.
• To develop psychology services to meet the growing demands of the
service.
• To develop regular dietetic input to the ward.
• To ensure that there are sufficient numbers of trained nurses on the ward.
In addition, ensure that trained nurses are not moved from the ward to
cover staff sickness on other wards.
• Develop an action plan to improve joint health and social care planning,
assessment of mood and cognition
• Continue to implement staff training to improve the care of stroke
patients.
• To ensure that the Emergency Department is staffed appropriately at night
to deal with the hyper acute stroke patient.
The Trust’s overall result is very good. The audit was divided into 3 main areas
:
1. Organisational audit
2. A retrospective case note review of 50 patients
3. A local survey of bereaved relatives
Results
- The organisational audit results were very good in terms of clear
policies and guidance being in place for end of life and a formal
feedback process for relatives. The gaps were a lack of 24/7 specialist
38
palliative care service and no clear continuous audit and education
programme on end of life care.
- The clinical audit revealed excellent clinical performance indicators, all
well above national average except for the number of reviews in last
24 hours of life.
- There were only 5 responses received to the local survey of bereaved
people. The comments received emphasised the need for clear
discussion at the end life.
The following actions have been identified in order to improve the services
provided to patients at end of life:
Audit of Patient
Information &
Consent
Actions:
• A continuous audit programme on care in the last few days of life to be
put in place by July 2014 which will report to the End of Life Steering
Group.
• End of life training to become mandatory in the trust by December 2014
and to develop an education strategy for how this training will be
provided.
• Development of a documentation tool for care provided in the last few
days of life which will emphasise need for clear communication and
review.
• Revision of the feedback process from relatives for care given in the last
few days of life.
• Discussion with the commissioners regarding 24/7 access to specialist
palliative care
This national audit consisted of three parts involving a review of the patient’s
records (clinical case notes), a staff and a patient survey:
The results demonstrated of the audited transfusions, 92% of patients felt
that they had been involved in the transfusion decision making process. 75%
of patients felt they had been given sufficient information about their
transfusions. However there were areas highlighted that could benefit from
improvement; obtaining valid consent, developing a more standardised and
structured approach for providing information to patients and obtaining
patient consent with the emphasis on appropriate documentation and staff
training.
National Cardiac
Arrest Audit
Actions:
• Present the results of the audit at staff training sessions
• Increase the availability and awareness of blood transfusion patient
information leaflets
• Review the blood transfusion record
• Promote use of ‘LearnBlood’ Transfusion e-learning package at staff
induction
The numbers of cardiac arrests per 1,000 hospital admissions has remained
stable at approximately 0.42 – 0.44. This compares favourably with national
statistics.
The annual total hospital admissions for 2014 were 2000 more than the
previous year however, overall calls were less (184 compared to 202). The
39
numbers of actual cardiac arrests were actually slightly increased. We
continue to have older (75+) and more elderly (85+) patients in cardiac arrest
than the national average. We also have more non shockable rhythm cardiac
arrests and less shockable types which have an impact on our overall survival
rates. Nationally, survival to discharge is approximately 17% however our
survival rates are 7 – 8%.
The following actions have been recommended.
National Diabetes
Audit
Actions:
• Continue to promote early anticipatory decisions relating to resuscitation
for all acute admissions by consultant review.
• Monitor the implementation of DNACPR forms against numbers of cardiac
arrests.
• Continue to Identify factors contributing to cardiac arrests in hospital by
performing retrospective reviews on a proportion of cardiac arrests
identifying events in the previous 48 hours
• Continue to support clinical areas where patients are more likely to suffer
cardiac arrest.
• Audit the post arrest period of care following return of spontaneous
circulation to identify potential improvements of care.
The audit looked at patients who were seen in secondary care between
01/01/12 to 31/03/13. The report focuses on care processes and treatment
targets. The results demonstrated that the Trust was not meeting the target
of 95% of patients receiving one of the eight care elements/processes, we did
meet 95% of patients for three elements/processes (blood pressure, body
mass index and smoking). We did not meet the target of 65% for patients
receiving all eight elements/ processes. Our results were all patients 54.4%,
Type 1 diabetes 45% and Type 2 diabetes 61.4%. When comparing data
nationally, compliance is 59.9% for England and Wales. The Trust have taken
part in the audit for the first time, which is an achievement in itself as this has
been a lot of hard work
We do meet the target in one of the care process (Smoking) and almost meet
it on two (BP, BMI). There is significant room for improvement in three care
processes (Serum Creatinine, Urine Albumin, Feet Screening).
Other hospitals in the region seem to be performing better. All of them have
been participating in the audit for some time. These results give a clear
picture for us to focus upon improvement.
The following actions/points for discussion have been identified:
Actions
• Proactive approach: Diabetes is a chronic disease and the follow up
appointments are usually every 6-12 months. This provides time to have
ALL the investigations undertaken (blood, urine, etc.) before rather than
on the day of follow up.
• More focused documentation (the Diabetes Form we use needs updating
to cover all the required for the audit information).
• Dedicated software is essential for live monitoring (rather than
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retrospective) of our performance. The 15 month period being captured
by this audit is a lot of time and we would be able to complete all the
observations requested provided we know what is missing.
• It has been recognised that the time was taken to release the reports from
each year’s audit makes it very difficult to elaborate on the results and
implement changes. This has been addressed centrally.
Severe Trauma Audit Overall the results April – November 2014 are favourable. We have the 2nd
& Research Network best Ws score in the Northern Trauma Network and we are in the top 10
(TARN)
hospitals in the country. A Ws score represents the number of excess deaths
or survivors per 100 patients standardised according to hospital case mix
using a calculation devised by TARN. The Trust Ws score was 4.05; this means
we achieved 4 excess survivors per 100 patients than was expected. The time
for patients to undergo a Computed Tomography (CT) scan is 0.8 hours which
is the same as the previous 12 months and 0.7 hours for significant head
injuries which is down from 0.8 hours the previous 12 months.
The data completeness figure for April – September 2014 has reduced and
measures have been identified to address this.
National Diabetes
Audit – Paediatrics
Actions:
• Improve data completeness to 80% by reviewing methods of patient
identification and investigating whether the number of expected cases is
accurate or whether this is too high
• Implementing fast track policies for CT scan including PAN CT scan for
head, neck, chest, and abdomen/pelvis to try and improve the time to CT
and times to reporting
• Developing and implementing an open fracture clinical guideline to ensure
British Orthopaedic Association Standards for Trauma (BOAST) national
guidelines are being followed
This national audit looks at the service provided for children and young people
with diabetes between 0-19 years of age. The audit results look at the period
prior to the Diabetes Psychologist being appointed in January 2014 and
following the expansion of the clinic to provide transitional care for children
and young people up to 19 years of age without any additional resources.
This has had a detrimental effect on the Trust performance in the audit.
The Trust achieve highly on HbA1C and annual review screening review with
the exception of routine venepuncture for lipids in the 12-16 year group
(HbA1C is a test usually done from a fingertip blood test, this measures
diabetes management over two to three months). However, the Trust is an
outlier regionally and nationally for HbA1C outcomes as only 13.9% of patients
HbA1C level is 58mmol/mol or less as per the target. The 2013/14 results
have also identified an issue with data entry for screening processes.
The following actions have been identified:
Actions:
• To explore the best use of current paediatric diabetes resources within the
Trust and Clinical Commissioning Group (CCG).
• To continue to deliver a best practice service to children and young people
under 16 years
• To support children and their families to self-manage their diabetes
41
•
College of
Emergency Medicine
– Asthma in Children
College of
Emergency Medicine
– Paracetamol
Overdose
Myocardial
Ischaemia National
Audit Programme
(MINAP)
To improve long term health outcomes for children and young people by
following the high HbA1C pathway for children and young people under 16
years old
• To ensure that all members of the multidisciplinary team complete all of
the data required into the national database
• To continue to actively support the local patient support group
This national audit looked at the care provided to children attending the
Accident & Emergency Department with moderate to severe asthma. The
audit results demonstrated that the Trust is very good at documenting
respiratory rate, oxygen saturation levels, heart rate and temperature. Good
treatment was acknowledged within Accident & Emergency with only 4/50
cases where there was no documentation of the medication used. The audit
did highlight some areas for improvement in relation to better documentation
of peak flow before and after treatment, ensure medication given on
discharge is recorded as such and recording of the time that medications are
given.
Actions:
• Education and training for nursing staff of the need to measure peak flow
on initial assessment.
• Raise awareness with relevant staff to remind them to refer to the Trust
guideline “Management of Acute Exacerbation of Asthma in Children &
Young People”
• Undertake a re-audit locally to measure improvement.
This national audit looks at the care provided to patients within the Accident
& Emergency Department who overdosed on paracetamol. There have been
some limitations interpreting the results of this audit due to the way in which
they have been published. The options of free text and not applicable were
added as options on the audit tool and the analysis of these have affected the
way in which the results have been published and benchmarked nationally.
Actions:
• The Trust is in the process of validating the data to understand where
improvements could be made to our service.
• A teaching session for junior doctors has been set up to share the results
once validated.
This national audit measures the quality of management of patients suffering
heart attacks (myocardial infarction) and angina (acute coronary syndrome) in
hospitals in England and Wales. The audit enables the Trust to measure its
performance against targets in the National Service Frameworks, which in
turn enables the Trust to improve the care and treatment of these patients.
The Trust continues to maintain a high level of performance in patient
management across key standards. Of note from last year were the concerns
regarding Secondary Prevention Medications. Over the last year this has been
consistently 100% in patients who are eligible to receive these medications on
discharge (especially ACE inhibitors – medicines used to treat high blood
pressure). On review of recent performance, it was noted that the problems
were related to IT issues (this also enabled us to review our data input)
42
National Bowel
Cancer Audit (NBCA)
Actions:
• Continue to ensure consistency of input of information into the cardiology
database by weekly review of data via electronic patient administration
system in collaboration with the Information Technology department
• Chest pain nurses to continue with data input and high standard of review
within A&E Department to ensure smooth flow of patients appropriately.
These nurses to be utilised as a cardiology resource in other areas.
• To ensure that all of the cardiology team are aware of the value of MINAP
data and its value to the general public
The colorectal team at Queen Elizabeth Hospital (QEH), Gateshead carry out
all methods of surgical treatment for colorectal cancer. Results from QEH have
been compared to those of the NBCA.
Overall the QEH performs well; we do not represent an adverse outlier in any
category and perform well compared to national figures in several areas. The
North East as a whole are doing very well compared to national figures for the
use of laparoscopic (keyhole) surgery in the treatment of colorectal cancer.
NBCA figures show our laparoscopic completion rate at 64.2% where the
national average is 44%. We feel that the 64% is an underestimation of our
use of laparoscopic access and perhaps better documentation and coding
would show this to be the case. Another area of success is in our low
postoperative length of stay. Only 52% of patients have a length of stay
greater than 5 days compared to a national average of 67-88%
(colonic/rectal). This represents a success of our well established Enhanced
Recovery Programme and the use of laparoscopic surgery. Our mortality and
re-admission rates compare favourably to national figures, though the
readmission rates may be falsely high due to the way in which attendances on
the ward were documented and recorded which has now been rectified.
Lung Cancer
Chronic Obstructive
Pulmonary Disease
(COPD) Audit
Actions:
• Better recording/documentation/coding regarding laparoscopic colorectal
surgery
2014/15 has been a year of transition in lung cancer with national audit
transferring providers. The Trust input remains at usual levels and we have
concentrated on trying to improve the Multidisciplinary Team (MDT). We
have carried our internal audit to ensure data quality. We expect to start
having surgical input into the local MDT from summer 2015.
Actions:
• Surgical input into the local MDT to commence in summer 2015.
This audit looked at the care given to patients with COPD. COPD is the name
for a collection of lung diseases including chronic bronchitis, emphysema and
chronic obstructive airways disease. People with COPD have difficulties
breathing, primarily due to the narrowing of their airways, this is called airflow
obstruction. Typical symptoms of COPD include:
• increasing breathlessness when active
• a persistent cough with phlegm
• frequent chest infections
The comparative data shows that we have a well-defined infrastructure, one
43
of the highest rate of COPD and exacerbation (a flare up or worsening) of
COPD needing hospitalisation in the country. However our specialist service
staff numbers lagging behind the rest of the country. There are aspects of this
audit that still need to be analysed and published. Once the analysis is been
completed an action plan will be developed with clear goals on how the
service will be improved if necessary.
Outstanding National Audit Reports to be published in 2015/16
National Heart Failure Audit
National Potential Donor Audit
Heavy Menstrual Bleeding
The reports of 22 local clinical audits were reviewed by the provider in 2014/15 and Gateshead Health
NHS Foundation Trust intends to take the following actions to improve the quality of healthcare
provided:
Local Clinical Audit
Priority for Improvement
A re-audit project to
measure the Trusts
compliance with
Endoscopy Global
Rating Scale Standards
for Oesophageal Stent
Insertion
This is a re-audit looking at 2013-14 data following previous audits of
endoscopic stent insertion reported in 2013 for 2010-2011 and 2010 for the
period 2007-2009.
Our 30 day mortality data for the last audit period appears to have improved
on the previous five years – although numbers are small, so this should be
interpreted with caution.
Actions:
• Develop a simple dysphagia (swallow assessment) scoring system and add
this as a mandatory field to the Dendrite system (electronic information
system).
• Patients to be given written dietary information on leaving the endoscopy
department. (This is available via the intranet). While this is not a
substitute for dietician input, it does ensure that all patients will receive
appropriate basic dietary information on discharge from the endoscopy
unit.
• Proposal to change local guideline to be discussed at Annual General
Meeting to state that all patients have a chest x-ray 4 hours after
oesophageal stent insertion
An audit to determine The results demonstrate that for the numbers of screening tools completed
whether the falls
within Accident & Emergency this practice could be improved. The staff were
screening tool for
aware of the risk of falls to patients aged over 65 years, however time
patients over 65 years pressures within the assessment period contributed to the form not being
old is being completed completed.
within the Accident &
Emergency
Actions:
Department
• Provide further education to staff on the importance of completing the
falls screening tool
• Review the role of the screening tool in the wider falls and syncope
(partial or complete loss of consciousness) referral pathway
44
An audit to look at the
use of Proton Pump
Inhibitors (PPI)
(antacids) in patients
with risk factors for
Clostridium Difficile
Infection
There was a total of 88 patients on the four wards with 42 of these (48%)
prescribed PPIs and 30 of these (34%) prescribed PPIs and antibiotics, 3 of
which had their PPI stopped while on antibiotics. Two consultants were shown
to stop PPIs while patients were prescribed antibiotics and it is appropriate
that this should become common practice with all medical staff. The PPI
should also be reviewed upon finishing the antibiotic course and if there is no
clinical indication for the PPI to be continued it should not be restarted and
clear notes made on the patient discharge summaries.
Actions:
• Clinical Guidelines to be developed regarding withholding PPIs if clinically
appropriate (i.e. the patient has no active GI bleed or ulceration), for the
duration of antibiotic use and also for 7 days thereafter.
• Re-audit following implementation of clinical guidelines in order to
measure effectiveness and improvement
An audit to look at the The results of the audit demonstrated high level of compliance with
care provided to acute documenting type of cancer and contacting consultant directly with patients
oncology patients
requiring oncology services. It did highlight that improvement could be made
within the Medical
in relation to documentation of named specialist consultant, documentation
Assessment Unit
of named cancer clinical nurse specialist, documentation of intention of
(MAU)
treatment and contacting oncology services regarding cancer related
admissions.
Actions:
• Amend proforma used when oncology patients present to MAU to include
sections to record; named specialist consultant, named cancer clinical
nurse specialist, intention of treatment and contacting oncology services
regarding cancer related admissions
• Distribute amended proforma and raise awareness of changes with
doctors in MAU
• Display posters containing contact information for QE oncology services in
MAU.
• Display list of Freeman Hospital oncology contact details within MAU
• Display contact details of consultants and associated special interests
within MAU
An audit to determine This audit was undertaken in response to a screening inspection the Trust
whether Specialist
underwent by the Quality Assurance Reference Centre (QARC) in which it was
Screening
identified that SSPs were being asked to be the support for patients instead of
Practitioners (SSPs)
an endoscopy nurse due to staffing pressures. It was acknowledged that this
are being used to
practice is not acceptable and that an audit should be undertaken to
offset the shortage of determine if this still continues.
endoscopy nurses on
Seven bowel cancer screening lists were monitored to ensure the correct
the bowel cancer
complement of endoscopy nursing staff supported the service. Results have
screening list at
shown this to be the case and the practice of requesting the SSP takes on a
Sunderland Royal
dual role within the endoscopy room has now ceased in accordance with the
Hospital
request of the Quality Assurance Reference Centre.
Action:
• Re-audit to be undertaken on a six monthly basis to ensure that the
practice remains as per the guidance set by the QARC
45
An audit to ascertain
whether the World
Health Organisation
(WHO) Surgical Safety
Checklist is being used
appropriately
The audit demonstrated that there is scope for significant improvement.
Actions:
• Distribute audit findings to relevant staff to make them aware of the
issues
• Establish executive and clinical leads to champion the use of the checklist
• Raise awareness with further education and training sessions with leads
from surgical, anaesthetics and nursing teams
• Standardise team brief
• Ensure that the completion of the checklist is a priority within
emergency theatre lists
A re-audit to
The results of the audit demonstrated that there was room for improvement,
determine whether
40% of patients had an AMTS done compared with 44% in 2013. Of the
Abbreviated Mental
patients that had confusion, 50% of patients had an AMTS done, compared
Test Scores (AMTS)
with 56% in 2013. Of the patients who did have an AMTS, the documentation
were undertaken on
was good – all proforma clearly legible with dates, time and signature of
Admission for patients clerking
over the age of 65
years old
Actions:
• Share audit results with relevant staff
• Change location of AMTS box in clerking proforma (currently hidden in
middle of neurological examination) in order to stand out more
• Further staff education and awareness raising and prompts for staff to
reiterate that AMTS must be done for ‘All patients admitted with
confusion’
• Additional box to be added to tick if AMTS attempted but abandoned and
space for reason why e.g. communication difficulties.
• Extra column alongside initial AMTS result with ‘date’ and ‘score’ to allow
for easy comparison if repeated at a later date to monitor progression.
An audit to measure
Of the 10 cases identified over a 24 month period, recognition of children with
whether management Meningococcal disease, appropriate initial management was good; all had
of Bacterial Meningitis appropriate investigations and treatment, however not all had their blood
& Meningococcal
pressure and neurological assessments checked. The average time to
sepsis for children and antibiotics was 3hrs 58 minutes. Four patients were not offered follow up in
young people is done paediatrics outpatient clinic.
in accordance with
Actions:
National Institute for
Health and Care
• Further education for staff around recording blood pressure, neurological
Excellence
assessment of all patients, completion of fluid balance sheets and all
children should be referred to audiology and have an outpatient follow up
appointment
An audit to monitor
There were 22 patients included in this audit. 55% were already on
the physical health of antipsychotic medication (a range of medications that are used for some types
patients on
of mental distress or disorder - mainly schizophrenia and manic depression
antipsychotics, in
(bipolar disorder)) at time of admission and 45% were started on
Gateshead Old Age
antipsychotics during admission. The results of the audit demonstrated that
Psychiatric wards
although physical health is monitored more often than required in this policy,
the standards of physical health monitoring were not met in full. The
monitoring is focused on the medical problems and not related to the
46
antipsychotic prescribing. Blood pressure, weight and body mass index (BMI)
monitoring (performed by the nursing staff) met the standards in full. Areas
identified for improvements were highlighted in monitoring glucose level
(especially fasting level), thyroid function, lipids, prolactin level and there is a
need for a documented monitoring plan. The kardexes should be completed
fully and should be rewritten in accordance with the Trust policy. The GP
discharge letter should contain a clear plan for on-going monitoring of
patients prescribed antipsychotic medication (when the next monitoring date
is due and who will carry this out – Gateshead Trust/GP).
A re audit to measure
whether actions
identified and
implemented to
improve nutritious
snack provision to
inpatients have been
effective
Actions:
• Raise awareness of the policy to ensure that all medical and nursing staff
are aware of the requirements and to ensure that best practice is provided
on a daily basis and in accordance with national guidelines.
• Development and implementation of a Trust policy related to physical
health monitoring of patients prescribed antipsychotic medication.
The results of the audit have shown that there has been a big improvement in
the awareness of the snack menus. The overall number of snack menu cards
being completed at ward level has quadrupled. The number of high risk
patients having nutritional snacks requested has increased by 36.2%.
However there are some areas where the service could be improved; high risk
patients being identified as requiring a nutritious snack but not having a snack
menu sent to kitchen and the service seemed to perform worst on a Monday.
Actions:
• Design future audit to look specifically at one of the problems identified
from the results of this audit. For example, 58% of the patients that have
been seen by a dietician and a nutritional snack has been suggested for
the patients treatment plan, did not have a menu card to request the
snack. As this is the most at risk group and the deficit is so large, this is the
area that will be focused upon in the future
• Consult with SafeCare Department on development and design of the
audit form
An audit to measure
The audit looked at 45 patients with spontaneous pneumothorax Overall
the management of
compliance with the guidelines was 58%. Management of patients with
Spontaneous
underlying lung disease and tension pneumothorax was excellent with 91%
Pneumothorax (air
and 100% compliance with the guidelines. For patients without underlying
that is trapped
lung disease compliance was 47%. Of the 25 errors made, 22 were due to
between a lung and
over-management including unnecessary pleural aspiration (a procedure
the chest wall that
where a small needle or tube is inserted into the space between the lung and
develops for no
chest wall to remove fluid that has accumulated around the lung), inter-costal
apparent reason on an chest drain insertion (drainage of the chest using a chest tube) and admission.
otherwise healthy
It was also found that information provided to patients on discharge could be
person) in a District
improved.
General Hospital
Actions:
Emergency
• Develop a training and education programme for relevant Emergency
Department
Department staff on British Thoracic Society guidelines in relation to
management of spontaneous pneumothorax
• Produce patient information leaflet for patients on discharge
47
•
An audit to monitor
compliance with
prescribing Venous
Thromboembolism
(VTE) (blood clot)
prophylaxis
(treatment) in
obstetrics
An audit to look at the
role of HE4 testing
(test for ovarian
cancer) in primary
care in women with
vague abdominal
(tummy) symptoms
A project to
determine whether
breast magnetic
resonance imaging
scan (MRI) from
request to second
look ultrasound scan
(USS) - is it performed
in a timely manner
Produce visual aid/checklist for management
pneumothorax to displayed in Emergency Department
of
spontaneous
The results identified that VTE risk assessment was completed at booking for
90% of patients. 14 out of 30 women had an identifiable risk at booking
prompting referral according to guidelines, 50% were referred to the
antenatal clinic. 100% of women had a VTE risk assessment complete during
established labour. 100% of women had a VTE risk assessment complete on
admission to the post-natal ward. However only 60% of women had VTE
prophylaxis correctly prescribed following caesarean section.
Actions:
• Clarify with staff which risk factors prompt a referral to antenatal clinic
• Update VTE clinical guideline to confirm that following a caesarean
section all women should have at least 7 days VTE prophylaxis unless
contraindicated (a condition or factor that serves as a reason to withhold
a certain medical treatment)
• Ensure that pregnant lady’s hand held notes contain the most recent VTE
clinical guidelines
156 who presented in primary care with vague abdominal symptoms had an
HE4 test alongside with CA125 (a blood test for ovarian cancer). Of those 156,
146 (93.6%) had a normal CA125; of which HE4 was normal in 124 (85%) and
raised in 22(15%).
A total of 10 (6.4%) had an abnormal CA125; of which 4(40%) had a normal
and 6(60%) an abnormal HE4 result. Two patients had cancer and both
tumour markers were raised in both cases. The results demonstrate that the
addition of HE4 testing to CA125 in primary care may improve the diagnostic
test accuracy statistics for ovarian malignancy (cancer) and assist
management protocols.
If this practice is to continue, the impact on imaging referrals needs to be
further assessed and a decision is required on further practice. If continuation
is decided then wider involvement of local gynaecology clinics and radiology
department is needed.
Actions:
• Review data retrospectively to assess whether extra trans-vaginal
sonography (TVS) referrals have been triggered as a result of introducing
the HE4 test.
• Team meeting to be arranged to discuss and decide future of test
• If decided that this practice will continue wider involvement of local
gynaecology team and imaging department will be required
There has been a 51% increase in the number of urgent preoperative MRI
scans since the previous audit in 2012. The average time from request to scan
has decreased despite this additional demand. All scans were performed
within the standard of 2 weeks apart from those delayed by patient choice
due to holidays. All scans were first read (result available to clinician) within
the standard of 7 days with an average of 2 days. Double reading (where two
doctors look at the results and give a report, these reports should match)
occurred with an average of 3.7days. Only 77% were double read. Second look
USS was performed in 12 cases with an average interval of 7.5days, 4 cases
48
according to protocol
exceeded the target of within 7 days.
Actions:
• Develop an education programme in order for more radiologists to gain
training/experience in breast MRI
• Raise awareness with staff to ensure that all reports are first read within 3
days of examination
• In order to minimise delays for second look USS reporting radiologists to
request any further breast imaging at time of report
An audit to measure
The results of the audit identified that problem lists were present in 86% of
whether we are
surveyed inpatients notes therefore a high percentage of inpatients notes are
meeting the standards meeting the QE standard for one problem list in hospital notes per week. On
for documentation of average there are over two problem lists in every patient’s notes per
problem lists in
week. Social issues were included in 70% of cases.
medical notes in
However the audit did highlight that improvements could be made in relation
elderly care wards.
to the inclusion of escalation plans within the problem lists as they are
Problem lists are
currently rarely included and 14% of inpatients notes did not contain a
essential in hospital
problem list for the previous week. The audit results demonstrated significant
notes to allow staff to variability between wards.
document, remember
and address relevant
Actions:
issues in patient
• Undertake a campaign to improve awareness of Trust guidelines on the
care. They are
requirement to include problem lists in inpatients notes
especially useful for
• Provide education and training for staff in order to improve percentage of
on-call doctors who
inpatients notes with weekly documented problem list including escalation
do not normally look
plans and social issues
after the patient, to
give a brief up to date
picture of relevant
problems and
developments in the
patients admission
During the audit period, 93 women referred with low grade cytology high risk
An audit to measure
the accuracy of DySIS (HR)/Human Papilloma Virus (HPV) positive were examined with the DySIS
colposcope.
Colposcopy (DySIS
colposcopy is a
The results demonstrated that the procedure was very successful, for 70
detailed examination
of the cervix (the neck (75%) of them histology is available and this was analysed. The sensitivity of
of the womb. DySIS is standard colposcopy for Cervical intra-epithelial neoplasia (CIN), CIN2+ in the
above population was 13% improving to 80% with the incorporation of the
a high performance
DySISmap.
imaging system
designed specifically
to provide your doctor Actions:
with advanced
• New colposcopists joining the department to be trained in using DySIS
information about the
colposcope
cells that cover the
• Results to be compared with the same group of patients examined by
delicate lining of the
conventional colposcopes
cervix). In patients
• Patient satisfaction survey to be undertaken with those patients who have
referred to clinic with
been examined using the DySIS colposcopy
49
low grade smears
•
A re-audit to measure
whether all decisions
regarding both
‘trauma’ and
‘discussion’ patients
should be
documented in the
patient’s notes after
the morning trauma
meeting.
Even distribution between both lists (5% trauma; 5% discussion)
Similar trend in respect to who is documenting in the notes
An audit to assess
whether patients
meet their nutritional
requirements with
ward based snacks
alone or if they do
require the extra
supplements during
their admission
following an operation
for fractured neck of
femur (broken hip)
Re-audit to re-assess accuracy/performance when larger patient
numbers will be available
The results identified that approximately 16% of decisions are not being
documented in the patient’s notes. This is an improvement since the audit in
July 2014 (25%)
All members of the team are actively involved in making sure decisions are
being documented in the notes
Increased awareness of importance of documenting trauma meeting decisions
A drop from 25% of decisions not being documented in the notes to only 16%
Actions:
• Night SHO/Trauma nurse to make sure wards have patient notes available
in the morning (on a trolley)
• On Ward 14 the SHO should be responsible for writing in the notes
• F1 to write on blank sheet to be added to the notes later where notes not
available
The main findings from this audit were that none of the fractured neck of
femur patients who were reviewed met their estimated nutritional
requirements through oral diet alone. Three patients who were already
prescribed supplements however were meeting at least one of their estimate
energy or protein requirements with both their oral diet and their prescribed
supplements.
An area of good practice was the fact that each of the patients did have a food
record chart. However improvements could be made in the timeliness and
quality of information contained within the chart.
Actions:
• Making sure that the fractured neck of femur pathway is implemented and
that all the patients admitted onto the ward with a fractured neck of
femur are prescribed either 2 Fortisip Compact or 2 Fortijuice supplement)
a day throughout their whole hospital admission.
• If the patients dislike the Fortisip or Fortijuice supplements finding a
similar nutrient providing supplement for them to have as an alternative
e.g. Nutilis
• If the patients dislike all the supplements then commence them on a snack
menu regardless of their Nutritional Risk Score.
• If the volume of supplement is too much, consider an alternative
supplement that is smaller in volume e.g. Calogen Extra Shot.
• Providing education and training to all ward staff including the doctors
regarding the fractured neck of femur pathway and its benefits, how to
complete the Nutritional Risk Score tool correctly and what each of the
scores means in relation to patient care e.g. offering Build Ups or referring
the patient to the dietician and which patients are eligible for the snack
menu e.g. even those patients who don’t have an Nutritional Risk Score of
50
•
Annual Suicide
Prevention and
Ligature Audit
2013/14
6 or more.
Providing training to all the staff on ward 14 around the completion of the
food record chart. Ensure it is explained to them what to do if a patient is
refusing their meal or having a small amount as well as encouraging them
to note down what snacks the patient has had to help us get a better
overall idea about what the patient is actually managing
The audit results showed a 50% increase in self harm events, which reflects
the findings of the National Suicide and Homicide Annual Report.
The in-patient wards demonstrated evidence in core care plans and
documentation that indicate a green light in relation to Standards 1-4 of the
audit; Standard 1 (appropriate level of care), Standard 2 (inpatient suicide
prevention), Standard 3 (post-discharge prevention of suicide) and Standard 4
(family or carer contact). Core care plans provided the evidence in the inpatient wards that demonstrate effective risk assessment, review,
patient/carer involvement and communication.
Introduction of core care plans across all areas would further improve the
service.
An audit to determine
the rate of Venous
Thromboembolism
(VTE) risk assessment
and antibiotic
prescribing practices
in medical inpatients.
An audit to measure
compliance with
National Institute for
Actions:
• Link nurse from each ward and department to attend Suicide Action Group
Meeting.
• Ward Manager’s check list to continue
• Community Mental Health Team audit tool to continue and be rolled out
to include Ellison Unit.
• Dendrite (electronic system) – all other departments have green light for
all standards due to clear, completed documentation. Electronic system is
a barrier to effective documentation and sharing information and this area
does need further discussion.
The drug charts of 207 medical inpatients across 11 wards at the QE Hospital
were audited as part of the usual ward round. 93% of patients audited had a
VTE risk assessment documented on their chart. Of the 84 patients who were
prescribed antibiotics, 99% were prescribed in the correct place, 88% had a
documented contra-indication and 70% had the planned duration on the
chart. The results demonstrated that the majority of patients are being
assessed for VTE risk and antibiotics are prescribed appropriately There is
room for improvement as we are aiming for 100% adherence and attention
needs to be paid particularly to the duration of antibiotic therapy.
Actions:
• To raise awareness of prescribing practices in the QE via a presentation of
findings at meeting of Association of Northern Physicians
• Audit findings to be presented in order to ensure pharmacy are aware of
prescribing practices audit findings to be communicated to pharmacy
department
The results of the audit demonstrated that attendance rates for the Elgin
Centre and the Blaydon Centre evening clinics showed to be around the
average and had high levels of cancellations rather than Did Not Attends
51
Health Care Excellence
(NICE) guidance managing overweight
and obesity among
children and young
people: lifestyle
weight management
services
This audit aims to
assess current
benzodiazepine (a
type of medication
known as
tranquilisers)
prescribing activity in
patients admitted to
the old age psychiatry
wards, at the QE
Hospital and assess
whether this is done
in line with the
Committee on Safety
of Medicines (CSM)
and NICE guidance.
(DNA’s). However the attendance rate at the QE evening clinics fell below
the average attendance rate and had high levels of DNA’s and was poorly
attended compared with the other two clinics. There were big variations in
attendance levels at the QE compared with the Elgin Centre and Blaydon
Centre during the summer holidays.
Actions:
• Due to the attendance rates, the recommendation is to stop the QE
evening clinic and instead offer patients slots on the Elgin clinic
Full data was collected for 31 patients aged between 61 years to 95 years.
Out of 31 patients, 10 (32%) had been prescribed a benzodiazepine prior to
admission. During admission, benzodiazepines were prescribed in 22 patients
(71%). The result showed that it was not documented that the risks of
prescribing benzodiazepines had been discussed with the patient or next of
kin prior to the prescription in any of the patients notes (0%). For all of the
patients who had ‘as required’ medication prescribed, there was a clear
indication for use documented on the medication chart (100%).
• Out of the 22 patients prescribed benzodiazepines, this was
reviewed in the weekly MDT meeting in 21 cases (95%). In the
other case, no documentation of review could be found.
• 2 patients were documented to have had one or more falls
during admission, one of these patients was prescribed a
benzodiazepine and the other was not.
• 10 patients (32%) were prescribed a benzodiazepine for longer
than 4 weeks.
• There were 6 patients out of 31 (19%) discharged on a
benzodiazepine. 4 of these patients were prescribed as
required Lorazepam 0.5mg. One was prescribed regular
Temazepam, and one prescribed regular Clonazepam.
• Of the 10 patients who had been prescribed a benzodiazepine
prior to admission, 4 of them were discharged on a
benzodiazepine, and the initial benzodiazepine was stopped in
the other 6 cases.
• The other 2 patients discharged on a benzodiazepine, this was
started during the admission.
• A clear indication for use was documented in 4 out of the 6
cases where patients were discharged on a benzodiazepine.
• 3 of the 6 patients discharged on a benzodiazepine had a follow
up plan and duration of use clearly stated in correspondence to
the GP.
• Documentation of indication for use of benzodiazepines
• Not many patients being discharged on benzodiazepines
• Prescriptions are generally being regularly reviewed
Actions:
• Documentation of discussion of risks prior to prescriptions, or
documentation of reasons why this could not be done
• Clearer communication with GP regarding ongoing prescriptions
•
Doctors prescribing benzodiazepines to be aware of the risks, and need to
communicate risks and benefits with patients and family members at the
52
•
•
•
earliest opportunity. Senior doctors could discuss this with juniors in
induction processes.
Clear indication and intended duration of use to be documented in
medical notes as well as on medication chart.
Benzodiazepine prescription to be reviewed at least weekly in all patients.
All patients discharged on a benzodiazepine should have indication,
duration of use, and follow up arrangements clearly documented in
correspondence to the GP.
Follow up audit to be completed in 6 months’ time. To increase the
amount of notes available it would be useful to carry out the audit on a
rolling basis and audit notes closer to patients discharge before they are
archived.
Participation in clinical research
The number of patients receiving relevant health services provided or sub-contracted by Gateshead
Health NHS Foundation Trust in 2014/15 that were recruited during that period to participate in
research approved by a research ethics committee was 1466. Although a slight drop in recruitment
from last year, it has been another successful period for Research & Development within the Trust.
Participation in clinical research demonstrates Gateshead Health NHS Foundation Trust’s commitment
to improving the quality of care we offer and making our contribution to wider health improvement.
Our clinical staff stay abreast of the latest possible treatment possibilities and active participation in
research leads to successful patient outcomes. In line with North East and North Cumbria: Clinical
Research Network, the Trust has focused on building the recruitment for both Portfolio and Industry
studies.
Gateshead Health NHS Foundation Trust was involved in conducting 246 clinical research studies in a
variety of areas including – cancer, dementia & neurodegenerative disease, diabetes, endocrinology,
medicines for children, mental health, stroke, rheumatology, gynaecological oncology, obstetrics and
various specialty groups between 2014/15.
Over the last year, researchers from the Trust have published over 46 publications and delivered four
presentations to a variety of audiences, the majority of which are as a result of our involvement in NIHR
research, which shows our commitment to transparency and desire to improve patient outcomes and
experience across the NHS.
There were 112 members of staff participating in research approved by a research ethics committee at
Gateshead Health NHS Foundation Trust during 2014/2015. These staff participated in research covering
10 medical specialties.
Our engagement with clinical research also demonstrates Gateshead Health NHS Foundation Trust’s
commitment to testing and offering the latest medical treatments and techniques. Gateshead Health
NHS Foundation Trust remains one of the top 100 performing Trusts (ranked 72 overall in the Guardian
League Table). NIHR Central Commissioning have just released their first report for the Quarter: July –
September 2014. This was the first time that that all research providers submitted their (PID)
Performance in Initiating & Delivering Clinical Research Report. Nationally only 17 Trusts met the NIHR
Time to Target figures by 100% - Gateshead Health NHS Foundation Trust was one of them.
53
Good News!
Research Study – SIPS Jnr (Developing and evaluating interventions for adolescents (14-17) with alcohol
use disorders who present through Emergency Departments)– the Trust is the top recruiting site in the
top recruiting region – North East & North Cumbria Clinical Research Network.
Research Study – PARAGON (whether a new drug, LCZ696 is safe and effective in preventing
cardiovascular death or heart failure hospitalisation compared to valsartan)– the Trust was the first site
nationally to recruit the first patient into the study and the Trust remains the top recruiting site for the
UK.
The Research & Development Team continues to grow with the appointment of an additional Cardiology
Research Nurse to work on Industry Studies within the Trust. The Trust is now considered a green light
site by one particular Pharmaceutical Company.
The Research & Development Team hosted an Information Event within the hospital dining room on
International Clinical Trials Day – 20th May 2014, to highlight the different areas of research within the
Trust for both patients and staff. The Event highlighted the National Campaign – ‘Research Changed my
Life’.
Use of the Commissioning for Quality and Innovation Framework
A proportion of Gateshead Health NHS Foundation Trust income in 2014/15 was conditional upon
achieving quality improvement and innovation goals agreed between Gateshead Health NHS Foundation
Trust and any person or body they entered into a contract, agreement or arrangement with for the
provision of relevant health services, through the Commissioning for Quality and Innovation payment
framework.
Further details of the agreed goals for 2014/15 and for the following 12 month period are available
electronically at http://www.qegateshead.nhs.uk/cquin
A monetary total of £4,145,190 of the Trust’s income in 2014/15 was conditional upon achieving quality
improvement and innovation goals. The Trust were paid a total of £3,939,496 for achieving the quality
improvement and innovation goals for 2013/14.
Registration with the Care Quality Commission (CQC)
Gateshead Health NHS Foundation Trust is required to register with the Care Quality Commission and its
current registration status is registered without conditions.
The Care Quality Commission has not taken enforcement action against Gateshead Health NHS
Foundation Trust during 2014/15.
Gateshead Health NHS Foundation Trust has not participated in any special reviews or investigations by
the Care Quality Commission during the reporting period.
54
The Care Quality Commission made two unannounced visits during 2014/15. One was to carry out
routine Mental Health Act monitoring visits of detention in hospitals. This visit was carried out in
February 2015 and covered Cragside and Ward 23.
The second unannounced visit took place in August 2014 and carried out routine monitoring of the
Looked After Children/Safeguarding process encompassing the Accident & Emergency Department,
Paediatric Ward and Maternity Services within the Trust.
There were no compliance issues identified in either of the visits.
Data Quality
Gateshead Health NHS Foundation Trust recognises that it is essential for an organisation to have good
quality information to facilitate effective delivery of patient care and is essential if improvements in
quality of care are to be made.
Gateshead Health NHS Foundation Trust submitted records during 2014/15 to the Secondary Uses
Service for inclusion in the Hospital Episode Statistics which are included in the latest published data.
The percentage of records in the published data is shown in the table below:
Which included the patient’s valid NHS Number
was:
Percentage for admitted patient care
Percentage for outpatient care
Percentage for accident and emergency care
Which included the patient’s valid General
Medical Practice Code was:
Percentage for admitted patient care
Percentage for outpatient care
Percentage for accident and emergency care
Trust %*
National %*
99.6%
99.8%
97.3%
99.20%
99.3%
95.2%
Trust %*
National %*
100.0%
100.0%
100.0%
99.9%
99.9%
99.2%
* SUS Data Quality Dashboard - Based on provisional April 14 to February
2015 SUS data at the Month 11 inclusion Date
Information Governance Toolkit
Gateshead Health NHS Foundation Trust’s Information Governance Assessment Report overall score for
2014/15 was 93% and was graded green - satisfactory.
Standards of Clinical Coding
Gateshead Health NHS Foundation Trust was not subject to the Payment by Results clinical coding audit
during 2014/15 by the Audit Commission.
55
Gateshead Health NHS Foundation Trust will be taking the following actions to improve data quality:
Data Quality Strategy Group which includes key staff from all specialties to highlight and drive
continual improvement.
Continual development of our Data Quality Metrics to ensure all appropriate indicators are covered
and align to national and local quality indicators.
Continue with daily batch tracing to ensure the patient demographic data held on our PAS matches
the data held nationally.
Circulate weekly patient level reports to allow the clinical services to fully validate 18 week and
cancer pathways.
Spot check audits to randomly select patients and correlate their health record information with that
held on electronic systems.
Continue to work the data quality leads throughout the Trust to promote and implement data
quality policies and procedures to ensure that data quality becomes an integral part of the Trust’s
operational processes.
Clinical Coding Quality Assurance Programme to provide assurance on the quality of coding within
the Trust.
Working with Commissioners to ensure commissioning datasets are accurate.
Review Internal Audit Department plans to include data quality processes.
56
2.4 Mandated Core Quality Indicators
Since 2012/13 NHS Foundation Trusts have been required to report performance against a core set of
indicators using data made available to the Trust by the Health and Social Care Information Centre
(HSCIC).
SHMI (Summary Hospital-level Mortality Indicator)
Gateshead Health NHS Foundation Trust considers that this data is as described for the following
reasons:
• The Summary Hospital-level Mortality Indicator (SHMI) reports mortality at a trust level across
the NHS in England and is regarded as the national standard for monitoring of mortality. For all
of the SHMI calculations since October 2011, death rates (mortality) for the Trust are described
as being ‘as expected’.
Gateshead Health NHS Foundation Trust has taken the following actions to improve the indicator and
percentage in (a) and (b), and so the quality of its services, by [please see pages 7 -13].
Gateshead Health NHS Foundation Trust intends to take the following actions to improve the indicator
and percentage in (a) and (b), and so the quality of its services, by [please see pages 30-34].
The value and
banding of
the summary
hospital level
mortality
indicator
“SHMI” for
the trust for
the reporting
period
Gateshead
Health NHS
Foundation
Trust
England
England
highest
England
lowest
Gateshead
Health NHS
Foundation
Trust
England
England
highest
England
lowest
Metric
Jan
11Dec
11
Apr
11 –
Mar
12
Jul
11Jun
12
Oct
11 –
Sept
12
Jan
12 –
Dec
12
Apr
12 –
Mar
13
Jul
12 –
Jun
13
Oct
12 –
Sept
13
Jan
13 –
Dec
13
Apr13
Mar14
Jul
13 Jun
14
Oct
13 Sep
14
Value
1.04
1.03
1.05
1.04
1.04
1.03
1.02
1.01
0.98
0.98
0.98
1.01
Value
1
1
1
1
1
1
1
1
1
1
1
1
Value
1.24
1.24
1.3
1.21
1.19
1.17
1.16
1.19
1.18
1.20
1.20
1.19
Value
0.69
0.71
0.71
0.68
1.11
0.65
0.63
0.63
0.62
0.54
0.54
0.59
Banding
2
2
2
2
2
2
2
2
2
2
2
2
Banding
2.04
2.04
2.04
2.06
2.02
2.07
2.06
2.06
2.06
2.06
2.04
2.05
Banding
1
1
1
1
1
1
1
1
1
1
1
1
Banding
3
3
3
3
2
3
3
3
3
3
3
3
Banding 1 – where the trust’s mortality rate is ‘higher than expected’
Banding 2 – where the trust’s mortality rate is ‘as expected’
Banding 3 – where the trust’s mortality rate is ‘lower than expected’
57
The percentage of patient deaths with palliative care coded at either diagnosis or specialty level for the trust for
the reporting period
Gateshead
Health NHS
Foundation
Trust
England
highest
England
lowest
England
Jan
11Dec 11
Apr
11Mar
12
Jul 11Jun 12
Oct
11Sep 12
Jan 12
– Dec
12
Apr 12
– Mar
13
Jul
12 –
Jun 13
Oct 12
–Sep
13
Jan 13
– Dec
13
Apr
13Mar
14
Jul
13 Jun 14
Oct 13
- Sep
14
10.40
%
9.90%
11.90
%
13.63
%
14.60
%
14.70
%
13.70
%
12.90
%
13.40
%
14.00
%
14.50
%
14.90
%
44.20
%
46.30
%
43.30
%
42.70
%
44.00
%
44.10
%
44.90
%
46.90
%
48.50
%
49.00
%
49.40
%
0.20%
0.30%
0.20%
0.10%
0.10%
4.20%
2.70%
1.30%
6.40%
7.40%
7.50%
17.90
%
18.40
%
19.20
%
19.50
%
20.40
%
20.65
%
21.29
%
22.35
%
23.94
%
24.95
%
25.30
%
41.70
%
0.40
%
17.20
%
Patients on Care Programme Approach (CPA) who were followed up within 7 days after discharge
from psychiatric in-patient care
Gateshead Health NHS Foundation Trust considers that this percentage is as described for the following
reasons:
•
1 patient (out of a total of ten) was not able to be followed up within 7 days after discharge.
Gateshead Health NHS Foundation Trust intends to take the following actions to maintain this
percentage, and so the quality of its services, by
•
Performance against the measure is monitored closely through the Mental Health Data reporting
Group and where necessary escalated through the appropriate forum.
Proportion of
patients on CPA
who were
followed up
within 7 days
after discharge
from
psychiatric
inpatient care
Gateshead
Health NHS
Foundation
Trust
England highest
England lowest
England
Apr –
Jun 12
Jul –
Sep 12
Oct –
Dec 12
Jan –
Mar 13
Apr –
Jun 13
Jul –
Sep 13
Oct Dec 13
Jan –
Mar 14
Apr –
Jun 14
Jul –
Sep 14
Oct –
Dec 14
Nil
return*
100%
100%
100%
100%
100%
Nil
return*
100%
100%
100%
90.0%
100%
77%
96.70%
100%
93.30%
97.40%
100%
93.00%
96.90%
100%
91.55%
97.27%
100%
90.00%
97.27%
97.50%
97.20%
97.60%
97.30%
97.40%
97.50%
* There were no qualifying patients for this period.
PROMs (Patient Reported Outcome Measures) for
• Groin hernia surgery
• Varicose vein surgery
• Hip replacement surgery
• Knee replacement surgery
Gateshead Health NHS Foundation Trust considers that the outcome scores are as described for the
following reasons:
58
Groin
• Our outcomes are in line with the national normal distribution using the EQ-5D measure.
• We will continue to share data with clinical teams and commissioners to ensure that health gains
can be maximised from future procedures. We will also discuss with patients considering surgery
the range of outcomes that can be expected to ensure they have an informed choice of
treatment, including alternatives to surgery where appropriate.
Veins
• We expect our outcomes to be in line with the national normal distribution using the EQ-5D
measure, however using the Aberdeen Varicose Vein Questionnaire we are a positive outlier.
• We will continue to share data with clinical teams and commissioners to ensure that health gains
can be maximised from future procedures. We will also discuss with patients considering surgery
the range of outcomes that can be expected to ensure they have an informed choice of
treatment, including alternatives to surgery where appropriate.
Hip
•
•
•
Our outcomes are below recommended parameters using the EQ-5D and Oxford hip score.
We will continue to share data with clinical teams and commissioners to ensure that health gains
can be maximised from future procedures.
See below for other actions taken to improve our outcome scores.
Knee
•
•
•
Our outcomes are below recommended parameters for the Oxford knee score.
We will continue to share data with clinical teams and commissioners to ensure that health gains
can be maximised from future procedures.
See below for other actions taken to improve our outcome scores.
Gateshead Health NHS Foundation Trust has taken the following actions to improve these outcome
scores, and so the quality of its services, by:
• Emphasising the importance of completing the six month questionnaire at pre-assessment and joint
care clinic, particularly the knee questionnaire to increase the sample of patients, which will in turn
increase the likelihood that the findings are truly representative of the patient experience.
• Developing a plan to begin a Consultant led audit using PROMS data to identify specific patterns and
draw further conclusions to allow for an action plan for improvement to be put in place.
• Revising the Patient Information Booklet for total hip replacement.
• Revising the Patient Information Leaflet for total knee replacement.
• Reinstated hip class for post-operative patients with open access.
• Established MDT group to review joint care pathway.
• Reinforce use of a Shared Decision Making Option Tool into out-patient clinics for patients with hip
and knee pain.
59
EQ-5D index case mix adjusted health gain
Adjusted average health gain
Period
Apr 14Sep 14*
Apr 13 Mar 14*
Apr 12 Mar 13
Apr 11 Mar 12
Apr 10 Mar 11
Apr 09 Mar 10
Location
Groin
Hernia
Varicose
Vein
Hip
Replacement
Knee
Replacement
Gateshead Health
NHS Foundation Trust
0.054
**
**
**
England
0.081
0.100
0.442
0.328
England High
0.125
0.142
0.501
0.394
England Low
0.009
0.054
0.350
0.249
Gateshead Health
NHS Foundation Trust
0.064
0.120
0.392
0.295
England
0.085
0.093
0.436
0.323
England High
0.142
0.149
0.539
0.414
England Low
0.008
0.023
0.332
0.209
Gateshead Health
NHS Foundation Trust
0.081
0.053
0.424
0.331
England
0.085
0.093
0.438
0.318
Gateshead Health
NHS Foundation Trust
0.054
0.079
0.393
0.285
England
0.087
0.095
0.416
0.302
Gateshead Health
NHS Foundation Trust
0.074
0.131
0.415
0.308
England
0.085
0.091
0.405
0.299
Gateshead Health
NHS Foundation Trust
0.092
0.076
0.372
0.295
England
0.082
0.094
0.411
0.285
*Provisional figures which will be finalised August 2015.
** Figure not calculated. Average case mix-adjusted scores have been calculated only where there are at
least 30 modelled records. The statistical models break down with fewer records and aggregate
calculations on small numbers may return unrepresentative results.
Emergency Readmissions within 28 Days
• Aged 0 – 15yrs
• Aged 16yrs or over
Data for this indicator is currently unavailable.
Unfortunately the publication for emergency readmissions to hospital within 28 days of discharge
indicators has been delayed this year while the HSCIC bring its production in-house from an external
contractor. They are currently reviewing the methodology and specifications which will have an impact
on when it will actually be published. It is highly unlikely that they will be published this year.
60
Indirectly age, sex, method of admission, diagnosis, procedure
standardised per cent
Emergency readmissions within 28 days
Aged 0-15 years
Gateshead Health
2006/07
2007/08
2008/09
2009/10
2010/11
2011/12
10.12
8.35
8.55
8.85
9.30
9.44
England
9.54
9.94
10.09
10.18
10.15
10.01
Highest medium acute trust
14.99
18.61
17.34
14.20
14.76
13.58
Lowest medium acute trust
6.63
4.77
5.10
6.33
6.04
5.10
Indirectly age, sex, method of admission, diagnosis, procedure
standardised per cent
Emergency readmissions within 28 days
Aged 16 years or over
Gateshead Health
2006/07
2007/08
2008/09
2009/10
2010/11
2011/12
11.83
11.51
11.78
12.08
12.34
13.15
England
10.43
10.57
10.90
11.16
11.42
11.45
Highest medium acute trust
12.99
13.32
13.08
13.30
13.00
13.50
Lowest medium acute trust
7.82
8.07
7.92
7.34
7.68
8.96
Trust’s responsiveness to the personal needs of its patients
The Gateshead Health NHS Foundation Trust considers that these percentages are as described for the
following reasons:
•
We are continually listening to what patients tell us in their feedback through a variety of media
sources and act upon this to improve the care we deliver to patients
The Gateshead Health NHS Foundation Trust has taken the following actions to improve these
percentages, and so the quality of its services, by:
•
•
Continually monitoring patient feedback through our local patient experience surveys and
Friends & Family Test feedback and acting upon areas for improvement
Continue to implement our Patient, Public and Carer Involvement and Experience Strategy
2014/17, that sets out a framework for how the Trust will improve the patient experience. It is
delivered through a framework on the concept of ‘5 steps to excellent care’.
The Gateshead Health NHS Foundation Trust intends to take the following actions to improve these
percentages, and so the quality of its services, by:
•
•
Implementing our strategy through the Patient, Public and Carer Involvement and Experience
Steering Group that includes key internal and external stakeholders such as HealthWatch, Local
Authority and Voluntary Groups and Organisations
Continually monitoring and acting upon feedback from patients, carers, the public and our staff
61
Responsiveness to the
personal needs of
patients
Average Weighted Score
Gateshead Health NHS
Foundation Trust
England Highest
England Lowest
England
2003/
04
2005/
06
2006/
07
2007/
08
2008/
09
2009/
10
2010/
11
2011/
12
2012/
13
2013/
14
71.1
71.0
67.0
65.7
73.2
74.0
71.4
71.3
70.3
73.6
83.3
56.0
67.4
82.6
55.8
68.2
84.0
55.1
67.0
83.1
54.6
66.0
83.4
56.9
67.1
81.9
58.3
66.7
82.6
56.7
67.3
85.0
56.5
67.4
84.4
57.4
68.1
84.2
54.4
68.7
Percentage of staff employed by, or under contract to, the Trust who would recommend the Trust as a
provider of care to their family or friends
The Gateshead Health NHS Foundation Trust considers that these percentages are as described for the
following reasons:
•
•
Gateshead Health NHS Foundation Trust has scored consistently above the national average and
often into the top 25% of Trusts in 2014/15 and shows that our staff value the organisation as a
place to work and receive care.
The results using the Staff Friends and Family Test postcards in Q1, Q2 and Q4 were higher than
those obtained by the National Staff Survey in Q3. This movement is reflected in the national
average.
The Gateshead Health NHS Foundation Trust has taken the following actions to improve these
percentages, and so the quality of its services, by:
•
•
•
•
•
•
•
•
•
•
•
Continued to promote the Trust’s vision and values, which place the patient at the centre of
everything we do;
Vision is used in all key documentation and referred to, in context, in the majority of training e.g.
dementia training, appraisal, excellent customer service, all leadership programmes;
New CONTACT appraisal documentation which puts the vision centre stage to assist managers to
help people achieve a clear line of sight between what they do and patient care;
Increased staff involvement in decision-making and shaping future services e.g. development of
regional Pathology service, new Emergency Care Centre;
Shared best practice at national/regional forums to gain wider recognition for what we do well
and publicise these internally;
Publicised internally patient stories, positive feedback and use storytelling as a method of
engaging staff in the patient experience;
Let staff know about innovative practices that we are engaged in that make us stand apart from
other trusts;
Advertise new technology (e.g. Clinical Skills Simulation Centre) that allows us to learn and
practise clinical care in an innovative way;
Improved internal and external communications to spread good news stories, positive
experiences of patients and staff;
Raise staff awareness during induction, mandatory training and ongoing staff development that
the Trust is proud of its achievements and is constantly looking at new and better ways of
working in the service of the patient/service user;
Celebrated success of external awards received by staff as well as holding our own staff awards
ceremony which recognises those staff who have gone above and beyond;
62
•
Any staff member who is mentioned by name in the Friends and Family test receive a letter of
commendation from the Director of Nursing.
Staff who would recommend the
Trust to their family or friends
2010
2011
2012
2013
2014
Gateshead Health NHS
Foundation Trust
70%
73%
69%
70%
75%
England highest
94%
93%
England Lowest
40%
38%
67%
67%
All Acute Trusts
66%
65%
65%
Percentage of patients who were admitted to hospital and who were risk assessed for venous
thromboembolism
The Gateshead Health NHS Foundation Trust considers that these percentages are as described for the
following reasons:
The Trust has made significant improvements in the screening of patients for risk of VTE where we have
moved from a position of 48% compliance for the period July- September 2010/11 to maintaining over
95% compliance since July 2013.
The Gateshead Health NHS Foundation Trust intends to take the following actions to improve these
percentages, and so the quality of its services, by
• Trialling and implementing an electronic systems for undertaking and recording VTE risk
assessment
• Further developing our programmes of education and monitoring compliance against our
internal standards of attendance
• Continually monitor performance and take action where necessary
• Continuing to refresh and promote our prevention of VTE awareness campaign
Percentage of
admitted patient
risk-assessed for VTE
Apr-12
May-12
Gateshead
Health NHS
Foundation
Trust
England Highest
England Lowest
All Providers of
NHS funded
acute care
93.0%
93.4%
92.9%
92.4%
93.6%
93.3%
Aug-12
92.4%
90.8%
93.9%
93.9%
Sep-12
Oct-12
92.3%
90.6%
94.0%
94.3%
Nov-12
Dec-12
92.1%
94.4%
90.8%
91.6%
93.8%
94.4%
Mar-13
92.0%
91.9%
94.2%
94.3%
Apr-13
91.2%
95.2%
Jun-12
Jul-12
Jan-13
Feb-13
63
Percentage of
admitted patient
risk-assessed for VTE
May-13
Jun-13
Jul-13
Gateshead
Health NHS
Foundation
Trust
90.6%
England Highest
England Lowest
All Providers of
NHS funded
acute care
95.5%
91.3%
95.7%
95.1%
95.3%
96.1%
95.8%
Oct-13
95.3%
95.1%
100.0%
80.1%
95.7%
95.8%
Nov-13
Dec-13
95.2%
95.0%
100.0%
100.0%
70.5%
70.7%
95.9%
95.5%
Jan-14
Feb-14
96.1%
100.0%
74.6%
96.0%
96.8%
95.4%
100.0%
100.0%
77.0%
83.2%
96.0%
96.0%
Aug-13
Sep-13
Mar-14
Percentage of
admitted patient
risk-assessed for VTE
Apr-14
Gateshead
Health NHS
Foundation
Trust
England Highest
England Lowest
All Providers of
NHS funded
acute care
95.3%
100.0%
85.7%
96.2%
May-14
95.3%
100.0%
87.7%
96.1%
Jun-14
95.2%
100.0%
83.7%
96.2%
Jul-14
95.2%
100.0%
88.4%
96.4%
Aug-14
95.5%
100.0%
80.6%
96.0%
Sep-14
95.4%
100.0%
86.7%
96.2%
Oct-14
95.0%
100.0%
88.9%
96.2%
Nov-14
95.0%
100.0%
74.9%
96.0%
Dec-14
95.2%
100.0%
74.0%
95.7%
Jan-15
95.0%
100.0%
74.1%
96.0%
N/A
N/A
Feb-15
95.7%
N/A
Source: http://www.england.nhs.uk/statistics/statistical-work-areas/vte/
The rate per 100,000 bed days of cases of C.difficile infection reported within the Trust amongst
patients aged 2 or over
The Gateshead Health NHS Foundation Trust considers that these percentages are as described for the
following reasons:
In order to support a reduction in Clostridium difficile infection across the Trust a targeted approach of
reducing infection risk and improving compliance for patient safety has been implemented.
The Gateshead Health NHS Foundation Trust has taken the following actions to improve these
percentages, and so the quality of its services by using the following approaches:
A number of developments have been implemented within the Trust to ensure compliance and also to
provide assurance that the Trust is delivering the best evidence based care for patient safety.
•
The ‘Diarrhoea Assessment & Management Pathway’ (DAMP) is being revised.
•
Multidisciplinary CDI Root Cause Analysis meetings are arranged within a 7-10 day timeframe.
64
•
•
DAMP compliance audits continue and results are disseminated to all relevant staff.
Provision of education regarding hand hygiene and CDI compliance with regard to provision of
single rooms has been delivered and continues.
Isolation/cubicle audits are completed by the IPCN team on a daily basis.
Ribotyping of CDI cases has been arranged with the Clostridium difficile Ribotyping Network
(CDRN) to determine if cross infection has taken place within specific clinical areas.
Datix of all CDI cases are submitted by ward managers with assistance from the IPCN team and
work is ongoing to review this process based on new guidance.
Environmental screening/surveillance is carried out.
A weekly CDI MDT meeting takes place and antimicrobial prescribing is reviewed along with all
aspects of CDI care.
•
•
•
•
•
Rate of C.difficile per 100,000 bed-days
for specimens taken from patients aged
2 years and over (Trust apportioned
cases)
2008/09
2009/10
2010/11
2011/12
2012/13
2013/14
Gateshead Health NHS Foundation Trust
52.3
54.8
27.8
16.1
17.5
12.2
England highest
128.9
92
71.2
58.2
31.2
37.1
England lowest
1.2
1.5
2.6
1.2
1.2
1.2
England
52.9
35.3
29.7
22.2
17.4
14.7
Source: https://www.gov.uk/government/statistics/clostridium-difficile-infection-annual-data
The number and rate of patient safety incidents reported within the Trust and the number and
percentage of such patient safety incidents that resulted in sever harm or death.
The Gateshead Health NHS Foundation Trust considers that these percentages are as described for the
following reasons
•
There has been no significant change in the percentage of severe harms reported during the
period of Apr – Sep 2014 when compared with Oct – Mar 2013 or with the previous year.
During this reporting period the Trust has seen an increase in the number of overall incidents
reported, however the rate of severe harm incidents has fallen slightly.
•
A reduction in severe harm incidents can be attributed to the reduction in the number of severe
harm falls reported during the 2014/2015 period with a 31% decrease in the number of severe
harm falls incidents reported to STEIS when compared with the 13/2014 period
The Gateshead Health NHS Foundation Trust has taken the following actions to improve these
percentages, and so the quality of its services, by
•
•
•
Focusing on reducing harm from falls adding it to the CQUIN indicators. A major part of this work
was rolling out the post falls protocol and updating the falls risk assessment tool from a
numerical risk grading tool in line with the recommendations from NICE.
Implementing the Datix Dashboard module which enables staff throughout the organisation to
view incidents and trending data more efficiently and effectively. This includes consultant
doctors
Implementing the action plans from the Patient Safety Culture assessment to produce
departmental and Trust action plans to improve safety across the Trust.
65
•
•
•
Improving the efficiency of the serious incident review process to ensure that lessons are learned
in a more timely way.
Continue to utilise SafeCare Alerts and Good Practice Bulletins to enable the sharing of good
practice to inform service delivery and notification of risks and harm that must be remedied.
Continuing to ensure that all staff are aware of their responsibilities with regard to incidents and
Duty of Candour via education and training.
Period
Apr 14 – Sep
14
Oct 13 – Mar
14
Period
Oct 13 – Mar
14
Apr 13 – Sep
13
Oct 12 – Mar13
Apr-12 to
Sep-12
Oct-11 to
Mar-12
Apr-11 to
Sep-11
Organisation name
Gateshead Health
NHS Foundation
Trust
Acute (non specialist)
organisations
Gateshead Health
NHS Foundation
Trust
Acute (non specialist)
organisations
Total number
of incidents
occurring
Rate of all
incidents per
1,000 bed
days
Number of
incidents
resulting in
Severe harm
or Death
Percentage of
total incidents
that resulted in
Severe harm or
Death
2,532
30.46
19
0.75%
2,168
0.36%
20
0.89%
587,483
2,256
26.92
Organisation name
Total number
of incidents
occurring
Rate of all
incidents per
100
admissions
Number of
incidents
resulting in
Severe harm
or Death
Percentage of
total incidents
that resulted
in Severe
harm or Death
Gateshead Health NHS
Foundation Trust
2,256
7.85
20
0.89%
925
0.65%
19
0.87%
631
0.47%
17
0.73%
828
0.63%
10
0.42%
875
0.75%
11
0.44%
944
0.79%
21
0.88%
806
0.70%
All Medium Acute
organisations
Gateshead Health NHS
Foundation Trust
All Medium Acute
organisations
Gateshead Health NHS
Foundation Trust
All Medium Acute
organisations
Gateshead Health NHS
Foundation Trust
All Medium Acute
organisations
Gateshead Health NHS
Foundation Trust
All Medium Acute
organisations
Gateshead Health NHS
Foundation Trust
All Medium Acute
organisations
141,822
2,180
7.59
133,207
2,342
8.09
132,052
2,375
8.2
117,134
2,509
10.54
120,225
2,385
115,398
10.02
66
Cluster Groups have changed in the latest release of data as has the method used for benchmarking. Rates have, therefore,
been re-calculated for the previous reporting period i.e. Oct13-Mar14 and are provided alongside the rate for Apr14-Sep14
(where the method for benchmarking has changed for the cluster).
67
3. Review of quality performance
2014/15 has been a successful year in relation to the three domains of quality:
Patient Safety
Clinical Effectiveness
Patient Experience
3.1 Patient Safety
Harm free care - measured by the NHS Safety Thermometer
We want to understand more about the quality of care our patients receive. To do this we undertake
work to help us to examine our care and to help us determine whether patients experience harm whilst
in our care. The method we have used to do this is the NHS Safety Thermometer. This is a national
initiative which includes improvement tools for measuring, monitoring and analysing patient harm and
‘harm free’ care. The four areas of harm which are measured are:
Pressure damage
Falls
Venous Thromboembolism (VTE)
Catheter related urinary tract infections (CAUTIs)
We have been collecting data using the Safety Thermometer for almost three years on 100% of our
patients once per month. Our clinical staff undertake a monthly data collection which is uploaded to the
Department of Health. As an organisation we are committed to making a difference at the bedside and
reduce harm from occurring to patients whilst in our care. The table below shows the percentage of
harm free care we have delivered each month.
Month
Trust % of
Harm Free
Care
Apr
May
June
July
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
93.3
96.7
93.4
97.8
96.0
96.0
95.3
95.0
95.0
94.0
95.1
95.6
The results are shared with clinical staff in a timely manner in order for the results to be analysed at
ward level and areas for improvement highlighted and addressed. The information is displayed on each
wards Time to Care dashboards which display key information about patient care as well as feedback
from our patients.
Pressure Ulcers
The NHS Safety Thermometer asks the organisation to record old pressure and new pressure damage.
An old pressure ulcer is defined as being a pressure ulcer that was present when the patient came under
our care, or developed within 72 hours of admission to our organisation. ‘New’ pressure ulcer is defined
as being a pressure ulcer that developed 72 hours or more after the patient was admitted to our
organisation.
68
Month
Sample
Apr
476
May
451
Jun
461
July
442
Aug
430
Sep
469
Oct
470
Nov
463
Dec
522
Jan
533
Feb
469
Mar
497
PD – All
17
12
16
9
10
10
11
16
15
18
12
17
PD - New
6
6
6
4
5
5
4
8
4
3
5
3
How did we achieve this?
Reducing harm from pressure ulcers is a Trust SafeCare priority. We need to have a clear understanding
of where and why pressure ulcers occur, what we can do to prevent them and also once they have
occurred, what we can do to stop them from deteriorating. Pressure ulcers are graded according to
severity from 1-4, with 4 being the worst.
Pressure ulcers are recorded via the Trust incident reporting system following validation at the bedside
by the tissue viability nursing team. The tissue viability team provides a specialist service to patients
with a wide variety of complex wounds including pressure ulcer prevention and management. This
triggers the need for a root cause analysis to be undertaken by the Ward Matron and Ward Sister with
the findings formally presented to the Director of Nursing. Root cause analysis is a technique that helps
us to understand why something has occurred in the first place. The learning is then shared with staff
across the hospital to inform our practice and help prevent further reoccurrence. By adopting this
approach a number of emerging themes have been highlighted which has enabled us to devise our
“Preventative Strategy against Pressure Ulcer Formation”. There is an increased need to find innovative
and simple ways for all members of the multi-disciplinary team to address this basic aspect of nursing
care into everyday clinical practice. Some of the improvement strategies we have implemented are
displayed below.
Education and Training:
It is vital that patients and families are encouraged to take an active role and agree a management care
plan so they are part of the decision making process. Pressure ulcer prevention training is provided by
the tissue viability team to all grades of staff including medical, nursing and allied health care
professionals.
Assessment:
All patients are assessed on admission using a recognised pressure ulcer risk assessment score. This will
identify those patients at risk of developing a pressure ulcer or who have existing ulcers. This is
recalculated on a weekly basis, on transfer to another ward or if the patients’ condition deteriorates.
Once a patient has been identified as requiring assistance to change their
position, as part of the Trust’s ‘Save our Skin Strategy’, an SOS sticker is
placed on the patient’s white board above their bed. This is used as a visual
prompt to staff that the patient is unable to move independently.
69
Documentation:
Care Standard 15 ‘Prevention and Treatment of Pressure Ulceration’ is required to
be initiated on admission setting out the expected standard of care to be provided.
A pictorial guide has been incorporated into this document to act as an aide
memoire to staff, to aid the appropriate selection of mattresses or cushions
available according to the patient’s level of risk or severity of pressure ulcer.
Intentional Rounding Chart:
The concept of Intentional Rounding can be described a structured process where nurses on the wards
carry out regular checks with individual patients at set time intervals. The rounding documentation tool
has been devised to incorporate the SSKIN bundle: a five step model to prevent pressure ulcers.
S = Support surface S = Skin inspection K = Keep moving I= Incontinence N = Nutrition
During these intentional rounding checks, nursing staff are required to document on the chart their
actions concerning positional changes.
Nutrition:
All patients on admission are nutritionally assessed. This may highlight the need for their dietary intake
to be monitored throughout their hospital stay and a referral to a dietician may also be triggered.
Patients who have had surgery, are at risk or have existing pressure ulcers are offered a cooked
breakfast instead of a continental breakfast and additional snacks on a daily basis to provide additional
nutrients.
Wound Management Chart:
It is essential that a comprehensive wound assessment is undertaken and an appropriate dressing
regime initiated and documented on a specifically developed Wound Management Chart. This chart
enables staff to document and monitor improvement or deterioration of pressure ulcers clearly.
Equipment:
All patients in our Trust are placed on a high specification foam mattress on admission. This mattress is
endorsed by the European Pressure Ulcer Advisory Panel for those patients who are at risk of
developing pressure ulcers, or have Grade 2 pressure ulcers.
To enable the safe repositioning of patients and to minimise pressure and shear forces all ward areas
store a selection of slide sheets appropriate to individual patient need.
Heel cushions are available for patients at high risk of pressure ulcers to their
heels whilst sitting up in the chair. The heel cushions aid the redistribution of
pressure away from the vulnerable heel area.
A range of chair cushions are also available for those patients who require additional protection whilst
sitting out in their chair.
70
Safety Cross:
As part of the Pressure Ulcer Prevention Strategy across the
Trust staff are required to complete a pressure ulcer calendar in
the form of a ‘Safety Cross’ on a daily basis. This highlights at a
glance how many days it is since the last pressure ulcer on the
ward.
Safety Calendar
We monitor our progress closely via both our Trust reporting
system and the Safety Thermometer. Safety Thermometer is an
audit undertaken on 100% of patients on one day every month.
Although significant improvements have been made in our
mission to eliminate harm from pressure ulcers across the
organisation; we acknowledge there are still improvements to be
made and will continue to further develop our improvement
work as we strive to eliminate all avoidable incidences of
pressure ulcers.
1
2
3
4
5
6
Month
7
9
11
13
15
17
19
21
8
10
12
14
16
18
20
22
23
24
25
26
27
28
29
30
Days without
incident
31
Falls
The Safety Thermometer asks the organisation to record the severity of any fall that the patient has
experienced within the previous 72 hours in a care setting (including home if the patient is on a district
nursing caseload). The number of falls are analysed in order to highlight if the fall occurred whilst the
patient was in hospital so targeted work can be undertaken on that ward to reduce the level of harm
occurring to patients.
Month
Sample
Falls - New
Apr
476
May
451
Jun
461
July
442
Aug
430
Sep
469
Oct
470
Nov
463
Dec
522
Jan
533
Feb
469
Mar
497
6
6
6
4
5
5
8
4
4
9
7
5
Led by the falls specialist nurse in collaboration with SafeCare the continuous improvement programme
for falls aims to achieve a reduction in overall falls and in particular a reduction in falls resulting in harm.
The falls improvement programme is discussed in more detail in section 1 on pages 17-18.
Catheter Related Urinary Tract Infections (CAUTI)
The Safety Thermometer asks the organisation to record whether the treatment for the urinary tract
infection (UTI) started before the patient was admitted to our organisation (old) or after the patient was
admitted to the organisation (new). As an organisation we are particularly interested in the number of
catheter related UTIs occurring after admission.
Month
Sample
CAUTI
Apr
476
May
451
Jun
461
July
442
Aug
430
Sep
469
Oct
470
Nov
463
Dec
522
Jan
533
Feb
469
Mar
497
3
0
2
1
2
7
5
6
6
6
4
4
The Trust continues to aim to reduce all avoidable Health-Care associated infections; this includes
Catheter Associated Urinary Tract Infections (CAUTI). The Infection Prevention and Control Nurses
provide on-going surveillance and follow up of all patients with infections from catheter specimens of
71
urine. If a deviation from the catheter care standard is identified in the care the patient received, then
an exception report is sent to the ward manager and modern matron for an action plan to be devised.
The catheter care record provides a care bundle for the catheter device management, prompting a daily
review of the need for a short term catheter with the aim of reducing the number of catheterisation
days, therefore directly reducing the patient’s risk of developing a CAUTI. This is audited weekly by each
ward to enable the Trust to continually monitor compliance of catheter care management
Venous Thromboembolism (VTE)
The NHS Safety Thermometer asks the organisation to record whether or not a patient is being clinically
treated for VTE of any type. A patient may be defined as having a new VTE if they are being treated for
a Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE) or any other recognised type of VTE with
appropriate therapy such as anticoagulants. If treatment for the VTE was started after the patient was
admitted to our organisation, it is counted for this measure as a new VTE. The numbers of new VTEs
remain small each month.
Month
Sample
VTE
Apr
476
May
451
Jun
461
July
442
Aug
430
Sep
469
Oct
470
Nov
463
Dec
522
Jan
533
Feb
469
Mar
497
5
1
3
2
1
2
1
1
1
0
0
0
The VTE Committee continues to oversee the implementation of guidelines for the prevention and
management of thromboembolism within the Trust in line with National Institute for Health and Care
Excellence (NICE) and other national guidance. It promotes the education and training of all relevant
clinical and support staff and leads multi-professional clinical audit relating to VTE prevention and care.
Root cause analysis continues to be undertaken on patients with a possible hospital associated
thrombosis where they are readmitted to hospital within 90 days of discharge with a diagnosis of DVT or
PE or they are discharged from a hospital stay with a diagnosis or DVT or PE. Any learning identified as a
result of these RCAs is shared with our clinical teams.
Safeguarding adults and children
Delivering safe services to vulnerable individuals is a key requirement for the organisation, to ensure
that the most vulnerable people are supported appropriately. Our aim is:
•
To continue to improve the quality and safety of our services and to improve further the
experience of patients, carers and families in contact with our services.
•
To value, support and empower all our staff and volunteers to do their best through education,
training and personal development to deliver high quality services which are responsive to the
needs of patients, carers and families.
Achievements and challenges in 2014/15
Gateshead received an unannounced CQC inspection into health services for Looked After Children and
Safeguarding in August 2014.
The CQC used a ‘whole systems’ approach for reviewing child protection and safeguarding within
health, which included tracking children’s journeys through the A&E department and paediatric areas.
The lines of enquiry were:
• The experiences and views of children and their families
72
•
•
•
The quality and effectiveness of safeguarding arrangements in health
The quality of health services and outcomes for children who are looked after
Health leadership and assurance of local safeguarding and looked after children arrangements.
Patient feedback to the CQC throughout the review was extremely positive. The CQC reported that
their inspectors saw excellent examples of safeguarding risk assessment within the Emergency
Department, with effective identification of vulnerabilities for the child and family. We were praised for
effective paediatric liaison, and for the Safeguarding children flagging system on the Trust’s Medway
system.
During their time in the Maternity Unit, the CQC spoke with both newly qualified and experienced
midwives in teams and used one of their accounts of effective Safeguarding Children Supervision as one
of the case studies in the inspection report.
In summary, the overall inspection was very positive and deemed Gateshead’s arrangements for
Safeguarding Children on the whole were very robust. The lead inspector stated that collectively,
health services for children are “close to the gold standard”, and the recommendations for
improvement for the Trust were minor ones. These included the need for Community Midwives to
attend safeguarding meetings at GP practices and updating of paperwork within the adult Emergency
Department to include information on children within the family. There were nine recommendations
for the Trust in total, including five for Maternity Unit, two for the Emergency Department, and two for
the Paediatric Medical staff. It is envisaged that these recommendations will be actioned and complete
within the first half of 2015.
Child Protection Plan flags on Medway system
Another achievement of 2014 was reaching an agreement with Gateshead Local Authority that they
would send the Trust Safeguarding Children team daily updates of all Gateshead children subject to
Child Protection Plans. This means that relevant staff are immediately made aware when a child attends
the Trust who is subject to a Child Protection Plan. Within the flagging system, they are also informed of
the category of the plan, the allocated social worker, and when the plan was discontinued. This has
significantly improved communication between Trust staff and Children’s Social Care, to enhance
effective safeguarding of this group of vulnerable children.
Mental Capacity Act and Deprivation of Liberty
Following a Supreme Court judgement in March 2014 there has been a considerable increase in
Deprivation of Liberty (DoLs) activity over the last year. This has required a close working partnership
between the Trust and our Supervisory Body (the Local Authority).
The support provided by the Safeguarding Adults Lead Nurse and the Older Person’s Mental Health
Liaison Team to assist staff with issues regarding patient capacity and advise if a possible deprivation of
liberty is taking place has been enhanced by the appointment of the MCA Project Development Officer.
This role is funded by the CCG and is currently running for six months with the possibility of an
extension.
These developments have contributed to a doubling of our DoLs applications over the past 12 months
from 25 applications in 2013 to 50 applications in 2014, and over 40 from January to end of March so far
this year. The applications to deprive someone of their liberty are subsequently reported to the Care
Quality Commission by the Safeguarding Adults Lead Nurse.
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The implications of the Supreme Court judgement have now been incorporated into Corporate
Induction training for all staff. In addition a network of Mental Capacity Act champions has been
established with training for this role currently being delivered.
The Prevent Strategy
‘Prevent’ continues to be an integral part of the Home Office counter-terrorism strategy; the aim of
which is to stop people becoming radicalised or supporting terrorism. The NHS is a key partner in
delivering the Prevent strategy across all health care areas. The strategy promotes collaboration and cooperation among the public sector to ensure vulnerable individuals are diverted away from a ‘precriminal space’ – before any crime is committed.
The Prevent agenda has been included in the NHS contract since April 2013; three members of the
Safeguarding Team subsequently attended a Train the Trainers event hosted by the Department of
Health. The Safeguarding Adult Lead Nurse initially took on the role of Prevent Lead in the Trust and
radicalisation was added into the Trust’s Safeguarding Adults policy. As a result of staff changes within
the Safeguarding team, the Strategic Lead for Safeguarding is now responsible for the delivery and
coordination of Prevent training across the organisation.
Awareness of this issue continues to be
raised via the Trust Mandatory Training day, Corporate Induction and initial awareness sessions were
delivered to staff in A&E and Mental Health. Formal training sessions were delivered to staff throughout
2014. Prevent will be one of the safeguarding priorities for 2015; in terms of continuing to raise
awareness across the organisation and to ensure that all priority staff groups receive the Wrap 3
training, via a training needs analysis.
Infection, Prevention and Control
All of our staff understand that good infection prevention and control (IPC) and a zero tolerance
approach to avoidable infection is essential to ensure provision of safe and effective care for all our
patients. The prevention and control of infection within any healthcare environment is a complex issue
and one that requires a comprehensive strategic approach. As a leading provider of quality healthcare,
the Trust recognises that the safe effective prevention and control of Healthcare Associated Infection
(HCAI) is fundamental to patient and staff safety and to the overall performance of the organisation.
• To this end a five year IPC Strategy was developed to affirm the
commitment of the Trust and its strategic approach to zero
tolerance of HCAI to provide person centred, safe and effective
health care to those who use our services.
• The zero tolerance approach to HCAI is reflected throughout the
strategy and is fundamental to the delivery of the Trust’s
organisational objectives in relation to patient safety, clinical
effectiveness, performance and the patient experience.
• A key focus for the Trust will be continuing to address HCAI and
drive down rates of avoidable infection which have become a major
concern for healthcare staff, our patients and the public. Some
infections are difficult to prevent or may have entered the hospital
from other sources.
• The Trust continues to fully support local and national initiatives to reduce all avoidable infection
and aims to continue to strengthen our preventative measures in 2015/16 to provide assurance
to our patients and their families that every effort has been made to keep them safe.
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Good IPC practice must be underpinned by a comprehensive programme of education and training.
Education and learning continues to be a key area of development ensuring all Trust staff are provided
with appropriate mandatory education and training as well as opportunities for further development.
Members of the IP&C Nursing Team have been supported to attend the North East Leadership Academy
(NELA) leadership development programme.
The Trust was represented nationally at ‘Infection Prevention 2014’ organised by the Infection
Prevention Society (IPS), the leading UK infection prevention organisation.
IPC Nurse Specialist Angela Cobb
submitted an abstract and poster
presentation which was selected within
one of the conference poster walks by
Professor Didier Pittet - World Health
Organisation as a notable example of
best practice. The poster demonstrated
the reduction of bacteraemia data and
improvements in patient safety with
regard to reducing MRSA and other
bacteraemia through introduction and
improving the blood culture kits now
used throughout the Trust. The kits have
contributed to the notable improvement
and reduction of the Trusts’ bacteraemia
rates.
Ensuring preventative measures and reducing infection is very important to the quality of patient care.
Whilst infections are monitored and followed up for patients during their stay, some key indicators such
as Meticillin resistant Staphylococcus Aureus (MRSA) and Clostridium difficile Infection (CDI) are used
nationally to benchmark and measure performance. The Trust remains one of the best performing
Trusts in the North East region with regards to mandatory HCAI reporting.
NHS England published ‘Clostridium difficile infection objectives for NHS organisations 2014/15 and
guidance on sanction implementation’. NHS England established the Trust CDI trajectory for 2014/15 at
24 post 72hr cases. All CDI cases are taken seriously, undergo root cause analysis (RCA) and further
investigation. The Trust has remained focused to ensure that this performance is maintained however it
has presented a constant challenge. A number of developments have been implemented within the
Trust to ensure complacency does not exist with regard to provision of patient care and CDI and also to
provide assurance that the Trust is delivering the best evidence based care for patient safety. All staff
must remain vigilant in the approach to zero tolerance and implementation of evidence based best
practice.
During 2014/15 the Trust reported one MRSA post 48hr bacteraemia case. A Post Infection Review (PIR)
was arranged and the outcomes and lessons learned from the PIR determined a number of clinical
learning opportunities and attributed responsibility to the Trust as an unavoidable HCAI. The Trust
demonstrated robust systems were in place providing assurance that the process of clinical learning was
arranged to prevent similar cases occurring in the future. With regards to MSSA and E. coli bacteraemia
the Trust has set challenging internal reduction targets alongside the established mandatory targets for
reduction of avoidable multi-resistant organisms. The Trust continues to be one of the best performing
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Trusts in the region maintaining one of the lowest MSSA and E. coli bacteraemia rates to date. Blood
culture contamination rates also remain within the national benchmark at <3%.
The UK has seen a small number
of repatriated healthcare staff
from Africa during the Ebola
Virus Disease (EVD) outbreak.
The potential risk of EVD to the
general public in the UK
continues to remain significantly
low with minimal risk of it
spreading to the general
population
and
this
is
emphasised by Public Health
England. The best protective
measures for non-affected
countries are adequate levels of preparedness. Staff training in applying and removal of personal
protective equipment (PPE) commenced during January 2015 in the Trust. A receiving area has been
identified within the Emergency Care Centre if there is any suspicion of EVD or any viral haemorrhagic
fever (VHF) following triage of a patient.
All IPC activity has been successfully achieved through the consolidated efforts of Trust staff and the
IP&C team through what has been a demanding year. In order to support a reduction in CDI and other
infections, a targeted approach of reducing infection risk and improving compliance for patient safety
along with a zero tolerance approach to avoidable HCAI has been implemented in line with national and
local guidance. The challenging economic future facing the NHS highlights our need to maintain quality
and focus on innovation, productivity and prevention of infection whilst ensuring that as a leading
provider of healthcare and a Foundation Trust we are compliant with regulatory requirements and
meeting our contractual obligations for IPC and ensuring patient safety.
3.2 Clinical Effectiveness
The New Emergency Care Centre (ECC)
Our new state of the art Emergency Care Centre has been fully functional since February of this year.
The new unit has distinct patient pathways which facilitates clinical teams to move to the patient rather
than the patient being moved around the organisation. The Centre has merged several distinct areas
into one unit including the former A&E, Walk in centre, Emergency Assessment Unit, Paediatrics, Short
Stay Unit and Ambulatory Care with the aim of having patients seeing the relevant specialty at a much
earlier point within their journey.
Ambulatory care
Our Ambulatory Care Unit is an alternative to being admitted through the traditional route of the
Emergency Admissions Unit, and is specifically aimed at those patients who require specialised hospital
care, but are able to be safely managed without an overnight admission. The service commenced and
was limited to patients with a potential diagnosis of pulmonary embolism, deep vein thrombosis, heart
failure or anaemia, however more recently this service has expanded to include any medical or surgical
condition that has the potential to be managed within a day or with follow up appointment from the
clinic. A dedicated nursing, medical and surgical team is available and the service runs from 0800 – 2200
hours each day of the week
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Educating patients at risk of malnutrition
Malnutrition affects an estimated 3 million in the UK. Our staff have been offering education, support,
and advice to those at risk. In December, ward 23 hosted a malnutrition awareness week event with Age
UK. One event held during the week was an afternoon tea for patients and carers. Those who attended
as well as enjoying the tea we given helpful tips and advice on how to avoid becoming malnourished
such as knowing about high calorie foods, how to fortify foods and local luncheon clubs available.
Working with young Gateshead mums to be to develop a new set of care
standards.
The Trust has developed a new set of standards caring for
pregnant young women developed through working closely
with a group of expectant young mums from Gateshead
Young Women’s Project. We wanted to explore some of the
challenges facing young people during pregnancy. The new
standards set out what younger people can expect from
health care at the Queen Elizabeth Hospital and outline some
of the things that the young people highlighted as their
biggest concerns. Many of these concerns and themes were
the same that we here from all pregnant mums but it was
good to be able to reassure them of the high standards
already in place at the QE.
Using technology to improve care for patients
Accuvein
Accuvein is a pioneering new technology used for locating veins and is proving a success with doctors,
nurses and patients alike in our A&E department. This is a hand held device that makes it easier for staff
to locate veins for procedures such as taking blood and inserting cannulas (putting a tube into veins to
drugs for example). This piece of equipment is held over the skin and uses infra-red light which is
absorbed by the haemaglobin in the blood. It then detects where it has been absorbed and projects a
real-time image (like a road map of the veins) back onto the skin. The benefit to patients is this reduces
the number of attempts to find a vein making it less painful and also reduces anxiety levels. Those
patients with small, fragile veins or damaged veins due to long term treatments or obese patients whose
veins are not close to the surface will benefit greatly from this useful piece of equipment. It will also
release health professionals time as the number of attempts at the procedure will be reduced.
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Using simulation to improve staff training
We have expanded our training capabilities with the addition of a new state-of-the-art wireless
simulation dummy called SimMan 3G, providing the most realistic medical training
experiences. SimMan 3G, due to its wireless technology is providing ‘real life’ medical scenarios for
training staff, including off-site scenarios, like car crashes. This dummy provides such a realistic
experience for healthcare staff because of a range of features that aren’t on standard simulation
dummies. They include having a heartbeat and measurable blood pressure and even responding to
actions the trainees have initiated. It displays neurological symptoms as well as physical symptoms; with
eyes that open, close and respond to light as well as the ability to respond verbally (the instructor will
send these to the dummy wirelessly). As well as this, SimMan 3G can bleed, cry and sweat and it
automatically recognises and responds to different drugs.
Medical simulation training provides the opportunity for staff to put
their theoretical knowledge to use in a realistic and controlled
environment. Simulation training is increasingly in demand in the
healthcare environment as it helps to avoid errors caused by human
factors, such as poor teamwork, poor communication skills and a lack of
awareness of the surroundings of a situation. Simulation training is one
of the best ways to transfer skills learned in the classroom to the real life
clinical environment. As well as SimMan 3G, the Trusts clinical skills
simulation centre has a SimMom that simulates emergency birth
situations, like a patient haemorrhaging during labour or needing an
emergency Caesarean section. The centre also houses a SimBaby and
SimJunior for paediatric training. The simulation centre is used by
medical students and staff training at all levels from across Trust and the
region. All of the scenarios are recorded by cameras so supervisors can
monitor actions and responses and those involved have the chance to
review their own performances.
Quality improvements in Gateshead Breast Screening Unit
The breast unit has introduced several new processes to improve the experience of patients. We have
introduced a system of text message reminders for screening appointments. Initially this was a simple
text stating when and where the appointment for screening was to be undertaken. However due to
patient feedback, we have now improved this service by enabling replies to the text reminders. In this
way requests for changes of appointment times or venues can be accommodated in a timely manner.
“Many thanks
for the
reminder”
“Yes thank you, can
confirm
appointment”
“I will be there.
Thanks for the text”
Another benefit recently initiated is an online appointment change facility, the link for this service has
been added to the appointment letter and we have had an excellent response particularly from younger
ladies who appear to appreciate being able to organise appointments online. Although this system has
only recently been introduced we are seeing a steady increase in the number of ladies using the system;
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in January there were 71 requests for appointment changes and in February 129 requests for
appointment changes.
In addition to the administrative improvements we have achieved, the medical staff have pioneered two
new processes to improve the diagnostic service for women recalled from screening or who present
with a breast symptom. The unit has purchased an intact machine which allows the operator to remove
a larger lesion from the breast in one rather than a number of procedures. This removes the need for
ladies who this procedure is suitable for, having several core biopsies taken. This also allows the
radiologist to entirely remove some small benign lesions without the need for surgery. The breast unit
has also introduced the use of microbubble ultrasound contrast to identify the sentinel axillary lymph
node. This is an innovative procedure being used in the breast unit which we anticipate will reduce the
need for axillary surgery, and will reduce the number of patients having to have second operations to
treat positive surgical axillary sentinel node biopsies.
Improving care at the end of life
Over the year, care at the end of life has remained under immense scrutiny. Nationally, this had led to
the withdrawal of the Liverpool Care Pathway as well as a system wide review of care provided.
Gateshead Health NHS Foundation Trust is dedicated to continuously improve care being provided to
patients at the end of life. Over 2014/15, the Trust has moved ahead with its agenda. Some of the
initiatives that have been developed are presented below:
Care in the last hours to days of life
Following the publication of the national review of the Liverpool Care Pathway, a Trust action plan was
produced by the palliative care team to ensure all the recommendations from the report are
implemented and audited. This action plan is overseen and monitored by the End of Life Care Steering
Group in the Trust. Some of the key action points have been:
Clear phasing out of the Liverpool Care Pathway by July 2014. The palliative care team ensured
via increased presence, trust bulletins and a PR exercise that all staff were aware the Liverpool
Care Pathway should not be used anymore.
To support all staff in the trust, good practice guidance was released via a SafeCare Bulletin
entitled ‘Care in the last days to hours of life’. This ensured that all clinical staff including doctors
and nurses could refer to the principles of good care in the last days of life. This guidance also
gave advice on the best way to clearly document the care that clinical staffs are providing. As a
further prompt, credit-card-sized reminders of practical ways to care were also released to staff.
A continuous audit programme for care in the last few days of life has been initiated and hence
since April 2014, there have two audits of care in the last few days of life. In addition, the Trust
also participated in the National Care of the dying audit in 2014. All the audits have shown that
care is of excellent standard and clear action plans have been initiated after each audit. The
audits are overseen by the End of life Steering Group.
To support the transition phase, the specialist palliative care team also held weekly lunch-time
drop-in sessions for all staff over a period of two months. The aim was to give an opportunity to
staff that had any questions or concerns about end of life care in the Trust to speak to a member
of the Specialist Palliative Care Team.
79
The Palliative Care Consultants have also actively participated in the regional End of Life Steering
Group. It is through this alliance that the regional group has adopted Gateshead’s Trust
guidance for the region. Working with this regional group has also led to the development of
new documentation to support good care in the last days of life, for both medical and nursing
staff. The documents have been piloted in St Bede’s Unit our palliative care ward and will be
rolled out from April 2014.
St Bede’s Palliative Care Unit
Following the move of St Bede’s Unit to the acute site at Queen Elizabeth Hospital in May 2012, it has
been possible to provide increasing access to specialist palliative care to a wider group of patients – life
limiting conditions including non-cancer diagnosis and other long term conditions for example end stage
heart failure and Chronic Obstructive Pulmonary Disease (COPD). A 30% increase in patients has been
seen over the last year as well as a large increase in referrals. Going forward, the vision for this unit is
that it becomes less clinical in appearance and reflects what other hospices within the region have
achieved .This is with the aim to provide a more homely environment to patients and families giving
them a home away from home. A project group developed to accomplish this vision has been successful
in redesign of the much out dated bath and work starts imminently to update the bedrooms and soft
furnishings.
The holistic nature of the care provided on this unit has been enhanced by the successful
implementation of two programmes:
an innovative arts programme, ‘room for you’ and
complementary therapies provided by Lifespan.
The room for you programme has helped patients and their carers through the illness by incorporating
arts and crafts into counselling. The programme has also supported staff to better care for the patients
by enabling staff to express their thoughts and feelings in a creative and non-threatening way. Lifespan
is a well-established organisation that provides complementary therapies to several hospices in this
region. Access to their services has benefited many patients in St Bede’s including their relatives who
can also access complementary therapies.
St Bede’s has passed two ward accreditations and all staff continue to strive towards maintaining their
competencies and skills via a regular teaching programme. The ward staff also acts as a resource in the
use of syringe drivers for other wards within the hospital.
New Appointments to the Specialist Palliative Care Team
This year a successful bid was awarded by Macmillan Cancer Charity to enable the appointment of two
key staff to the team:
Specialist palliative care nurse
The team appointed another Specialist Palliative Care Nurse who started working in August 2014. This
has significantly improved the response times to referrals enabling the team to have more direct patient
contact and also to deliver more clinical teaching to clinical staff around palliative and end of life care.
End of Life Care Facilitator
This is a new role for this Trust with the successful applicant commencing in November 2014. This is an
incredibly important role and the post holder is predominantly working on the education of staff to
highlight end of life care, driving forward projects and innovations to improve pathways within the Trust
in line with national and regional guidance.
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Palliative and End of Life Care Training and Education in the Trust
The specialist palliative care team have delivered a wide range of education and training to different
members of staff including palliative care link nurses, nursing assistants, trained staff, allied health
professionals and junior doctors. A training needs analysis for the Trust specifically around End of Life
Care has also been written mandating end of life care training to all staff. This is being achieved through
a targeted approach delivering training to staff according to their needs. A video has been filmed by the
palliative care team which will act to sensitise all staff about issues arising at the end of life. This video is
now part of mandatory training for all staff.
End of Life Steering Group
The End of Life Steering Group has representation from all areas across the Trust and has successfully
provided the strategic lead in delivering the End of Life Care Strategy for the Trust. The group was
restructured in the autumn of 2014 with the aim of achieving efficient work streams.
Clinical Commissioning Group (CCG) End of Life Group
The specialist palliative care team have been working closely with primary care to review end of life
services and implement action plans to improve key elements. A recent workshop for all key
stakeholders explored the pathway and a high level action plan was developed and agreed.
3.3 Patient Experience
Friends and Family Test
We have implemented the Friends and Family Test (F&FT) within inpatient areas, patients attending
A&E, in Maternity Services and more recently this year in Day case and Outpatient services, Children’s
services and Mental Health services in line with national requirements. This patient experience survey is
called the F&FT because it is based on asking all patients a standard question: “How likely are you to
recommend the service to friends and family if they needed similar care or treatment?”
The F&FT provides our patients with another easy way of providing us with direct feedback through
asking a very simple question. All patient responses are reviewed and used to ensure we are providing
the best possible services to our patients. Before we implemented the test we undertook an exercise
asking patients how they would like to be asked the question, for example by text message. They said
they would prefer to be given a postcard and consequently this was the method we chose to
implement.
Changes to the F&FT
Following a stakeholder wide consultation beginning October 2013 there were several amendments
made to the guidance with the main one being the decision to change the way the F&FT is scored from
October 2014. The six response options remain the same, but a percentage recommends score is now
calculated. This is achieved by adding the ‘likely’ and the ‘extremely likely’ response numbers divided by
the total number of responses giving a total percentage would recommend score. Previously the ‘likely’
response was classed as a neutral response. In addition the percentage would not recommend score is
calculated adding the number of ‘unlikely’ and ‘extremely unlikely’ responses divided by the total
number of responses giving a percentage would not recommend. This change came into effect from
October 2014.
Inpatients
The acute inpatients results for both response rate and score have been pleasing. Due to unprecedented
pressures over the winter period our response rate has fallen, however our percentage would
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recommend scores have remained good throughout. Results for our inpatient F&FT from April 2014 to
March 2015 are in the table below.
Month
Inpatient
% would
recommend
% would not
recommend
Inpatient
Response
Rate %
Apr
n/a
May
n/a
Jun
n/a
July
n/a
Aug
n/a
Sep
n/a
Oct
96.2
Nov
98.7
Dec
97.4
Jan
96.3
Feb
94.5
Mar
96.4
n/a
n/a
n/a
n/a
n/a
n/a
2.0
1.1
0.5
1.1
1.2
1.4
35.5
41.3
46.0
46.8
36.3
33.1
36.0
32.1
24.8
18.9
26.9
45.0
The graph below shows our favourable inpatient position compared with local Trusts since September
2013 and has converted the old net promoter scores to give a results based on the new scoring system
for the whole period.
Through this process patents have left us lots of comments about their care which are fed back to the
individual areas. We are once again undertaking a review of these to see where we can further improve
our patents experience.
A&E Department
We are delighted with our increased response rates for our A&E department this year using the token
system alongside comment cards so those patients who wish to, can leave more detailed feedback. The
comment card asks patients:
“If we could change one thing to improve your experience in the A&E today what would that be?”
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Our results for the A&E Friends and Family Test for the year April 2014 to March 2015 are displayed in
the table below.
Month
A&E
% would
recommend
% would not
recommend
A&E
Response
Rate %
Apr
n/a
May
n/a
Jun
n/a
July
n/a
Aug
n/a
Sep
n/a
Oct
93.7
Nov
95.3
Dec
92.7
Jan
92.1
Feb
90.2
Mar
92.7
n/a
n/a
n/a
n/a
n/a
n/a
2.7
3.4
3.0
2.0
3.8
2.4
22.6
28.6
25.1
29.4
35.4
31.1
31.7
18.7
21.9
28.2
13.2
12.0
The graph below shows our favourable A&E position compared with local Trust since September 2013
and has converted the old net promoter scores to give results based on the new scoring system for the
whole period
Maternity
We successfully implemented the F&FT in maternity services in October 2013. This involves asking
women the standard question at four touch points in their care:
1.
2.
3.
4.
36 week antenatal appointment
Following homebirth or on discharge from delivery suite or birthing unit
At discharge from the postnatal ward
On discharge from the community post natal midwifery team
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Our response rates have been variable across the four maternity touch points however we have
received consistently good scores in respect of patients who would recommend us. Establishing the
eligible patient criteria (to enable response rates to be calculated) for this F&FT has been challenging
due to patients moving from one provider to another for different parts of their maternity care. This has
been recognised as an issue nationally and from July 2014 this has no longer collected for questions one,
three and four. The table below highlights our results for the percentage of patients who would/would
not recommend our maternity services at each of the touch points.
Month
Q1 % would recommend
Q1 % would not
recommend
Q2 % would recommend
Q2 % would not
recommend
Q3 % would recommend
Q3 % would not
recommend
Q4 % would recommend
Q4 % would not
recommend
Oct
66.7
0
Nov
100
0
Dec
100
0
Jan
100
0
Feb
100
0
Mar
100
0
98.2
0
98.6
0
98.3
1.7
100
0
89.4
8.5
98.8
0
100
0
98.6
1.4
95.5
2.3
100
0
91.3
6.5
97.7
0
100
0
100
0
100
0
100
0
100
0
100
0
In October 2014 we commenced collection of the F&FT in outpatient services. The results for the total
outpatient services scores are outlined in the table below. Response rates are not collected for this
F&FT.
Month
% would recommend
% would not recommend
Oct
92.7
1.9
Nov
93.7
1.5
Dec
95.7
1.0
Jan
94.6
1.1
Feb
95.3
1.2
Mar
94.1
1.6
In January 2015 we implemented the F&FT into mental health services. The results for total mental
health services scores are outlined in the table below. Response rates are not collected for this F&FT.
Month
% would recommend
% would not recommend
Jan
100
0
Feb
100
0
Mar
98
0
In February 2015 in our maternity unit, we began to trial the use of IPADS to collect the F&FT feedback.
This was based on feedback from women attending maternity services who said they would prefer this
method.
In addition, in preparation for the token system being used for F&FT being abolished on 1st April by NHS
England, we have also been trialling some other methods of collecting F&FT in our A&E department.
These methodologies include the use of a paper form and collecting F&FT via IPADS.
The National Patient Survey Programme
The National Patient Survey Programme of annual surveys includes: Adult Inpatient; Mental Health;
Outpatients; Maternity Services and Emergency Departments. These national surveys are valuable as
they provide information on various aspects of service and are used to measure and monitor our
84
performance against Trusts locally and nationally. An overview of the latest results A&E department and
the annual inpatient surveys is shown on the following pages;
Our National A&E Department Survey Results.
How our scores compare with other
Based on patients´ responses to the
Trusts
survey, our Trust scored
8.0 / 10
Arrival at A&E
6.3 / 10
Waiting times
Doctors and nurses
8.4 / 10
(answered by all those who saw a
doctor or nurse)
8.0 / 10
Care and treatment
8.4 / 10
Tests (answered by those who
had tests only)
8.3 / 10
Hospital environment and
facilities
6.5 / 10
Leaving A&E (answered by
those who were not admitted to
hospital or to a nursing home
only)
8.5 / 10
Experience overall
Picker Inpatient Survey 2014 (results published February 2015)
The inpatient survey is currently undertaken on an annual basis by the Picker Institute Europe. The
picker Institute were commissioned by 78 Trusts to undertake the inpatient survey on their behalf. Our
results are therefore compared against the 77 other Trusts. This survey allows us to look at trends over
time helping focus attention on improvements and those areas where performance may be slipping.
85
Comparing results over time:
A total of 60 questions were used in both the 2013 and 2014 surveys. Comparing our 2014 results with
2013 we were:
“All aspects from entering
Significantly better on 2 questions
reception were 1st class”
Significantly worse on 1 questions
No significant difference on 57 questions.
Lower scores are better
The Trust has significantly improved on the following questions
2013
2014
Hospital: hand-wash / gels not available or empty
5%
2%
Surgery: results not explained in a clear way
31%
22%
The Trust has worsened significantly on the following questions
Care: staff did not do everything to help control pain
2013
22%
2014
31%
Picker presents the results in the form of problem scores. The problem score shows the percentage of
patients for each question who, by their response, have indicated that this particular aspect of their care
could have been improved. Therefore lower scores are better.
Comparing results with others:
When comparing our results for 2014 with the other 77 Trusts using Picker to collect their patient
feedback, the survey results showed that we were:
Significantly better on 29 questions
Significantly worse on 0 questions
No significant difference on 33 questions.
Overall these are very positive results for the Trust. We are
undertaking some intensive work to understand why
patients are saying staff do not do everything to help
control pain so that we can work with our staff to
improve this.
“I would have preferred a
little more choice of food”
“The staff were patient
and reassuring about my
concerns”
Continuing developments and improvements within our maternity services
2014 has been a further year of continued development and improvements for Gateshead Maternity
Services. Our postnatal ward is now a modern, bright ward area that provides en- suite bathrooms,
toilets and facilities for other children and the opportunity for partners to stay overnight. The family or
‘the jungle room’ is a huge success as it facilitates the opportunity for friends and family to spend stress
free time together in bright and modern room. Improvements in the environment have continued, with
the refurbishment of our ‘family suite’. This enables families who have suffered bereavement, or whose
baby is in need of intensive care, to remain close, in a small self-sufficient area. This room has a private
external access and parking space for bereaved parents, as after talking to these parents, it is clear, that
leaving their baby in the hospital, and walking out through the main maternity reception is very painful
and distressing.
86
The QE Maternity service is also engaged in two large national programmes to reduce stillbirth rates in
England and prevent untoward outcomes at birth. We have also signed up to the Maternity Safety
Thermometer, which measures key performance outcomes for our mothers, which we can use to
benchmark and improve our performance.
We pride ourselves in developing the service in line with our
service user needs and suggestions; therefore we have allocated
free parking bays outside the unit for partners of our mothers
when in labour. We are also in the process of upgrading the
entrance area to the main reception to create a more modern,
comfortable and bright reception area. The Pregnancy Assessment
Unit has also undergone a number of developments to improve the
flow of mums to be and their families through our service. This
included some process transformation work with the Trust team,
and the development of an electronic appointment system.
What our mothers think of our service is hugely important to us
and because of this we have successfully engaged the views of
recently delivered mother by having two very well attended coffee
mornings, and Christmas fayre. A ‘Friends of the QE Maternity’ service facebook page has also been set
up, and a lot of interest developed there. We also asked some young mums to visit our unit for their
opinions.
We hope to continue with our innovation and development into 2015, and be the maternity service of
choice for all women in Gateshead.
Caring for Carers
Gateshead Health NHS Foundation Trust has signed up to the Carers’ Charter which promotes a culture
that recognises the vital role carers play. The aim is to promote a voice for carers in hospital to support
them in their role providing appropriate information and that carers are fully involved in discharge from
hospital. Gateshead Carers and Gateshead Health NHS Foundation Trust are also working together to
highlight their commitment to carers by signing up to the Gateshead Carers ‘Carer Friendly Employer’
Charter.
Caring for Carers is a Trust forum which meets bi-monthly with representation from a range of carer
support organisations including Gateshead Carers Association, Crossroads, Alzheimer’s Association as
well as ward staff to identify ways to improve carer experiences. We also link with Gateshead Carers
Strategy Group.
Mandy Ramsey in her role as ‘working carer support’ from Gateshead Carers Association (GCA) has
commented that ‘ involvement with the Trust for GCA is fantastic, as we are able to promote our
services to all carers via patients and their families, as well as working carers at the Trust. GCA would
like to continue to build upon our existing support and develop new materials to be made available to
staff that can be used for all families undergoing patient care, as well as being accessible for working
carers at the Trust, and this is something that hopefully we can develop in the near future. So as well as
all the good work the Trust does around patient carer support, there is a commitment to supporting
staff who are carers as well.’ Mandy in her role has provided drop ins at the Trust as well as one to one.
The Trust took part in Carers week 2014 event in Saltwell Park. This provided opportunities for carers to
feedback about their experience within the Trust. Gateshead Carers Association and Crossroads
87
supported the QE Carers Week event providing information and advice, and referrals for on-going
support with stands in the Queen Elizabeth Hospital as well as in Saltwell Park with input from ward
teams.
This is a campaign started by Kate Granger, a doctor, who is a terminally ill cancer patient. During a
hospital stay she made the stark observation that many staff looking after her did not introduce
themselves before delivering care. This felt very wrong so she decided to start a campaign to encourage
and remind healthcare staff about the importance of introductions in the delivery of care. She firmly
believes it is not just about knowing someone's name, but it runs much deeper. It is about making a
human connection, beginning a therapeutic relationship and building trust. She believed this to be the
first rung on the ladder to providing compassionate care.
On 13th August 2014 we asked our staff to make a pledge to always introduce themselves to every
patient they meet and this continues to be a focus of our work in the Trust.
Care for patients with learning disabilities
The Trust continues to have close links with the Disability partnership within Gateshead and the North
East. As a member of the partnership we are taking part in a refresh to look at the way we work
together and provide a vision for the future to engage the various members of the partnership. An
external company will be hosting workshops for users and partners to look at provision of care for
2015/16. We have pledged our support and engagement with this, and look forward to presenting the
vision to everyone in the near future.
88
Listening to Concerns and Complaints
The Trust acknowledges the value of feedback from patients and visitors and continues to encourage
the sharing of personal experiences. This type of feedback is invaluable in helping us ensure that the
service provided meets the expectations and needs of our patients through a constructive review.
For the year 2014/15 we received a total of 234 formal complaints which is consistent with the same
figure from the previous year. Promoting a culture of openness and truthfulness is a prerequisite to
improving the safety of patients, staff and visitors as well as the quality of healthcare systems. It
involves apologising and explaining what happened to patients who have been harmed as a result of
their healthcare treatment or when in-patients or outpatients of the Trust. It also involves apologising
and explaining what happened to staff or visitors who have suffered harm. It encompasses
communication between healthcare organisations, healthcare teams and patients and/or their carers,
staff and visitors and makes sure that openness, honesty and timeliness underpins responses to such
incidents.
The culture of “Being open” should be fundamental in relationships with and between patients, the
public, staff and other healthcare organisations. The Duty of Candour introduced from 1st April 2013 is
the contractual requirement to ensure that the Being Open process is followed when a patient safety
incident results in moderate harm, severe harm or death.
The introduction of the Duty of Candour process does not appear to have resulted in a significant
increase in the numbers of complaints and concerns received.
Complaints and Concerns 2010/2015
900
786
800
775
706
700
591
600
533
500
400
300
200
243
194
234
234
185
100
0
2010/11
2011/12
2012/13
Complaints Received
2013/14
2014/15
PALS
During 2014/15 the top five main reasons to raise a formal complaint were in relation to;
• Clinical Assessment (A&E & Outpatient) (65)
• Clinical Assessment (Inpatient) (56)
• Communication (29)
• Operations & Procedures (15)
• Attitude (13)
89
Complaints Performance Indicators
Complaints received
Acknowledged within 3 working days
Complaints closed
Closed within agreed timescale
Number of complaints well founded#
Concerns referred to PALS
Outturn 2014/15
234
234
219
106
92
775
# Complaints well founded = complaints either fully or significant part upheld.
Complaints Indicators
Number of closed complaints reopened
Number of closed complaints referred to parliamentary
ombudsman
Outturn 2013/14
22
Outcome of complaints referred to parliamentary ombudsman
Awaiting decision
Complaints upheld
Complaint referred back for local resolution
Declined to be investigated
Intervention
Outstanding from previous year – upheld
Outstanding from previous year - declined
Outturn 2013/14
1
1
0
1
0
0
0
6
As a result of complaints and concerns raised over the past year a number of initiatives have been
implemented.
Following a complaint the protocol for the dietician to add the Fortisip to the drug chart without
the need for a doctor’s signature was reviewed. In the future as soon as the dietician has decided
a patient needs additional supplements they can be written on to the drug chart immediately
and prevent a delay.
A new system has been implemented as a result of our investigations into maternity care. If
women are identified by the community midwife that they are small for dates, they will be asked
to attend the pregnancy assessment unit for an immediate consultation and review that day.
Complications of pregnancy identified in clinic should have indicated that the patient should
have been sent to the pregnancy assessment for an emergency review but this did not happen.
As part of the action plan to prevent a reoccurrence a senior midwife will now be in the
antenatal clinic to support the junior doctors in their decision making and ensure that there are
no missed opportunities to intervene if required.
To prevent any delays in an assessment for aids being carried out for patients being discharged
to a nursing home the following actions have been taken:•
•
Documentation for the multi-disciplinary allocation meeting needs to be reviewed and
needs to include the names of staff present and the reasons for allocation to a particular
discipline.
Waiting times for multi-disciplinary referrals should form part of the decision process for
allocation of referral.
90
•
•
Feedback should be given to the manager of the nursing home to ensure that referrals
are more detailed.
The use of telephone triage/assessment should be reviewed in order to gain more
information to inform categorisation of patients being referred.
Concern was highlighted about the delay in receiving results and appropriate treatment
following a biopsy of an abdominal growth. This episode highlighted a distinct lack of
communication between the department’s MDT Coordinator / Secretaries and referring
(internal) clinicians and / or their secretaries. In future any communication which takes place
verbally between the department and the referring clinician’s secretary is also to be followed up
/ confirmed via email. In addition that the patient’s notes are to be hand delivered to the
referring clinician/secretary if required in order to ensure patients are not lost in the system.
Amendments have been made to the Physiotherapy and Orthotics appointment letters to advise
of the location of the departments following an issue raised by an elderly patient.
Service Line Manager is to meet with commissioners to discuss how the current fragmented
service is causing problems for both patients and parents following a parent highlighting the
frustration experienced by the lack of progress and communication between the departments
and organisations involved in child’s care.
3.4 Focus on Staff
Investors in People Champion
Investors in People (IiP) is an international award which recognises excellent people practices which
directly contribute to a high performing organisation. Having achieved the gold standard in November
2012, which demonstrates that the organisation has reached the highest level of attainment, the
organisation wished to share good practice with others by becoming an IiP Champion in 2013.
The Trust continues to network with other successful organisations through the Champion network and
provides numerous organisations, including other trusts, with information, advice and guidance to
support them to improve their own people practices. This is an excellent way of enhancing the
reputation of the Trust and to ensure that we gain recognition for what we do well.
Health and Well-being
The Trust continues to hold the Investors in People Health and Well-being Good Practice Award, and is
recognised nationally as well as regionally as an exemplary
organisation which recognises the importance of keeping
staff well
and emotionally resilient in order to provide better quality
care to
patients and service users.
Most recently, in January 2015, we attained the North East Better Health at Work Gold Award, which
recognises that the Trust has a well-established strategy to address staff health and well-being and a
structured approach to events and activities which raise awareness of key health issues both within the
organisation and also reaching family, friends and the wider community.
91
In the past twelve months activities and events have included:
Promotion of “Stoptober” campaign, No Smoking Day in March 2015 and weekly, on-site Stop
Smoking sessions specifically for staff, provided by a local Pharmacy;
Annual “Celebrating our Staff” awards ceremony at the Sage Gateshead;
Provided internal “Building your personal resilience” workshops for staff and one-to-one
resilience coaching;
Conducted a second resilience training impact evaluation – 20% improvement in well-being
indicated;
Delivered a resilience master class as part of the NE Leadership Academy Leadership Summit in
July 2014;
Promoted Dry January and encouraged zero alcohol intake for the whole month;
Staged our annual 5-a-side football tournament at Gateshead Leisure Centre;
Access to on-site holistic therapies for staff and seasonal special offers;
“Movember” moustache competition to raise awareness of male cancers;
Staged a June Carers event, including staff who are carers;
Conducted a health needs assessment in July to gain information from staff on health and
lifestyle choices to prioritise future HWB work;
Promotion of e-publications on health, safety and well-being for staff to access on-line;
Subsidised Zumba classes for staff, family and friends;
Canvassed views of cyclists within the Trust to ensure we meet their needs and to encourage
others to cycle to work through our Bike to Work Scheme;
Provided an in-house Mindfulness taster session for staff and have supported manager training
in mindfulness techniques;
Promotion of Men’s Health Day in June 2014;
Continuation of GO! Gateshead scheme offering staff subsidised membership of Gateshead
Council fitness and leisure facilities;
Christmas carol service for staff, friends, family and patients.
Developing our leaders
The Trust last year launched its Leadership Strategy, which was the result of an Organisational Health
Index (OHI) questionnaire, conducted in spring 2013, which identified clear growth opportunities for
leadership. Since that time, OD and Training has made leadership development at all levels a priority.
The purpose of the strategy is to ensure effective leadership within the Trust, necessary to sustain
organisational health and excellence, in the context of a rapidly changing health environment.
We believe that effective leadership means not only having the right knowledge and skills, but
demonstrating the right behaviours and values to ensure patient safety and quality. Our strategy has
embraced the Healthcare Leadership Model as a means of ensuring that consistent messages are given
around appropriate leadership behaviours.
The following leadership development programmes have been offered to managers and leaders in the
last year:
92
Chrysalis
Developed last year, this two-day programme for team leaders and supervisors provides
an introduction to leadership and management. This in-house workshop was designed
to address a perceived shortfall in leadership development at this level.
Kaleidoscope
This well-respected in-house leadership and management programme is, as its name
suggests, constantly changing and adapting to meet the leadership development needs
of managers within the Trust. We continue to rely on internal expertise from a range of
senior managers to deliver most of this programme, which evaluates very well and is
delivering more confident and competent front-line managers.
Leadership and Transformation
Tier 2 monies, allocated for the development of health professionals, have
been utilised to commission a leadership development programme in
partnership with Sunderland University for more established leaders and
managers who wish to stretch their current understanding of leadership and to
gain new insights into contemporary leadership thinking.
The programme requires participants to undertake 360 degree feedback and complete an assignment
and reflection log which provides them with a University Certificate of Post Graduate study and holds 40
Post Graduate credits. A further two cohorts of managers and leaders have undertaken this programme
of study this year and 29 out of 30 have completed thus far.
PRISM
This internal four-day programme has been designed to provide a sound
introduction to leadership and transformation for all consultant staff and SAS
doctors within the Trust.
One to one coaching support is an integral part of the programme, which offers
the participant time to discuss particular areas for development, identified by the individual themselves.
One programme of 16 consultants has been successfully completed and evaluated very well. Another
has started in March 2015.
NHS Leadership Academy Programmes
The national NHS Leadership Academy has launched a number of programmes,
which are free of charge to Trusts. OD and Training has actively promoted these
programmes to make sure we gain maximum benefit in terms of staff gaining
important leadership knowledge and skills and that we gain value for money in
ensuring a very good take-up of these learning opportunities.
93
Listening to our staff through the NHS Staff Survey
We continue to participate in the annual staff survey. The Trust’s approach to staff engagement, in
terms of the Staff Survey has always been to involve staff and key stakeholders in devising local
questions which will provide the organisation with local information.
The Trust’s Improving Working Lives (IWL) Working Group, which includes staff representatives, plays a
role in monitoring and reporting on staff feedback gained through the survey. The Trust has an open
and transparent approach to publicising Trust-wide and departmental results and acting upon them to
improve staff satisfaction and well-being at work.
All NHS Trusts in England are required to take part in the annual National NHS Staff Survey. The survey
enables each organisation to benchmark itself against other similar NHS organisations and the NHS as a
whole, on a range of measures of staff satisfaction and opinion. This year the Trust agreed to carry out a
census of all staff and our response rate is illustrated in the table below.
2013
Response rate
Trust
50%
2014
National
average
50%
National
average
42%
Trust
50%
Trust improvement/
deterioration
No Change
Measured against 29 Care Quality Commission key indicators, we came out most favourably compared
to other acute trusts in the UK in the following areas:
2013
Top 4 ranking scores
% of staff believing the
trust provides equal
opportunities for career
progression or promotion
% of staff having equality
and diversity training in last
12 months
% of staff experiencing
discrimination at work in
last 12 months
% of staff having well
structured appraisals in last
12 months
Trust
improvement/
deterioration
2014
Trust
National
average
Trust
National
average
94%
88%
92%
87%
2% Decrease
71%
60%
78%
63%
7% improvement
8%
11%
8%
11%
No Change
39%
38%
43%
38%
4% Improvement
94
The Trust’s lowest four ranked scores were:
2013
Bottom 4 ranking scores
Trust
National
average
Trust
improvement/
deterioration
2014
Trust
% of staff agreeing that
their role makes a
88%
91%
89%
difference to patients
% of staff witnessing
potentially harmful errors,
35%
33%
36%
near misses or incidents in
last month
staff motivation at work
3.75
3.86
3.75
% staff able to contribute
64%
68%
66%
to improvements at work
Italics indicate a lower score is better for that Key Finding
National
average
91%
1% Improvement
34%
1% Decrease
3.86
No Change
68%
2% Improvement
Our ratings show that we are:
In the top 20% of acute Trusts for seven key scores;
Better than average in eight key scores;
Average in six key scores;
Below average in seven key scores;
Worst 20% in one key score.
We have improved on last year’s results in the following areas:
Percentage of staff receiving an appraisal in the last 12 months
Percentage having Equality and Diversity Training in the last 12 months
Key priorities for the coming year:
Work-related stress
Staff involvement in service improvement
Motivation/staff engagement
Managers’ role in engagement and staff involvement
Clear vision and key priorities of Trust and where staff fit in
Leadership capability at every level
Maintenance of staff appraisal compliance (essential for IiP)
The chart below shows the percentage of staff that have completed the national staff survey in 2014
who said they would recommend the Trust to their family or friends who responded agree/ strongly
agree compared to other Trusts within the region.
Trust
Gateshead NHS FT
Newcastle
Northumbria
South Tyneside
Sunderland
2013
70%
87%
77%
64%
59%
2014
75%
85%
81%
63%
63%
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3.5 Quality overview - performance of Trust against selected indicators
In the following sections are a range of quality indicators where the Trust performance can be
seen. These further develop the three domains of quality (Patient Safety, Clinical Effectiveness and
Patient Experience). The indicators themselves have been extracted from NHS nationally mandated
indicators, Commissioning for Quality and Innovation (CQUIN), and locally determined measures. Trust
performance is measured against a mixture of locally and nationally agreed targets. The key below
provides an explanation of the colour coding used within the data tables.
Target achieved
Although the target was not achieved, it shows either an improvement on previous year or
performance is above the national benchmark
Target not achieved but action plans in place
Where applicable, benchmarking has been applied to the indicators using a range of data sources which
are detailed in the relevant sections. The Trust recognises that benchmarking is an important attribute
that allows the reader to place the Trust performance into context against national and local
performance. Where benchmarking has not been possible due to timing and availability of data, the
Trust will continue to work with external agencies to develop these in the coming year.
1) Visible Leadership for Safety and Culture
Outcomes of Trust Wide MaPSaF Patient Safety Culture Assessment:
2010/11
2011/12
2012/13
2013/2014
2014/2015
Target
Pro-Active /
Generative
*No
Assessment
Due
*No
Assessment
Due
Pro-Active
*No
Assessment
Due
*No
Assessment
Due
MaPSaF Assessment undertaken in May – September 2013 as part of a three year cycle.
Executive Quality and Safety Walkabouts (implemented from February 2010):
2010/11
2011/12
2012/13
2013/14
2014/15
Target for
2014/15
Cumulative Walkabouts Undertaken
42
33
28
24
23
48
Average Walkabouts Undertaken
per month
3.5
2.8
2.3
2
1.9
4
Cumulative Actions Identified
101
51
42
49
35
N/A
Cumulative Actions Implemented
77
50
39
34
27
N/A
0
0
0
0
90% less
than 60
days old
15
Outstanding Actions (more than 60
days old)
(85%
completed
within 60
days)
Source: Trust Quality Dashboard
96
In December 2014, the Corporate Management Team, approved a proposal to combine both the Executive Walkabout and
Night Visit schedules into one schedule of monthly visits. The visits now entail visiting a number of defined areas between
2.00pm-5.00pm, alternating the following month with a night visit between 8.30pm-11.30pm. This new process allows us to
work more efficiently within current resources and to work within a framework that facilitates a discussion focussing on
quality and safety. This new system has already demonstrated improved attendance for visits.
2) Team Effectiveness / Efficient / Innovative
Mandatory Training
Compliance (Percentage
take up on allocated
places)
Personal Development
Plan (PDP) Compliance
(Staff with a timely
completed PDP)
2008/
09
2009/
10
2010/
11
2011/
12
2012/
13
2013/
14
2014/
15
Target
National
Benchmark
59%
55%
64%
67.00%
70.40%
82.40%
78.55%
90%
N/A
42.40%
51.90%
48.60%
53.90%
54.00%
77.40%
66.15%
90%
N/A
4.00%*
Staff Sickness and
Absence (As reported
from personnel)
5.29%
4.96%
4.49%
4.31%
4.70%
5.06%
5.00%
3.4%
(Apr 2014
– Sep
2014)
Staff Turnover (Labour
turnover based of Full
Time Equivalent)
12.08%
10.54%
12.44%
10.89%
10.59%
10.62%
15.92%
10%
N/A
*The National Benchmark is calculated using the average of the months April to September 2014 and is
available from http://www.hscic.gov.uk/catalogue/PUB16383 - “NHS Sickness Absence Rates July 2014Sept 2014 Quarterly Tables”
97
3) Safe Reliable Care / No Harm
A) Reducing Harm from Deterioration:
HSMR
2008/09
2009/10
2010/11
2011/12
2012/13
2013/14
2014/15
Target
National
/ Peer
97.3
99.8
107.4
111.04
107.8
93.0*
105.6‡
<100
100
1.05
1.04
1.01**
1.01‡‡
As
expected
As
expected
As
expected
As
expected
1.00
(Jul 11 Sep 12)
(Oct 11Sep12)
(Oct 12Sep 13)
(Oct 13Sep 14)
As
expected
or lower
than
expected
0.70%
0.74%
0.84%***
0.91%‡‡
SHMI
SHMI Percentage of
admitted
patients whose
treatment
included
palliative care
(contextual
indicator)
Risk Adjusted
Mortality Index
Score taken
from CHKS
using RAMI
2012
Crude
mortality rate
taken from
CHKS
Crude
mortality rate
taken from CDS
Number of
calls to the
CRASH team
Of the calls to
the arrest team
what
percentage
were actual
cardiac arrests
Cardiac arrest
rate (number
of cardiac
arrests per
1000 bed days)
N/A
N/A
N/A
N/A
(Oct 10 Sep 11)
(Oct 11Sep12)
(Oct 12Sep 13)
(Oct 13Sep 14)
N/A
91
82
82
93
90
N/A†
2.71%
2.68%
2.51%
1.99%
2.09%
1.82%††
<100
<1.98%
1.78%
<1.99%
N/A
194
165
180
176
177
200
192
N/A
N/A
52.1%
46.7%
48.3%
55.7%
44.1%
37.0%
44.8%
N/A
N/A
0.506
0.39
0.49
0.526
0.46
0.40
0.46
N/A
N/A
* April 2013-February 2014 taken from Dr Foster
**The national performance is taken from the SHMI October 2012 to September 2013 Executive Summary and can be found on the
following website: https://indicators.ic.nhs.uk/webview
*** NHS Choices – Clinical Indicators
†this measure is no longer used by the Trust, for Mortality indices the Trust uses HSMR, SHMI
††Crude Mortality, whilst previously taken from CHKS is now taken from Dr Foster for April 2013 – February 2014.
‡ April 2014-December 2014 taken from DR Foster
‡‡HSCIC - SHMI Publication January 2015 (July 2013 - June 2014)
98
2008/09
2009/10
Not
54
available
Sept10
to Mar11
Not
Not
available
available
Number of Patient Slips,
Trips and Falls
1601
Rate of Falls per 1000
bed days
Number of Patient Slips,
Trips and Falls Resulting
in Harm
Hospital Acquired
Pressure Damage (grade
2 and above)
Community Acquired
Pressure Damage (grade
2 and above)
Rate of Harm Falls per
1000 bed days
Ratio of Harm to No
Harm Falls (i.e. what
percentage of falls
resulted in Harm being
caused to the patient)
2010/11
2011/12
2012/13
2013/14
2014/15
Target
155
295
206
188
161
Year on
year
Reduction
228
587
652
845
772
N/A
1607
1448
1560
1570
1541
1687
N/A
7.63
8.14
8.13
9.18
9.25
8.71
9.26
Reduction
(<8.5)
840
793
613
457
447
424
468
N/A
3.01
2.69
2.63
2.4
2.57
4
52.50%
4.02
49.30%
Reduction
(Less than
<2.25)
25.1%
11%
2.2%
8.7%
7.1%
reduction reduction reduction reduction Increase
37.10%
29.30%
28.50%
27.50%
Year on
Year
reduction
27.74%
‡‡‡HSCIC - SHMI Publication January 2015 (July 2013 – June 2014)
Percentage of provider spells with palliative care coding, Jul13-Jun14 (xls).xls
B) Reducing Avoidable Harm:
2008/
09
2009/
10
2010/
11
2011/
12
2012/
13
2013/
14
2014/
15
Target
23.95
30.99
34.78
20.61
27.72
27.45*
N/A
N/A
375
398
305
294
325
344
338
N/A
Medication error – No
Harm
311
307
N/A
Medication error –
Minimal Harm
28
21
N/A
Medication error –
Moderate Harm
5
8
<5
Medication error –
Severe
0
2
0
Rate of adverse events
per 1000 bed days using
the Global Trigger Tool
(rate stated is average
achieved across all audits
undertaken in the year)
Number of Medication
Errors
Source: Trust incident reporting system Datix
* April 2013-October 2013 after which time this measure was not used
99
Never Events
Total Patient
Incidents per
100,000 bed days
Rate of patient
safety incidents
resulting in
severe harm or
death per 100
admissions
2008/
09
0
2009/
10
0
2010/
11
0
2011/
12
1
2012/
13
1
2013/
14
0
2014/
15
2
2373
2802
2998
3394
3447
3386
3259
N/A
N/A
N/A
0.11
0.17
0.19
0.16
N/A
0.13
(Oct 10
to Mar
11)
Target
0
Source: Trust
incident
reporting
system Datix
C) Infection Prevention and Control:
2008/
09
2009/
10
2010/
11
2011/
12
2012/
13
2013/
14
2014/
15
Target
MRSA Bacteraemias
apportioned to Acute
Trust post 48hrs
16
7
3
2
1
1*
1+
0
MRSA Bacteraemias
per 1,000 bed days
0.08
0.035
0.017
0.012
0.006
0.006
0.005
Year on year
Reduction
Clostridium Difficile
Infections post 72hrs
–
107
105
48
27
22**
16***
14++
<24
Clostridium Difficile
Infections per 10,000
bed days
5.362
5.319
2.702
1.589
1.296
1.23
1.43
Year on year
Reduction
Uniform Policy
98.00%
99.10%
99.20%
99.30%
98.70%
99.60%
98.99%
100%
Hand Hygiene
96.50%
97.00%
98.60%
98.00%
98.40%
99.60%
98.79%
100%
Intravenous Cannula
85.30%
91.90%
95.20%
94.60%
94.90%
96.80%
96.40%
100%
Indwelling Catheter
91.90%
96.40%
95.60%
94.80%
95.90%
97.80%
97.36%
100%
Equipment Clean and
Records Up To Date
97.60%
97.70%
98.60%
98.10%
98.00%
98.60%
97.81%
100%
+In 2014/15 the trust reported 1 MRSA bacteraemia. A Post Infection Review (PIR) meeting took place in February 2015. The
outcomes and lessons learned from the PIR determined a number of clinical learning opportunities and attributed
responsibility to the Trust as an unavoidable healthcare associated infection in agreement with the Commissioners. The Trust
demonstrated robust systems were in place providing assurance that the process of clinical learning was arranged to prevent
similar cases occurring in the future.
++ In 2014/15 the Trust had 26 cases of CDI; 12 cases of CDI were deemed as being unavoidable by an expert appeal panel.
This meant that the Trust had a total of 14 avoidable cases of CDI against a trajectory of 24.
100
*In 2013/14 the Trust had one case of MRSA bacteraemia however; this was as the result of a contaminated specimen not an
infection.
**In 2012/13 the Trust had 29 cases of Clostridium Difficile infection (CDI), 7 cases of CDI were deemed as being unavoidable
by an expert appeal panel. This meant that the Trust had a total of 22 avoidable cases of CDI against a trajectory of 21.
***In 2013/14 the Trust had 20 cases of CDI; 4 cases of the CDI were deemed as being unavoidable by an expert appeals
panel. This meant that the Trust had a total of 16 avoidable cases of CDI against a trajectory of 17.
101
4) Right Care, Right Place, Right Time
Care of patients following a Stroke:
2011/12
2012/13
2013/14
2014/15
National
Target
National
Benchmark
85.30%
89.08%
Apr12Feb13
87.27%
90.50%
90%
83.4%††
N/A
27.13%
54.65%
N/A
N/A
1. Number of patients
scanned within 1 hour of
arrival at hospital.
20%
90.40%
94.89%
50%
44.0%††
2. Number of patients
scanned within 24 hours of
arrival at hospital
85%
91.50%
94.59%
N/A
N/A
3. Number of patients who
arrived on stroke bed within
4 hours of hospital arrival
(when hospital arrival was
out of hours)
59%
81.10%
78.68%
N/A
N/A
4. Number of patients seen
by stroke consultant or
associate specialist within
24h
84%
81.90%
83.18%
95%
76.5%††
5. Number of patients with a
known time of onset for
stroke symptoms
58%
48.90%
89.49%
N/A
N/A
6. *Number of patients for
whom their prognosis
/diagnosis was discussed
with relative/carer within
72h where applicable
98%
97.30%
98.50%
N/A
N/A
7. Number of patients who
had continence plan drawn
up within 72h where
applicable
94%
97.90%
98.80%
N/A
N/A
8. Number of potentially
eligible patients
thrombolysed
80%
98.10%
99.40%
90%
82.2%††
9. *Bundle 1: Seen by nurse
and one therapist within
24h and all relevant
therapists within 72h (proxy
for NICE QS 5)
48%
64.20%
76.88%
60%
52.7%††
Percentage of patients who spend >90%
of time within a dedicated stroke unit
79.00%
Stroke bundle of 12 indicators
Stroke Bundle of 12, percentage of
patients who receive bundle of 12 key
elements of care
(when
bundle
of 9)
102
10.Bundle 2: Nutrition
screening and formal
swallow assessment within
72 hours where appropriate
99%
93.60%
96.10%
N/A
N/A
11.Bundle 3: Patient's first
ward of admission was
stroke unit and they arrived
there within four hours of
hospital arrival
68%
74.90%
72.73%
90%
56.9%††
12.*Bundle 4: Patient given
anti-platelet within 72h
where appropriate and had
adequate fluid and nutrition
in all 24h periods
69%
87.00%
95.20%
N/A
N/A
Source: Sentinel Stroke National Audit Programme October – December 2013 Results
https://www.strokeaudit.org/Clinical/Documents.aspx
†† Source:https://www.strokeaudit.org/results/Clinical-audit/National-Results.aspx October - December 2014
It is to be noted however that the benchmarking data is the latest available and covers a three month period whereas the
Trust’s results are for the full year measured internally against a bundle of 12 indicators.
103
Other Indicators:
†† FFCE’s refer to First Finished Consultant Episodes. A patient’s treatment or care is classed as a spell of care.
Within this spell can be a number of episodes. An episode refers to part of the treatment or care under a specific
consultant, and should the patient be referred to another consultant, this constitutes a new episode.
Percentage of
Cancelled
Operations from
FFCE’s††
Percentage of
Patients who
return to
Theatre within
30 days
(Unplanned /
Planned /
Unrelated)†
Fragility Fracture
Neck of Femur
operated on
within 48hrs of
admission /
diagnosis
Proportion of
patients who are
readmitted
within 28 days
across the Trust
2008/
09
2009/
10
2010/
11
2011/
12
2012/
13
2013/
14
2014/
15
Target
Benchmark
0.68%
0.74%
0.50%
0.25%
0.29%
0.68%
0.97%
0.80%
1.1%**
5.02%
4.43%
4.69%
4.73%
4.31%
4.53%
5.43%
Improve
Year on
Year
N/A
n/a
86.80%
91.00%
91.90%
85%
91.72%
91.15%
90%
N/A
10.58%
10.91%
9.55%.
9.32%
9.42%
9.18%*
9.48*
Improve
year on
year
N/A
† In previous years this figure was expressed as the number of returns to theatre within 30 days. To allow be`er comparison
of these figures from year to year, this figure is now expressed as a rate of return within 30 days.
* Figures taken from Dr Foster and provide a full year for 2013-14, and year to date December for 2014-15.
** NHS England Statistics - NHS Cancelled Elective Operations Quarter Ending March 2015
2008/
09
Proportion of
patients
undergoing knee
replacement who
are readmitted
within 30 days
Proportion of
patients
undergoing hip
replacement who
are readmitted
within 30 days
n/a
n/a
2009/
10
3.99%
4.68%
2010/
11
2011/
12
2012/
13
2013/
14
2014/
15
4.67%
4.96%
5.37%
4.34%
4.35%
23 patients
readmitted
25 patients
readmitted
23 patients
readmitted
17 patients
readmitted
20 patients
readmitted
4.80%
5.14%
7.26%
6.96%
7.91%
16 patients
readmitted
20 patients
readmitted
26 patients
readmitted
24 patients
readmitted
28 patients
readmitted
Target
Benchmark
Improve
Year on
Year
N/A
Improve
Year on
Year
N/A
104
5) Positive Patient Experience
Inpatient’s
Questionnaire
(Nov 2013-March
2014)
Domain
Inpatient’s
Questionnaire
(Apr 2014March 2015)
Target /
Benchmark
Score out of a possible 6
Communication
5.76*
5.86*
5.4
Care
5.85*
5.91*
5.4
Compassion
5.90*
5.96*
5.4
Overall composite Score
5.84*
5.91*
5.4
Care
Communication
* This is an average of scores taken from several questions in each domain.
The overall composite score is an average of all scores in the questionnaire.
2013/14
(Nov 13 to Mar 14)
2014/15
Target /
Benchmark
5.35
5.61
5.4
5.84
5.93
5.4
If your family or anyone else close to you
wanted to talk to a doctor did they get
the opportunity to do so?
5.89
5.94
5.4
Have you been involved as much as you
wanted to be in decisions about your care
and treatment?
5.81
5.91
5.4
Have you found someone to talk to about
your worries and fears?
5.90
5.94
5.4
Do you get enough help from staff to eat
your meals?
5.97
5.97
5.4
Do you get enough help from staff with
washing and dressing?
5.95
5.97
5.4
If you pressed the call bell, did staff
respond promptly?
5.75
5.82
5.4
Question
When you reached the ward, did you get
enough information about ward routines
e.g. mealtimes, visiting, doctors ward
rounds?
When you had important questions to ask
a member of staff did you get answers
that you could understand?
105
Compassion
Did the staff do everything they could do
to help control any pain you were
experiencing?
5.89
5.92
5.4
Do the staff looking after you have a
caring and compassionate attitude?
5.89
5.95
5.4
Do you feel you are treated with respect?
5.92
5.96
5.4
Do you feel you are treated in a friendly
manner?
5.92
5.97
5.4
Are you given enough privacy and treated
with dignity when discussing your
condition or treatment?
5.93
5.98
5.4
106
Responsiveness to Inpatients’ Personal Needs #
Question
2008/
09
2009/
10
2010/
11
2011/
12
2012/
13
2013/
14
2014/
15
Picker
Institute
Average of
Participating
Trusts
Was the patient as
involved as they wanted
to be in decisions about
their care and treatment?
N/A
N/A
51%
58%
61%
60%
61%
57%
Did the patient find
someone to talk to about
their worries and fears?
N/A
N/A
43%
51%
49%
50%
45%
39%
Was the patient told
about medication side
effects to watch out for?
N/A
N/A
40%
45%
47%
54%
49%
41%
Was the patient told who
to contact if they were
worried?
N/A
N/A
80%
81%
83%
83%
82%
81%
Was the patient given
enough privacy when
discussing their condition
or treatment?
N/A
N/A
76%
77%
79%
76%
81%
76%
Overall Composite Score†
N/A
N/A
58%
62%
64%
65%
64%
59%
223
206
194
185
243
234*
234
Less than
234
Complaints
# Information taken from 2014 Picker report.
*233 complains reported in previous quality account as one complaint was withdrawn then subsequently reinstated
following production of the data table.
For the period 2010-11 – 2012-13 this score was based on the average of four questions, this has now been updated to
include the question “Was the patient given enough privacy when discussing their condition or treatment?”
107
6) Safe, Effective Environment, Appropriate
Equipment & Supplies
2008/09
2009/10
2010/11
2011/12
2012/13
2013/14
2014/15
Target
National
Average
CLEANLINESS
score
n/a
n/a
n/a
n/a
n/a
98.93%
99.64%
n/a
97.25%
FOOD score
Excellent
Excellent
Excellent
Excellent
Excellent
86.10%
89.14%
n/a
88.79%
ENVIRONMENT
score
Excellent
Excellent
Excellent
Excellent
Excellent
90.29%
90.79%
n/a
91.97%
Excellent
Excellent
Excellent
Excellent
Excellent
92.11%
94.33%
n/a
87.73%
67
68
94
92
85
54
39†
<50
n/a
44
43
28
29
23
21
14†
<13
n/a
n/a
98.56%
98.82%
98.70%
98.50%
98.80%
98.64%†
98.0%
n/a
PRIVACY and
DIGNITY score
No Harm to Staff
– Needle Stick
Injury
No Harm to Staff
– RIDDOR
Reportable
Injury
Maximiser
Results
Source: PLACE 2014 Organisation Scores – Health & Social Care Information Centre
http://www.hscic.gov.uk/catalogue/PUB14780
†Source: Trust Quality Dashboard
108
3.6 National targets and regulatory requirements
No.
1
2
3
4
5
6
7
8
9
Indicator
Maximum time of 18
weeks from point of
referral to treatment
in aggregate –
admitted
Maximum time of 18
weeks from point of
referral to treatment
in aggregate – nonadmitted
Maximum time of 18
weeks from point of
referral to treatment
in aggregate –
patients on an
incomplete pathway
A&E – maximum
waiting time of four
hours from arrival to
admission / transfer /
discharge
All cancers: 62 day
wait for first
treatment from:
urgent GP referral for
suspected cancer /
NHS Cancer
Screening Service
referral
All cancers: 31 day
wait for second or
subsequent
treatment,
comprising: Surgery /
Anti-cancer drug
treatments /
Radiotherapy
All cancers: 31 day
wait from diagnosis
to first treatment
Cancer: two week
wait from referral to
date first seen,
comprising: all urgent
referrals (cancer
suspected) / for
symptomatic breast
patients (cancer not
initially suspected)
Care Programme
Approach (CPA)
Q1
Q2
Q3
Q4
2014/
15
2013/
14
2012/
13
Target
National
Average
90.64%
92.37%
92.00%
91.40%
91.61%
94.25%
96.90%
90%
88.8%**
97.55%
97.06%
96.83%
96.52%
96.93%
97.36%
98.50%
95%
95.5%**
94.74%
94.93%
94.66%
94.39%
94.68%
94.28%
96.30%
92%
93.3%**
96.65%
96.14%
95.41%
94.02%
95.52%
95.19%
95.60%
95%
93.60%
86.9%
85.3%
88.9%
88.4%
87.3%†
85.0%
88.6%
85%
83.8%**
95.6%
93.3%
93.7%
95.2%
94.7%†
97.4%
98.1%
90%
93.8%**
98.5%
98.3%
100.0%
100.0%
99.2%†
98.0%
98.0%
94%
96.1%**
100%
99.3%
100%
99.4%
99.7%†
99.80%
100%
98%
99.7%**
N/A
N/A
N/A
N/A
N/A
N/A
N/A
94%
97.4%**
100.0%
100.0%
100.0%
99.7%
99.9%†
98.8%
99.8%
96%
97.8%**
93.5%
93.9%
93.9%
93.1%
93.6%†
92.6%
94.0%
93%
93.9%**
93.7%
95.0%
92.1%
91.0%
92.9%†
95.7%
95.3%
93%
92.9%**
100%
100%
90%
N/A
93.3%††
100%
N/A
95%
97.2%**
109
16
17
18
19
20
patients, comprising:
receiving follow up
contact within seven
days of discharge /
having formal review
within 12 months
Minimising mental
health delayed
transfers of care
Mental health data
completeness:
identifiers
Mental health data
completeness:
outcomes for
patients on CPA
Certification against
compliance with
requirements
regarding access to
health care for
people with a
learning disability
Data completeness:
community services,
comprising: Referral
to treatment
information / Referral
information /
Treatment activity
information
nil
return*
nil
return*
nil
return*
nil
return*
nil
return*
nil
return*
nil return*
95%
Not
available
0%
0%
0%
0%
0%
0%
0%
< 7.5%
Not
available
99.0%
98.9%
99.3%
99.6%
99.2%
99.2%
99.5%
97%
Not
available
100.0%
100.0%
76.9%
90.0%
93.5%
85.2%
100.0%
50%
Not
available
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Not
available
92.5%
93.5%
91.8%
91.7%
92.4%
91.8%
92.7%
50%
Not
available
100%
100%
100%
100%
100%
100%
95.70%
50%
Not
available
100%
100%
100%
100%
100%
100%
92.90%
50%
Not
available
Source: http://www.england.nhs.uk/statistics/statistical-work-areas
Indicators 10-13 are not applicable. Indicator number 15 (MRSA) of the Compliance Framework 2013/14 was removed on publication of the Risk
Assessment Framework August 2013.
* There were no qualifying patients for this period
**Figures relate to data published for 11 months of 2014-15 to the end of Feb 15.
† Cancer figures are indicaave - March submission not due until Friday 8th May.
††Figures relate to published data to the end of Q3 2014-15.
110
Annex 1: Feedback on our 2014/15 Quality Account
4.1
Gateshead Overview and Scrutiny Committee
Based on Gateshead Care, Health and Wellbeing OSC’s knowledge of the work of the Trust during 201415 we feel able to comment as follows:General
The OSC wished to congratulate the Trust on the format of the report which it considered was user
friendly.
The OSC was reassured that where is necessary for locum doctors to be used appropriate training and
induction is in place.
Patient Safety
Priority 3- Reduce Inpatient falls that cause harm to patients
The OSC noted that in spite of a significant amount of work the Trust had not managed to achieve its
target in relation to reducing the rate of harmful falls but was reassured that this remains a high priority
for the trust and by the steps outlined to progress this work going forwards.
Infection Control
The OSC noted the Trust’s good performance in this area and the systems in place to ensure a robust
approach to tackling infection control but indicated it was aware of circumstances when containers for
hand washing in the hospital were empty. The OSC queried whether it was possible to instigate a system
of staff checks which are signed off at particular times during the day in order to tackle this issue. The
Trust agreed to explore the potential for instigating such checks.
Patient Experience
The OSC was concerned to note that the responses to the Picker Patient Survey had highlighted an
increase in patients saying that staff are not doing everything they can to help control pain. The OSC was
informed that the Trust is taking this very seriously and investigating this issue to see what action needs
to be taken particularly as the information from the national Survey appears to contradict findings from
the Trust’s own regular inpatient surveys.
The OSC is supportive of the Quality Account overall and was pleased to note that CQC has no
compliance issues in regard to the Trust.
The OSC was also pleased to note that the unannounced inspection into health services for Looked After
Children and Safeguarding in August 2014 had been positive and deemed that Gateshead’s
arrangements for Safeguarding Children were on the whole very robust subject to a few minor areas for
improvement.
111
4.2
Gateshead Clinical Commissioning Group
Newcastle North & East, Newcastle West and Gateshead Clinical Commissioning
Groups for Gateshead Hospitals NHS Foundation Trust Quality Accounts 2014/2015
NHS Newcastle Gateshead CCG, North Tyneside CCG and Northumberland CCG welcome the
opportunity to review and comment on the Quality Account for 2014/15 and would like to offer the
following commentary.
We remain committed to commissioning high quality services from Gateshead Hospitals NHS
Foundation Trust (GHFT) and take seriously their responsibility to ensure that patients ‟needs are met
by the provision of safe, high quality services and that the views and expectations of patients and the
public are listened to and acted upon”.
The CCGs would like to commend the Trust for the excellent progress made in the year to meet all the
priorities and targets it set for improvement, in particular:
•
•
•
•
•
•
Reducing mortality rates; noting the regional liaison work, the morbidity& mortality steering group,
and the introduction of non-invasive ventilation for very poorly patients.
Focus on dementia- friendly environments, staff training, and recognition of sufferers.
Reducing falls- as part of a 3 year strategy, multiple measures in place, we noted the slight reverse
in progress this year at the Trust; and encourage you to continue to look both internally and to
other Trusts for interventions to return to the previous downward trend.
Improving medication safety- very good progress and results.
Open and honest care - all targets met.
Roll out of 15 steps challenge - and the benefits being realised for patients and carers.
We very much support the Trust in its ambitions for 2015/16 to maintain and improve quality of care:
1.
2.
3.
4.
5.
6.
Reduce avoidable hospital deaths (including focus on sepsis)
Implement “Saving Babies Lives” campaign
Continued focus on falls reduction
Continue to improve medication safety (including the part Patients Own Drugs can play in this)
Think safe phase 2 campaign- in orthopaedics speciality
Implement the “family voices” project at end of life
The CCGs particularly wish to convey support to the Trust on the continued clear focus on quality and
safety for patients and staff, despite considerations for financial pressures at the Trust and nationally.
Finally congratulations on the achievements outlined in the report which we believe accurately reflect
the Trusts commitment to delivering a high quality patient centred service.
Dr Neil Morris
Medical Director
NHS Newcastle Gateshead CCG
28 May 2015
Chris Piercy
Executive Director of Nursing, Patient Safety and Quality
112
4.3
Healthwatch
Healthwatch Gateshead – Response to Gateshead NHS Foundation Trust Quality
Accounts 2014/15
Healthwatch Gateshead welcome the opportunity to comment on the Quality report for Gateshead NHS
Foundation Trust 2014/15.
As a consumer champion we are always looking to see how our local healthcare providers can learn,
improve and build upon patient experience.
We are particularly pleased to see and acknowledge that the trust has shown achievements in many of
its aims through 2014/15 but disappointed that it has not met its aim to reduce patient falls, however
acknowledge that this will continue to be a priority 2015/16.
We acknowledge progress as reported by the trust under many of its priorities. We are pleased to see
that the trust has signed up to implementing a number of initiatives within its priorities 2015/16,
particularly the ‘Think Safe’ and ‘Family Voice’ projects
Overall we are pleased to see how the trust is clearly making good progress in meeting its priorities and
making clear commitments to patient safety, continuing to listen and learn from its patients.
Healthwatch Gateshead
113
4.4
Council of Governors Representative
The Governors of Gateshead Health NHS Foundation Trust have been consulted on and involved in the
formation of the Trust’s Quality Account in 2014/15. Governors have been continuously involved in
refreshing the Trust’s strategic plans with their involvement at various Trust committees and the Council
of Governors meetings throughout the year. At each of the Council of Governors meeting during
2014/15, a range of reports have been presented, which enable Governors to receive and discuss quality
and patient safety matters and progress against our quality priorities. In January 2015 a Governor
workshop was held where Governors were consulted on the quality priorities for inclusion in the Quality
Account 2014/15.
Overall the Quality Account clearly demonstrates the Trust’s ongoing commitment to delivering high
quality and safe patient care and improved health outcomes.
Comments received from Governor’s:
“From reading the report it is evident that staff are doing some excellent work to meet really challenging
targets”
“The Quality Account 2014-2015 shows a high level of commitment, dedication and expertise from staff
at all levels to deliver care of a high standard in QE Gateshead. There is also evidence of continuous
effort to maintain or improve on those standards”
114
Annex 2: Statement of directors’ responsibilities in
respect of the quality account
The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts)
Regulations to prepare Quality Accounts for each financial year.
Monitor has issued guidance to NHS foundation trust boards on the form and content of annual quality
reports (which incorporate the above legal requirements) and on the arrangements that NHS foundation
trust boards should put in place to support the data quality for the preparation of the quality report.
In preparing the Quality Report, directors are required to take steps to satisfy themselves that:
•
the content of the Quality Report meets the requirements set out in the NHS Foundation Trust
Annual Reporting Manual 2014/15 and supporting guidance
•
the content of the Quality Report is not inconsistent with internal and external sources of
information including:
o
o
o
o
o
o
o
o
o
o
o
•
•
•
•
•
board minutes and papers for the period April 2014 to May 2015
papers relating to Quality reported to the board over the period April 2014 to May 2015
feedback from commissioners dated 14/05/2015
feedback from governors dated 20/05/2015
feedback from local Healthwatch organisations dated 12/05/2015
feedback from Overview and Scrutiny Committee dated 12/05/2015
the trust’s complaints report published under regulation 18 of the Local Authority Social
Services and NHS Complaints Regulations 2009, dated 06/05/2015
the 2014 national patient survey 2015
the 2014 national staff survey 2015
the Head of Internal Audit’s annual opinion over the trust’s control environment dated
22/05/2015
CQC Intelligent Monitoring Report dated July 2014 and December 2014
the Quality Report presents a balanced picture of the NHS foundation trust’s performance over
the period covered
the performance information reported in the Quality Report is reliable and accurate
there are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Report, and these controls are subject to review to confirm
that they are working effectively in practice
the data underpinning the measures of performance reported in the Quality Report is robust and
reliable, conforms to specified data quality standards and prescribed definitions, is subject to
appropriate scrutiny and review and
the Quality Report has been prepared in accordance with Monitor’s annual reporting guidance
(which incorporates the Quality Accounts regulations) (published at
www.monitor.gov.uk/annualreportingmanual) as well as the standards to support data quality
for the preparation of the Quality Report (available at
www.monitor.gov.uk/annualreportingmanual).
115
The directors confirm to the best of their knowledge and belief they have complied with the above
requirements in preparing the Quality Report.
By order of the board
NB: sign and date in any colour ink except black
Date:
Signed
5 June 2015
Chairman
5 June 2015
Chief Executive
116
Glossary of Terms
Antimicrobial
Is an agent that kills micro-organisms or inhibits their growth. Antimicrobial medicines can be grouped
according to the micro-organisms they act against. For example, antibacterial are used against bacteria
and antifungals are used against fungi.
Board of Directors
A board of directors is a body of elected or appointed members who jointly oversee the activities of an
organisation.
Care Quality Commission (CQC)
The CQC is the independent regulator of all health and adult social care in England. The aim being to
make sure better care is provided for everyone, whether that’s in hospital, in care homes, in peoples’
own homes, or elsewhere.
Commissioning for Quality and Innovation (CQUIN)
The CQUIN framework was introduced in April 2009 as a national framework for locally agreed quality
improvement schemes. It enables commissioners to reward excellence by linking a proportion of English
healthcare provider’s income to achievement of local quality improvement goals.
Commissioners
These are responsible for ensuring that adequate services are available for their local population by
assessing need and purchasing services.
Clinical Audit
Clinical audit measures the quality of care and service against agreed standards and suggests or makes
improvements where necessary.
Clostridium Difficile (C. Diff)
Clostridium difficile is a bacterium that occurs naturally in the gut of two-thirds of children and 3% of
adults. It does not cause any harm in healthy people, however some antibiotics can lead to an imbalance
of bacteria in the gut and then the Clostridium difficile can multiply and produce toxins that may cause
symptoms including diarrhoea and fever. This is most likely to happen to patients over 65. The majority
of patients make a full recovery however, in rare occasions it can become life threatening.
Datix
Datix is an electronic risk management software system which promotes the reporting of incidents by
allowing anyone with access to the trust Intranet to report directly into the software on easy-to-use web
pages. The system allows incident forms to be completed electronically by all staff.
Department of Health (DOH)
The Department of Health is a department of the UK government with responsibility for government
policy in England on health, social care and the NHS.
Dignity
Dignity is concerned with how people feel, think and behave in relation to the worth or value that they
place on themselves and others. To treat someone with dignity is to respect them as a valued person,
taking into account their individual views and beliefs.
117
Diabetic Ketoacidosis
Diabetic ketoacidosis is a dangerous complication of diabetes mellitus in which the chemical balance of
the body becomes far too acidic.
Duty of Candour
Duty of candour places a legal obligation on health care providers to be open about any patient safety
incident resulting in a moderate harm, severe harm or death.
Healthcare Quality Improvement Partnership
The Healthcare Quality Improvement Partnership (HQIP) was established in April 2008 to promote
quality in healthcare, and in particular to increase the impact that clinical audit has on healthcare quality
in England and Wales.
Hospital Standard Mortality Ratio (HSMR)
The HMSR is an indicator of healthcare quality that measure whether the death rate at a hospital is
higher or lower than would be expected.
Foundation Doctors
A Foundation Doctor (FY1 or FY2) is a grade of medical practitioner in the United Kingdom undertaking
the Foundation Programme which is a two-year, general postgraduate medical training programme
which forms the bridge between medical school and specialist/general practice training. The grade of
Foundation Doctor has replaced the traditional grades of Pre-registration House Officer and Senior
House Officer.
Foundation Trust
A Foundation Trust is a type of NHS organisation with greater accountability and freedom to manage
themselves. They remain within the NHS overall, and provide the same services as traditional trusts, but
have more freedom to set local goals. Staff and members of the public can join the board or become
members.
Healthcare- associated infection
This is an avoidable infection that occurs as a result of the healthcare that a person receives.
Healthwatch
Healthwatch are local like-minded individuals and organisations who share a commitment to
improvement and learning and a desire to improve services for local people local.
Hospital Episode Statistics (HES)
This is a data warehouse containing a vast amount of information on the NHS, including details of all
admissions to NHS hospitals and outpatient appointments in England. HES is an authoritative source
used for healthcare analysis by the NHS, Government and many other organisations.
Joint Consultative Committee
This is a group of people who represent the management and employees of an organisation, and who
meet for formal discussions before decisions are taken which affect the employees.
Meticillin- Resistant Staphylococcus Aureus (MRSA)
MRSA is a bacterium responsible for several difficult to treat infections in humans. MRSA is, by
definition, any strain of staphylococcus aureus bacteria that has developed resistance to antibiotics
118
including penicillins and cephalosporins. It is especially prevalent in hospitals, as patients with open
wounds, invasive devices and weakened immune systems are at greater risk of infection than the
general public.
Monitor
Monitor is the independent regulator of NHS Foundation Trusts. Established in January 2004 to
authorise and regulate NHS Foundation Trusts it is independent of central government and directly
accountable to parliament.
National Confidential Enquiries
These are enquiries which seek to improve health and healthcare by collecting evidence on aspects of
care, identifying any shortfalls in this, and disseminating recommendations based on these findings.
Examples include Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries in the
UK (MMBRACE) and the National Confidential Enquiry into Patient Outcome and Death (NCEPOD)
National Confidential Enquiry into Patient Outcome and Death (NCEPOD)
NCEPOD's purpose is to assist in maintaining and improving standards of medical and surgical care for
the benefit of the public by reviewing the management of patients. This is done by undertaking
confidential surveys and research, and by maintaining and improving the quality of patient care and by
publishing and generally making available the results.
National Institute for Health and Clinical Excellence (NICE)
The National Institute for Health and Clinical Excellence provides guidance, sets quality standards and
manages a national database to improve people’s heath and prevent and treat ill health. It makes
recommendations to the NHS on new and existing medicines, treatments and procedures, and on
treating and caring for people with specific diseases and conditions. It also makes recommendations to
the NHS, local authorities and other organisations in the public, private, voluntary and community
sectors on how to improve people’s health and prevent illness.
National Patient Survey
The NHS patient survey programme systematically gathers the views of patients about the care they
have recently received because listening to patients' views is essential to providing a patient-centred
health service.
National Patient Safety Agency (NPSA)
The National Patient Safety Agency promotes improved, safe patient care by informing, supporting and
influencing the health sector. It is an arm’s length body of the Department of Health, established in 2001
with a mandate to identify patient safety issues and find appropriate solutions.
National Health Service Litigation Authority (NHSLA)
The NHSLA is a special health authority responsible for handling negligence claims made against NHS
bodies. It also aims to raise safety standards and reduce the number of negligent or preventable
incidents through its risk management programme.
Overview and Scrutiny Committee
Overview and Scrutiny Committees in local authorities have statutory roles and powers to review local
health services. They have been instrumental in helping to plan services and bring about change. They
bring democratic accountability into healthcare decision-making and make the NHS more responsive to
local communities.
119
Patient Advice and Liaison Service (PALS)
PALS is an impartial service designed to ensure that the NHS listens to patients, their relatives, their
carers and friends answering their questions and resolving their concerns as quickly as possible.
Plan, Do, Study, Act (PDSA) cycles
Plan, do, study, act (PDSA) cycles are used to test an idea by temporarily trialling a change and assessing
its impact. The four stages of the PDSA cycle are:
Plan - the change to be tested or implemented
Do - carry out the test or change
Study - data before and after the change and reflect on what was learned
Act - plan the next change cycle or full implementation
Picker Institute
Picker Institute is a non-profit organisation that works with patients, professionals and policy makers to
promote a patient centred approach to care. It uses surveys, focus groups and other methods to gain a
greater understanding of patients’ needs. It is a world leader focusing on the measurement of the
patient experience and recognised as an important source of information, advice and support.
Pressure Ulcers
Pressure ulcers are also known as pressure sores or bed sores. They occur when the skin and underlying
tissue becomes damaged. In very serious cases the underlying muscle and bone can also be damaged.
Research
Clinical research and clinical trials are an everyday part of the NHS and are often conducted by medical
professionals who see patients. A clinical trial is a particular type of research that tests one treatment
against another. It may involve patients, people in good health or both.
Risk
The potential that a chosen action or activity (including the choice of inaction) will lead to a loss or an
undesirable outcome.
Risk assessment
This is an important step in protecting patients and staff. It is a careful examination of what could cause
harm so that we can weigh up if we have taken enough precautions or should do more to prevent harm.
Root Cause Analysis
This is a technique that helps us to understand why something has occurred in the first place. The
learning is then shared with staff across the hospital to inform our practice and help prevent further
reoccurrence.
Secondary Use Services- SUS
A system designed to provide management and clinical information based on an anonymous set of
clinical data.
Special Review
A special review is carried out by the Care Quality Commission. Each special review looks at themes in
health and social care. They focus on services, pathways and care groups of people. A review will usually
result in assessments by the CQC of local health and social care organisations as well as supporting the
identification of national findings.
120
Trust Board
The Trust Board is accountable for setting the strategic direction of the trust, monitoring performance
against objectives, ensuring high standards of corporate governance and helping to promote links
between the trust and the community. The Chair and Non-Executive Directors are lay people drawn
from the local community and are accountable to the Secretary of State. The Chief executive is
responsible for ensuring that the board is empowered to govern the organisation and to deliver its
objectives.
121
Appendix A: Participation in National Clinical Audits and National Confidential
Enquiries
During 2014/15, 33 national clinical audits and five national confidential enquiries covered NHS services
that Gateshead Health NHS Foundation Trust provides.
During that period Gateshead Health NHS Foundation Trust participated in 100% national clinical audits
and 100% national confidential enquiries which it was eligible to participate in.
The national clinical audits and national confidential enquiries that Gateshead Health NHS Foundation
Trust was eligible to participate in during 2014/15 are listed below. This also gives details of the
National Audits that the Trust was not eligible to take part in.
Name of Audit
Trust
participating
% of case
submission
Adult Critical Care
(Case Mix Programme – ICNARC)
Yes
National Emergency Laparotomy Audit (NELA)
Yes
Joint Registry
(NCAPOP)
Yes
Severe Trauma
(TARN)
Adult Community Acquired Pneumonia
Yes
Non Invasive Ventilation
Yes
Pleural Procedures
Yes
1090 cases
submitted – no
minimum
requirement
110 cases
submitted – no
minimum
requirement
1381 – cases
submitted – no
minimum
requirement
27% (71 out of 264
cases)
Data entry
continues until
31.05.15
Not running this
year as per BTS
email 17.12.14
7 cases submitted
– no minimum
requirement
Acute
Yes
Cancer
Bowel Cancer
(NCAPOP)
Yes
Lung Cancer
Yes
149 cases
submitted – no
minimum
requirement
224
122
(NCAPOP)
Oesophago-gastric Cancer
(NCAPOP)
Yes
National Prostate Cancer Audit
Yes
(data collection
period 01/01/14 –
31/12/14)
81 cases
submitted –
requirement was
over 80
123 cases
submitted – no
minimum
requirement
Heart
Acute myocardial infarction and Acute
Coronary Syndrome
(MINAP) (NCAPOP)
Cardiac Rhythm Management
Yes
91%
Yes
Heart Failure
(NCAPOP)
Yes
National Cardiac Arrest Audit
(NCAA)
Yes
National Vascular Registry
Yes
122 cases
submitted – no
minimum
requirement
314 – cases
submitted no
minimum
requirement
86 – cases
submitted no
minimum
requirement
73 – cases
submitted – no
minimum
requirement
Long term conditions
National Diabetes Inpatient Audit – Adult
(NADIA)
Yes
National Audit of Diabetes
Yes
Diabetes audit – Paediatric
Yes
Data was not
collected during
2014/15
National Diabetes
Audit are not able
to provide case
numbers as this a
joint
primary/secondary
care and numbers
would not
correlate
435 – cases
submitted no
minimum
123
Inflammatory Bowel Disease (IBD)
Yes
National Chronic Obstructive Pulmonary
Disease (COPD)
Yes
Pulmonary Rehabilitation Audit
Yes
Rheumatoid and early inflammatory arthritis
Yes
requirement
40 – cases
submitted – non
minimum
requirement
32 – cases
submitted no
minimum
requirement
Data entry
continues until
10.07.15
54 – cases
submitted no
minimum
requirement
Older people
Falls and Fragility Fractures Audit Programme
– National Hip Fracture Database running
during 14/15
Yes
Sentinel Stroke National Audit Programme
(SSNAP)
Yes
National Audit of Dementia
Yes
Older People (care in emergency
departments)
Other
Yes
Elective Surgery
(PROMS)
National Audit of Intermediate Care
Yes
297 – cases
submitted no
minimum
requirement
379 – cases
submitted no
minimum
requirement
In pilot phase.
Data collection
between August
and November
2015
89% (89 out of
maximum of 100)
Yes
74% (1132 out of
1538)
1 – case submitted
no minimum
requirement
Yes
100% (8 out of 8)
Women & Children’s
Epilepsy 12 audit (Childhood epilepsy) –
Round 2
Neonatal intensive & special care
(NCAPOP)
Yes
226 – cases
submitted no
minimum
requirement
124
Fitting Child (care in emergency departments)
Yes
44% (22 out of
maximum of 50)
Yes
48% (24 out of
maximum of 50)
Mental Health
Mental Health (care in emergency
departments)
The Trust was not eligible to take part in the National Audit listed below by the Department of Health as
we do not provide these services:Chronic Kidney Disease in Primary Care
Paediatric Intensive Care (PICNet)
National Adult Cardiac Surgery Audit
Coronary Angioplasty (NICOR Adult Cardiac Interventions Audit)
Head & Neck Cancer (DAHNO)
Paediatric Cardiac Surgery (NICOR Congenital Heart Disease Audit)
Prescribing in Mental Health Services (POMH)
Pulmonary Hypertension
Renal Replacement Therapy (Renal Registry)
Standards for Ulner Neuropathy at elbow testing (UNE)
Audit of transfusion in children and adults with Sickle Cell Disease
The Trust has taken part in the following National Audits additional to the list provided by the
Department of Health:National Care of the Dying
National Audit of Red Cell Issue Trace Audit
Heavy Menstrual Bleeding
National Diverticulitis Audit
National Post-Partum Haemorrhage
Gateshead Health NHS Foundation Trust participation in National Confidential Enquiries 2014/15
Name of Enquiry
NCEPOD – Lower Limb Amputation Study
NCEPOD - Gastrointestinal Haemorrhage
Study
NCEPOD - Sepsis Study
MMBRACE - Mothers and Babies: Reducing
Risk through Audits and Confidential Enquiries
in the UK
NCISH – National Confidential Inquiry into
Suicide and Homicide
Trust
participating
Yes
Yes
% of requirement
Yes
Yes
60% (3/5)
100% (11/11)
Yes
No eligible
patients during the
reporting period
50% (1/2)
100% (5/5)
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Appendix B: Independent Auditor’s Report to the Board of Governors of
Gateshead Health NHS Foundation Trust on the Quality Report
We have been engaged by the Council of Governors of Gateshead Health NHS Foundation Trust to
perform an independent assurance engagement in respect of Gateshead Health NHS Foundation Trust’s
Quality Report for the year ended 31 March 2015 (the ‘Quality Report’) and certain performance
indicators contained therein.
Scope and subject matter
The indicators for the year ended 31 March 2015 subject to limited assurance consist of the following
two national priority indicators:
• Percentage of incomplete pathways within 18 weeks for patients on incomplete pathways at the end
of the reporting period.
• Maximum waiting time of 62 days from urgent GP referral to first treatment of all cancers.
We refer to these two national priority indicators collectively as the ‘indicators’.
Respective responsibilities of the directors and auditors
The directors are responsible for the content and the preparation of the Quality Report in accordance
with the criteria set out in the NHS Foundation Trust Annual Reporting Manual issued by Monitor.
Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything
has come to our attention that causes us to believe that:
• the Quality Report is not prepared in all material respects in line with the criteria set out in the NHS
Foundation Trust Annual Reporting Manual;
• the Quality Report is not consistent in all material respects with the sources specified in the Detailed
Guidance for External Assurance on Quality Reports 2014/15 (‘the Guidance’); and
• the indicators in the Quality Report identified as having been the subject of limited assurance in the
Quality Report are not reasonably stated in all material respects in accordance with the NHS Foundation
Trust Annual Reporting Manual and the six dimensions of data quality set out in the Guidance.
We read the Quality Report and consider whether it addresses the content requirements of the NHS
Foundation Trust Annual Reporting Manual and consider the implications for our report if we become
aware of any material omissions.
We read the other information contained in the Quality Report and consider whether it is materially
inconsistent with the documents below:
• board minutes for the period April 2014 to May 2015;
• papers relating to quality reported to the board over the period April 2014 to May 2015;
• feedback from Commissioners, dated May 2015;
• feedback from governors, dated May 2015;
• feedback from local Healthwatch organisations, dated May 2015;
• feedback from Overview and Scrutiny Committee dated May 2015;
126
• the trust’s complaints report published under regulation 18 of the Local Authority Social Services and
NHS Complaints Regulations 2009, dated May 2015;
• the 2014/15 national patient survey;
• the 2014/15 national staff survey;
• Care Quality Commission Intelligent Monitoring Report, dated December 2014;
• the Head of Internal Audit’s annual opinion over the trust’s control environment, dated 22 May 2015;
and
• any other information included in our review.
We consider the implications for our report if we become aware of any apparent misstatements or
material inconsistencies with those documents (collectively, the ‘documents’). Our responsibilities do
not extend to any other information.
We are in compliance with the applicable independence and competency requirements of the Institute
of Chartered Accountants in England and Wales (ICAEW) Code of Ethics. Our team comprised assurance
practitioners and relevant subject matter experts.
This report, including the conclusion, has been prepared solely for the Council of Governors of
Gateshead Health NHS Foundation Trust as a body, to assist the Council of Governors in reporting the
NHS Foundation Trust’s quality agenda, performance and activities. We permit the disclosure of this
report within the Annual Report for the year ended 31 March 2015, to enable the Council of Governors
to demonstrate they have discharged their governance responsibilities by commissioning an
independent assurance report in connection with the indicators. To the fullest extent permitted by law,
we do not accept or assume responsibility to anyone other than the Council of Governors as a body and
Gateshead Health NHS Foundation Trust for our work or this report, except where terms are expressly
agreed and with our prior consent in writing.
Assurance work performed
We conducted this limited assurance engagement in accordance with International Standard on
Assurance Engagements 3000 (Revised) – ‘Assurance Engagements other than Audits or Reviews of
Historical Financial Information’, issued by the International Auditing and Assurance Standards Board
(‘ISAE 3000’). Our limited assurance procedures included:
• evaluating the design and implementation of the key processes and controls for managing and
reporting the indicators
• making enquiries of management
• testing key management controls
• limited testing, on a selective basis, of the data used to calculate the indicator back to supporting
documentation
• comparing the content requirements of the NHS Foundation Trust Annual Reporting Manual to the
categories reported in the Quality Report.
• reading the documents.
127
A limited assurance engagement is smaller in scope than a reasonable assurance engagement. The
nature, timing and extent of procedures for gathering sufficient appropriate evidence are deliberately
limited relative to a reasonable assurance engagement.
Non-financial performance information is subject to more inherent limitations than financial
information, given the characteristics of the subject matter and the methods used for determining such
information.
The absence of a significant body of established practice on which to draw allows for the selection of
different, but acceptable measurement techniques which can result in materially different
measurements and can affect comparability. The precision of different measurement techniques may
also vary. Furthermore, the nature and methods used to determine such information, as well as the
measurement criteria and the precision of these criteria, may change over time. It is important to read
the quality report in the context of the criteria set out in the NHS Foundation Trust Annual Reporting
Manual.
The scope of our assurance work has not included governance over quality or non-mandated indicators,
which have been determined locally by Gateshead Health NHS Foundation Trust.
Conclusion
Based on the results of our procedures, nothing has come to our attention that causes us to believe
that, for the year ended 31 March 2015:
• the Quality Report is not prepared in all material respects in line with the criteria set out in the NHS
Foundation Trust Annual Reporting Manual;
• the Quality Report is not consistent in all material respects with the sources specified in the Guidance;
and
• the indicators in the Quality Report subject to limited assurance have not been reasonably stated in all
material respects in accordance with the NHS Foundation Trust Annual Reporting Manual and the six
dimensions of data quality set out in the Guidance.
KPMG LLP
Quayside House
110 Quayside
Newcastle upon Tyne
NE1 3DX
5 June 2015
128