Account of
the Quality of
Clinical Services
2014/2015
Exceptional healthcare, personally delivered
1
Contents
Contents
2
Statement on the quality of services from the Chief Executive
3
Statement of Directors’ responsibilities in respect of the Quality
Account - 2014/15
6
Part 1 Priorities for Improvement
7
Priorities for Improvement in 2014/15
8
How did we get on with these priorities?
9
Our Priorities for Improvement for 2015/16
12
Moving forward - from opening of Brunel
13
Part 2 Assurances on Quality from the Trust Board
17
Reducing Harm from Infection
22
Friends and Family Test
27
Part 3 Improving quality and safety of patient care
34
Part 4 Improving patient experience
52
Part 5 Audit, Research and Data Quality
60
Part 6 What other organisations say about the Trust
82
Care Quality Commission Inspection
83
Part 7 Engagement and Consultation in choosing our priorities
87
External Comments
88
Part 8 Appendices
95
Appendix 1 - Mandatory Indicators Table
96
Appendix 2 - 2014/15 CQUINS
98
Appendix 3 - List of services provided by NBT in 2014/15
100
Appendix 4 - Auditors Opinion
102
Account of the Quality of Clinical Services 2014/2015
Statement on
the quality of
Contents
services from the
Chief Executive
Account of the Quality of Clinical Services 2014/2015
3
Statement on
the quality of
Contents
services from the
Chief Executive
North Bristol NHS Trust is one of the largest
acute hospital trusts in the country with
approximately 1,050 beds and employing
more than 9,000 staff. The Trust provides
hospital and community services to a local
population of around 900,000 people in
Bristol, South Gloucestershire and North
Somerset. Specialist services including
neurosciences, renal medicine, orthopaedics
and plastics are accessed by patients across
the south west, the UK and, in some cases,
the rest of the world.
In 2014/15 the Trust delivered services from three
hospitals – Southmead Hospital, Cossham Hospital in
Kingswood and Frenchay Hospital (which closed in
May 2014). We also provide community services for
children and young people in South Gloucestershire
and Bristol via our Community Children’s Health
Partnership (CCHP).
The Trust works in close partnership with NHS
Clinical Commissioning Groups (CCGs), GPs, local
authorities and community organisations to ensure
our services are of the highest quality and meet the
needs of our patients.
Here at North Bristol NHS Trust our vision is
“exceptional healthcare, personally delivered”.
We support our staff at all times to deliver care
that they are proud of and would recommend to
friends and family. Our Executive Directors and senior
staff undertake regular walk-rounds and ensure
comprehensive reporting on staffing numbers, safety
indicators and patient satisfaction rates.
The big move
Very few organisations have ever been through as
much change as we have over the last year and none
have been inspected by the Care Quality Commission
so soon afterwards.. In May 2014 the doors to the
Brunel building at Southmead finally opened, on
time and on budget, after years of planning and
construction. Over a two week period, 540 patients
were safely and successfully transferred into the new
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Account of the Quality of Clinical Services 2014/2015
facilities from existing wards and departments at
Southmead and Frenchay.
Our staff have settled into their new surroundings,
and are delivering high quality, safe care. There were
problems in the first months following the move
into the Brunel, most notably in theatres, but staff
have pulled together to turn things around. This was
always going to be a challenging time but we are
proud of the way our staff have worked to adapt to
the changes.
We understand that in some cases the patient
experience has not been what we would strive for
during this time, but we would like to assure our
patients that we are working hard to improve things.
The Brunel building offers state-of-the-art facilities that
have been designed to meet the needs of 21st century
healthcare and we are now seizing the benefits the
building offers. Around three-quarters of beds are in
single rooms with their own bathroom. This has led to
a massive reduction in hospital acquired infections and
has significantly reduced the risk of ward closures due
to outbreaks of norovirus. The environment is designed
to be healing, with access to light and plenty of views
onto gardens. One of the biggest benefits that we hear
about is that patients sleep well in the single rooms,
aiding their recovery.
Work continues on the second phase of the hospital
development which includes a new patient and
visitor car park - located right next to the main
entrance, more staff parking and landscaped
gardens. This will be complete in Summer 2016.
A challenging winter
Like many other NHS trusts, we had a difficult
winter. The particular pressure for us has been
around emergency medical care for frail and elderly
patients, where we have experienced an eight
per cent increase over the last 12 months. These
pressures have at times resulted in overcrowding
the Emergency Department.
Care Quality Commission report
In February, the Care Quality Commission (CQC)
published its report into our services and rated the
Trust overall as “requires improvement”. Every single
service was rated as being “good” in the context of
caring and staff were described as being “committed
and passionate”.
The CQC were concerned about the impact
overcrowding was having in the Emergency
Department (ED) and as a result rated this service
as “inadequate” but acknowledged that improving
discharge processes for patients was something that
required close working with other partners. Internal
In 2014/15 we carried out:
■■
87,454 inpatient and day case episodes
■■
84,930 people were treated in our
Emergency Department
■■
266,811 outpatient appointments
■■
6,313 babies were born at Southmead, at
home or in our birth centre at Cossham Hospital
improvements include the recruitment of additional
consultants and nurses, better triage of patients
upon arrival, improved privacy and dignity within the
corridor area and ensuring that observation from
the reception area is more welcoming and effective.
More widely we are working closely with partners
across the local health and social care system to
ensure a safe and well managed discharge once
patients are well enough to leave the hospital.
I am particularly pleased that the CQC described
our maternity service in Cossham Hospital and our
community services for children and young people
as “outstanding”. Among the changes being
made to address matters raised is the more rapid
assessment of patients when they arrive in ED, the
opening of a new GP Assessment Area and the
introduction of four additional cubicles for initial
assessment to reduce pressure. I am confident
that, with our action plans already progressing and
having now settled in to our new hospital, we can
expect to see further benefits that will enable us to
provide quality care that achieves the best possible
outcomes for all our patients.
While the Trust aspires to being significantly better
than average its current CQC Trust rating is average
for the NHS as a whole.
system in the world. Sign up to Safety requires NHS
organisations to listen to patients, carers and staff,
learn from what they say when things go wrong and
take action to improve patients’ safety.
One of the first steps is the development of a plan
that describes what we will do to reduce harm and
save lives by working to reduce the causes of harm
and take a preventative approach.
Plans are built around five core pledges: putting
safety first, continually learning, being honest and
transparent, taking a leading role in collaborative
learning and supporting people to understand why
things have gone wrong and how to put them
right. North Bristol NHS Trust’s action plan builds on
existing practices and new measures.
These, coupled with the improvement priorities
identified through consultation with staff and
patients, will provide a continued emphasis on
the safety of services during 2015/16. We will also
be revising our Quality Strategy during 2015 to
support the Trust’s overall strategy in order to set an
ambitious forward plan. This will in turn drive our
quality priorities and our approach to their delivery.
Passionate about safety
This Trust has always been at the forefront of patient
safety initiatives and during this year we became
one of the first 12 NHS organisations in England to
sign up to a three-year Government-led campaign
that aims to make the NHS the safest healthcare
Andrea Young
Chief Executive
North Bristol NHS Trust
Account of the Quality of Clinical Services 2014/2015
5
Statement of Directors’
responsibilities
in
Contents
respect of the Quality
Account - 2014/15
The directors are required under the Health
Act 2009, National Health Service (Quality
Accounts) Regulations 2010 and National
Health Service (Quality Account) Amendment
Regulation 2011 to prepare Quality Accounts
for each financial year. The Department of
Health has issued guidance on the form and
content of annual Quality Accounts (which
incorporate the above legal requirements).
The directors confirm to the best of their knowledge
and belief they have complied with the above
requirements in preparing the Quality Account.
By order of the Board
NB: sign and date in any colour ink except black
Signatures and dates in final published copy.
In preparing the Quality Account, directors are
required to take steps to satisfy themselves that:
The Quality Account presents a balanced
picture of the Trust’s performance over the
period covered
Signed.....................................................................
■■
The performance information reported in
the Quality Account is reliable and accurate;
25th June 2015
Date....................................................................... .
■■
There are proper internal controls over the
collection and reporting of the measures
of performance included in the Quality
Account, and these controls are subject to
review to confirm that they are working
effectively in practice
Peter Rilett
Chairman
■■
The data underpinning the measures of
performance reported in the Quality Account
is robust and reliable, conforms to specified
data quality standards and prescribed
definitions, is subject to appropriate scrutiny
and review; and
Signed.....................................................................
The Quality Account has been prepared in
accordance with Department of
Health guidance
Andrea Young
Chief Executive
■■
■■
6
Account of the Quality of Clinical Services 2014/2015
25th June 2015
Date........................................................................
1.Priorities for
Improvement
Account of the Quality of Clinical Services 2014/2015
7
1.Priorities for
Improvement
Contents
Every year the Trust manages a wide range of
quality improvement targets and measures,
set by the Trust Board, Commissioners, NHS
England and the Department of Health
– as well as those that are as a result of
requirements of specialist national reviews and
recommendations from national NHS related
organisations such as NICE, Royal Colleges,
Care Quality Commission and others.
These are included as part of our overall quality
strategy under the headings of patient safety, clinical
effectiveness and patient experience. The connection
between good performance and high quality care,
and the range of issues that remain priorities for
the board include falls, pressure ulcers, nutrition,
medicines safety, infection prevention and control.
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Account of the Quality of Clinical Services 2014/2015
In addition to all the other quality and safety
targets, each year Trusts are asked to choose up to
5 priorities for improvement which are chosen in
consultation with patients, public and staff.
Involving the public in
identifying these priorities
We asked our clinical teams to make suggestions
for priorities to improve patient care. This list was
then discussed with the Trust’s Patient Panel and
the Patient Experience Group members to obtain
their views.
These topics were then compiled into a survey
for patient and public consultation which was
distributed to the Trust’s Foundation Trust members
who wish to take part in surveys.
Presentations including the shortlist were made to
Local Authority Health Scrutiny Committees to seek
their views.
As a result, over 180 patients and members of
the public completed the survey. The results of
the survey were analysed and ranked according to
importance as rated by patients and carers. These
were discussed by the Trust’s Quality Committee to
agree the final priorities prior to final approval by
the Trust Board.
Our Priorities for Improvement
for 2014/15
The 5 ‘steps to safer surgery,’ which incorporate the
WHO Checklist must be used for all patients undergoing
invasive procedures in NBT and are listed as:
1. Improve theatre safety - ensuring that
surgical teams work safely and ensure high
quality care through effective communication
and rigourous procedures before, during and
after each operation performed.
STEP 1: TEAM BRIEF
STEP 2: SIGN IN
2. Improve discharge information to GPs providing timely and accurate information when
patients leave hospital to ensure that their GP
is fully aware of their clinical condition and can
continue their care safely and effectively.
STEP 3: TIME OUT
STEP 4: SIGN OUT
3. Improve management of sepsis developing a deeper understanding of the
main causes of sepsis in patients, where this
most frequently occurs and delivering effective
treatment in a timely way.
4. Improve cancer patient experience supporting patients diagnosed with cancer in
a timely and effective way to provide the best
treatment with care, dignity and in supportive
partnership with national charities and peers.
How did we get on with
these priorities?
1. Improve Theatre Safety - 5 Steps
to Safer Surgery and World Health
Organisation (WHO) Checklist
The first job of all health care professionals is to
keep patients safe. North Bristol NHS
Trust (NBT) is committed to providing services of
exemplary quality and safety, giving the patient the
best possible experience and outcome. It is known
that the way teams work together (leadership,
communication, shared situational understanding
and the opportunity to ‘speak up’) contributes
significantly to protecting patients from harm.
It is the responsibility of everyone involved in the
perioperative care of the patient to;
■■
Work and communicate as part of a team
■■
Have the courage to protect patients and
colleagues by speaking out if they have any
concerns regarding patient safety
■■
Receive challenge from a colleague in a
positive and professional manner, giving the
concerns others may have due consideration
STEP 5: TEAM DE-BRIEF
NBT currently monitors compliance for every
patient with a 2014/15 performance of 87.4%
for Safer Surgery Compliance and 95.2% WHO
Compliance against a target of 100%. The chart
(see Page 11) illustrates the strong improvements
made in the 5 steps to safer surgery during the
year and the more gradual improvements made in
WHO Compliance.
The Head of Nursing for Core Clinical Services,
with support of the Theatre Matron, are examining
the key factors influencing the remaining areas of
non-compliance with the WHO checklist to ensure
continued improvement in 2015-16.
2. Improve discharge information
to GPs
The Trust achieved just over 78% of discharge
summaries sent within 24 hours in April 2014 but
performance then dipped to just over 74% at the
time of the hospital move in May 14. Since then
performance has improved aided by, for example,
a new discharge summary launched for the Medical
Day care, which is much easier to use and shorter.
Similarly a tailored discharge summary is being
worked on for hip fractures that will also be easier
and quicker to complete.
In 2015/16 this will continue as a Quality Account
priority and is also a local CQUIN (commissioning
contract) incentive which focusses on timeliness of
discharge summaries and the development of these
as summary care plans to be given to the patient
for the following specialties:
■■
Respiratory
■■
Diabetes
■■
Cardiology
■■
Renal
Account of the Quality of Clinical Services 2014/2015
9
3. Improve management of sepsis
In 2014-15, a committee to advance the
management of sepsis was set up and met monthly
to discuss strategies to gather data on sepsis
incidence and the management of patients with
sepsis within the Trust.
Initially there was very little information collected on
the numbers of patients with severe sepsis, where
they were located and managed within the Trust, as
well as compliance with consensus guidelines for the
management of sepsis (“Sepsis 6”).
Information gathering has shown that most
patients with severe sepsis are initially cared for
in the Emergency Department (ED) or the Acute
Admissions Unit (AAU). Systems have been put in
place to enable these patients to be tracked and their
outcomes measured. Original research conducted
in the Trust has shown that Early Warning Scores
(EWS) are predictive of outcomes in blood stream
infection – a form of severe sepsis – and sequential
audits carried out in AAU over the winter of 2014 15
have provided baseline data on sepsis management
in terms of the six interventions required within one
hour of the diagnosis of severe sepsis. Improvements
in the proportion of patients receiving oxygen (3-fold
increase); lactate measurement (3-4 fold increase);
blood cultures (2-fold increase); antibiotics (3-4-fold
increase) have been observed. Education of Trust
staff about sepsis and the management of patients
with sepsis has developed. Many staff groups have
targeted education on sepsis with simulation training
in the ward areas, where patients are treated, being
delivered to the multidisciplinary team. The acute
oncology team has delivered teaching on Neutropenic
Sepsis and introduced a screening tool to the
admission team which has increased the proportion
of patients with neutropenia being treated with
antibiotics within an hour of presentation.
In the next year, this work needs to be built on
in terms of increasing staff awareness of sepsis,
education of its management and audit of
performance.
4. Improve cancer patient
experience
NBT takes part in the annual National Cancer Patient
Experience Survey. The NBT results for the 2014
Survey showed significant improvement over those
for 2013, with the Trust being in the top ten of the
most improving Trusts. This reflects the emerging
impact of NBT’s strategies to improve the care for
patients diagnosed and treated for cancer, as well
as those living with and beyond cancer. Continued
positive progress has been made in addressing
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Account of the Quality of Clinical Services 2014/2015
key areas for improvement including verbal and
written information-giving and communication
with patients, the care provided by doctors, clinical
nurse specialists (CNS) and ward staff, as well as
support for people with cancer and the provision of
information to patients regarding free prescriptions
and financial advice.
The role of the clinical nurse specialist is pivotal in the
pathway of cancer patients and the Cancer Patient
Experience Survey nationally provided evidence that
patients who have a named CNS in charge of their
care report favourably on their experience. At NBT,
each specialist cancer team has CNS support so that
all patients are assigned a named CNS. The survey
results showed improved scores on all 4 questions
over 2013 relating to the support provided by CNS’s
at NBT, with the question concerning the allocation
of a named CNS in charge of a patient’s care,
showing statistically significant improvement over the
four year period since 2010.
During 2014/2015 the Cancer Services Team at
NBT has been working with colleagues across the
Trust to explore opportunities to improve patient
referral processes into the Trust and to review the
referral process for suspected cancer patients. This
work is looking at different aspects of the referral
pathway and is exploring straight-to-test pathway
opportunities to improve the patient experience prediagnosis. There are numerous benefits of facilitating
GPs to book suspected cancer patients directly into
appointments or to provide straight-to-test services
and so reduce delays in delivering the pathway and
stream-lining of Trust processes.
NBT has continued to lead nationally on cancer
survivorship during 2014/2015 by building expertise
and capacity in implementing alternative approaches
to cancer aftercare. We are in the process of bringing
about a service redesign in the approach to care and
support for people affected by cancer. This involves
implementing an integrated model of survivorship
into the care pathway for everyone diagnosed and
treated for cancer, with a greater focus on recovery,
health and wellbeing after treatment. Some of the
teams have already implemented a risk stratification
process to ensure more targeted and tailor-made
follow up for patients following cancer treatment.
All cancer teams run regular “Living Well” events
offering information and advice on health and
wellbeing pre and post-treatment and signposting to
local support services. In addition a number of cancer
teams in collaboration with the psychology service
also run self-management courses for patients.
Evaluations of these programmes indicate high
levels of patient satisfaction and improved patient
experience and outcomes.
WHO & 5 Steps to Safer Surgery – Compliance Rates 2014/15
100%
WHO Compliance
95%
90%
5 Steps to Safer Surgery
85%
80%
75%
70%
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
2014
Jan
Feb
Mar
2015
Discharge Summaries Sent Within 24 Hours
84.0%
82.0%
80.0%
78.0%
76.0%
74.0%
72.0%
70.0%
Apr 14 May 14 Jun 14
Jul 14
Aug 14 Sep 14
Oct 14
Nov 14 Dec 14 Jan 14
Feb 14
Total sent within 24 hours
Account of the Quality of Clinical Services 2014/2015
11
Remote surveillance of follow up has been introduced
for breast, prostate and colorectal cancer patients
and most teams are undertaking health needs
assessments and care planning as well as starting
to implement treatment summaries which provide
a succinct record of diagnosis and treatment, and
prompt primary care teams to undertake cancer care
reviews and alert patients to potential effects that
may occur many years after treatment. We also have
a regular nutritional clinic and work in partnership
with Macmillan and the local Authorities to run
exercise programmes specifically designed for cancer
patients. Our aim is to scale up and embed all the
interventions into routine practice across all tumour
sites for all patients to further enhance the patient
experience and to ensure sustainability of high quality
care for cancer patients in partnership with primary
care providers.
A key milestone in our strategy to improve the
patience experience at NBT was the opening in
September 2015 of our NGS Macmillan Wellbeing
Centre at Southmead Hospital. The centre staffed
by a centre manager, cancer support workers and
volunteers is our hub for the provision of advice,
support and information to anyone living with or
after a cancer diagnosis, or anyone concerned about
cancer. Living Well events and self-management
courses are hosted in the centre involving the use of
a range of partners. Equipped with meeting rooms
for education, one-to one support, complementary
therapies, nutritional and exercise sessions, as well
as financial and back-to-work advice, the centre is
providing cancer-related information in a variety of
media and formats to a steadily increasing number
of patents, relatives and staff from both hospital and
community settings.
During 2014/2015 we have been involved in a
Macmillan funded pilot trialling new roles to provide
tailored support for cancer patients post treatment
across Bristol. As part of this pilot at NBT, we
appointed 2 part time Cancer Support Workers
based at the NGS Macmillan Wellbeing Centre
providing face to face and telephone support and
sign posting of services. These new roles have proved
to be highly successful and crucial in the success of
the Wellbeing Centre. They provide a useful template
for the development of innovative and cost effective
new ways of providing support to cancer patients
at NBT and we are currently exploring a range of
avenues to maintain and enhance these posts when
the pilot ends. The Trust is also participating in a
project working with Prostate Cancer UK to further
develop, embed and evaluate the survivorship
programme in prostate cancer.
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Account of the Quality of Clinical Services 2014/2015
Our Priorities for
Improvement for 2015/16
We will continue to improve the quality of care
for patients as set out in our contract, including
prevention of patient deterioration, continuing
to reduce pressure ulcers, reduce falls, infection
prevention and control and improving nutrition and
the management of sepsis. In addition through
our consultation we have agreed with patients and
staff to address the following priorities:
1. Improving care for patients with
dementia
2. Improve our patient’s overall
experience in hospital
3. Improving the recognition, diagnosis
and treatment of Acute Kidney
Injury (AKI)
4. Improving the quality and timeliness
of information provided to GP’s when
patients go home to ensure there is
safe handover to primary care
How we will measure progress
with these priorities
Improvement measures will be set for each
priority and the data will be collected and
analysed to track progress. This will be monitored
closely by the Trust’s Quality Committee
chaired by the Medical Director. Its membership
includes the Director of Nursing and Director of
Operations as well as Clinical Directors, chairs of
quality and safety committees and other key staff
involved in monitoring or progressing quality and
safety priorities.
Reporting on a wide range of quality measures
is presented to the Board every month as part
of an Integrated Board Report. This includes
measurements of progress against improvement
measures set, shown on a quality dashboard.
The report is included in the public session of
the Trust Board and is published on the Trust’s
external website as part of the papers. In addition
the information is reported via the Quality Sub
Group to South Gloucestershire, Bristol and North
Somerset CCGs the main local commissioners
for the Trust’s services, plus NHS England who
commission specialised services.
Moving Forward
– 2014-15,
Success
Opening of
Brunel
Benefits
■■ Move delivered safely, on time and on budget.
■■ Infection control - significantly reduced
risk of norovirus, no MRSA, Trust met
C-Diff trajectory
■■ Less noise - more sleep for patients
■■ Increased privacy in single rooms
■■ Services housed under ‘one roof’ -
beneficial for patients and staff
■■ Excellent quality building and facilities -
award-winning design.
■■ ‘Move-makers’ to welcome and support
patients, and public into Brunel
Challenges
■■ Shortage of Car Parking until phase 2 opens
■■ Risk of social Isolation for patients in single
rooms
■■ Initial building related issues (e.g. doors, fire
alarms, theatres not open)
■■ New ways of working for staff in single rooms
■■ Initial loss of theatre capacity, which resulted
in more operations being cancelled than
predicted to cover the move period.
What we’re doing
■■ Theatre improvement programme to
improve productivity, including processes
and equipment and therefore reduce
cancellations.
■■ Fresh Arts programme – e.g. knitting circles,
concerts in sanctuary, live music in atrium,
music at the bedside
■■ Free patient Wi-fi
■■ TVs in quiet rooms and A&E
■■ Phase 2 improvements - Car parking will
be significantly increased in Phase 2 with
internal access to the hospital, more spacious
area for buses, ambulances, taxis and
patients’ drop off points. More green space.
■■ Community Arts centre
Account of the Quality of Clinical Services 2014/2015
13
Chronicle of
the Move
2014 was a year of unprecedented change
for North Bristol NHS Trust’s staff and
patients. After many years of planning
and construction the new Brunel building
was officially handed over to the Trust by
developers Carillion on March 26.
Staff and patients (past and present) attended
including 17-year-old Kray Mundy who was a patient
at the unit in 2008 for several months after he
suffered a serious stroke. His mum, Soniya said: “It’s a
wonderful place and is like a second home to us. It is
home, my bubble. The staff here are so wonderful.”
Over the next two months a massive operation
was undertaken which saw the Trust equip
the building and thousands of staff take part
in training and familiarisation tours before
staff and patients began to move in during an
unforgettable two weeks in May. The Brunel
building saw services from Southmead and Frenchay
centralised on one site for the first time.
Dr Amber Young, Lead for Specialist Paediatrics, said:
“This is the end of a very long journey. I will miss
the Barbara Russell Unit hugely but I am extremely
excited about moving such a high quality specialist
service to a nationally-renowned children’s hospital.”
Specialist children’s services and
remembering Frenchay
Frenchay always had a strong history of children’s
neurosciences and burns. One of the first big
milestones was the move of these services and
associated staff to the Bristol Children’s Hospital
which would see, for the first time, all local hospital
services (including accident and emergency) for
children under one roof.
On April 28 a special party was held at the Barbara
Russell Children’s Ward ahead of its big move on
May 7.
On May 8 hundreds of staff from Frenchay – many
of whom worked at the hospital for their entire
careers – gathered at the Redwood Restaurant for a
celebration event which included the burial of a time
capsule in the grounds by children from the local
primary school which will be unearthed in 50 years.
Patients move into the Brunel
The first patients started moving into the Brunel
during the week commencing May 12.
The first patients were moved from C ward, the
acute respiratory unit. They were wheeled through
a tented walkway erected by a team from Royal
Marines Reserve Bristol and into the new building
by porters.
Nurses from the Trust’s Learning & Research Centre
were back in scrubs to help with the transfer of
patients, with support from administrators from the
department. They were joined by volunteer retired
nurses who used to work for the trust and were
involved in escorting patients into the new building.
The team were involved in a combination of taking
patients from the ward, helping with final checks
and then taking them over to the Brunel and settling
them in to their new rooms.
Among the first patients to move across to the
Brunel building was Sally Limb. Once she had settled
into her new room in the Brunel Sally said she was
impressed with the facilities.
14
Account of the Quality of Clinical Services 2014/2015
She said: “I love the private toilet and shower and
I love that I can hang things up in a wardrobe. It
is so airy and light and the air coming in, which
is particularly good when you have respiratory
problems. I think we are all excited to be here.”
Once the first patients were settled in, our fantastic
team of Move Makers started work. These are
volunteers who are based near the main entrance
who can help people get checked in for their
appointments and guide people to where they
need to be. Originally meant to be in place for a few
weeks, the Move Makers have been so successfully,
they are now based here on a permanent basis.
The transfer of vascular surgery into the Trust means
that Southmead Hospital is now delivering 24/7
multidisciplinary specialist vascular care inside the Brunel
for both elective and emergency patients. This has
led to a reduction in the time it takes for urgent cases
to access theatre and patients spending less time in
hospital after they have undergone their procedure.
The Brunel: a bright future
A&E moves and services transfer
from Frenchay
Perhaps one of the most anticipated elements of
the move was the transfer of the Accident and
Emergency (A&E) department from Frenchay to
Southmead. This took place at exactly 2am on
Monday, May 19 when the Frenchay department
closed its doors and the Southmead unit opened to
patients. Before the department closed a poignant
blessing was held by one of the hospital chaplains
and staff released balloons into the night sky.
By May 28 all services, teams and departments were
in place. In total 540 patients were successfully and
safely moved into the building over the course of
the two week period. Later in the summer, the new
breast care centre and adjoining Macmillan Wellbeing
Centre opened at the refurbished Beaufort House
and work got underway to demolish the old hospital
buildings which will make way for additional car
parking for staff and patients, landscaping and an
on-site sterile services department. And in October
we became the specialist major arterial centre for
patients in Bristol, Bath & North East Somerset, South
Gloucestershire and some parts of Wiltshire and
Somerset. The entire site is due for completion in
spring 2016.
Despite some well documented issues and problems
which have been dealt with, the Brunel building really
is revolutionising how we care for patients who are
now reaping many important benefits such as very
low infection rates, excellent Trauma care due to the
improved layout and team working and improved
privacy and dignity.
Juliette Hughes, Matron, said: “We are really
pleased with how the night has gone. We have
been planning for this move for a long time and
everything went as it should have.” The new
department is much bigger with larger cubicles
and better access to scanning and X-ray facilities,
including a CT scanner actually located in the unit
which is used for trauma and stoke patients. There
is also a helipad right outside.
Once A&E moved, staff and patients from the other
wards and departments at Frenchay began the
journey across the city. This started with the transfer
of the intensive care unit when 19 patients were
transported by the RAF’s large ambulance vehicle,
which is known as a ‘jumbulance’.
Account of the Quality of Clinical Services 2014/2015
15
Patient Stories
Throughout this Quality Account we
will be sharing patient stories to give
examples of how we communicate closely
with people who use our services and
work with them to provide a personally
delivered service.
Patient Story 1 - Brief Outline
Mrs Brown (not her real name) is a lady in her
eighties, married for more than 60 years and living
with her husband. Her daughters had grown up
and lived away from home. She had reasonably
good health until her later years when she required
major surgery at Frenchay Hospital.
During her time as an inpatient, around three
months, she recalls good and bad experiences
of different things. Mainly the good things
outweighed the bad and she describes ‘getting
by’ with the help of her daughters. One of her
daughters, a nurse, spoke with the doctors about
issues with her medication, which were resolved.
Following discharge she now suffers with short
bowel syndrome which required her to visit
Frenchay Day Hospital. Following the move from
Frenchay to Southmead Mrs Brown now visits
the Southmead Medical Day Care about once a
week. She enjoyed her experience at Frenchay Day
Hospital finding the centre a small, friendly and
inviting place. Mrs Brown described it as always
clean, warm and friendly, she was very sad when
it was announced the centre was closing. She
and her family were very apprehensive about the
move...... Frenchay was more convenient for her to
get to, and for her daughter who dropped her off
right outside the door.
16
Account of the Quality of Clinical Services 2014/2015
The staff are friendly and
efficient and as I am a long
standing member everyone
makes the time to speak
to me and makes sure I am
happy and comfortable.
The first day they arrived at Southmead was
quite stressful, as she felt it was for staff, because
everything was new and bewildering. The volume
of traffic around the front door and being dropped
off on her own whilst her family went to park
made her feel very nervous. Mrs Brown still visits
Southmead every week and finds the day centre an
enjoyable experience, although it took her a while
to settle in.
“The staff are friendly and efficient and as I am a
long standing member everyone makes the time
to speak to me and makes sure I am happy
and comfortable.”
2.Assurances on
Quality from
the Trust Board
Account of the Quality of Clinical Services 2014/2015
17
2.Assurances
on Quality
from the
Trust Board
Review of Services
During 2014/15, the Trust provided a wide
range of NHS services. These are listed in
Appendix 3.
The Trust reviews data and information related to
the quality of these services through regular reports
to the Trust Board and the Trust’s governance
committees. Each clinical service undergoes
monthly Executive review in which performance
against standards of quality and safety are
reviewed. These reviews discuss with clinical teams
and managers any areas of concern and also
continuous quality improvement. The Trust has
therefore reviewed 100% of the data available to
them on the quality of care in all its NHS services.
The income generated by the NHS services
reviewed in 2014/15 represents 100% percent of
total income generated from the provision of NHS
services by the North Bristol NHS Trust for 2014/15.
Mortality
The Trust has a good record on patient mortality
and both internal and external assessments of
its performance indicate that it is consistently
performing at or better than the national expected
levels on a range of measures that are used to
monitor and assess mortality.
Hospital Standardised Mortality
Ratio - HSMR
HSMR is a measurement which compares a hospital’s
actual number of deaths with their predicted number
of deaths, taking into account factors such as the age
and sex of patients, their diagnosis, whether their
admission was planned or an emergency. If a Trust
has an HSMR of 100, this means that the number
of patient deaths is as expected, based on the
seriousness of their condition. If the HSMR is above
100 this means that more people have died than
would be expected. In contrast an HSMR below
100 means that fewer die than expected.
Chart 1 opposite shows that mortality is at or
below expected levels for almost all of the year.
There is a rise in December 2014 but it is important
to note that this remains within the ‘expected
range.’ There is a potential for some seasonal
element to factor into this during December
nevertheless we are reviewing this closely to ensure
any learning opportunities have not been missed.
Standardised Hospital Mortality
Indicator - SHMI
SHMI is the preferred method used to measure
and compare patient mortality but is more
recently introduced than HSMR. The SHMI
includes post-discharge deaths (30 days).
The Trust SHMI is also below the Trust national
average of 100, which indicates that NBT is
performing as would be expected.
The key differences in methodology between
HSMR and SHMI indicators are;
■■
HSMR is a sample of 56 diagnoses where
around 85% of hospital deaths occur. HSMR
is adjusted for more factors than SHMI, most
significantly palliative care, but also other sub
groups, such as social deprivation, past history
of admissions and source of admission
■■
SHMI includes all deaths, regardless of
whether they were attributable to the
hospital. So, for example, if 30 days after
being in hospital, someone dies falling out
of a tree, it would still be included in SHMI
Palliative Care - Mortality Comparator
Percentage of patient deaths with palliative care coded either at diagnosis or specialty level for NBT during the
reporting period 2014-15;
Provider
North Bristol NHS Trust
18
Palliative Deaths
Total Deaths
Palliative Coding Rate
592
1935
29.04%
Account of the Quality of Clinical Services 2014/2015
0
Aug-14
Sep-14
Oct-14
Nov-14
Jul 13 - Jun 14
Jul-14
Apr 13 - Mar 14
National benchmark
Jan 13 - Dec 13
Jun-14
Oct 12 - Sep 13
Undefined
Jul 12 - Jun 13
May-14
Apr 12 - Mar 13
Expected range
Jan 12 - Dec 12
Apr-14
Oct 11 - Sep 12
Mar-14
Jul 11 - Jun 12
Low relative risk
Apr 11 - Mar 12
Feb-14
Jan 11 - Dec 11
High relative risk
Ovt 10 - Sep 11
Jan-14
Jul 10 - Jun 11
Financial Year 2010/11
94
Provider
Royal Devon
Maidstone
University Hospital
Heart of England
City Hospitals
South Tess Hospitals
Blackpool Teaching
United Lincolns
Northern Lincoln
University Hospital
Brighton & Sussex
East Kent Hospital
County Durham
Cambridge University
Barking, Havering & Redbridge
Worcestershire
Doncaster & Bassetlaw
Norfolk & Norwich
East Lancashire
Portsmouth Hospital
Nottingham University
Royal Cornwall
Lancashire Teaching
Leeds Teaching
East Sussex
Sheffield Teaching
Southend University
Western Sussex
Calderdale & Huddersfield
Barts Heath
Gloucestershire
St George’s Heath
York Teaching
The Newcastle University
Barnet & Chase Farm
Pennine Acute
Wirral University
Plymouth Hospital
Royal Berkshire
University Hospital
St Helens & Knowsley
Mid Yorkshire Hospital
North West London
Sandwell & West Bromwich
Hull & East Yorkshire
Shrewsbury & Telford
The Royal Wolverhampton
University Hospital
North Bristol
The Dudley Health
Northumbria
Oxford University
Lewisham Health
University Hospital
Epsom and St Helier
Imperial College
Derby Hospitals
The Royal Bournemouth
King’s College
East & North Hertfordshire
Palliative Coding Rate
Relative Risk
Chart 1: Hospital Standardised Mortality Ratio Jan-14 – Dec-14
130
125
120
115
110
105
100
95
90
85
80
75
70
65
60
Confidence intervals
Dec-14
Chart 2: SHMI Trend to Quarter 1 2014/2015
100
99
98
97
96
95
(NB – HSMR and SHMI data is published in arrears – charts shown are the latest available).
Chart 3: Crude palliative coding rate of deaths by trust (all non-specialist
Crudeacute
palliativeproviders)
coding rate of deaths
trust
(all non-specialistin
acute
providers)
forto
all admissions
in July 2012
forbyall
admissions
July
2013
June 2014
60
to June 2013
50
40
30
20
10
(NB – Palliative care data is published in arrears – charts shown are the latest available).
Account of the Quality of Clinical Services 2014/2015
19
The rate of palliative care coding is relatively
high. The Trust is reviewing the accuracy of this
recording. The fact of being a specialist palliative
care and MacMillan unit may result in this position.
Palliative care coding rates may impact HSMR but
do not effect SHMI.
Safety Review of Every
Patient Death
Whilst the published and independently assessed
NBT data outlined in Charts 1, 2 and 3 is
reassuring and should give patients and referring
clinicians’ confidence in our clinical safety level, we
are not complacent and continuous improvement
is the goal for our longer term quality and safety
improvement work.
A new system to support the formal screening and
review of all in-patient deaths was introduced in
April 2014 and underpins our objectives to prevent
avoidable harm and death. This is undertaken to
provide an objective review. To date there have
been more that 600 patient deaths which have
been reviewed in this way. It is reassuring to note
that no cases of avoidable death have been found
during these reviews. The information from this
Mortality Screening and Review work is compared
with other data from the Trust to look for potential
learning and improvement opportunities by the
Trust’s Quality Surveillance Group.
Patient Reported Outcome
Measures (PROMS)
All NHS patients having hip or knee replacements,
varicose vein surgery, or groin hernia surgery are
invited to fill in PROMs questionnaires. When
patients go into hospital, they are asked to fill in
a short questionnaire before their operation. The
NHS asks patients about their health and quality
of life before they have an operation, and about
their health and the effectiveness of the operation
afterwards. This helps the NHS measure and
improve the quality of its care.
Charts 4 and 5 are produced centrally for all NHS
Hospital providers to provide an overview of
top-level Patient Recorded Outcome Measures
(PROMS) for the chosen procedures. The
horizontal bars show the proportion of completed
patient questionnaires for which the patient’s
condition worsened (left of the centre line) or
improved (right of the centre line), the triangle
markers show the national average for the same
measure. These averages are not casemix adjusted
and so direct comparison of provider and national
position is not advised.
20
Account of the Quality of Clinical Services 2014/2015
NB. Varicose Vein scores for NBT are not present
as the Trust does not perform this procedure. Data
returns for Groin Hernia and Hip replacement
Revisions fell below the threshold for reporting (less
than 30 returned PROM questionnaires)
Venous thromboembolism (VTE)
This is a condition in which a blood clot (a thrombus)
forms in a vein. It most commonly occurs in the
deep veins of the legs; this is called deep venous
thrombosis (DVT). The thrombus may dislodge
from its site of origin to travel in the blood and then
lodge in another part of the body, commonly in
the lungs, causing a pulmonary embolism (PE). VTE
causes considerable mortality and morbidity in the
United Kingdom and its treatment is associated with
considerable cost to the health service.
A significant proportion of VTE events are related
to a recent hospital admission (hospital-acquired
VTE) and are potentially preventable. The risk of
developing VTE depends on the condition and/
or procedure for which the patient is admitted
and on any predisposing risk factors (such as age,
obesity, previous episodes of VTE, and other coexisting conditions).
Since 2010, NICE (National Institute for Health
and Clinical Excellence) has recommended that
patients should be risk assessed on admission
to identify those at increased risk of VTE. Our
Clinical Commissioning Group requires that we risk
assess 95% of patients on admission & provide
appropriate thromboprophylaxis (measures to
reduce the risk of developing VTE) to at least 90%
of patients.
Audit data from Feb ’14 to Jan ’15 show that
95.2% of patients were risk assessed and 94.8%
received appropriate thromboprophylaxis. In 2014
there were 237 patients with hospital-acquired
thromboses. The figures for 2011–2014 are
displayed in the graph.
Our focus in the Thrombosis Committee for the
year ahead is to further reduce the number of
patients affected by avoidable VTE and to increase
patients’ awareness of this issue.
Groin Hernia
Chart 4: Improvement rate (unadjusted scores) by procedure and measure
EQ VAS
37.9%
Hip Replacement
EQ-5D Index
89.3%
EQ VAS
65.7%
Oxford Hip Score
Knee Replacement
Varicose Vein
50.6%
EQ-5D Index
96.8%
EQ-5D Index
81.4%
EQ VAS
56.3%
Oxford Knee Score
93.9%
EQ-5D Index
54.0%
EQ VAS
40.4%
Aberdeen Varicose Vein
Questionnaire
84.2%
-100%
-80%
%Worse
-60%
-40%
% Improved
-20%
0%
20%
40%
60%
80%
100%
Unchanged
Groin Hernia
Chart 5: Percentage of patients that have improved for each procedure
and scoring mechanism (unadjusted)
EQ-5D Index
EQ VAS
Hip Replacement
EQ-5D Index
EQ VAS
Varicose Vein
Knee Replacement
Oxford Hip Score
EQ-5D Index
EQ VAS
Oxford Knee Score
EQ-5D Index
EQ VAS
Aberdeen Varicose Vein
Questionnaire
-100%
-75%
%Worse
-50%
-25%
% Improved
% England Worse
0%
25%
50%
75%
100%
% England Improved
Chart 6: Patients with hospital-acquired Thromboses 2011-2014
Hospital acquired VTE
350
300
280
287
237
250
207
200
150
100
50
0
2011
2012
2013
2014
Year
Account of the Quality of Clinical Services 2014/2015
21
Reducing Harm from Infection
In 2014/15 there were no cases of Methicillin
Resistant Staphylococcus Aureus (MRSA) blood
stream infection recorded within the Trust, compared
to 1 case in 2013/14. As a Trust we have continued
to make significant improvement, which has been
sustained since June 2011 as illustrated opposite.
2014/15 has seen a significant improvement in the
reduction of the numbers of patients recorded as
having Clostridium difficile (C.diff) and the Trust has
met the national set target of no more than 79 cases
with the final figure being 44 cases. This year’s final
figure shows a continued year on year reduction
in C.diff patients since 2010/11, as reflected in the
chart opposite.
Number of infections against target set
Type of infection
2013/14
2014/15
DoH target
Cases of MRSA
1
0
0
Cases of Cdiff
67
44
<=79
There are systems and processes of investigation
in place for each case enable us to establish
common themes and areas of improvement.
We achieve this through:
■■
Strengthening our infection prevention and
control policies and processes to assist staff
in achieving best practice
■■
Ongoing clinical staff education programmes
■■
Collaborative working with the wider health
care community on the management of MRSA,
C.diff and other incidences as they arise.
The Trust remains focused on a zero tolerance to
infection continuously striving for reductions of
infection acquired by patients cared for by the
Trust. We remain committed to making further
improvements over the next year.
Patient Safety Incidents
The Trust is committed to providing high quality care
to patients within a safe environment and therefore
it is the policy of the Trust to take all reasonable steps
to minimise the risk of harm to patients in the course
of their treatment and care. However, when incidents
do occur the Trust wants to ensure that we learn
lessons to improve patient safety.
An open and learning culture operates within the
Trust and all patient safety incidents are reported to
the National Reporting & Learning Service (NRLS) and
the Care Quality Commission (CQC). The Trust also
adheres to the principles of Being Open as defined
by the National Patient Safety Agency (NPSA). Being
Open encourages and supports a culture of honesty
and transparency when communicating with patients
and their families following an incident in which
a patient was harmed. Work has been conducted
around the Duty of Candour process and the Trust is
in the process of rolling it out along with the revised
Never Event framework published by NHS England
for the 2015/16 financial year.
Organisational feedback reports from the NRLS
indicate a level of reporting from NBT at the lower
end of the mid-range of national reporting figures.
This has fallen over the past year, as illustrated
below which is something that is being actively
addressed through engagement with clinical
directorates and through improvements in the
incident reporting system, eAIMs, that came into
effect in October 2014 and are not therefore
reflected in the national data.
22
Account of the Quality of Clinical Services 2014/2015
Chart 7: Quarterly MRSA case rates per 100k bed days
12.0
11.0
10.0
9.0
8.0
7.0
6.0
5.0
4.0
3.0
2.0
Jul-Sep 14 -
Oct-Dec 14 -
Jan-Mar 15 -
Oct-Dec 14 -
Jan-Mar 15 -
Apr-Jun 14 -
Jan-Mar 14 -
Oct-Dec 13 -
Jul-Sep 13 -
Apr-Jun 13 -
Jan-Mar 13 -
Oct-Dec 12 Regional
Jul-Sep 14 -
NBT
Jul-Sep 12 -
Apr-Jun 12 -
Jan-Mar 12 -
Oct-Dec 11 -
Jul-Sep 11 -
Apr-Jun 11 -
Jan-Mar 11 -
Oct-Dec 10 -
Jul-Sep 10 -
0.0
Apr-Jun 10 -
1.0
National
Chart 8: Quarterly C-Difficile case rates per 100k bed days
12.0
11.0
10.0
9.0
8.0
7.0
6.0
5.0
4.0
3.0
2.0
NBT
Regional
Apr-Jun 14 -
Jan-Mar 14 -
Oct-Dec 13 -
Jul-Sep 13 -
Apr-Jun 13 -
Jan-Mar 13 -
Oct-Dec 12 -
Jul-Sep 12 -
Apr-Jun 12 -
Jan-Mar 12 -
Oct-Dec 11 -
Jul-Sep 11 -
Apr-Jun 11 -
Jan-Mar 11 -
Oct-Dec 10 -
Jul-Sep 10 -
0.0
Apr-Jun 10 -
1.0
National
Organisations
Chart 9: Comparative incident reporting rate, per 1000 beddays,
for 140 acute (non-specialist) organisations.
0
10
20
30
40
50
60
70
80
Reporting Rate (per 1,000 bed days)
Your Organisation's Reporting Rate
Highest 25% of Reporters
Middle 50% of Reporters
Lowest 25% of Reporters
Account of the Quality of Clinical Services 2014/2015
23
A high proportion of incidents reported this year
resulted in either no harm or low harm to patients,
which demonstrates a positive approach to incident
reporting and a pro-active safety culture. The Trust
is slightly above the national average in terms of
Moderate and severe incidents. The roll out of the
Duty of Candour will help to raise awareness of
Moderate harm incidents with the aim of reducing
level of harm in the future through shared learning,
particularly across different clinical teams.
There were 87 serious incidents (compared to 54
last year). All of these incidents were thoroughly
investigated using root cause analysis (RCA)
methodology and an action plan for each incident
was implemented. All RCA reports and the
implementation of action plans are agreed and
monitored by the Trust’s Clinical Risk Committee.
An increasing trend in serious harm from falls,
following the move to Brunel, was given specific
attention and an action plan put in place in order
to minimise the occurrence with good effect.
Types of Serious incidents reported to STEIS March 2014 to Feb 2015
Types of SI reported Mar 2014 - Feb 2015 N = 87
Type
Numbers
Fall
35
Pressure Ulcer
18
Clinical
8
12 hour trolley breach
5
Unexpected Death
5
Other
18
Maternal Death
3
Delayed diagnosis
3
Surgical complication
2
Wrong site surgery
2
Delay in treating deteriorating patient
2
Retained Foreign Object
1
Death in Custody
1
The rate of Serious Incidents reported per bed day across the Trust has varied per month over the past year.
The main extremes, between May and August 2014, relate to the Move into the new hospital. In particular, an
increased number in serious falls incidents occurred post Move but have now reduced. The median rate remains
unchanged throughout the year.
24
Account of the Quality of Clinical Services 2014/2015
Chart 10: Incidents reported by degree of harm for large acute NHS Trusts,
01 April 2014 to 30 September 2014
100
Percent of incidents occuring
90
80
73.7%
72.1%
70
60
50
40
30
21.8%
20.7%
20
10
4.0%
0
None
Low
6.1%
0.9%
0.4%
Moderate
All large acute organisations
0.1%
Severe
0.3%
Death
Your organisation
Chart 11: Serious incidents reports per 1000 bed days Apr 2014 to Mar 2015
0.5
0.45
0.35
0.3
0.25
0.2
0.15
0.1
0.05
Rate per 1000 bed days
Feb 15
Jan 15
Dec 14
Nov 14
Oct 14
Sep 14
Aug 14
Jul 14
Jun 14
May 14
Apr 14
0
MAR 14
Per 1000 Bed Days
0.4
Median
Account of the Quality of Clinical Services 2014/2015
25
Never Events
‘Never events’ are a particular type of serious
incident that are wholly preventable, have the
potential to cause serious patient harm, and there is
evidence that the type of never events has occurred
in the past, and is easily recognised and clearly
defined as such (NHS England 2015)1.
There were three confirmed never events reported by
the Trust in 2014/15, details of which are as follows;
Wrong Site Surgery –
Chest Drain Insertion
A patient was admitted via the Emergency
Department with shortness of breath and not
coping at home. A chest x-ray was performed,
which required the insertion of a left sided chest
drain. On reviewing the post procedure chest
x-ray it had been interpreted incorrectly and the
image was inverted and mislabelled prior to the
procedure. Therefore the chest drain had been
sited on the incorrect side.
On discovery the Respiratory Registrar immediately
explained to the patient the sequence of events
and apologised for the error. The patient
was consented for a right sided chest drain
insertion. The procedure was successful with no
complications. The Respiratory Registrar also
immediately informed the patient’s consultant who
reviewed the patient and also apologised to the
patient and his family.
The following learning points have been taken
forward;
1. All images must have the appropriate lead markers
2.All lead markers are to be visible on all images and
not collimated off
3.If for any reason the lead marker is not visible
and an electronic one has to be added another
radiographer must check it is correct. The form will
be signed by both radiographers acknowledging
the image has been double checked and re scan in.
4.An audit to be carried out to see how many
images have a lead marker visible. Radiology aim is
for 100%. The audit will be on going
5.Re-examine patient prior to insertion of chest
drain for pneumothorax
6.Always check orientation and labelling of chest
x-ray prior to interpretation of pathology. Including
orientation of cardiac silhouette
7. Always compare current chest x-ray with previous
chest x-rays if available
8.Standardised checklist for the insertion of chest
drains to include orientation check
1
26
Revised Never Events Policy and Framework March 2015
Account of the Quality of Clinical Services 2014/2015
Wrong Site Surgery –
Plastic Surgery
A patient was listed for wider local excision of
lesion which took place 13 weeks after an incisional
biopsy of the lesion. The delay resulted in the
operative site being faint and hard to see. The
situation was compounded by the fact that the
photographs taken of the operative site were not
available in the notes on the day of surgery. Despite
this, the operative site was agreed with the patient
and marked in theatre. The excision went ahead,
the surgery site was dressed and the patient went
home. It was 15 days later that the patient reported
the surgery as being undertaken to the wrong site.
The following learning points have been taken from
this event;
1.The anatomical diagram should have been
marked to show the operative site and all listing
forms should be filed in the notes.
2.The lesion should have been marked on prior to
the photograph being taken
3.There should have been less of a gap between
the incisional biopsy and the wider local excision
Wrong Site Surgery - Spinal
This case involved misinterpretation of the position
of a spinal marker leading to greater initial exposure
of the disc being operated upon than was required.
The problem was identified and resolved during the
procedure and the patient informed immediately
following its completion. Following a second
operation, not related to this issue, the patient
made an uneventful post-operative recovery and
was successfully discharged. This case identified the
degree of difficulty that interpretation of images
involves and the need for extra vigilance when specific
patient factors make interpretation more difficult.
The outcomes of the Root Cause Analysis
investigation have been shared through the
Neurosurgery Clinical Governance meeting and also
within the Spinal Consultants Multi-Disciplinary Team
meeting. A specific teaching session for Neurological
Specialist Registrars is also to be undertaken.
NHS England Patient Safety Alerts
Patient Safety Alerts are actioned in line with the
mandated deadlines to ensure that all necessary
improvements are made. Progress is reported to
the Trust Board within the monthly Integrated
Performance Report.
At the end of 2014/15, there were no
outstanding patient safety alerts relating to
North Bristol NHS Trust.
2014 National NHS Staff Survey Recommendation to Friends & Family
There is a national survey of NHS staff which takes
place in Quarter 3 of the financial year. This survey
is recognised as an important way of ensuring that
the views of staff working in the NHS inform local
improvements and provide input into local and
national assessments of quality, safety and delivery
of the NHS Constitution.
The score below corresponds to the survey
questions relating specifically to staff
recommendation of the Trust as a place to work or
NHS Staff Survey 2014 - Staff Satisfaction
receive treatment. It is correlated from a group of
questions which include:
■■
Staff job satisfaction
■■
Whether staff would recommend their Trust
to others as a place to work
■■
Staff motivation
The score is from 1 to 5. 1 represents staff unlikely
to recommend the Trust and 5 represents those
likely to recommend the Trust.
NBT
2013
NBT
2014
National
Average
Score out of 5
Staff recommendation of NBT as a place to
work or receive treatment
850 staff at NBT were invited to complete the
survey during September to December 2014. Our
response rate was 25% and is amongst the lower
response rate for acute trusts in England. Previous
response rates at NBT were 52% (2013), 54%
(2012) and 58% (2011).
We were disappointed with the decrease in
score from last year’s result and lower response
rate. This is understood to be a reflection of the
momentous challenges faced by the Trust in a
year where we merged Frenchay and Southmead
services to the central Southmead site and settled
into the new Brunel building. The underlying
aspects of those challenges included: new working
environments, new ways of working, new transport
arrangements, new teams, high activity levels and
staff turnover. Also, a change in the national survey
methodology from postal to largely electronic may
have impacted on our response rate.
NBT is fully committed to making meaningful and
sustainable improvement to staff experience, through
key staff engagement initiatives, positive wellbeing
support, training interventions, the successful delivery
of the CQC action plan and development of a clear
and ambitious wider Trust Strategy.
3.56
3.29
3.67
Through the quarterly Staff Friends and Family Test
(SFFT) survey we are monitoring the questions:
‘Would you recommend NBT to friends and family
as a place to receive treatment’ and ‘Would you
recommend NBT to friends and family as a place to
work’. With over 1900 staff completing the SFFT
survey in Quarter 4 of 2014-15, we have already
seen an improvement in comparison to Quarter
2’s SFFT results. During the Quarter 4 SFFT 66%
of staff reported that they were either likely or
extremely likely to recommend NBT as a place to be
treated, a 6% increase on the results from Quarter
2 and 46% of staff reported that they were either
likely or extremely likely to recommend NBT as a
place to work, a 7% increase on Quarter 2’s report.
Directorates have received their breakdown of
the NHS Staff Survey 2014 results for sharing
and discussion with staff and involving them in
developing the way forward. Each Directorate
then develops an action plan, with staff input,
which aims to focus on key areas for improvement
and further development. To support this work
NBT undertakes a comprehensive leadership
development programme to build leadership and
management capability.
Account of the Quality of Clinical Services 2014/2015
27
Friends and Family Test – Patients
Friends & Family Test first began in April 2013
when it was implemented across all inpatient
wards and in the Emergency Department (ED).
Maternity came on board in October 2013 and we
were an early starter piloting the Friends & Family
Test in outpatients from October 2014.
guidelines. So in addition to highlighting the Net
Promoter Score, we also report the percentage of
all patients who state that they would recommend
(‘extremely likely’, or ‘likely’) or not recommend
(‘extremely unlikely’ or ‘unlikely’) the Trust to their
family and friends. This new measure will always
be higher than the Net Promoter Score because
it has expanded the number of response types
included in the positive measure and it does not
subtract the neutral and negative responses from
the positive score.
The tables below show the response rates and net
promoter scores for all areas mentioned above
over the last year. From November 2014, as part
of reporting to Trust Board we also included the
new way of measuring the Test, as per national
Inpatients April 2014 – March 2015
From April 2014 the CQUIN target, attached to the response rate, changed to 25% for Qtr. 1 and then
increased to 30% by Qtr. 4. However during March 2015, the response rate target was increased to 40%.
Net Promoter
Score
% Recommend
% Not
Recommend
Response
Rate
CQUIN
response rate
target
Apr-14
68
95%
1%
33%
25%
May
67
95%
2%
12%
25%
June
67
92%
4%
14%
25%
Qtr. 1
67
94%
2%
20%
July
72
95%
2%
27%
30%
Aug
62
92%
3%
26%
30%
Sept
69
95%
2%
28%
30%
Qtr. 2
68
94%
2%
27%
Oct
64
93%
3%
26%
30%
Nov
70
94%
3%
30%
30%
Dec
67
94%
2%
30%
30%
Qtr. 3
67
94%
3%
29%
Jan-15
66
94%
2%
33%
30%
Feb
66
94%
2%
35%
30%
Mar
67
94%
2%
44%
40%
Qtr 4
66
94%
2%
37%
Month
2014/15
28
Account of the Quality of Clinical Services 2014/2015
Emergency Department April 2014 – March 2015
From April 2014 a new CQUIN target response rate of 20% was introduced for the Emergency Department.
Net Promoter
Score
% Recommend
% Not
Recommend
Response Rate
CQUIN
response
rate target
April 2014
72
95%
3%
8%
20%
May
53
83%
9%
5%
20%
June
42
84%
6%
21%
20%
Qtr. 1
56
87%
6%
11%
July
39
83%
7%
23%
20%
Aug
46
86%
6%
20%
20%
Sept
52
90%
4%
19%
20%
Qtr. 2
46
86%
6%
21%
Oct
50
90%
3%
19%
20%
Nov
58
89%
5%
21%
20%
Dec
80
97%
2%
3%
20%
Qtr. 3
63
92%
3%
14%
Jan 2015
72
94%
3%
10%
20%
Feb
65
88%
7%
8%
20%
Mar
74
94%
2%
24%
20%
Qtr 4
70
92%
4%
14%
Month 2014/15
Maternity April 2014 – March 2015
There is no national target for maternity, however a local target for Maternity has been set at 15% from the start.
Net Promoter
Score
% Recommend
% Not
Recommend
Response Rate
CCG target
April 2014
72
95%
2%
17%
15%
May
73
95%
1%
19%
15%
June
68
95%
1%
14%
15%
Qtr. 1
71
95%
1%
17%
July
72
97%
1%
18%
15%
Aug
64
95%
3%
20%
15%
Sept
63
92%
3%
16%
15%
Qtr. 2
66
95%
2%
18%
Oct
67
94%
1%
18%
15%
Nov
67
96%
2%
20%
15%
Dec
69
96%
1%
16%
15%
Qtr. 3
68
95%
1%
18%
Jan 2015
69
96%
2%
20%
15%
Feb
69
98%
1%
17%
15%
Mar
67
97%
2%
19%
15%
Qtr 4
68
97%
2%
19%
Month 2014/15
Account of the Quality of Clinical Services 2014/2015
29
Outpatients and Day Case October 2014 – March 2015
Net Promoter
Score
% Recommend
% Not
Recommend
Response Rate
Oct 2014
67
91%
6%
3%
Nov
72
90%
6%
1%
Dec
52
84%
9%
2%
Qtr. 1
64
87
8%
2%
Jan 2015
70
91%
6%
1%
Feb
64
91%
4%
3%
Mar
68
93%
3%
3%
Qtr. 2
67
92%
4%
1%
Month 2014/15
Overall we have had a reasonable year in terms
of gathering Friends & Family Test (FFT) data,
particularly in light of the challenge of moving into
the Brunel Building, which meant a whole new way
of working, including how FFT was delivered.
of feedback to support staff to improve patient
care and monitor their results. It also helped us to
assess the impact on number of responses in terms
of achieving our final quarter of CQUIN targets and
to see how staff and patients responded to using
technology. Additional patient experience questions
can be added to help us get richer feedback. We
also aim to pilot text messaging in outpatients.
The pilots will help us develop a business case and
recommended approach for the future.
Inpatient wards have achieved or been close to
achieving their 30% response rate target. Over the
year they have exceeded the TDA Net Promoter
Score target of 60. The Emergency Dept. (ED) has
continued to find the survey process challenging.
Their scores did improve when they had a
dedicated member of staff administering the Test.
Unfortunately they were unable to continue funding
this post. During March 2015 the introductory trial of
an electronic Feedback Kiosk in their waiting room
certainly helped to boost numbers. We also trialled
hand held devices across nine wards during March to
test out the use of technology to capture feedback in
a real time way. This improved reporting and quality
Maternity have consistently met their local Clinical
Commissioning Group (CCG) response rate target
of 15%.
As part of our drive to use FFT data to improve
services wards have a ‘Knowing How Your Ward
is Doing’ board outside the wards that highlight
patient feedback and action taken. These are being
rolled out across all outpatient areas. “You Said,
We Did” examples include:
You Said
We Did
There are no clocks in the single bedrooms
We have bought and are installing clocks
Food portions too small
Catering team visited to watch how we served and in
liaising with us portion sizes have increased
Lonely in single rooms
Look left and right and smile as walking past
Two top performing areas in FFT over the last year
have been Gate 28b, a care of the elderly ward
who managed to come top three times and Gate
7a, a stroke ward, who came top twice.
30
Account of the Quality of Clinical Services 2014/2015
Other top performers include Gate 27a, Gate
33a, Gate 33b and Cotswold. Our Chief Executive
attends in person to presents top performing
areas with a certificate.
National Patient Survey – Emergency Department
Every two years the CQC commissions a national survey to be undertaken across all Emergency Depts. (ED).
The last survey was carried out in 2014 and the previous survey in 2012. In comparison to the last survey, the
Trust has improved significantly in two areas:
Table 1: Areas improved in:
Lower scores are better
2012
2014
Arrival: not enough privacy when discussing condition and receptionist
63%
50%
Leaving: not fully told when to resume normal activities
73%
55%
The Trust has not worsened in any areas since 2012.
In comparison to other Trusts commissioning Picker to undertake this survey (73 Trusts); the Trust has improved
significantly in:
Lower scores are better
Trust
Average
4%
7%
Lower scores are better
Trust
Average
Hospital: unable to get suitable refreshments
39%
30%
Hospital: felt bothered or threatened by other patients
The Trust has significantly worsened in the following area:
Account of the Quality of Clinical Services 2014/2015
31
Care
Care
The iCARE programme was launched in September
2014 in order to build upon our strengths in
caring for patients and supporting colleagues,
by recognising and spreading best practice.
Care
iCARE stands for:
Care
I take responsibility for;
Communication that’s effective
Attitude that’s positive
Respect for patients, carers and colleagues
Environment that’s conducive to care.
Approximately 4,500 staff have attended an
iCARE session including all new staff at induction
and bespoke sessions for staff working in various
environments, including receptionists in the
Emergency Department, the Sterile Services
Department, Facilities, the IT Service Desk and
Switchboard, Volunteer Services, and the Acute
Assessment Unit. It has enabled people who work
directly with patients to reflect on how they work
together to provide an environment conducive to
care, and enabled staff who work in support areas
to see how their work enables others to provide
high quality care.
Each month the iCARE Moments award has been
an opportunity to highlight a moment when an
individual or team did something that made a
big difference to patients. Recent iCARE
Moments include:
XXX* spoke to me about a proposal to offer Staff Development’s help with
feeding patients at lunchtime. Through her initiative, we have 10 volunteers, both
nurses and administrators who have volunteered to be ‘Mealtime Companions’
(on top of their day job). xxx contacted Ward Sisters who are enthusiastic about
this and she has arranged training for feeding assistance to the volunteers. xxx has
done this by influencing her colleagues and thinking about what small actions we
could take that will have a positive impact on wards staff and patients alike, with
the emphasis very much on improving patient experience and supporting one of
the most important priorities – supporting patient’s hydration and nutrition.”
“I overheard this lovely HCA taking the time to be a shoulder to cry on for a very
distressed patient. Although the ward was busy (bells ringing and understaffed),
she dealt with the situation with such care and wonderful empathy. To top it off
she ran along to make tea once the tears had dried up. It doesn’t sound much
but sometimes all that is needed to create a smile is sweet tea and open ears.
She came to us fresh out of school (first job, no experience) just over a year ago.
She is now a confident bright young lady. She has flourished in her role and is
guaranteed in putting a smile on any face.
* XXX - name removed for confidentiality reasons
32
Account of the Quality of Clinical Services 2014/2015
Following a best interest meeting and consultation with
Richard’s partner and family it was agreed that further
clinical investigation would not improve his quality of life.
The family agreed that Richard’s needs were to be met in
a care home. A continuing health care assessment was
completed and the allocated social worker assisted the
family in identifying an appropriate home.
Patient Story 2
Dementia Care
Richard (not his real name), a gentleman in his
nineties from Bristol lived with his partner of 15
years. He was a retail business owner who had
been retired for a number of years. He has three
children, a daughter and two sons.
Richard was admitted to hospital after being observed
to have abdominal pain, weight loss and an altered
bowel habit by his partner. Three years earlier he had
been diagnosed with Frontal Temporal Dementia by
the memory service. Due to his ill health and dementia
Richard had become increasingly confused and
agitated. He had been supported in the community by
a Community Psychiatric Nurse and a care package.
His GP arranged admission to assess and investigate his
abdominal pain.
Communication between his children and partner
was established from admission as Richard was not
able to communicate his needs. His son had power of
attorney for financial affairs and his partner had been
providing his personal care increasingly due to his lack
of acceptance of carers. He had become increasingly
agitated and physically aggressive.
Richard had a short admission during September during
which he had a fall after commencing new medication
for his mood. The medication was stopped and he
had a comprehensive assessment by the Complex
Assessment Liaison Service team that was available for
his recent admission.
On admission, at the beginning of October, Richard
was found to have salmonella in his stool which
required him to spend time in his single room. He was
at high risk of falls and had a 1:1 carer identified. In
addition he had a Deprivation of Liberty Safeguard
(DOLS) in place. Richard’s partner was concerned about
his isolation and also about discharge arrangements
having been told that he was medically fit for discharge
a few days after admission.
Richard’s partner was able to speak about her concerns
with Dr Haworth, dementia specialist, who had
first diagnosed his dementia in the memory service.
Information about the memory café run at Southmead
Hospital and the Alzheimer’s Society about leaving
hospital was provided.
His partner was able to raise concerns and express her
distress regarding his discharge planning and placement
which might have meant that his house would have to
be sold consequently limiting the time his partner could
spend with him as she would have to return to living in
her house some distance away. She was reassured that
discharge would be planned and discussed with the
family and a case worker was assigned to them.
The dementia matron and trainer established a good
relationship with Richard and his partner, affording
her the time she needed to discuss and process the
decisions and changes that were happening to both
her and Richard. They were actively encouraged
and supported to attend the memory café, at times
observation and care were given to Richard allowing
his partner to have an opportunity to discuss and clarify
issues whilst moving the leaving hospital plans forward.
Unfortunately Richard was assessed by a number of care
homes who were unable to meet his needs.
By this time Richard had become more aggressive and
confused expressing this physically with his carers,
this change was attributed to a urinary tract infection.
Richard’s partner was able to assist the nursing staff
to encourage compliance with medicines to treat
the infection. Liaison between the acute ward team,
community psychiatric team and acute older adult
psychiatric liaison service led to an agreed plan. With
observation, changes to his medication and increasing
his compliance with taking medication Richard’s
aggressive behaviour and confusion started to settle.
Richard’s mood improved with pain control, treatment
for his infection and changes to his dementia
medication. A care home was identified, funding
approved and he was discharged in mid-November.
An excerpt of poetry written by Richard’s
partner as part of the Fresh Arts week.
On the day I met your poet
Care for me, I plead
what do I need?
The mind no longer sees
all it could
The meal awaits
I no longer eat what I should
I sit in my seat
The drink awaits
Two sips are gone
It goes old and cold,
Like me
Care for me, I plead
what do I need?
The love, the care, the closeness
touch and holding
please heed
my cries to lead
me on to a better life.
I strive to find
I search to find
But what am I looking for?
Account of the Quality of Clinical Services 2014/2015
33
3.Improving
quality and
safety of
patient care
34
Account of the Quality of Clinical Services 2014/2015
Preventing deterioration
Patients who are deteriorating often
show signs and symptoms indicating their
worsening state. Early Warning Scores (EWS)
calculates a score based on the patient’s key
measurements and provides an indicator
of how sick a patient is, thus enabling the
recognition and escalation of care of patients
whose condition is worsening.
All inpatients within the Trust have their
physiological observations (respiratory rate,
levels of oxygen, pulse, blood pressure, level of
consciousness and temperature) mesured and
recorded according to our Observations Policy.
This early recognition and management of patient
observations may prevent avoidable patient
admissions to the Intensive Care Unit (ICU) and
help prevent avoidable cardiac arrests and the need
for Cardiopulmonary Resuscitation (CPR).
Cardiac arrests in hospital are rarely a sudden
event. There is evidence to show that patients
will often present with signs of deterioration prior
to suffering a cardiac arrest. Using cardiac arrest
rates we can demonstrate that, by using the Early
Warning System, our staff have the tools to help
recognise these signs, and in doing so potentially
prevent the patient deteriorating.
Account of the Quality of Clinical Services 2014/2015
35
36
Apr 11
Trustwide
Account of the Quality of Clinical Services 2014/2015
Target (95%)
Nov 13
Dec 13
Jan 14
Dec 13
Jan 14
Jun 13
May 13
Apr 13
Mar 13
Nov 13
0%
Oct 13
20%
Sep 13
40%
Oct 13
60%
Sep 13
80%
Aug 13
100%
Jul 13
Chart 14: If EWS>=4, escalation followed?
Jul 13
Target (95%)
Aug 13
Jun 13
May 13
Apr 13
Jan 13
Feb 13
Median 2008 (2.4)
Median 2013 (0.9)
Mar 13
Trustwide
Median 2009 (2.5)
Median 2014 (0.6)
Jan 15 -
Oct 14 -
Jul 14 -
Apr 14 -
Jan 14 -
Oct 13 -
Jul 13 -
Apr 13 -
Jan 13 -
Oct 12 -
Jul 12 -
Apr 12 -
Jan 12 -
Oct 11 -
Jul 11 -
Apr 11 -
Jan 12 -
1.6
Feb 13
Dec 12
Nov 12
Jul 11 Oct 11 -
1.8
1.6
Jan 13
Dec 12
Nov 12
Oct 12
Sep 12
Aug 12
Apr 11 -
Jan 11 -
Oct 10 -
Jul10 -
Apr 10 -
Jan 10 -
Oct 09 -
Jul 09 -
Apr 09 -
2.7
1.4
1.31.3 1.3
1.3
1.3
1.2
1.2
1.11.1
1.1
1.1
1 1
1
1
1
1
0.9
0.9 0.9
0.9
0.9
0.9
0.9
0.8 0.8
0.8
0.7
0.7
0.7
0.6
0.6 0.60.6
0.6 0.6 0.6
0.5
0.5
0.5
0.5
0.5
0.4
3.0
2.9
2.8
2.8 2.8
2.7
2.7
2.7
2.6
2.5
2.5
2.22.3
2.3 2.4
2.3
2.3
2.2
2.2
2.1
1.9 1.9
1.9
1.8 1.8
1.8
1.7
1.6
1.5
1.5
1.4
1.2
Oct 12
Sep 12
Jul 12
Jun 12
May 12
Apr 12
Mar 12
Feb 12
Median 2007 (2.5)
Median 2012 (0.9)
Aug 12
Jul 12
Jun 12
May 12
Apr 12
Mar 12
Feb 12
Jan 12
Crash Calls Rate
Median 2011 (1.2)
Jan 12
Dec 11
Jan 09 -
3.6
Dec 11
Oct 11
Nov 11
2.9
Nov 11
Jul 08 Oct08 -
2.4
Sep 11
2.6
Oct 11
3.7 3.7
Sep 11
Jan 08 -
2.2
2.1
Apr 08 -
3.1
Aug 11
3.4
Aug 11
Jul 07 Oct 07 -
2.4 2.3
Jul 11
Jun 11
Apr 07 -
3.8
Jul 11
Jun 11
May 11
Apr 11
Rate per 1000 discharges
2.1
May 11
Jan 07 -
Chart 12: Cardiac arrest rates
3.4
2.9
1.7
Median 2010 (1.9)
Chart 13: Q7 - Target 02 range circled on drugs chart
100%
80%
60%
40%
20%
0%
Cardiac Arrest rates
The Trust’s cardiac arrest rate continues to reduce. Chart 12 shows that the Trust median rate is 0.7 per 1000
discharges, which compares favourably with the current national average of approximately 1.5 per 1000.
The reduction in the number of cardiac arrests in the Trust during this period is shown below;
Total
■■
2011/12
2012/13
2013/14
2014/15
215
163
148
125
Chart 13 shows that the Oxygen target
range prescribing for safer oxygen
administration has not improved.
■■
We are working with specific Directorates to
ensure doctors are completing target Oxygen
saturations on admission with assistance of
our pharmacy teams and specialist nurses.
If a patient scores EWS of 4 or more, ward staff escalate to a doctor for urgent assessment in 99% of cases,
exceeding the 95% target, as shown in Chart 14. This ensures that patients receive appropriate management
reduces the risk of further deterioration.
Achievements
■■
Sustained improvement in EWS escalation
within the context of the MOVE to the
Brunel building
■■
Low cardiac arrest rates demonstrating that
patients can be monitored safely in the
new building.
■■
Clearer communication from the wards via
our Switchboard Operators, to the medical
staff and Site Nurse Practitioners to ensure
timely response to unwell patients.
■■
Closer working with Sepsis Group
■■
Established a Top Tips internet page for
junior doctors to support them in assessing
acutely ill patients with guidance on common
presentations such as “The Drowsy Patient”
Ongoing work 2015/2016
■■
To test and implement the National Early
Warning Score chart on the inpatient wards as
part of regional work to use one single early
warning score process for all acute hospitals
in the West of England. North Bristol Trust
and University Hospitals Bristol have agreed to
develop a single chart for both hospitals
■■
Implementing the National Early Warning
Score in the Emergency Department so that
patients arriving to and being transferred
from ED have their observations clearly
handed over to the next team
■■
Work with GPs and community services to use
the National Early Warning Score for acutely
unwell patients to enable clear handover of
unwell patients to the Emergency Department
and Ambulance Service
■■
Developing a structured assessment tool for
reviewing unwell patients to improve their
management, encourage escalation
to senior teams and improve communication
to nursing staff
■■
Developing a joint educational programme
for junior doctors and Specialist Nurse
Practitioners seeing acutely unwell patients
using Simulation training scenarios
■■
Promoting the use of SBAR for nurses
escalating concerns to doctors. (Situation,
Background, Assessment, Recommendation)
■■
Working with our ward pharmacists and
specialist nurses in specific directorates where
oxygen prescribing is variable
Account of the Quality of Clinical Services 2014/2015
37
Chart 15: Patients with Grade 2 or above pressure ulcers
Patients
with
2 or bed
abovedays
Pressure Ulcers
rate
perGrade
10,000
Rate per 10,000 Bed Days
14
Rate per 10k bed days
12
10
8
6
4
2
Mar 15
Feb 15
Jan 15
Dec 14
Nov 14
Oct 14
Sep 14
Aug 14
Jul 14
Jun 14
May 14
Apr 14
0
Chart 16: Pressure ulcers Grade 3 (green), 4 (purple) YTD
Pressure Ulcers Grade 3 (green) Grade 4 (purple) YTD
3
2
38
Account of the Quality of Clinical Services 2014/2015
Mar 15
Feb 15
Jan 15
Dec 14
Nov 14
Oct 14
Sep 14
Aug 14
Jul 14
Jun 14
0
May 14
1
Apr 14
Number of Pressure Ulcers
4
Reducing pressure ulcers
During 2014/15 we have seen a similar level to
that reported in the previous year 2013/14 in the
number of patients developing a pressure ulcer when
comparing the rates per 10,000 bed days. We were
unable to reduce the number of patients recorded as
having grade 4 pressure ulcers with a total of 6 cases
in comparison to 2 in the previous year. However
progress has been made in the reduction of grade 2
and grade 3 pressure ulcers.
The prevention of pressure ulcers remains a
fundamental aspect of Patient safety and focuses
directly on the quality of the patient’s experience.
The Trust wide pressure ulcer rate per 10,000 bed
days has been between 10 and 20 over the past
12 months. Although there was improvement
after the introduction of the SKIN Bundle and
audit measures in March 2011 this reduction
stagnated early on in the programme and no
significant gains have been made since.
This year we commenced a complete review
of the assessment and ongoing care for
pressure ulcers, and the training and education
programmes needed to take this forward This
has included the improvement of policies and
protocols surrounding pressure ulcers and tissue
viability, risk identification communicated between
staff within the Trust and also to community
providers, and risk escalation procedures along
with the completion of RCAs on serious pressure
ulcers to identify the underlying causes.
Pressure Ulcers
All grade 4 and 3 pressure ulcers continue to
be reported as serious incidents with a full
investigation as to cause and lesson learnt, which
are discussed collaboratively with our external
partners to demonstrate and give assurance that
patient care is the primary focus.
The Trust remains focused on a zero tolerance
to avoidable health care acquired pressure
ulcers continuously striving for reductions. We
remain committed to the challenge of further
improvements over the next year, with reductions
in Pressure Ulcers being one of the key elements of
the Trust’s Safety programme (Sign up to Safety).
2013/14
2014/15
Grade 4
2
7
Grade 3
37
14
Grade 2
455
382
Explanation of Pressure Ulcer Grades
Grade 1
This is indicated by non blanchable redness that does not subside after pressure
is released. The skin might be hotter or cooler than normal, have an odd texture,
and it can be painful to the individual.
Grade 2
This is damage to the first layer of skin extending into, but no deeper than this
layer. At this stage, the ulcer may be referred to as a blister or abrasion.
Grade 3
This grade indicates more serious damage as the sore extends into the full
thickness of the skin and may extend into the deeper tissue layer. There is less
blood supply making it more difficult to heal. At this stage, the sore or wound
may be much larger under the surface.
Grade 4
This grade is the most serious ulcer. It is the deepest ulcer, extending through
skin into the muscle, tendon or even bone.
Account of the Quality of Clinical Services 2014/2015
39
Safeguarding Vulnerable People
The Trust has a Safeguarding Committee that
oversees reporting structures and monitors the
safeguarding agenda in all of the Trust’s services.
As an organisation we are committed to making
safeguarding a high priority for all members of
the Trust. Safeguarding standards are reported
annually to the Clinical Commissioning Groups
and performance activities are reported quarterly
to the Commissioners and the Local Safeguarding
Children Boards
The Safeguarding Committee has responsibility for
setting and monitoring the delivery of the Trust’s
strategic priorities for safeguarding through the
Trust and providing assurance to the Board. The
Committee is supported by two operational groups
who carry out the work in relation to safeguarding;
■■
Children (child protection)
■■
Vulnerable adults - including people with
dementia, adults with learning disabilities
and mental health
Safeguarding Children
The Trust is committed to promoting and
safeguarding the welfare of children and young
people who use our services. At all times a child’s
welfare is paramount. The Trust takes action to
ensure that the risk of harm to children’s welfare is
minimised and, where there are concerns about a
child or young person, staff within the Trust take
action to address this.
The definition of a child is anyone under the age of
18, but young people aged 16-18 years are usually
treated in adult services. Therefore all clinical staff
receive Level 2 Safeguarding Children training.
The CQC Inspection in November 2014 found that
robust safeguarding procedures were in place with
clear lines of reporting. Also that staff were aware
of these procedures and their own responsibilities
to safeguard children and young people.
Staff work collaboratively with other agencies
involved in safeguarding children and follow
national and local legislation, policy and guidance.
The Trust provides child protection training to all
staff to ensure they have an appropriate level of
competence in this area of work. Safeguarding
Training compliance is monitored through the
Safeguarding Children Operational Group; the
figures are reported quarterly to Bristol and South
Gloucestershire Safeguarding Children Boards.
Significant changes to the training requirement
40
Account of the Quality of Clinical Services 2014/2015
have been made as a result of the revised
Intercollegiate Document (2014). The Named
Nurses have worked with the training department
to develop an electronic knowledge based
assessment to be completed three months post
Level 1 and Level 2 training. This will provide some
quality assurance whether learning outcomes are
being achieved.
Lessons learnt from all Serious Case Reviews and
Serious Incidents are included in current training
packages. Formal child protection supervision
is provided for all staff with a child protection
caseload. In addition reflective practice and
peer review relating to safeguarding children is
increasing throughout clinical directorates.
The Trust provides care to children and young
people, via the Community Child Health
Partnership (CCHP) for Bristol and South
Gloucestershire. These services include community
paediatrics, health visiting, school health nursing,
allied health professionals and Child and Adolescent
Mental Health. Within CCHP we provide 24 hour
Consultant Community Paediatric cover for child
protection cases including sexual abuse. This
service’s overall rating was outstanding following
the CQC inspection in November 2014. CCHP
was described as having a child and young person
centred culture with children and young people
being full partners in their care.
Children are also seen in a range of other settings
throughout NBT such as minor injuries and the
Emergency department and outpatient clinics. The
Trust’s inpatient paediatric services transferred to
University Hospital Bristol in May 2014. However
young people between 16 – 18 years will continue
to be inpatients on our adult wards, an audit has
been completed to establish and monitor the level
of staff knowledge with regard to safeguarding
16 – 17 year olds patients who are being treated as
inpatients in the Brunel Building.
Our Maternity services provide care for mothers
and babies, with some mothers under the age of
18 themselves. Maternity services have developed
a safeguarding team, consisting of three full time
staff, with further development planned of a
perinatal health and bereavement support role in
2015. Babies requiring specialist care are treated in
the highly respected level 3 Neonatal Intensive Care
Unit. There is 24 hour on call service provided by the
Designated Supervisor of Midwifery to ensure there is
safeguarding support for clinical staff at all times.
Safeguarding Vulnerable Adults
The Safeguarding of vulnerable adults remains
a high priority for the Trust. This area of practice
requires collaborative working with other health
providers, health and social care commissioners and
the local authority and the police.
The Trust’s Safeguarding Adult Team is made
of a Safeguarding Adult Lead (full time) and
Safeguarding Manager (half time) supported by a
full time administrator.
The Director of Nursing is the Executive Lead
for Adult Safeguarding and chairs the Trust
Overarching Safeguarding Committee. Adult
Safeguarding has its own subcommittee which is
chaired by the Trust Safeguarding Adults Lead.
Over the last year the Trust has seen a steady climb
in the number of referral s (please see below) The
Trust has received three notifications of Serious
Case Review however these have not reported to
date. The Trust has been involved in a number (3)
Domestic Homicide Reviews and is delivering on
these actions plans.
Year
Q1
Q2
Q3
Q4
Total
2013/14
22
12
42
34
100
2014/15
54
57
105
98*
214
• Quarter 4 figures compiled before quarter end.
The Trust has maintained its focus on Safeguarding
Adults, Mental Capacity Act (including Deprivation
of Liberty) Training which now includes PREVENT
awareness, Domestic Abuse and Violence and
Female Gentile Mutilation, as well as Human
Trafficking awareness.
Adult safeguarding moves on to a statutory
footing in April 2015 with the introduction of the
Care Act 2014 and the Trust has been planning
for implementation. The Trust believes that this
will increase the scope of adult safeguarding as
the criteria for who is an “adult at risk of harm”
(formally Vulnerable adult) and the “threshold”
for investigation is likely to be lower.
Safeguarding Adult Boards will also have a
statutory underpinning. NBT through its Adult
Safeguarding Lead attends both Bristol and South
Gloucestershire boards and contributes to sub
group work on both boards.
Safety and Quality Improvement
work streams
North Bristol NHS Trust is one of the 12 Pathfinder
NHS Organisations to the national Sign Up to Safety
campaign. We are seeking to utilise the depth and
breadth of our existing quality improvement and
safety experience from within the organisation to
improve our approach to harm reduction.
The Sign Up to Safety campaign provides an
opportunity to introduce a single unified and
system wide approach to reducing harm. After
extensive discussion the Trust identified 4 key areas
for targeted improvement work, which are:
1. In-Patient Falls
2. Pressure Ulcers
3. Sepsis
4. Acute Kidney Injury
The approach seeks to build upon some of the
improvements made as part of the Trust work with
the Safer Patients Initiative and the South West
Quality & Safety Programme in previous years. It
also takes account of the significant and historic
changes following the combination of acute
services on to a single site and into a brand new
Hospital building.
Learning achieved through discussions with our
frontline teams, patient representatives and the
quality improvement and safety experts within the
organisation has been applied to create the Safety
improvement Plan and develop the faculty referred
to overleaf.
Account of the Quality of Clinical Services 2014/2015
41
Quality and Safety
Improvement Faculty
At the end of January 2015 a half day workshop was
held to launch North Bristol Trust’s Quality and Safety
Faculty, which was attended by a diverse group of
people with an interest in safety from all corners
of the organisation. The afternoon comprised of
talks from clinicians already engaged in safety work;
poster presentations of the work that has been done
previously; and workshop discussions about how
the programme will be taken forward to ensure
maximum engagement with all staff in the Trust. The
outcomes of the event have formed part of the NBT’s
Safety Strategy.
General Wards Work Stream – Falls
Falls can have a devastating outcome for patients.
Serious falls can result in fractures, increased length
of stay in hospital and in severe cases result in the
death of a patient. So preventing and reducing
the incidence of falls – especially serious falls – is
an important priority for the Trust. Not all falls are
preventable but many falls can be avoided with
good risk assessment, preventative interventions
and the right training and support of staff.
What we did last year
(2014/15)
Launch a new Falls Prevention
Bundle
The Hospital Patient Falls Prevention Group worked
very hard to develop new tools and interventions in
preparation for our patients being cared for in the
new Brunel Building, especially in the single rooms.
A new care bundle was developed and launched in
April 2014.
New Falls Risk Tool
A simplified electronic tool has been implemented
which increased the identification of patients at risk
of falls. This tool is used for all inpatients within 6
hours of admission.
Falls Risk Alert sticker
Every patient at risk of falls has a sticker placed
in the clinical notes to communicate this risk to
the ward teams. Doctors are particularly asked to
review 3 things:
42
■■
Confusion
■■
Medications that may increase falls
■■
Blood pressure changes on standing
Account of the Quality of Clinical Services 2014/2015
So far our data is showing us that the number
of patients who should have these stickers and
reviews is increasing each month.
New Intentional Rounding Tool
A new comfort rounding tool has now been
implemented and is used for every inpatient in the
Brunel Building. The rounds ensure that patients’
needs are checked every hour as a minimum. This is
especially important for patients in single rooms.
Enhanced Observation
Many patients who have memory problems or are
acutely confused, have the highest risk of falls in
hospital. Ward staff identify these patients and
ensure they are either in the 4-bed bays on the
wards or are located in a cluster of single rooms so
that increased observation of them can take place
by the nursing teams and reduce the chance of the
patients falling. Patients are identified on a “ward
falls map” and discussed at the morning Safety
Briefings. Patients at high risk of falls, who are in
single rooms, are brought into the bay area in the
daytime where they can be observed more closely.
A new Falls Prevention Care Plan
A new care plan which prompts ward staff to put
in place preventative measures, particularly focusing
on enhanced observation and safe toileting, in
single rooms, has been implemented and is used
for every patient at risk of falls.
As set out below, the falls rate has increased
despite these interventions being implemented.
Other hospitals in the country who have moved to
buildings with high numbers of single rooms have
also experienced increases in their falls rates (of up
to 50% in some cases).
The overall number of Falls rate has increased by
9.6% compared to last year and the number of
serious falls has increased by 112%.
■■
There have been 2388 falls in the Trust since
1st April 2014 (last year it was 2178).
■■
Falls rate has increased to 6.88 per 1000 bed
days (last year it was 5.82)
■■
There have been 34 serious falls (last year
there were 16) resulting in;
- 23 hip fractures
- 4 intracranial haemorrhages
- 7 other injuries resulting in significant harm
The majority of the increased serious injury falls
occurred soon after the MOVE to the new hospital.
The number of serious falls is now falling and has
been decreasing for the last 5 months.
Jan 11
Account of the Quality of Clinical Services 2014/2015
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
Dec 13
Nov 13
Oct 13
Sep 13
Aug 13
Jul 13
Jun 13
May 13
Apr 13
Mar 13
Feb 13
Jan 13
Dec 12
Nov 12
Oct 12
Sep 12
Aug 12
Jul 12
Jun 12
May 12
Apr 12
Mar 12
Feb 12
Jan 12
Dec 11
Nov 11
Oct 11
Sep 11
Aug 11
Jul 11
Jun 11
May 11
Apr 11
Mar 11
Feb 11
No of serious falls
Feb 15
Dec14
Oct 14
Aug 14
Jun 14
Apr 14
Feb 14
Dec13
Oct 13
Aug 13
Jun 13
Apr 13
Feb 13
Dec12
Oct 12
Aug 12
Jun 12
Apr 12
Feb 12
Dec11
Oct 11
Aug 11
Jun 11
Apr 11
Feb 11
Dec 10
Falls per 1000 bed days
Feb 15
Jan 15
Dec 14
Nov 14
Oct 14
Sep 14
Aug 14
Chart 17: Patients with Falls Risk Alert Sticker in Notes
90
80
70
60
50
40
30
20
10
0
Sticker in notes
Chart 18: Monthly Falls Rate per 1000 Bed days - Dec 2010 – Feb 2015
9.00
8.00
7.00
6.00
5.00
4.00
3.00
2.00
1.00
0
Month
Chart 19: Number
of Serious Falls Jan 2011 - Feb 2015
Number of Serious Falls Jan 2011 - Feb 2015
7
6
5
4
3
2
1
0
Month
43
Ongoing work 2015/2016
■■
Using technology. We are testing the use
of bed and chair sensor alarms in the single
rooms in Brunel with the aim to reduce falls
in patients who may not remember to call
for assistance when they want to mobilise
The Trust first achieved the 95% target in
November 2011 and has maintained this even
during the MOVE. Since moving to the Brunel
building, we have twice reviewed our data
collection and ensure we target wards with most
admissions – and currently this is on 17 wards.
■■
Delivery of Falls Prevention training to all
medical, nursing, pharmacy and therapy
staff. Falls is one of the themes of our Sign
Up to Safety Programme and training forms
a substantial part of these plans
In 2012 our data was submitted to the national
“Quality, Innovation, Productivity and Prevention”
(QIPP), benchmarking which shows that NBT is the
best performing Trust in England and Wales.
■■
Moving and Handling equipment to be
purchased for all wards to encourage safe
transfer of patients with poor mobility on
and off the toilet
■■
Footwear campaign to ensure all inpatients
wear safe footwear
■■
Developing an Enhanced Care Nursing Team
for patients with confusion who are at risk
of falls, to provide increased observations for
these patients
■■
Working with the Dementia Team to ensure
all wards have activities for patients with
cognitive problems and a safe environment
Medicines Management
Workstream
As part of the South West Quality and
Improvement Programme we continue to focus on
the following areas:
In publicising our work we have had posters
displayed at the Pharmacy Management National
Forum, London (11/2012) and the European
Hospital Pharmacy Conference, Paris (3/2013) and
ran workshops at the Pharmacy Management
National Forum, London (11/2013 and 11/2014)
and also at the European Hospital Pharmacy
Conference, Hamburg (3/2015).
The team were shortlisted finalists for our work in
the HSJ Award (2014); Lean Healthcare Academy
Award (2014) and HSJ National Patient Safety
Awards (2013).
We have also published articles on our work:
“Improving Medicines Reconciliation on Admission“:
Hospital Pharmacy Europe (v. 074: Summer 2014);
“Medicines Reconciliation on Admission – other
issues - at North Bristol NHS Trust (NBT)”: Hospital
Pharmacy Europe (v. 075: Autumn 2014) and “On
using a DVD to educate doctors” [Clinical Pharmacist
(2010); Volume 2: p.187].
Medicines Reconciliation
Now that the team has achieved and maintained
our target, we will continue to monitor and review
admissions data on a regular basis and are now
starting to focus on Medicines Reconciliation
on Discharge. We have also started to focus
on elective admissions and are working with
pre-operative assessment clinic staff to improve
this process.
Why is this important?
Missed doses
Ensuring an accurate record of medications
on admission to hospital is important for safe
treatment. Reconciliation is a process of confirming
the medication that a patient is taking with at least
two independent sources of information.
Why is this important?
■■
Medicines Reconciliation
■■
Missed doses
■■
Warfarin
Prescribing errors can result in harm to patients
and the aim of this process is to ensure when
patients are admitted to hospital that important
medicines aren’t stopped and that new medicines
are prescribed, with a complete knowledge of
what a patient is already taking. NBT set a target of
95% for patients admitted to have their medicines
reconciled within 24 hours.
44
Progress to Date
Account of the Quality of Clinical Services 2014/2015
Avoiding missed doses is important to ensure a
patient’s care is not compromised. Missed doses
were highlighted as an issue at the Trust following
a review of incident forms.
Progress to Date
Reductions in missed doses have been demonstrated
over a number of years. Pharmacists continue to
measure missed doses on a daily basis and wards
have been asked to collect data via an e-tool on a
weekly basis. Medicines Management Technicians
Chart 20: Number of patients with reconcilliation (six months medians)
100%
100%
90%
90%
80%
80%
70%
70%
South West
South
West
Programme
Programme
begins
begins
New Hospital
New
Hospital
opens
May 2014
opens May 2014
SP1-2
SP1-2
Program
Program
ends
ends
SP1-2
SP1-2
Program
Program
starts
60%starts
60%
50%
50%
Phase 4:
Feb
20114:- Feb 2013
Phase
(31 -- Feb
20 Wards)
Feb 2011
2013
(31 - 20 Wards)
Phase 5:
Feb
2013
Phase
5: - now
- 15
Wards)
Feb(20
2013
- now
(20 - 15 Wards)
Aug 10
Nov 10
Nov 10
Feb 11
Feb 11
May 11
May 11
Aug 11
Aug 11
Nov 11
Nov 11
Feb 12
Feb 12
May 12
May 12
Aug 12
Aug 12
Nov 12
Nov 12
Feb 13
Feb 13
May 13
May 13
Aug 13
Aug 13
Nov 13
Nov 13
Feb 14
Feb 14
May 14
May 14
Aug 14
Aug 14
Nov 14
Nov 14
May 10
Aug 10
Feb 10
May 10
Nov 09
Feb 10
Aug 09
Nov 09
May 09
Aug 09
Phase 3:
Aug
2009
Phase
3: - Feb 2011
30 Wards)
AugSWOPSI
2009 - (11
Feb-2011
SWOPSI (11 - 30 Wards)
Feb 09
May 09
Nov 08
Feb 09
Aug 08
Nov 08
May 08
Aug 08
Feb 08
May 08
Nov 07
Feb 08
Aug 07
Nov 07
May 07
Aug 07
May 07
40%
40%
Phase 1:
Phase 2:
Feb
2007
2008
Phase
1: - July 2008 Aug
Phase
2: - Jul 2009
(8 - 11
Feb 2007 (1-8
- JulyWards)
2008 Aug 2008
Jul Wards)
2009
(1-8 Wards)
(8 - 11 Wards)
Chart 21: Percentage of patients with one or more missed doses
across North Bristol NHS Trust
100%
90%
80%
70%
60%
50%
Phase 1:
February 2000 - July 2010
Phase 2:
August 2010 - April 2011
Phase 3:
May 2011 - September 2012
Phase 4:
October 2012 - October 2013
(31 - 20 Wards)
Jan 15
Nov 14
Sep 14
Jul 14
May 14
Mar 14
Jan 14
Nov 13
Sep 13
Jul 13
May 13
Mar 13
Jan 13
Nov 12
Sep 12
Jul 12
May 12
Mar 12
Jan 12
Nov 11
Sep 11
Jul 11
May 11
Mar 11
Jan 11
Nov10
Sep 10
40%
Phase 5:
October 2013 - now
Account of the Quality of Clinical Services 2014/2015
45
are also policing missed doses and looking at drugs
where missed doses have occurred and highlighting
this to the Pharmacists who also review data on a
regular basis for underlying causes.
However, since the MOVE to the Brunel building
we have seen an increase in the number of missed
doses. We are now targeting wards breaching the
target on the monthly reports with a RAG rating of
red. Poor performing wards are highlighted to ward
managers and pharmacists. The team are working
closely together to ensure improvements are being
made and a new Safety Briefing is being finalised
together with an updated flow diagram on how to
access drugs and avoid missed doses.
We were also shortlisted as finalists for our work in
the Patient Safety + Care Awards (2014).
We also undertook work on patients with
Parkinson’s disease in association with “The get it
on time campaign” to ensure that these patients
do not miss crucial medication. The Pre-registration
Pharmacist won the UKCPA best pre-registration
pharmacist award (Nov 2013) for her work on
this and had a poster accepted at the European
Hospital Pharmacy Conference, Barcelona (3/2014)
Warfarin
Why is this important?
The NPSA flagged Warfarin (an antico-agulant) as
being a medicine with a high number of adverse
incidents with increased risk of bleeding associated
with poor control of warfarin management. Since
2012, numbers of INRs over 6 (a monitoring
measurement for warfarin) have consistently
decreased with many dosing errors eliminated. All
junior doctors will now complete an e-learning
module on anticoagulants as part of Trust induction.
Progress to Date
From November 2011 we have been monitoring
INRs greater than 6 on a daily basis – we now
have monthly data from February 2012 to
present. Using a mini root cause analysis (RCA)
tool from February 2012 pharmacists have been
investigating causes of INRs greater than 6 that
occurred during inpatient stays.
46
Account of the Quality of Clinical Services 2014/2015
From the work over a six month period we
were able to identify that interacting drugs and
inappropriate prescribing were the main causes
of inpatient INRs greater than 6. We’ve taken
this forward to update our anticoagulation chart
to allow prescribers and pharmacists to more
prominently display interacting medications, and
made a change to the low dose loading regimen
for warfarin. Key important themes have also been
taken into the new doctor’s e-learning package.
In March 2013, we updated our Warfarin prescription
chart and we have rolled this out to all wards. Wards
also received training on completion of the charts to
ensure that warfarin is prescribed at 2pm (although
administration will still be at 6pm).
The new e-learning package on anticoagulation for
doctors, with main focus, on warfarin was made
live in Spring 2014. A similar package for nurses
with main focus on warfarin has will be made live
in March 2015.
Data for the monthly number of unique patient
numbers for NBT inpatients having a warfarin
control test and how many warfarin control test did
each unique patient have has been obtained. The
run chart shows that the number of NBT inpatients
having an INR greater than 6 has reduced since
November 2011. The number of inpatients have
warfarin control tests (INR tests) has also reduced.
A medication safety alert for Warfarin was
circulated in November 2014 to all clinical staff.
The newer oral anticoagulants Apixaban,
Rivaroxaban and Dabigatran are now widely
prescribed and constitute a bleeding risk. Patient
safety work with these medicines has included
patient information leaflet, Anticoagulation
Alert Cards, patient counselling checklists and a
Medication Safety Alert in March 2014.
Future work includes:
■■
Auto-text that appears on pathology reports
for all inpatient INRs greater than 5
■■
No of days since the last INR greater than
6 for each ward area to go on the ward’s
monthly Quality Synopsis reports
■■
Feeding back findings of mini RCA analysis for
inpatient INRs greater than 6 to Directorate
Clinical Governance leads quarterly
Feb 12
Inpatient INR
greater than 6
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
Dec 13
Nov 13
Oct 13
Sep 13
Aug 13
Jul 13
Jun 13
May 13
Apr 13
Mar 13
Feb 13
Jan 13
Dec 12
Nov 12
Oct 12
Sep 12
Aug 12
Jul 12
Jun 12
May 12
Apr 12
Mar 12
Chart 22: Warfarin
30
400
25
350
300
20
250
15
200
10
150
100
5
50
0
0
Inpatients having INR
tests for Wayfarin
Account of the Quality of Clinical Services 2014/2015
47
Quality of Cancer Services
Cancer Services at North Bristol Trust (NBT)
provides a framework to allow the Trust to
ensure that each cancer patient receives the most
appropriate treatment through a multi-disciplinary
team (MDT) approach. In addition, it monitors
adherence to cancer standards to ensure that the
provision of cancer care remains of the highest
quality. The core Cancer Services Team consists
of a Lead Cancer Clinician, a Cancer Manager, a
Lead Cancer Nurse as well as a Cancer MDT and
Performance Manager with support from MDT
co-ordinators and data clerks who cover all of
the Cancer MDT meetings. There are 11 cancer
specific teams within NBT, a Palliative Care Team
and an Acute Oncology Service. Each cancer team
has a lead clinician working closely with clinical
nurse specialists in cancer and palliative care. The
cancer specialist nurses are supported by Macmillan
support workers. Improving Cancer Patient
Experience was a priority for the Trust in 2014 and
as highlighted above huge improvements have
been made and recognised in this area.
Peer Review
(See table on page 49)
National Cancer Peer Review (NCPR) is a national
quality assurance programme for NHS cancer
services. The programme involves both selfassessment by cancer service teams and external
reviews of teams conducted by professional peers,
against nationally agreed “quality measures”.
In 2014 the National Cancer Peer Review
Programme stipulated a sub-set of cancer MDTs
and groups that were required to self-assess
(SA) against the national Peer Review Measures.
All appropriate groups required to action this
activity completed self-assessment in the required
timeframe and the number of measures including
compliance achieved is noted in the table opposite.
In addition to the self-assessments undertaken the
Lung MDT team was visited as part of an external
validation (EV) process. The overall feedback from
this visit was that the MDT is a well-led, cohesive
and patient-focussed team, however the external
validation team highlighted an immediate risk
48
Account of the Quality of Clinical Services 2014/2015
regarding the availability of patient notes and this
was escalated and actioned within the Trust. Other
concerns highlighted as part of Peer Review activities
are being actioned and will be updated as part of
the 2015 Peer Review Process. In 2015 it has been
decided that all teams and groups will be assessed
and the core cancer services team are working with
directorate colleagues to progress this work.
Cancer Performance
(See table on page 50)
As outlined in the national cancer waiting time
guidance document, the Trust is tasked to deliver
7 national cancer waiting times targets that can be
summarised as follows:
1. Two weeks from urgent GP referral for
suspected cancer to first outpatient attendance
2. Two weeks from symptomatic breast
referral (cancer not suspected) to first
outpatient attendance
3. One month (31 days) from decision to treat to
first definitive treatment for cancer
4. One month (31 days) from decision to treat
or earliest clinically appropriate date (ECAD)
to subsequent treatment (surgery, drug or
radiotherapy) for all cancer patients including
those with a recurrent. At NBT this is noted
separately for surgery and drug patients
5. Two months (62 days) from urgent GP referral
for suspected cancer to first definitive treatment
for cancer (31 days for suspected children’s
cancers, testicular cancer, and acute leukaemia)
6. 62 days from referral from NHS Cancer
Screening Programmes (breast, cervical and
bowel) to treatment for cancer
7. 62 days from a consultant’s decision to upgrade
the urgency of a patient (e.g. following a nonurgent referral) to first treatment for cancer
The Trust has not been able to meet all these
targets consistently over the past year and the
cancer service team has been working with the
directorates to develop trajectories with action
plans and milestones that aim to deliver these
targets moving forward.
Cancer Peer Review Assessments & Compliance
MDT/Topic
Assessment
No. of
type & %
Measures compliance
Acute Oncology
5
SA - 40%
Acute Oncology - Gen
10
SA - 80%
Acute Oncology – In Patient
4
SA - 75%
Brain & CNS – Trust
22
SA – 100%
Brain – Rehabilitation
18
SA – 81%
Brain – Neuroscience MDT
18
SA – 82%
Brain - Skull Base
18
SA – 91%
Brain - Pituitary
18
SA – 91%
Breast
16
To assess in
2015
Chemotherapy
36
SA – 89%
Oncology Pharm Service
5
SA – 100%
Colorectal
18
SA – 100%
Colorectal Diagnostic
1
SA – 100%
Gynaecology Diagnostic
2
SA – 100%
Haematology
18
SA – 94%
SIHMDS
5
SA – 60%
Lung
15
SA – 87% &
EV 67%
Palliative Care
25
To assess in
2015
Sarcoma Trust
8
SA – 100%
Sarcoma – MDT
20
SA – 80%
Skin – Local
18
To assess in
2015
Skin - Specialist
20
To assess in
2015
Skin – Immuno.
1
To assess in
2015
Skin - Melanoma
17
To assess in
2015
Urology - Local
18
To assess in
2015
Urology - Specialist
21
To assess in
2015
Urology - Testicular
17
To assess in
2015
Urology - Penile
17
To assess in
2015
Comments
Issues with insufficient consultant oncologist
support for the service. Discussed actions to ensure
service is appropriately developed.
Issues with insufficient consultant oncologist
support for the service. Discussed actions to
ensure service is appropriately developed.
Head for the Service has been agreed as this
was an issue with compliance.
Issues around the availability of patient notes
meant compliance noted at external validation
meeting was decreased. Matter has been
escalated and addresses as part of Trust wide
actions to improve patients’ notes access.
Account of the Quality of Clinical Services 2014/2015
49
National Cancer Waiting Times Performance
Q1
Q2
Q3
Q4
YTD
Total #
Patients
Patients seen within 2 weeks of an urgent
GP referral (93% target)
93.2%
93.5%
93.4%
92.4%
93.1%
18,358
Patients with breast symptoms seen by
specialist within 2 weeks (93% target)
94.2%
88.1%
95.8%
96.1%
94.1%
847
Patients receiving first treatment within
31 days of cancer diagnosis (96% target)
90.7%
93.5%
95.9%
94.7%
93.8%
2,948
Patients waiting less than 31 days for
subsequent surgery (94% target)
88.7%
92.4%
91.8%
92.7%
91.5%
1,037
Patients waiting less than 31 days for
subsequent drug treatment (98% target)
100%
97.1%
100%
100%
99.2%
132
Patients receiving first treatment within
62 days of urgent GP referral
(85% target)
74.3%
75.9%
82.6%
84.4%
79.4%
1,523
Patients treated within 62 days of screening
(90% target)
87.2%
93.2%
93.8%
90.9%
91.6%
244
Patients treated within 62 days of consultant
upgrades (90% target)
87.2%
89.1%
94.4%
80%
89.1%
96
Standard
The 2 week wait and non-symptomatic breast 2
week wait performance for year to date has been
achieved. Screening performance is achieving above
the national average.
Performance against 31 day, first treatment and
subsequent surgery target has continued to be
challenging throughout the year. Challenges around
capacity pressures within the Urology service have
been identified as a key area to address in order to
solve this performance issue.
The 62 day screening and consultant upgrade
target performance at year to date were 91.6%
50
Account of the Quality of Clinical Services 2014/2015
and 89.1% against a 90% target. The 62 day year
to date performance on the GP referral patients is
79.4% below the target (85%) however significant
improvements have been made over the last 6
months of the year and the target was achieved in
the months of November, December and February.
Each patient who breaches a cancer waiting times
treatment target is reviewed by the managerial and
clinical team to understand if the breach was caused
due to medical, patient choice or system related delay
and appropriate actions are identified as necessary to
progress any issues this process highlights.
Patient Story 3
Emergency Department
Judith (not her real name), a 93 year old
collapsed at home at night. She was found
late the next morning and brought in by
ambulance to the Emergency department.
She was admitted to stroke ward via the
Emergency Department with a diagnosis of Right
intra parenchymal haemorrhagic stroke with sub
arachnoid blood. The doctor had a discussion with
her daughter as Judith was drowsy. Judith had a
dense Left hemiparesis and an unsafe swallow – and
it was decided with her daughter that she needed a
Nasogastric tube, so she could be safely fed.
Since the fall Judith was having frequent seizures. It
was explained to her daughter was that these were
likely due to an extension of her mother’s stroke.
Judith was seen by the physiotherapist,
occupational therapist and speech and language
therapist, all of whom felt Judith was too medically
unwell to partake in therapy. The dietician was
involved taking regular reviews of Judith’s feeding
regimen in terms of the type and amount of feed
administered depending upon her blood chemistry.
Judith was on hourly observations and the care
plan included oxygen therapy. The hourly checks
were to ensure Judith was comfortable and if she
was in pain. Judith also had a wound skin care
plan, as she had sustained a skin tear at the time
of her fall at home. Judith had a daily bed bath.
She was also on a complex regime of different
medications to treat the after effects of the stroke
and continuing seizures.
She continued to have frequent seizures; an
epilepsy chart- was used to describe the type of
seizure and length of time of each seizure.
The Consultant met with her daughter and son
in law to talk about what ‘ceilings of care’* they
wanted for Judith and it was agreed that an High
Dependency Unit/Intensive Care Unit admission
would not be appropriate.
Seven days into her hospital stay Judith began
having seizures every half an hour over a period of
five hours. These were managed with a variety of
medications which eventually brought the seizures
under control and she was stabilised. Overnight
Judith was more comfortable, observations
continued and she slept in an elevated position.
However in the early hours of the morning her
condition deteriorated. She had an intermittent
respiratory effort and during the doctors examination
at 8.00am she sadly passed away. The doctor met
with the family an hour later.
*a predetermined highest level of care by a medical team.
Account of the Quality of Clinical Services 2014/2015
51
4.Improving
patient
experience
52
Account of the Quality of Clinical Services 2014/2015
2014/15 was a year of significant changes for
patients culminating in the move of services
to the Southmead site and more specifically
the Brunel Building. Moving to the new site
brought about many benefits for patients
but also a number of challenges as previously
outlined. In addition during the year a new
role ’Head of Patient Experience’ was created
reporting to the Director of Nursing to bring
an enhanced strategic and practical focus to
improvement work across the Trust.
The Trust continues to engage with Patients,
Carers and the Public through a number of
groups and forums within individual specialities
and at Trust level through the Patient Experience
Group and the Patient Partnership Panel. These
provide an incredibly valuable contribution making
improvements in the patient experience.
The Patient Experience Group
The Patient Experience Group is chaired by the
Director of Nursing and its membership includes
patient and carer representation, the Carers
Support Centre, HealthWatch, the Trust’s Patient
Experience Leads, the Patient and Community
Engagement Manager and The Head of Patient
Experience. This group meets bi-monthly to receive
and discuss the results of the Friends & Family Test
and other national patient surveys in addition to
ideas and proposals from the Trust. This year the
group had the opportunity to discuss the CQC
inspection report in addition to contributing to
thinking about the Trust’s Strategic vision for the
future. It regularly receives Friends & Family Test
results and key themes for discussion and action
and was instrumental in identifying the Quality
Account priorities for this year.
Building on the collaborative working relationship
we had with Local Involvement Networks, we work
closely with our local HealthWatch. In August 2014,
they came and set up a stall in our atrium for a
week, to raise the profile of their organisation and
to speak to patients, carers, relatives and members
of the public visiting the Brunel Building. It was a
successful week all round and in October 2014 they
presented their findings to our Patient Experience
Group. Key themes included: parking; distance
from Beaufort car park to Brunel for patients with
mobility issues; lack of knowledge about shuttle
bus; administration of letters and booking of
appointments malfunctioning in terms of incorrect
dates; patient entertainment – isolation of older
people in single rooms and confusion on way
finding in Brunel. They also presented a report on
our discharge process and key feedback included;
the lack of voluntary and community sector
support post discharge, our discharge process
taking too long and greater need to have a follow
up check-up from hospital post discharge. Both
reports helped us target improvement.
Good quality feedback is key to informing quality
improvement of the Patient Experience. This
involves gaining feedback from a wide range
of our patients and carers reflecting our patient
population. In order to achieve this we have piloted
various methods of feedback in the Trust including
electronic tablets, video kiosk and text messaging.
Since April 2013 the Trust has implemented the
Friends & Family Test across all wards where
patients stay with us at least one night, in our
Emergency Department, across the key stages of
our maternity service and during 2014 throughout
our outpatient services. The results are set out
within the Friends and Family Test section earlier
within this Quality Account.
Key patient experience work for the year ahead
will be to maintain and build our response rates for
the Friends & Family Test because this increases the
information we have to drive the improvement of
our services.
Work of the Trust’s Patient Panel
The long standing Patient Panel has continued to
meet during the year. The panel’s membership
is majority lay members who give freely of their
time to help the Trust and is chaired by one of
their number. In addition to the lay members staff
from the Clinical Governance Directorate attend
the panel on a regular basis, supported by other
attendees for specific items. Members contribute
by participating in Quality, Care and environmental
audits, proof reading patient information leaflets
and sitting on various committees including Quality,
Clinical Effectiveness, Clinical Risk, Clinical Audit
in addition to the Falls Group and Pressure Ulcer
Steering Group.
Account of the Quality of Clinical Services 2014/2015
53
During the year panel members have shared their
experiences, both positive and negative, of the new
Brunel building including:
■■
Outpatient appointment letters, information,
signposting and the time needed between
arriving on site and appointment times
■■
Drop off and traffic congestion outside the
main entrance
■■
The availability of wheelchairs within the
building
■■
Mixed experiences of volunteers
■■
Display screen siting within the waiting areas
■■
Single room advantages and the potential
for patients to feel isolated
■■
Patient food
■■
Patient entertainment and Wi-Fi
■■
The Arts Programme
■■
Car Parking
The Patient Panel receive Friends and Family Test
reports and updates at every meeting. Panel
members met with:
■■
■■
54
The General Manager responsible for
Out Patients to discuss issues and
possible solutions
The Head of IT infrastructure and the Project
Manager for Patient Entertainment to
discuss progress with patient entertainment
following the contractual issues with the
initial supplier other arrangements and
changes to IT were required. Patient Wi-Fi
was made available so that patients could
access entertainment on their own devices.
The arrangements for Televisions in the
wards are now in place and being rolled out
across the Trust
Account of the Quality of Clinical Services 2014/2015
Complaints
Every complaint is important to the Trust and to
reflect this they are all personally responded to
by the Chief Executive, who takes a ‘hands on’
interest in every issue. Each case informs and
demonstrates the impact of our care and treatment
for patient’s, which provides a catalyst for change
and improvement in the services we strive to deliver
to ensure the best patient experience possible.
Last year the significant logistical and practical
changes created by the transfer of the majority
of our clinical services to the new Brunel Building
at Southmead proved challenging for staff and
patients alike. As a consequence complaint
numbers and related activity saw a significant
increase, of 35.5%.
Additionally we have managed many low level
concerns expressed outside of the formal complaints
process. These have typically related to staff
adjusting to the new working environment and
practical issues connected with the building works
on the Southmead site, which will be concluded by
the Summer of 2016. We have sought to respond to
the issues and to limit disruption by:
■■
Creating additional visitor parking and
manually policing traffic at the drop-off area
in front of the main hospital
■■
Moving to “pay on exit parking” and
introducing more convenient ways to pay
■■
Improving the self-check-in system for
patients
■■
Servicing and adjusting the automatic doors
throughout the public areas
■■
Centralising out-patient booking to ensure a
more responsive service
■■
Improving telephone responsiveness
throughout the Trust and removing many
“dead end” numbers
■■
Updating contact details within departmental
letters to ensure the correct contact details
are included
■■
Introducing Wi-Fi for patients’ to allow
them to use personal communication
devices and to access entertainment
services via the internet
Complaint Themes:
The graph below shows a breakdown of the top 6 categories of complaint.
32
(3)%
57 (6)%
91 (10)%
431 (46)%
260 (28)%
62 (7)%
Admission/discharge/transfer
Communication/information
All aspects of clinical treatment
Delay/cancellation inpatient
Attitude of staff
Delay/cancellation outpatient
Despite planning which included increasing support
resources within the central complaints department
the scale of these additional volumes has adversely
impacted the Trust’s ability to respond to all
complaints within the agreed timescales. This also
meant it was not possible to acknowledge and
respond to all posts on the Patient Opinion and
NHS Choices web sites. Additional staff resources
have now been recruited and a formal plan of
action has been devised to resolve this situation.
An increasing preference for the emailing of
complaints has continued and now 85% of
all complaints related correspondence is
received electronically.
The Parliamentary Health Service Ombudsman
advised that they would investigate 20 complaints
during the year as they did not feel the Trust’s
response(s) demonstrated all the principles of good
complaint handling had been followed. These are:
1. Getting it right
2. Being customer focused
3. Being open and accountable
4. Acting fairly and proportionately
5. Putting things right
6. Seeking continuous improvement
Account of the Quality of Clinical Services 2014/2015
55
Following completion of their investigations the
Ombudsman upheld one and partially upheld a
further four complaints. Eight cases are still under
investigation and seven were found to be not
justified. These cases proved a valuable source of
information to help further improve the complaints
process. Additionally the Patient’s Association
(which assisted the NHS following the Francis
Report) has been engaged to help the Trust reform
our complaints process. They are running a series
of workshops for key staff to explore current best
practice, and consider how changes to the process
can increase the responsiveness and quality of
replies to the complainant in order to improve the
individual’s experience and the Trust ability to learn.
They have also reviewed in detail a small number
of complaints investigations and response letters
against their best practice standards. The results
have been received recently and are being reviewed
alongside the workshops referred to above. It is
anticipated this will deliver significant refinements
to the existing processes within the Trust.
Complaints & Concerns 2011/12 – 2014/15
Year
2011/12
2012/13
2013/14
2014/15
Number of complaints
774
832
757
1006
Rate of Complaints per 1000 patient episodes
2.14
2.26
1.3
3.4
The overall total of cases received increased
reflecting the pattern of increased complaints
across the whole of the NHS and the Trust’s
particular circumstances of huge change.
Monitoring and Feedback
In order to continue to take advantage of potential
learning by the Trust, robust monitoring has been
undertaken within the Complaints Team to provide
information on services and analysis of complaint
data. This includes:
56
■■
Monthly feedback to directorates on details
of complaint numbers, types, specialties,
and graphical analysis of the data. Response
times and action plans are also closely
monitored along with returned complaints
and the reason for the return
■■
A “dashboard” of key information is also
produced monthly for Trust Board Meetings
■■
In our iCARE programme, real complaints
and compliments are used in training for
all existing staff as well as new staff on
induction, this helps staff look at care issues
form the patients perspective
■■
Information about complaints is included in
medical staff appraisals
Account of the Quality of Clinical Services 2014/2015
Complaints Action Plans
Action Plans are created for all complaints to
facilitate tracking and to record the lessons learned
to help improve services and patient experience.
Improving our Management and
Learning from Complaints
The significant increases in complaints, concerns
and enquiries proved challenging to manage and
led to an increase in the number that could not
be responded to within the agreed timescales.
The Trust has engaged the Patients Association to
support improvements in our approach, consisting
of an initial investigation of the quality of our
complaints investigations and taking the learning
from this into a series of three workshops for
clinical and administrative staff during March, April
and June 2015. This has been well-attended with a
real appetite to use this as an opportunity to learn
from poor patient experiences and use this
to improve our services.
An improvement plan to manage the overdue
complaints and to review and redesign our overall
approach was approved at the Trust Board in April.
In terms of improving the responsiveness, the plan
aims to ensure that;
We have continued to make good progress with
our Carers Strategy Work Plan during 2014 / 2015
and ensuring that carers are recognised as ‘expert
partners’, particularly in the discharge planning of
the person for whom they care.
1.All 2014 complaints are resolved by
31st May 2015,
During the last 12 months our Hospital Carers
Liaison Workers, employed by the Carers Support
Centre have been provided with a workbase within
the Brunel Building at Southmead Hospital. Regular
meetings are held between the Carers Support
Centre Manager, the Liaison Worker, the Trust’s
Head of Patient Experience and the Dementia Care
Matron. The Hospital Carers Liaison Workers have
been supporting carers on a 1:1 basis whilst the
person they care for is in hospital. We have ensured
that more carers are provided with the support
they need within the hospital environment, are
involved in the discharge planning process and have
the support and information they need to continue
their caring role once they are home again. We
have supported carers at discharge planning and
best interest meetings, accompanied carers to
visit nursing homes and have also signposted
them to external sources of support, such as RNIB
Befriending Service and counselling services.
2.All quarter 4 (January-March 2015) complaints
are resolved by 30th June; and
3.A ‘routine’ position is achieved of replying to
all complaints within agreed timescales with no
overdue complaints by 31st July 2015.
Compliments
Over 4,300 compliments were recorded during
2014/15. These were received in many forms,
from telephone messages to thank you cards and
emails. Positive feedback is shared with staff and
patients to promote and celebrate good practice as
well as to boost staff morale. As part of our future
strategy around improving patients’ experience we
will be looking at more systematic ways of inviting,
collecting and learning from positive feedback,
which can easily be overlooked when focusing on
the more challenging issues.
Carers
Carers have a unique and valuable role to play
in the provision of healthcare, particularly if the
person they care for is in hospital. Carers are in
effect our “expert partners in care”. Our Carer’s
Charter recognises and clarifies our responsibilities
to carers:
■■
Valuing carers as equal partners
■■
Providing carers with ID cards, reduced car
parking and access to the Staff Restaurant
■■
Supporting carers by providing information
on carers’ rights
■■
Ensuring carers have a voice in the planning
and delivery of services
■■
Sharing information, with the patient’s
consent
■■
Involving and supporting young carers
■■
Inclusion in discharge planning
The 1:1 support work with carers started in
February 2013 and over the first 12 months we saw
the number of referrals to both our Southmead
and Frenchay services increase significantly, this
fell during the move in May 2014 but recently has
been increasing again. The Hospital Carers Liaison
Workers also attend the Memory Café on a weekly
basis offering support to Carers.
Carer Awareness Training is provided for all staff
through their Trust induction every month.
57
Involvement of patients and
the public
The Trust’s Patient and Community Engagement
Manager co-ordinates a programme of work to
actively engage and involve patients, the public
and community groups in the design, planning and
delivery of its services. This activity includes:
■■
■■
■■
■■
■■
■■
58
Involvement and communication programme
ensuring the engagement of patients,
carers and the local community with the
development of the new hospital
Improving the patient experience through
the work of the Patient Experience Group
which has a membership of patients, carers
and a cross section of staff e.g. therapists,
volunteers and nurses
Specialty patient groups which are involved in
the delivery of care
Patients’ or voluntary/statutory organisations’
involvement through service or specialist user
groups e.g. Diabetes, renal users group, BUST
Multi agency work such as the Bristol Race
Equality Health Partnership and Care Forum
(an umbrella organisation for health & social
care groups)
The Trust is developing good working
relationships with South Gloucestershire and
Bristol ‘Healthwatch’ as these groups develop,
to ensure a wide involvement of patients,
carers and the local community
Involvement of Members
Over the last year we have worked hard to establish
and engage our member base, recognising that our
members represent the communities and people
that we care for. As of April 2015 we have just
under 16,000 public members representing our
four constituencies – Bristol, South Gloucestershire,
North Somerset and the rest of England and Wales.
Our members have participated in various surveys
and focus groups, including giving us their views of
the art work around the hospital and giving us their
opinions of the hospital for our quality account.
They have received regular updates on the areas
that interest them and have been invited to various
events and forums.
We are currently developing an exciting programme
of events for 2015/2016 and look forward to our
members continued support into the new year
and beyond.
To find out more about Foundation Trust
membership or to sign up as a member,
visit www.nbt.nhs.uk/ft or drop us a line
at membership@nbt.nhs.uk.
Patient Story 4
Responding to
Complaints
Mr Brown (not his real name) is an 80 year
old who had an emergency admission in
July following a fall down a flight of stairs.
He sustained a cervical fracture which was
treated surgically by undergoing a cervical
fusion under the neurosurgeons. He has two
daughters and several grandchildren.
Mr Brown had difficulties swallowing and was
treated in Intensive Therapy Unit with pneumonia. He
was transferred back to the neurosurgical wards for
his ongoing care that included needing a special soft
diet texture ‘D’ with no oral fluids. He also had naso
gastric feeds.
The Ward Sister met with Mr Brown and his
daughters and agreed a number of actions;
■■
Reminding all staff to check what desserts
are allowed when patients are on a
textured diet
■■
This was included in ward safety briefings
and individual patient handover
■■
Signs were put on the outside of the side
room door indicating exactly what textured
diet he allowed as Mr Brown constantly
asked new staff for a cup of tea
■■
Training was arranged for staff in swallowing
and diets as the ward had a high number of
newly qualified staff
■■
Mr Brown was helped to select a meal from
the puree list each day, the kitchen staff
were included and kept a list of the patients
previous days choice - this prevented the
same meal being selected and ensured variety
■■
The kitchen advised serving textured meals in
the containers as when served onto a plate
the meal lost all its “form” and looked rather
a runny mess. This was discussed with the
family and they were happy with this
■■
When ward meals were late or there was a
delay due to the number of patients needing
help to eat, this would be communicated to
patients still waiting for their meal so they
knew their meal was on the way –
not forgotten
Mr Brown was aware of this, but he was not always
compliant and often asked staff to have a cup of tea
and something to eat, on occasion this was given to
him by nursing staff
After he had been in hospital several weeks a
complaint was received from his daughter;
“My Father has been in hospital for 2 months. I am
disappointed with the safety, quality, rotation of the
flavours and presentation of his special diet meals. At
times his meal is forgotten, although other patients in
the same area are having their meals on time and he
is overlooked. When he does get a meal it is served
in the plastic container it is heated in, sat on a plate
There are a variety of flavours to choose in the plastic
ready meals. There is “no rotation” or choice given.
On one occasion he received the cheese style option
for three days running. My sister and I pointed this
out to the staff but nothing changed.
Staff were also serving him ice cream against medical
advice (in his notes) “no liquid orally” ice cream as it
melts into liquid to digest. Serving my dad ice cream
is negligence” - having a liquid intake orally has been
proven following SALT tests to go onto his chest,
he has already had pneumonia once and another
lung infection.”
The family were happy with the actions taken and
also wanted to share the good aspects of care their
father had received. The family subsequently wrote
to say they were delighted in the turnaround of
care and mealtimes and have given the ward gifts
of chocolates to say thank you. Mr Brown was
discharged home in mid-September.
The family were happy with
the actions taken and also
wanted to share the good
aspects of care their father
had received.
Account of the Quality of Clinical Services 2014/2015
59
5.Audit,
Research and
Data Quality
60
Account of the Quality of Clinical Services 2014/2015
Participation in clinical audits
■■
43 national clinical audits were listed to
be reported in the Quality Account for
2014/15. This did not include the National
Confidential Enquiries
■■
During April 2014 - March 2015, 32 of
the 43 (74%) national clinical audits
covered NHS services that North Bristol
NHS Trust provides
■■
During April 2014 - March 2015 North
Bristol NHS Trust participated in all 32 of
the national clinical audits
National Audits listed for the
Quality Account 2014 -15
The national clinical audits and national
confidential enquiries that North Bristol
NHS Trust participated in during April 2014
–March 2015 (stated in the DH list of audits
for inclusion in the Quality Account) are as
follows in Table 1a, 1b, & 2 overleaf.
Account of the Quality of Clinical Services 2014/2015
61
Table 1a – National Clinical Audits
Title
62
Eligible to
participate
Acute Coronary Syndrome or Acute Myocardial Infarction (MINAP)
Yes
Adult Community Acquired Pneumonia
Yes
British Society for Clinical Neurophysiology (BSCN) and Association of Neurophysiological Scientists (ANS) Standards for Ulnar Neuropathy at Elbow (UNE) testing
Yes
Bowel Cancer (NBOCAP)
Yes
Cardiac Rhythm Management (CRM)
Yes
ICNARC - Case Mix Programme (CMP)
Yes
Chronic Kidney Disease in Primary Care
No
Congenital Heart Disease (Paediatric Cardiac Surgery) (CHD)
No
Coronary Angioplasty/National Audit of PCI
Yes
Diabetes (Adult)
Yes
Diabetes (Paediatric) (NPDA)
No
Elective Surgery (National PROMs Programme)
Yes
Epilepsy 12 Audit (Childhood Epilepsy)
Yes
Falls and Fragility Fractures Audit Programme (FFFAP)
Yes
Fitting Child (Care in Emergency Departments)
No
Head and Neck Oncology (DAHNO)
No
Inflammatory Bowel Disease (IBD) Programme:
IBD Casenote Review & Patient Experience
National Biological Therapy Audit
IBD Organisational Audit
Yes
Lung Cancer (NLCA)
Yes
Major Trauma: The Trauma Audit & Research Network (TARN)
Yes
Maternal, Newborn and Infant Clinical Outcome Review Programme (MBRRACE-UK)
Yes
Mental Health (Care in Emergency Departments)
Yes
National Adult Cardiac Surgery Audit
No
National Audit of Dementia
Yes
National Audit of Intermediate Care
No
National Cardiac Arrest Audit (NCAA)
Yes
National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme
Yes
National Comparative Audit of Blood Transfusion Programme:
- Audit of Patient Blood Management in Scheduled Surgery
- Patient Information & Consent
Yes
Account of the Quality of Clinical Services 2014/2015
Table 1a – National Clinical Audits
Eligible to
participate
Title
National Confidential Inquiry into Suicide and Homicide for People with Mental Illness (NCISH)
No
National Emergency Laparotomy Audit (NELA)
Yes
National Heart Failure Audit
Yes
National Joint Registry (NJR)
Yes
National Prostate Cancer Audit
Yes
National Vascular Registry
Yes
Neonatal Intensive and Special Care Audit Programme (NNAP)
Yes
Oesophago-Gastric Cancer (NAOGC)
Yes
Older People (Care in Emergency Departments)
Yes
Paediatric Intensive Care Audit Network (PICANet)
No
Pleural Procedure
Yes
Prescribing Observatory for Mental Health (POMH)
No
Renal Replacement Therapy (Renal Registry)
Yes
Pulmonary Hypertension (Pulmonary Hypertension Audit)
No
Rheumatoid and Early Inflammatory Arthritis
Yes
Sentinel Stroke National Audit Programme (SSNAP)
Yes
The following projects are Confidential Enquiries that are listed by the Department of Health (DoH) to be
reported in the Trust Quality Account for 2014/15:
■■
4 national confidential enquires were listed to be reported in the Quality Account for 2014/15
■■
During April 2014 - March 2015, 4 of the 4 (100%) National Confidential Enquiries covered NHS
services that North Bristol NHS Trust provides
■■
During April 2014 - March 2015 North Bristol NHS Trust participated in 4 of the 4 (100%) Confidential
Enquiries that it was eligible to participate
Table 1b: Confidential enquiries
Eligible to
participate
Title
National Confidential Enquiry into Patient Outcome & Death (NCEPOD) – Sepsis
Yes
National Confidential Enquiry into Patient Outcome & Death (NCEPOD) –
Gastrointestinal Haemorrhage
Yes
National Confidential Enquiry into Patient Outcome & Death (NCEPOD) –
Lower Limb Amputation
Yes
National Confidential Enquiry into Patient Outcome & Death (NCEPOD) – Tracheostomy Care
Yes
Account of the Quality of Clinical Services 2014/2015
63
Table 2 – National Clinical Audits & Confidential Enquiries
Eligible to
participate
Participating
Acute Coronary Syndrome or Acute Myocardial Infarction (MINAP)
Yes
Yes
Adult Community Acquired Pneumonia
Yes
Yes
British Society for Clinical Neurophysiology (BSCN) and Association of
Neurophysiological Scientists (ANS) Standards for Ulnar Neuropathy at
Elbow (UNE) testing
Yes
Yes
Bowel Cancer (NBOCAP)
Yes
Yes
Cardiac Rhythm Management (CRM)
Yes
Yes
ICNARC - Case Mix Programme (CMP)
Yes
Yes
Chronic Kidney Disease in Primary Care
No
N/A
Congenital Heart Disease (Paediatric Cardiac Surgery) (CHD)
No
N/A
Coronary Angioplasty/National Audit of PCI
Yes
Yes
Diabetes (Adult):
National Insulin Pump
National Pregnancy in Diabetes (NPID)
National Diabetes Foot Care
Yes
Yes
(inpatient
elements
only)
Diabetes (Paediatric) (NPDA)
No
N/A
Elective Surgery (National PROMs Programme)
Yes
Yes
Epilepsy 12 Audit (Childhood Epilepsy)
Yes
Yes
Dalls and Fragility Fractures Audit Programme (FFFAP)
Yes
Yes
Fitting Child (Care in Emergency Departments)
No
N/A
Head and Neck Oncology (DAHNO)
No
N/A
Inflammatory Bowel Disease (IBD) Programme:
IBD Casenote Review & Patient Experience
National Biological Therapy Audit
IBD Organisational Audit
Yes
Yes
Lung Cancer (NLCA)
Yes
Yes
Major Trauma: The Trauma Audit & Research Network (TARN)
Yes
Yes
Maternal, Newborn and Infant Clinical Outcome Review Programme
(MBRRACE-UK)
Yes
Yes
Mental Health (Care in Emergency Departments)
Yes
Yes
National Adult Cardiac Surgery Audit
No
N/A
National Audit of Dementia
Yes
Yes
National Audit of Intermediate Care
No
N/A
National Cardiac Arrest Audit (NCAA)
Yes
Yes
Title
64
Account of the Quality of Clinical Services 2014/2015
Table 2 – National Clinical Audits & Confidential Enquiries (DH Required)
Eligible to
participate
Participating
National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme
Yes
Yes
National Comparative Blood Transfusion Programme:
- Audit of Patient Blood Management in Scheduled Surgery
- Patient Information & Consent
Yes
Yes
National Confidential Inquiry into Suicide and Homicide for People with Mental
Illness (NCISH)
No
N/A
National Emergency Laparotomy Audit (NELA)
Yes
Yes
National Heart Failure Audit
Yes
Yes
National Joint Registry (NJR)
Yes
Yes
National Prostate Cancer Audit
Yes
Yes
National Vascular Registry:
UK Carotid Endarterectomy
Abdominal Aortic Aneurysm (AAA) Programme
Vascular Database
Yes
Yes
Neonatal Intensive and Special Care Audit Programme (NNAP)
Yes
Yes
Oesophago-Gastric Cancer (NAOGC)
Yes
Yes
Older People (Care in Emergency Departments)
Yes
Yes
Paediatric Intensive Care Audit Network (PICANet)
No
N/A
Pleural Procedure
Yes
Yes
Prescribing Observatory for Mental Health (POMH)
No
N/A
Renal Replacement Therapy (Renal Registry)
Yes
Yes
Pulmonary Hypertension (Pulmonary Hypertension Audit)
No
N/A
Rheumatoid and Early Inflammatory Arthritis
Yes
Yes
Sentinel Stroke National Audit Programme (SSNAP)
Yes
Yes
National Confidential Enquiry into Patient Outcome & Death (NCEPOD) –
Sepsis
Yes
Yes
National Confidential Enquiry into Patient Outcome & Death (NCEPOD) –
Gastrointestinal Haemorrhage
Yes
Yes
National Confidential Enquiry into Patient Outcome & Death (NCEPOD) –
Lower Limb Amputation
Yes
Yes
National Confidential Enquiry into Patient Outcome & Death (NCEPOD) –
Tracheostomy Care
Yes
Yes
Title
Confidential enquiries
Account of the Quality of Clinical Services 2014/2015
65
North Bristol NHS Trust participated in 12 other national clinical audits and 7 national registries during April
2014 – March 2015 that are not included in the Department of Health (DoH) list of audits for inclusion in the
Quality Account. These audits are listed in Table 3 below:
Table 3: National Clinical Audits & National Registries (additional to DH required)
Title
Specialty
Eligible
Participating
Neo-Natal Unit
Yes
Yes
Trustwide
Yes
Yes
General Surgery
Yes
Yes
Dermatology
Yes
Yes
Rheumatology
Yes
Yes
Cardiology
Yes
Yes
Anaesthetics
Yes
Yes
Renal
Yes
Yes
Anaesthetics
Yes
Yes
Society for Acute Medicine Benchmarking Audit
(SAMBA)
Medicine
Yes
Yes
UK NSC National Hepatitis B in Pregnancy Audit
Obstetrics
Yes
Yes
Breast Services
Yes
Yes
Theatres/Neurosurgery
Yes
Yes
Urology
Yes
Yes
British Association of Endocrine & Thyroid Surgeons
(BAETS) Registry
General Surgery
Yes
Yes
National Bariatric Surgery Register
General Surgery
Yes
Yes
Trustwide
Yes
Yes
Surgical Site Surveillance - Neurosurgery
Neurosurgery
Yes
Yes
Wound Surveillance – Infection of Wound Site
(Orthopaedics)
Orthopaedics
Yes
Yes
National Clinical Audits
Vermont-Oxford Network
National Care of the Dying – 4th Round
Sepsis in Emergency General Surgery Admissions –
A Multicentre Audit
National UK Re-Audit of the Safe Introduction
and Continued Use of Isotretinoin in Acne
British Society for Rheumatology National
Gout Audit
National Cardiac Rehabilitation (NACR)
National Audit Project 5
National Kidney Care Audit – Vascular Access
Potential Donor Audit
A National Audit of the Practice and Outcomes of
Implant Breast Reconstruction
Registries
UK Shunt Registry
British Association of Urological Surgeons (BAUS)
Cancer Registry and Audit
Red Cell Issue Trace Survey
66
Account of the Quality of Clinical Services 2014/2015
Table 4 – National Clinical Audits & Confidential Enquiries
Eligible to
participate
Title
Participating
Cases
Submitted
Data
Submission
Compliance
National Clinical Audits
Acute Coronary Syndrome or Acute Myocardial
Infarction (MINAP)
Yes
Yes
574/574
Adult Community Acquired Pneumonia
Yes
Yes
69/10
> 100%
British Society for Clinical Neurophysiology
(BSCN) and Association of Neurophysiological
Scientists (ANS) Standards for Ulnar Neuropathy
at Elbow (UNE) testing
Yes
Yes
20/20
100%
Bowel Cancer (NBOCAP)
Yes
Yes
276/267
> 100%
Cardiac Rhythm Management (CRM)
Yes
Yes
Yes****
ICNARC - Case Mix Programme (CMP)
Yes
Yes
1505/1505
100%
Chronic Kidney Disease in Primary Care
No
N/A
N/A
N/A
Congenital Heart Disease (Paediatric Cardiac
Surgery) (CHD)
No
N/A
N/A
N/A
Coronary Angioplasty/National Audit of PCI
Yes
Yes
199/199
100%
Diabetes (Adult):
National Insulin Pump
National Pregnancy in Diabetes (NPID)
National Diabetes Foot Care
Yes
Yes
(inpatient elements
only)
89/95
29/29
94%
100%
Diabetes (Paediatric) (NPDA)
No
N/A
N/A
N/A
Elective Surgery (National PROMs Programme)
Yes
Yes
901/1873
48%
Epilepsy 12 Audit (Childhood Epilepsy)
Yes
Yes
33/34
97%
Falls and Fragility Fractures Audit Programme
(FFFAP)
Yes
Yes
445*
98%*
Fitting Child (Care in Emergency Departments)
No
N/A
N/A
N/A
Head and Neck Oncology (DAHNO)
No
N/A
N/A
N/A
Inflammatory Bowel Disease (IBD) Programme
Casenote Review and Patient Experience
National Biological Therapy Audit
Organisational Audit
Yes
Yes
28/28
29/29
100%
100%
Lung Cancer (NLCA)
Yes
Yes
210
22
≥75%
Yes
Yes
1193/1010
> 100%
Yes
Yes
34/34
100%
Yes
Yes
50/50
100%
No
N/A
N/A
N/A
(to end of Feb 15)
100%
National Clinical Audits
Major Trauma: The Trauma Audit & Research
Network (TARN)
Maternal, Newborn and Infant Clinical
Outcome Review Programme (MBRRACE-UK)
Mental Health (Care in Emergency Departments)
National Adult Cardiac Surgery Audit
Account of the Quality of Clinical Services 2014/2015
67
Table 4 – National Clinical Audits & Confidential Enquiries
Title
Eligible to
participate
Participating
Yes
Yes
No
Yes
100%
Cases
Submitted
Compliance
N/A
Yes
N/A
Data
Collection
Starts Aug 15
N/A
148/148
N/A
N/A
N/A
N/A
Yes
Yes
98/10
> 100%
Yes
Yes
24/24
100%
No
N/A
N/A
N/A
National Emergency Laparotomy Audit (NELA)
Yes
Yes
Data
collection
ongoing
N/A
National Heart Failure Audit
Yes
Yes
351/356
99%
National Joint Registry (NJR)
Yes
Yes
1392/1392
100%
National Prostate Cancer Audit
Yes
Yes
733
Data
collection
ongoing
National Vascular Registry:
UK Carotid Endarterectomy
Abdominal Aortic Aneurysm (AAA) Programme
Vascular Database
Yes
Yes
Yes****
N/A
Neonatal Intensive and Special Care Audit
Programme (NNAP)
Yes
Yes
2402
(All Cases on
Database)
Yes
Yes
Yes
Yes
53/54
100/100
98%
100%
No
N/A
N/A
N/A
Yes
Yes
10/8
> 100%
No
N/A
N/A
N/A
Yes
Yes
540
(All Patients on
Haemodialysis)
All Patients on
Haemodialysis
100%
No
N/A
N/A
N/A
Yes
Yes
National Audit of Dementia
National Audit of Intermediate Care
National Cardiac Arrest Audit (NCAA)
(2013/2014 Data)
National Chronic Obstructive Pulmonary
Disease (COPD) Audit Programme
National Comparative Blood Transfusion
Programme:
- Patient Information & Consent
National Confidential Inquiry into Suicide
and Homicide for People with Mental Illness
(NCISH)
Oesophago-Gastric Cancer (NAOGC)
Older People (Care in Emergency Departments)
Paediatric Intensive Care Audit Network
(PICANet)
Pleural Procedure
Prescribing Observatory for Mental Health
(POMH)
Renal Replacement Therapy (Renal Registry)
Pulmonary Hypertension (Pulmonary
Hypertension Audit)
Rheumatoid and Early Inflammatory
Arthritis***
76
(Recruited)
N/A
100%
N/A
635/616
Sentinel Stroke National Audit Programme
(SSNAP)
68
Yes
Account of the Quality of Clinical Services 2014/2015
Yes
(Locked to 72hrs)
515/616
(Locked to
discharge)
> 100%
83%
Table 4 – National Clinical Audits & Confidential Enquiries
Eligible to
participate
Title
Participating
Cases
Submitted
Compliance
Confidential Enquiries
75%
(Data Collection
for this study
is still open and
ongoing)
National Confidential Enquiry into Patient
Outcome & Death (NCEPOD) – Sepsis
Yes
Yes
3/4
National Confidential Enquiry into Patient
Outcome & Death (NCEPOD) –
Gastrointestinal Haemorrhage
Yes
Yes
5/7
71%
National Confidential Enquiry into Patient
Outcome & Death (NCEPOD) –
Lower Limb Amputation
Yes
Yes
6/6
100%
National Confidential Enquiry into Patient
Outcome & Death (NCEPOD) –
Tracheostomy Care
Yes
Yes
4/4
100%
The expected number of cases to be input is the figure from 2013/2014 since referral patterns changed in the
move from Frenchay to Southmead and an accurate figure for 2014/2015 could not be given.
**
Data from report published in 2014.
***
Information from the 9 month interim report, case ascertainment not included within. Estimated
submission quotas can be derived from the National and Regional data and it appears that NBT is submitting
more than is the average. This National Clinical Audit relies on consent from patients for their information to be
submitted and therefore no case ascertainment target can be put in place.
****
Cases submitted but records not kept by clinician.
***** Cases submitted but expected case number not known.
Account of the Quality of Clinical Services 2014/2015
69
The reports of 27 national clinical audits were reviewed by North Bristol NHS Trust Clinical Audit
Committee (on behalf of the Trust Board) between April 2014 and March 2015 and North Bristol
NHS Trust intends to take the following actions to improve the quality of healthcare provided. The
remaining five national clinical audits were reported after the year end and will be included within
the Quality Account for 2015/16.
1. British Thoracic Society (BTS)
Bronchiectasis Audit 2012)
Reviewed June 2014
The Respiratory Specialty has been reviewing the
clinic capacity issues to design a safe and effective
clinic format and process. In addition to the review
a Bronchiectasis Clinic proforma is now in place
that aims to ensure that junior doctors conduct
key checks at each patient visit. As patients
with bronchiectasis need to self-manage their
condition, the Respiratory team is developing and
re-designing the BTS Self-Management Plan tool
in the Trust format as the team believe this will be
beneficial to the local population.
2. BTS Non-Invasive Ventilation
(NIV) Audit 2012
Reviewed June 2014
The following actions have been taken to improve
the care of patients being treated by NIV.
■■
A new non-invasive ventilator (Phillips
Respironics 202 ventilator) has been
introduced into the new hospital and all
relevant staff will receive training. In addition
to this the Trust will be introducing Bi-level
Positive Airway Pressure (BiPAP) Care Plan for
patients on BiPAP NIV
■■
A Physiotherapy Management Programme
for NIV patients is being developed to ensure
that patients are reviewed early in their care
by a physiotherapist with competencies in
respiratory support
■■
Discussions are taking place with the MDT
regarding the development of a Pulmonary
Rehabilitation Service
3. National Joint Registry 10th
Annual Report
Reviewed June 2014
Clinicians are required to request consent from
patients before the data can be used for the
National Joint Registry. This was a field within
the National Joint Registry that required further
70
Account of the Quality of Clinical Services 2014/2015
compliance by the Trust, and therefore, a prompt
for clinicians to remind them to request consent to
patient data being used for the Registry NJR was
entered onto the Neck of femur (NOF) proforma.
Patient Reported Outcome Measures (PROMS)
are also an important element of the Registry
and the Orthopaedic department is working with
‘Amptitude’ to deliver these questionnaires for
patients who have received a spine, hip, knee,
shoulder, foot or ankle trauma.
4. National Heart Failure Audit
Report (published
November 2013)
Reviewed June 2014
To ensure that all data is being submitted to
the National Heart Failure database, the Heart
Failure team conducts quarterly checks for data
completeness. During these checks it was identified
that the lack of a clear diagnosis had been noted as
a problem. A process has now been implemented,
whereby a rigorous review of case-notes by the
audit nurse occurs on a regular basis. The audit
nurse identifies cases where the diagnosis is unclear
or incorrect and arranges ad-hoc meetings with
the Heart Failure Specialist Cardiologist to discuss
these cases to gain the Consultant’s opinion.
Following these meetings any miscoded episodes
are corrected.
Drug prescribing regimes need to be improved and
the production of a heart failure management plan
proforma has been investigated. This would ensure
that a clear drug management plan for heart failure
patients is available. The Trust is working with the
Bristol Heart Failure (BHF) in-reach nurses to develop
this. In respect to the follow-up of patients, the heart
failure management plan proforma will also contain
entries and guidance on follow-up.
There is now a seven- day cardiology cover in the
new hospital to allow for increased inpatient review.
Patients admitted with acute, decompensated
heart failure will be referred for an echocardiogram
to allow for a correct diagnosis, optimisation of
treatment and ensure a follow up by a heart failure
specialist during admission.
5. National Vascular Access
Report 2012
Reviewed June 2014
This national clinical audit is not listed for the
Quality Account, but the Trust Clinical Audit
Committee has oversight on all national clinical
audit projects and the report and action plan were
reviewed at the June 2014 Committee meeting.
The following recommendations were approved:
■■
■■
■■
Funding has been secured to develop
better pathways between North Bristol
NHS Trust (NBT) and Commissioning Care
Groups (CCG)
When patients present late, requiring renal
replacement therapy, alternative therapies
will be considered to allow time for the
formation of vascular access. This process
has now begun with medical insertion of
peritoneal catheters taking place
When patients commence dialysis with a
venous catheter, the clinicians now conduct
a root cause analysis to determine the
reasons and to improve the process
6. National Lung Cancer Audit
Report 2013
Reviewed June 2014
As a result of the findings from the National Lung
Cancer Audit Report the Lung Cancer Team has
implemented a validation exercise of the data that
has been input into the national audit database.
This is conducted on a monthly basis to ensure that
all data fields have been entered and that the data
input is accurate.
7. National Carotid
Endarterectomy Audit Round 5
Report
Reviewed September 2014
The Trust continues to input data into the National
Carotid Endarterectomy Audit and the results for
Round 5 of the audit showed that NBT patients
receiving surgery within 14 days of symptoms that
triggered referral had improved from the previous
national report (now at 63%), were above the
national average (56%) but improvement was still
necessary. Continued emphasis has, therefore,
been placed on the timely referral and action of
surgery to raise performance levels.
Due to the reconfiguration of the local Vascular
Service, a review was conducted to identify how
trusts/surgeons within the three trusts (United
Hospital Bristol, North Bristol and Royal United Bath)
are comparing with national trends. The findings
showed that all three trusts were improving in line
with national trends to shorter pathway times. Stroke
and death rates were broadly similar. There was no
evidence of outlying performance by any of the local
network units, nor by individual surgeons in the
network. The Vascular Access Service reconfiguration
took place in October 2014 and the new service is
now ‘housed’ at North Bristol NHS Trust.
8. National Cardiac Arrest Audit
(NCAA) – April – December
2013 Report
Reviewed September 2014
There is always a time delay in respect to the lead
organisation reporting the quarterly reports to
trusts. All NCAA reports are reviewed by the North
Bristol NHS Trust Resuscitation Team when they are
received and areas showing where compliance is
not good are addressed.
In the NCAA report 2013 the Trust cardiac arrest
rates were high (measured against admissions)
compared with other hospitals in the study. The
Trust only included patients who stayed over-night
in the admission figures until now. Therefore, from
May 2014 all day case and emergency admissions
will be included. This inclusion will rectify any
inconsistencies in data comparisons.
9. National Audit of Percutaneous
Coronary Interventional (PCI)
Procedures (Published
January 2014)
Reviewed September 2014
In respect to improving data collection and
submission to the PCI national audit database,
the Cardiology Audit Nurses have now taken over
responsibility for the data entry, checking and
analysis. The Audit Nurses identify and upload the
data and review any missing data with the relevant
Consultant. In addition the nurses will compare
Myocardial Infarction National Audit Programme
(MINAP) and PCI data to ensure accuracy.
Implementing on a quarterly basis the mortality and
adverse event reporting within North Bristol NHS
Trust will ensure accuracy of published Trust. Local
reports of adverse events will be reviewed with the
consultant responsible to ensure accurate reporting.
Account of the Quality of Clinical Services 2014/2015
71
With an Acute Coronary Syndrome (ACS) nurse
role now well established the target to reduce
admission to angiography times continues. The
ACS nurse works collaboratively with the Cardiac
Catheter laboratory staff to identify and address
any delays to angiography.
10.The Trauma Audit & Research
Network (TARN), Quarter
2013/14 results Reviewed September 2014
North Bristol NHS Trust is a Major Trauma Centre
for the region and inputs data to the national TARN
database.
The TARN results are published by the lead
organisation on a quarterly basis and the
TARN team review the results on publication.
In September 2014, the 2013/14 results were
reviewed at the Clinical Audit Committee where it
was confirmed that the TARN team had taken the
following actions:
■■
■■
72
A new Plastic Surgeon was appointed,
increasing the number of plastic surgeons
capable of performing free flaps. In addition
an Orthopaedic Surgical Trauma Specialist
was appointed
Monthly network teleconferences occur
and this greatly improves communication
across the network both for acute patients’
transfers and sharing/discussion of
TARN data
■■
There is new theatre scheduling within
the new hospital that includes increased
specialist orthopaedic and ortho-plastic
theatre capacity
■■
Repatriation times back to Trauma Units
have improved due to well embedded
systems now in place increasing bed
availability at the Major Trauma Centre
■■
The TARN audit recommends that for
each case where the Glasgow Coma Scale
(GCS) is less than 9 a definitive airway
management should be managed within
30 minutes of arrival in the Emergency
Department. Within the Trust each case not
meeting this target is discussed and analysed
at the Trauma Monthly Mortality & Morbidity
(M&M) meetings
Account of the Quality of Clinical Services 2014/2015
11. British Society for
Rheumatology (BSR) National
Gout Audit 2013
Reviewed November 2014
This national clinical audit is not listed for the Quality
Account, but the Trust Clinical Audit Committee has
oversight on all national clinical audit projects and
the report and action plan were reviewed at the
November 2014 Committee meeting.
Only 4 Trusts in the South West actually took
part, one of these trusts being North Bristol NHS
Trust. The Trust believes that it is important to
contribute to national data and to enable patient
care to be improved. Although there were not
large numbers of patients submitted to the audit,
the Rheumatology consultants reviewed that data
and submitted the following recommendations for
approval from the Clinical Audit Committee.
There needs to be continued emphasis on the
importance of initiating at a low dose, titrating
dose against serum urate to aim for the BSR target
of 300µmol/Lor less.
This aim will be assisted by encouraging clinicians
to attend national meetings where the promotion
of national guidelines is highlighted and to trial
telephone consultations (consultant to patient) to
ensure correct dosage is maintained. In addition,
there will be a regular session on gout in the
Specialist Registrar Training Days.
Clinic letters to GPs will include appropriate
information on the use of urate lowering therapy
(ULT) as in most cases patients are seen once or
twice in hospital and then have to be discharged
back to their GP.
12.National Audit of Seizure
Management in Hospitals
(NASH2) 2013
Reviewed November 2014
To improve compliance with the management of
patients presenting to the Emergency Department
(ED) with a seizure, the ED team has implemented
the following recommendations:
■■
■■
■■
Junior doctors are reminded at Induction
that it is imperative to document blood
sugars, neurological examination findings,
ECG results and that driving discussions
have taken place with the patient. This
information must all be entered in the
medical notes
Copies of first fit referral clinic form and seizure
checklist for medical and nursing staff and
information sheets for patients are stocked and
placed in the relevant drawers in ED to enable
ease of access for all relevant staff
Nurses, particularly all new starters, are
reminded of the importance of the basic
mechanisms (BM) in respect to seizures
patients and taking electrocardiograms
(ECG) in all patients with this condition
13. Vermont-Oxford Network.
Annual Report for Infants
Born in 2012
Reviewed November 2014
Although this national audit is not listed for the
Quality Account, the Trust feels that it is important
to contribute to this international network audit.
In the 2012 Annual Report, the Trust was listed as
being an outlier when compared to the network
average in respect to chronic lung disease and late
infection rates. To address this issue the Neo-natal
Intensive Care Unit (NICU) has put in place the
following to ensure improvement in care:
■■
Weekly Pseudomonas Aeruginosa (PsA)
surveillance data is taken
■■
Designated area for preparation of IV drugs (as
per recent Medicine and Healthcare products
Regulatory Agency (MRHA) guidance)
■■
To improve admission temperatures there
has been liaison with Central Delivery Suite
(CDS) regarding temperature in delivery
rooms and positioning of resuscitaires with
regard to ceiling air vents
■■
NICU is implementing new guidance for
infusion of Ibuprofen to target the treatment
of patent ductus arteriosus (PDA) closure rates
14.National Care of Dying Audit
for Hospitals Round 4 –
published May 2014
Reviewed November 2014
As a result of the findings for Trust and to underpin
the key organisational elements for the delivery
care for patients at the end of life, the following
improvements will be made.
A revised Trust ‘Caring for Patients at End of Life’
document has been introduced and will be audited
for compliance four months after introduction. The
document will be implemented on all wards and
this document will include information regarding
multi-disciplinary team (MDT) decision, a space
for signature of consultant and a space for record
of discussion with patient (if possible) and the
family. There will be an hourly observation chart
for all dying patients and Red and Amber used to
highlight action to be taken, e.g. give medication as
needed (prn). In addition the reviewed document
will include an initial assessment and a daily MDT
review regarding clinically assisted nutrition and
hydration, including discuss with patient, if possible
and family and the offer of pastoral care to the
dying patient and family.
Communication skills training for staff in the care
of the dying will be mandatory. This training will
include skills for supporting families and those close
to dying patients.
15. Sentinel Stroke National Audit
Programme (SSNAP) –
April – June 2014
Reviewed November 2014
The SSNAP data is published on a quarterly basis
and the Stroke Team regularly reviews this data to
identify how the care of Stroke patients is being
managed. On reviewing the quarterly date for
April-June 2014, the Stroke Team recommended
that there should be a change in the stroke pathway
to enable the acceptance of direct referrals to
the team from Primary Care. To enable this to be
achievable Advanced Nurse Practitioners (ANPs)
will be appointed and fully trained as independent
assessors and be enabled to take General Practitioner
(GP) direct referrals. This would improve the flow
from the Emergency Department to the Stroke Unit.
All patients would then potentially reach the Stroke
Unit within four hours. The ANPs would also perform
swallow assessments.
Account of the Quality of Clinical Services 2014/2015
73
16.National Diabetes Inpatient
Audit 2013
18.National Lung Cancer Audit
Report 2014 –Mesothelioma
Reviewed November 2014
The National Diabetes Inpatient Audit Report and
Action Plan were reviewed by the Clinical Audit
Committee and the following recommendations
approved in respect to improving patient care:
■■
■■
■■
The capacity of multi-professional foot clinics
need to increase to allow patients with
more complex foot disease to have access to
optimal management as an outpatient and to
prevent admission. – Daily consultant led foot
clinic is now in place with additional staff
The following recommendations from the Lung
Cancer Team were approved by the Committee:
A new blood glucose chart has been
implemented and is place in all clinical areas
(Reviewed January 2015)
The ICNARC data is normally published on a
quarterly basis but with the merging of the
Frenchay and Southmead hospitals merging into
the new Brunel hospital building, a report for
the initial data from the new hospital site was
produced. On reviewing the new hospital data the
figures showed that the hospital was comparable
with the CMP average. The Intensive Care Unit
(ICU) team recommended that although there was
consistent implementation of ICU admission and
discharge procedures, there was still the need to
improve patient flow and reduce admissions after
cardiac arrest.
74
The first Mesothelioma Report for the National
Lung Cancer Audit was published in September
2014 and was reviewed at the Trust Clinical Audit
committee in January 2015.
Clear care pathways are required to ensure
that patients admitted with diabetic foot
disease have access to specialist assessment
within 24 hours of admission with timely
vascular and/or orthopaedic consultant
review if appropriate. This must include
an interim pathway to cover the current
situation of two site working well as a
definitive care pathway for use in the new
hospital. – North Bristol NHS Trust is now
‘housed’ on one site, and has the Tertiary
Vascular Service on site. There is in place a
definitive integrated pathway for inpatient
management of diabetic foot disease
17. The Intensive Care National
Audit & Research Centre
(ICNARC) – Case Mix
Programme (CMP).
14th May – 30th June report.
Published October 2014.
Account of the Quality of Clinical Services 2014/2015
Reviewed January 2015
■■
To ensure that the International
Mesothelioma Interest Group (IMIG) staging
is recorded at the multi-disciplinary team
(MDT) meetings to allow for input into the
Lung Cancer national database, the updated
staging system was to be circulated as a
reminder to all relevant Trust staff
■■
The report stated that audit time from
referral to diagnosis had a median nationally
of 28 days, with the local network time
being more than 30 days. Therefore, the
Trust will be reviewing the diagnostic
pathways, procedures and pathological
processes to improve patient experience and
reduce pathway days
■■
To reduce the number of emergency
presentations of patients to the pleural
service, the Respiratory consultants will
deliver GP teaching sessions and include an
article in the local GP news about admission
avoidance in respect to this condition
19. NAP5 – 5th National Audit
Project of the Royal College
of Anaesthetists and the
Association of Anaesthetists
of Great Britain & Ireland:
Accidental Awareness during
General Anaesthesia
Reviewed January 2015
The NAP5 project was not listed for the Quality
Account and although stated as a National Audit
would be termed better as a ‘study’. The report was
published in October 2014 and the Lead Consultant
Anaesthetists agreed that there would be reminder
teaching and refresher sessions for all anaesthetists
to, if possible, avoid the use of muscle relaxant unless
absolutely needed for the operation. A local protocol
is in place stating the above is ‘best practice’.
20.National Review of
Asthma Deaths
Reviewed January 2015
The National Review of Asthma Deaths report
was published in May 2014. One of the key
recommendations from this report was that every
NHS hospital should have a designated, named
clinical lead for asthma. A business case has been
submitted for funding for a dedicated asthma lead
that could take ownership of the management of
patients with asthma within the Trust. Results of
this business case are awaited.
21. College of Emergency Medicine
(CEM) Severe Sepsis & Septic
Shock 2013-14
Reviewed January 2015
From reviewing the results of the Severe Sepsis
and Septic Shock the Clinical Audit Committee
approved the following changes that have been
implemented to improve the care of patients
presenting/at risk of severe sepsis and septic shock
within the Emergency Department (ED):
■■
The back of the ED Cerner card now
incorporates Systemic Inflammatory
Response Syndrome (SIRS) criteria
■■
An ED Teaching Programme is in place
whereby there is small group teaching for
junior doctors on delivery of antibiotics and
sepsis, plus nursing staff drop-in sessions to
ensure recognition of the sick adult and sepsis
■■
A new antibiotic guideline specific to ‘sepsis
without focus’- is in place. This guideline was
implemented by Trust Sepsis Committee
■■
Introduction of a new Sepsis Trolley to Acute
Admissions Unit (AAU)/ED to include all
components of sepsis 6
23.National Pregnancy in
Diabetes Report 2013 –
published October 2014
Reviewed March 2015
The results for the Trust were generally in line
with the national average. However, the reporting
organisation for this audit showed that for the Trust
25% of patients were being seen after 12 weeks
gestation as opposed to 8.8% in the South-west.
North Bristol NHS Trust believes this is likely due
to a recording issue and has contacted the lead
organisation (Health and Social Care Information
Centre (HSIC)) for this audit to ask for a breakdown
of their figures. Unfortunately, the lead organisation
was unable to provide this information.
To address the above issue the Maternity Unit is
checking the robustness of data regarding the
booking gestation and will be producing a data
validation report.
A review of hypoglycaemia management audit is
also currently underway to identify any issues in
respect to hypoglycaemia in neonatal admissions.
This was an area that was highlighted as an
improvement being required.
24.BTS 2014 Pleural
Procedures Audit
Reviewed March 2015
The Clinical Audit Committee reviewed the
findings and action plan for the BTS Pleural
procedures Audit and agreed with the Respiratory
Physicians that the following actions needed to
be implemented to improve care for patients
undergoing a pleural procedure.
■■
To generate a chest drain insertion proforma
for doctors to complete and for this to be
filed in the patients notes
■■
Refresher teaching sessions for nurses
working on the respiratory ward regarding
drain management
■■
Training sessions for Registrars regarding
chest drain insertion and management
that will including best practice methods
of securing drains after insertion. The first
training session took place in December 2014
22.National Joint Registry –
11th Annual Report
Reviewed March 2015
The 11th Annual Report was reviewed by the
Clinical Audit Committee and the initial actions
from the 10th Annual Report reviewed in June 2014
were in place and continuing. A further action in
respect to the reviewing of the data entry and data
completeness to the National Joint Registry is now
a standing agenda item at the Clinical Governance
meetings where any issues are highlighted.
Account of the Quality of Clinical Services 2014/2015
75
25.National Clinical Audit of Rheumatoid & Early Inflammatory Arthritis
– published November 2014 –
Reviewed March 2015
As a result of the findings from the first Annual Report for the National Clinical Audit of Rheumatoid & Early
Inflammatory Arthritis (EIA), the following recommendations have been made for implementation;
■■
This national audit is to be a standing agenda
item for the Consultant Meetings to keep
recruitment of patients a priority
■■
To insert a paragraph into the local ‘General
Practitioner (GP) News’ to inform GPs that
there is now a national standard that patients
presenting with inflammatory synovitis need
to be referred for specialist opinion within
three days
■■
76
The Trust figures for seeing patients within
three weeks of referral are below the national
and regional average. However, the Trust
does see all new referrals of potential EIA
patients within the standard referral target
time of 18 weeks. There are enough EIA slots
but better organisation is needed to ensure
that non EIA patients wait slightly longer (but
within 18 weeks). Work is ongoing with the
New Referrals Booking Team to develop clear
guidelines for moving patients without
EIA to a later slot to enable EIA patients to
be seen sooner
Account of the Quality of Clinical Services 2014/2015
■■
On analysing the data for the following
questions:
a)offering short–term glucocorticioids and
a combination of disease-modifying antirheumatic drugs within 6 weeks of referral
b)whether a treatment target date was set
■■
It appears that the questions are interpreted
differently by clinicians. Therefore,
discussions have taken place between all
relevant clinicians within the Trust to ensure
the interpretation of each questions is clear
■■
North Bristol NHS Trust does not at present
provide educational and self-management
activities within one month of diagnosis
of EIA. The Rheumatology Team feels that
this is an important service and a meeting
will take place with the Allied Health
Professionals (AHPs) who provide the
Trust’s Living Well with Arthritis Education
Course to develop such a programme for
EIA patients
26.Sentinel Stroke National
Audit Programme (SSNAP)
Organisational Audit 2014 –
Reviewed March 2015
The results for the 2014 SSNAP Organisational
Audit showed improvement from the national audit
conducted in 2012 but there were a number of
areas where actions needed to be taken to further
improve quality of patient care.
the service is exploring the possibility of having
Transient Ischaemic Attack (TIA) clinics morning
and afternoon and publicising to referrers the
urgency of referral and giving accurate information
to patients. This would require additional
administration support for TIA clinic and clinic
space to run all day TIA clinics.
An Advanced Nurse Practitioner (ANP) has now
been trained in swallow screening but is only
present 5 days per week. The recommendation is
to have three ANPs trained in swallow screening
and be able to provide 7 day cover by July 2015.
Since changes to commissioning structure, the local
strategic group has not met and the Departmental
Stroke Speciality meeting is now the only group.
The Stroke Service will be proposing forming a
HIT to review the entire stroke pathway to include
community rehabilitation provision. Links with
the Stroke Association and Bristol Area Stroke
Foundation are also being strengthened.
The results show that the Trust needs to improve
staffing levels at weekend to improve the audit
performance and a Business Case has been
submitted for more nursing staff during weekends.
To ensure that patients and carers have good
information readily available, a new Stroke/TIA
information leaflet rack will be in place on the
relevant Stroke wards and regularly stocked.
Access within 5 days to social work expertise,
orthotics, orthoptics and podiatry has been
achieved and with a new psychologist appointed
there is now access for inpatients to Clinical
Psychologists and the provision of following
aspects of psychological care: Mood assessment/
higher cognitive function assessment/mood
treatment/higher cognitive function treatment/
non-cognitive behavioural problems assessment
and/or treatment. Clinical Psychologist assessment
is not routinely offered for out-patients. Therefore,
discussions regarding psychology provision
for stroke outpatients will take place with the
neuropsychology department and be incorporated
into Bristol Health Partners, Health Integration
Teams (HIT).
27. The Trauma Audit & Research
Network (TARN) Quarter 1, 2 &
3 2014/15 results –
In respect to the Allied Health Professional (AHP)
resource for stroke patients, the Trust is in line
with the national median for dietetic input but
the resource allocated has decreased from the
2012 findings. This issue needs to be highlighted
with the Dietetics department. The Occupational
Therapy (O/T) and Physiotherapy input is below
the national average and an increase in staffing in
these fields is required. This would improve patient
rehabilitation and reduce length of stay for the
patient. To address this issue a Business Case has
been submitted. In respect to Pharmacist input, the
resource allocated is below the national median
and these figures have been highlighted
to Pharmacy.
The Stroke Service did not see, investigate &
initiate treatment for all high risk patients within
24 hours of first medical contact. Therefore
Reviewed March 2015
The results for April – Dec 2014 were as expected
or listed as much better than expected. To
ensure these good results continue the following
recommendations have been implemented:
■■
Increased the number of TARN data
inputters to provide more resilience in cases
of sickness and unexpected absence, to
cover recent staff departure and to reflect
the increased workload due to an increase in
patient numbers
■■
The Severn Network Open Fracture
Guidelines have been agreed and in place
■■
The Severn Network has agreed that there
will be automatic transfer into Emergency
Department (ED) via Trauma Team Leader for
patients accepted by Orthoplastics at North
Bristol NHS Trust
■■
There is ongoing analysis of every ‘missed
case’ with feedback to individuals concerned
■■
An introduction of Consultant led RATing
(Rapid Assessment and Treatment in the
Emergency Department)
■■
Publication of consultant specific timing from
admission to CT scan (standard is within 30
minutes of admission)
Account of the Quality of Clinical Services 2014/2015
77
Local Clinical Audit Reports
Reviewed by the Quality
Improvement and Clinical Audit
Department during 2014 –2015
Each local clinical audit is reviewed in accordance
with the Clinical Audit Policy which states that
each clinical audit project must produce a
report in the Trust standardised format with an
accompanying Specific, Measurable, Achievable,
Realistic, Timebound (SMART) action plan. These
are reviewed by senior members of the Quality
Improvement and Clinical Audit Department before
the clinical audit project is formally marked as
completed. 114 Local Clinical Audit Reports were
reviewed in this way during 2014-15.
A review of a random sample of 10 clinical audit
projects over a six month period is undertaken at
six monthly intervals and the results of this review
are presented to the Clinical Audit Committee.
The project lead is required to provide an update
on the progress of the action plan for the review
which includes details of completed actions within
the action plan along with accompanying evidence,
and revised action by dates for outstanding actions.
The Quality Improvement and Clinical Audit
Department undergoes regular review by Internal
Audit which provides assurance that these
processes are being adhered to.
continues to lead cutting edge research in key areas
of our population’s health and wellbeing.
Patient views and input regarding participation in
trials are actively sought via NBT led patient and
public forums. To ensure we are putting patients
first, we have developed a ‘Take Part Be Involved’
patient involvement in research strategy to ensure
patients are involved not only in clinical trials, but
also that they are able to help shape our future
research. Members of the public are also a key part
of our funding decision process for our charitable
funds scheme Springboard.
Our mission continues to be to improve patient
health through our excellence in world class
translational and applied health services research
and our culture of innovation. Our aims, detailed in
our strategy for research 2012-16 are to:
■■
Be World-leading - actively participate in Bristol
Health Partners in which world-class clinical
services, research and innovation and teaching
are strategically and operationally integrated
■■
Deliver high quality research of direct patient
benefit - support our staff to deliver high
quality translational and applied health
services research of direct patient benefit
■■
Embed a research culture in clinical service
delivery - develop a culture across NBT
in which research and innovation are
embedded in and aligned with routine
clinical services, leading to significant health
gains and efficiency improvements in health
services delivery
■■
Increase research income - increase the
income from research and innovation and use
that income in support of our strategic aims
Research activity at the Trust
During 2014, the Trust was involved in around 430
separate research studies and the National Institute
for Health Research (NIHR) supported 215 of these
studies, including 34 commercial studies, through
its research networks.
The number of patients receiving NHS services
provided or sub-contracted by NBT in 2014 to
participate in research approved by a research
ethics committee and within the NIHR portfolio was
2821. Participation in clinical research demonstrates
North Bristol NHS Trust’s commitment to improving
the quality of care we offer and to 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.
Recent research has shown evidence that research
activity in acute English NHS Trusts is associated
with lower mortality outcomes for emergency
admissions 2. There were approximately 280 clinical
staff directly involved in research approved by a
research ethics committee at North Bristol NHS
Trust during 2014. These staff participated in
research covering all medical specialties and NBT
Trust Data Quality
Hospital Episode Statistics
The Trust submits a wealth of information and
monitoring data centrally to our commissioners
and the Department of Health. The accuracy of this
data is of vital importance to the Trust and the NHS
to ensure high quality clinical care and accurate
financial reimbursement.
Our robust data quality reporting, controls and
feedback mechanisms are routinely audited and
help us monitor and maintain high quality data.
We submitted records during 2014/15 to the
Secondary Users’ Service for inclusion in the
Hospital Episode Statistics (HES) which are included
in the latest published data.
Research Activity and the Association with Mortality
Ozdemir BA, Karthikesalingam A, Sinha S, Poloniecki JD, Hinchliffe RJ, et al. (2015) Research Activity and the Association with
Mortality. PLoS ONE 10(2): e0118253. doi:10.1371/journal.pone.0118253.
2
78
Account of the Quality of Clinical Services 2014/2015
The percentage of records in the published data
which included patient’s valid NHS number remains
consistent in each of the three domains:
Data at
31 December 2014
2013/14
2014/15
Admitted Patient Care
99.4%
99.5%
Out Patients
98.6%
98.4%
A&E
97.8%
97.4%
Clinical Coding Accuracy
Accurate Clinical Coding is an essential element of
the Trust’s ability to understand its clinical activity,
in terms of audit and mortality statistics, and to
ensure accurate reimbursement for care provided.
In 2014/15 the Audit Commission (via Capita
Health) continued its programme auditing the
accuracy of Payment by Results (PbR) data,
however this year the Trust’s clinical coding
department was not selected to be part of this
programme due to high standards identified in
prior years’ audits. The Trust was subject to an
assurance audit but this was focused on admission
methods used to inform billing and therefore not
relevant to coding accuracy.
The department’s clinical coding auditor has
continued to run an extensive inpatient activity
audit programme in 2014/15 covering multiple
specialties, including a 200 FCE (Finished
Consultant Episode) Information Governance audit.
The focus of this audit was split across two specialty
areas. 100FCE’s were focused on General Surgery
(excluding endoscopic procedures), and the other
100 FCE’s was focused on Well and Neonate babies,
both inpatient and day case activity was reviewed.
The audit showed the following accuracy results:
Area
Accuracy
Primary Diagnosis
92.9 %
Secondary Diagnosis
89.5 %
Primary Procedure
91.8 %
Secondary Procedure
83.0 %
A number of other areas were also audited
in line with this programme. The themes
covered were selected via external benchmarks,
recommendations from prior audits and through
links with clinicians, areas reviewed included:
■■
Gynaecology admissions
■■
Neurology admissions
■■
Major Trauma admissions
■■
Surgical specialities admissions including
vascular surgery
■■
Orthopaedic admissions
The audits continue to reflect accurate coding and
good practice in comparison to our peers, results
that reflect a dedicated team of clinical coders,
strong clinical engagement and a rigorous audit
and training regimen.
This year the department have worked closely with
clinicians from both Vascular surgery and Neurology
to help improve data recording and capture.
Neurology consultants visited the coding
department and had a 1:1 session to help with their
understanding of clinical coding, and discuss areas
where collaborative working could help improve the
quality of the coded data to more accurately reflect
the clinical picture, whilst still working within national
clinical coding standards. This resulted in a number of
local policies being implemented.
As the Trust’s Vascular service has grown in size
exponentially this year it was felt that a closer
working relationship between the consultants
and coders was required to meet the demands of
the growing complexity of work coming to NBT.
A weekly meeting was introduced, whereby the
consultant of the week, a coding representative
and the vascular MDT co-ordinator meet to
validate all of the prior week’s discharged and
coded episodes of care. This process has proved
beneficial to both parties and has allowed regular
and constant access to clinicians that are engaged
in improving data quality.
The coding department’s trainer and auditor also
provided training to the coding team to meet the
needs of this extended vascular service, along with
support from a Vascular consultant.
The Clinical Coding department will be continuing
with their internal audit programme in 2015/16, and
will also be introducing some new quality measures
that will provide further data quality assurance, and
enhance the current audit programme in place.
These quality measures will further develop clinician
engagement, clinical data capture and recording
and contribute towards providing a robust internal
programme of audit.
Account of the Quality of Clinical Services 2014/2015
79
Information Governance Toolkit
Overall Scores
NBT is Level 2 compliant across the 45 requirements
in the v12 assessment, thus meeting the national
standard. There is a drop from 90% (v11) to 67%
(v12) in the ‘compliance score’ as the Trust decided
to concentrate on obtaining robust and reliable
Level 2 evidence (the minimum required) in light
of the number of changes that have occurred in
IM&T infrastructure due to the new hospital at
Southmead, changes in Cerner Millennium (the
Trust’s Patient Administration System) and in
preparation for the forthcoming implementation of
CSC Lorenzo (a replacement Patient Administration
System in October 2015).
The IG Toolkit is now in its 12th year (v12). Evidence
is required to be uploaded to support the selfassessment across 45 requirements. There are two
possible grades:
Satisfactory (green); level 2 achieved on all
45 requirements
Not Satisfactory (red); level 2 not achieved
on all requirements
The purpose of the IG toolkit is to drive
improvement. All organisations are expected to
achieve level 2 in all requirements in accordance
with the NHS Operating Framework (informatics
planning 2011/2012).
80
The compliance levels at March 2015 (prior to
submission) and for the previous two years are
shown below;
Assessment
Stage
Level 0
Level 1
Level 2
Level 3
Total
Req’ts
Overall
Score
Current
Grade
Version 12
(2014-2015)
Current
0
0
44
1
45
67%
Satisfactory
Version 11
(2013-2014)
Published
0
0
13
32
45
90%
Satisfactory
Version 10
(2012-2013)
Published
0
0
8
37
45
94%
Satisfactory
Account of the Quality of Clinical Services 2014/2015
Patient Story 5
Diagnosis and further involvement
We had the original diagnosis from a Paediatrician
in training.
Family Story –
Living with ADHD
Noticing the first signs
We were in there for 2 hours. I didn’t think it would
take that long. They observed him, asked us some
questions about home life and school life, and got
him to do certain little things and at the end I was
told that he did have Attention Deficit Hyperactivity
Disorder (ADHD). I was angry and relieved when they
finally diagnosed him. Somebody had listened to me.
I first started to notice at play group. He was about 3.
He wasn’t as advanced or meeting the milestones as
some of the other children - hand writing, fine motor
skills, cutting with scissors and reading. He was very
withdrawn and quiet. I knew there was something
wrong. Trying to get somebody to listen to me was
difficult because I was told that I worry too much
and that he was gonna be fine. You then think is it
me, am I reading too much into it? So you tend to
leave it and not pursue it. As he got older I noticed
his behaviour more. He was on an IEP (Individualised
Education Plan). He was having problems in school
with his friends, he wasn’t happy. Generally life was
hard on a daily basis.
Generally when he is on medication, he’s very
quiet, hardly eats anything during the day at all.
First thing on a morning he’s very hard work.
Trying to get him to take his tablets can take up
to an hour every morning. He doesn’t like the
taste and that creates more problems. When the
medication wears off I think the school gets the
best of it, round about 6 o’clock he becomes very
loud and very argumentative and very hard work.
If I have any problems with my son’s behaviour or
for example his medication, then I ring and the
Paediatrician always rings me back, she always
gives me advice over the phone, she’s always on
hand when I need to speak to her.
Referral to Community Health
Services
What happened next?
When my son was 10 ½, there was an incident at
home, something happened and I was crying, my
son was very upset and I rang and spoke to my GP.
The GP said that he would get a referral because
my son had got into a state and said he didn’t want
to live anymore. It took 6 months between being
referred by my GP and seeing the Paediatrician.
His school work has definitely improved, teachers
have said that. He’s caught up now. He was never
disruptive or naughty. He was just very fidgety and
couldn’t concentrate. He’s got the concentration
now that’s really good. I have been seeing the
Paediatrician for almost 2 years now. My son goes
back every 6 months for a check-up and we’re left
to get on with it.
Account of the Quality of Clinical Services 2014/2015
81
6.What other
organisations say
about the Trust
82
Account of the Quality of Clinical Services 2014/2015
Care Quality Commission (CQC)
Full Inspection Outcomes
By law all Trusts must be registered with
the CQC under section 10 of the Health
and Social Care Act 2008 - to show they are
meeting essential quality standards. NHS
Trusts have to be registered for each of the
regulated activities they provide at each
location from which they provide them.
The Trust is registered for all of its regulated
activities, without conditions. Without this
registration, we would not be allowed to
see and treat patients.
The Care Quality Commission (CQC) inspected
North Bristol NHS Trust in November 2014 as
part of its routine inspection programme, just a
few months after the move into the new Brunel
building at Southmead Hospital. The CQC has
never before inspected a hospital so soon after
such a big move but paid credit to the Trust for
the smooth nature of the move. Despite some
teething problems which are being dealt with,
patients are now reaping some important benefits
from the new hospital such as very low infection
rates and improved dignity and privacy. Within the
final report, every single service was rated as being
“good” in the context of caring and Trust staff
were described by the CQC as being “committed
and passionate.”
The Trust has not taken part in any special reviews
or investigations by the CQC under section 48 of
the Health and Social Care Act 2008 during the
reporting period.
The ratings for each location were summarised
as follows;
Our ratings for Southmead Hospital
Safe
Effective
Caring
Responsive
Well-led
Overall
Inadequate
Requires
improvement
Good
Inadequate
Requires
improvement
Inadequate
Medicalcare
Requires
Requires
improvement improvement
Good
Requires
Requires
Requires
improvement improvement improvement
Surgery
Requires
Requires
improvement improvement
Good
Requires
Requires
Requires
improvement improvement improvement
Critical care
Requires
improvement
Good
Good
Requires
improvement
Good
Requires
improvement
Maternity and
gynaecology
Requires
improvement
Good
Good
Requires
improvement
Good
Requires
improvement
Good
Good
Good
Good
Good
Good
Urgent and
emergency services
Services for children
and young people
End of life care
Requires
Requires
improvement improvement
Good
Requires
Requires
Requires
improvement improvement improvement
Outpatients and
diagnostic imaging
Requires
improvement
Good
Requires
improvement
Overall
Requires
Requires
improvement improvement
Good
Requires
Requires
Requires
improvement improvement improvement
Not rated
Good
Requires
improvement
Account of the Quality of Clinical Services 2014/2015
83
Our ratings for Frenchay Hospital
Safe
Effective
Caring
Responsive
Well-led
Overall
Outpatients and
diagnostic imaging
Requires
improvement
Not rated
Good
Requires
improvement
Good
Requires
improvement
Overall
Requires
improvement
Not rated
Good
Requires
improvement
Good
Requires
improvement
Caring
Responsive
Well-led
Overall
I
I
Good
Our ratings for Cossham Hospital
Safe
Effective
Maternity and
gynaecology
Good
Good
Outpatients and
diagnostic imaging
Good
Not rated
Good
Good
Good
Good
Overall
Good
Good
Good
Good
Good
Good
Outstanding Outstanding
I
Outstanding
Our ratings for Mental Health services
Child and adolescent
mental health wards
Safe
Effective
Caring
Responsive
Well-led
Overall
Good
Good
Good
Good
Good
Good
Good
Good
Good
Effective
Caring
Responsive
I
I
Good
I
I
Good
Caring
Responsive
Child and adolescent
Requires
mental health services improvement
Requires
Requires
improvement improvement
Our ratings for Community Health services
Safe
Community health
services for children,
young people
and families
Good
Overall
Good
Outstanding Outstanding
Outstanding Outstanding
Well-led
Overall
I
I
I
I
Well-led
Overall
Outstanding Outstanding
Outstanding Outstanding
Our ratings for North Bristol NHS Trust
Safe
Overall Trust
84
Effective
Requires
Requires
improvement improvement
Good
Account of the Quality of Clinical Services 2014/2015
Requires
Requires
Requires
improvement improvement improvement
Copies of the full reports for the Trust and each individual location inspected by the CQC are available publicly
at the following website links;
Trust-wide Quality Report;
http://www.cqc.org.uk/sites/default/files/new_reports/AAAB8185.pdf
Southmead Hospital
http://www.cqc.org.uk/sites/default/files/new_reports/AAAB8186.pdf
Cossham Hospital
http://www.cqc.org.uk/sites/default/files/new_reports/AAAB8187.pdf
Community Health Services for Children Young People and families (East gate House base)
https://www.cqc.org.uk/sites/default/files/rvj_coreservice_community_health_services_for_
children_young_people_and_families_north_bristol_nhs_trust_scheduled_20150211.pdf
Child and Adolescent Mental Health wards (Riverside Unit)
http://www.cqc.org.uk/sites/default/files/new_reports/AAAB9387.pdf
Child and Adolescent Mental Health Services
http://www.cqc.org.uk/sites/default/files/new_reports/AAAB8188.pdf
Frenchay Hospital
http://www.cqc.org.uk/sites/default/files/new_reports/AAAB8189.pdf
The CQC did raise concerns about overcrowding in the Emergency Department (ED) and issued a Warning
Notice on 16th December 2014 and rated this service as “requires improvement” within the Full Inspection
report received in February 2015. In addition 9 Compliance Actions were made, as follows;
Type
Date
Health and Social Care Act 2008 Regulation
Enforcement Action
16/12/2014
Regulation 9 HSCA 2008 (Regulated Activities) Regulations 2010
Care and welfare of people who use services
Compliance Action
11/02/2015
Regulation 9 HSCA 2008 (Regulated Activities) Regulations 2010
Care and welfare of people who use services
Compliance Action
11/02/2015
Regulation 10 HSCA 2008 (Regulated Activities) Regulations 2010
Assessing and monitoring the quality of service providers.
Compliance Action
11/02/2015
Regulation 11 HSCA 2008 (Regulated Activities) Regulations 2010
Safeguarding people who use services from abuse
Compliance Action
11/02/2015
Regulation 13 HSCA 2008 (Regulated Activities) Regulations 2010
Management of medicines
Compliance Action
11/02/2015
Regulation 9 HSCA 2008 (Regulated Activities) Regulations 2010
Care and welfare of people who use services
Compliance Action
11/02/2015
Regulation 16 HSCA 2008 (Regulated Activities) Regulations 2010
Safety, availability and suitability of equipment.
Compliance Action
11/02/2015
Regulation 15 HSCA 2008 (Regulated Activities) Regulations 2010
Safety and suitability of premises
Compliance Action
11/02/2015
Regulation 22 HSCA 2008 (Regulated Activities) Regulations 2010
Staffing
Compliance Action
11/02/2015
Regulation 23 HSCA 2008 (Regulated Activities) Regulations 2010
Supporting staff
Account of the Quality of Clinical Services 2014/2015
85
Overcrowding in ED is one of the symptoms of
pressure across the health and social care system.
There are a number of internal actions that the
Trust is prioritising to ensure that discharge is
planned effectively from the outset of a patient’s
admission, including improvements in bed
management, focusing on discharges before
midday, implementing case managers and opening
a new discharge lounge in the main hospital
for patients. The CQC has acknowledged that
improving discharge processes for patients is
not something the Trust can fix on its own. We
are working closely with our partners across the
health and social care community locally to reduce
the number of patients remaining in hospital
with complex discharge needs, for example
those requiring additional care at home, nursing
home placements or rehabilitation support. The
combination of these internal challenges and
system-wide factors makes it difficult to free up
beds and move patients from an overcrowded ED
into the main hospital.
Actions Taken and future plans
As required by the CQC’s inspection process,
a detailed action plan was submitted towards
the end of March 2015 to the CQC for their
consideration. Pending their review of these actions
and a further spot check within the Emergency
Department, the Warning Notice remains in place
as at 31 March 2015.
Some actions have been delivered, key examples
within our Emergency Department including the
recruitment of additional consultants and nurses,
improving the initial triage of patients upon arrival,
improving privacy and dignity within the corridor
86
Account of the Quality of Clinical Services 2014/2015
area and ensuring that coverage and observations
from the reception area are more effective. More
widely we are working closely with partners across
the local health and social care system to ensure a
safe and well managed discharge once patients are
well enough to leave the hospital.
Delivery of these actions is being monitored by
the Trust Board and also by the CQC and our
commissioners to ensure that they are properly
implemented and sustained.
National Peer Review of Severn
Major Trauma Network
Our major trauma service, as part of the Severn
network was subjected to a national peer review
in March 2015. The review was a culmination of
visits to all trauma units, the children’s hospital
and the ambulance service. The chair of the panel
summarised the findings by commending the
improvement in trauma mortality outcomes against
a background of huge infrastructure change.
The network is currently sixth best out of the 23
networks for mortality and NBT is ranked first for
mortality out of the 23 major trauma centres. The
current data demonstrates five extra survivors per
100 major trauma patients admitted to the centre.
The network was also commended for leadership,
the presence of 24-hour consultant team
leaders, damage control surgery training and the
development and delivery of high quality patient
pathways in rib fracture fixation and spinal cord
injury. Some further work is required, for example
in the rehabilitation sphere but the Trust welcomed
the panel’s comments and extended thanks to the
entire trauma service for this outstanding review.
7.Engagement
and Consultation
in choosing our
priorities
Account of the Quality of Clinical Services 2014/2015
87
7.Engagement
and Consultation
in choosing our
priorities
As part of the process to determine the Trust priorities for quality in 2015/16 the Trust undertook
a programme of engagement with patients & carers, staff, Local Authority Health Overview and
Scrutiny Committees, Clinical Commissioning Groups and others. This has included meetings,
targeted discussions and specific presentations about the Quality Account e.g.:
■■
Review with Trust Patient Panel –
February 2015
■■
Review with Patient Experience Group –
March 2015
■■
Presentation/Discussion at Quality
Committee – March 2015
The following organisations were invited to
comment on the draft of the Quality Account:
■■
South Gloucestershire - Public Health
Scrutiny Committee
■■
Bristol - People Scrutiny Commission
■■
Presentation to Bristol City Council People
Scrutiny Commission – April 2015
■■
North Somerset - Health Overview &
Scrutiny Panel
■■
Presentation to North Somerset Council
Health Overview & Scrutiny Panel –
April 2015
■■
NHS South Gloucestershire Clinical
Commissioning Group
■■
Supply of presentation for South
Gloucestershire Public Health and Health
Scrutiny Committee – April 2015
NHS Bristol Clinical Commissioning Group
■■
■■
NHS North Somerset Clinical Commissioning
Group
■■
Presentation to Trust Patient Panel –
April 2015
■■
North Bristol Trust - Patient Panel
■■
Bristol Healthwatch
■■
South Gloucestershire Healthwatch
■■
North Somerset Healthwatch
The Trust also undertook an on-line survey of the
Trust’s members to ascertain views on the priority
topics for the year ahead.
The draft Quality Account was circulated for
comment in the period 8th May to 8th June 2015.
A list of the organisations sent the document as
part of the consultation is shown below.
88
External Comments
Account of the Quality of Clinical Services 2014/2015
Commentary from the
South Gloucestershire
Public Health Scrutiny
Committee
No comments received.
Commentary from the
Bristol People Scrutiny
Commission
At its meeting of 13th April 2015 the Commission
received a presentation setting out the progress
against its 2014/15 priorities, and its proposed
priorities for 2015/16. There was general consensus amongst members that the priorities chosen
were appropriate, particularly ‘Improving care for
patients with dementia’.
The following salient points were noted;
■■
Members were re-assured to note the
action plan in relation to the Emergency
Department.
■■
Members were pleased to note the Progress
made in key areas since the Inspection and
particular reference was made to Improving
the flow of patients through the hospital.
■■
It was noted that single rooms in Brunel
were beneficial for many aspects of care, i.e.
infections control, but it noted the increased
the risk of falls. Members were satisfied that
improvements were planned.
Account of the Quality of Clinical Services 2014/2015
89
Commentary from the
North Somerset Health
Overview & Scrutiny
Panel
Members acknowledge the vast scale of the
challenge associated with the move to the new
hospital at Southmead and, despite the significant
teething problems (many of which were flagged
up by joint scrutiny prior to the move), the Panel
recognises the Trust’s impressive progress in
delivering this project.
The Panel also notes the significant progress made in
implementing the action plan resulting from the CQC
inspection carried out in November 2014.
Patient Experience
The Panel appreciates the significant patient benefits
associated with the new hospital’s state of the art
facilities, noting that 75% of the hospital’s 800 beds
are single rooms.
However, whilst the Panel acknowledges the Trust’s
progress in addressing the transitional issues, there
is still some way to go and North Somerset patients
continue to encounter difficulties, mostly relate to
accessing (public transport access, parking and access
routes) and discharge from the Hospital.
With respect to patient engagement, our colleagues
at Healthwatch North Somerset have commented
that their impressions from involvement in the Patient
Engagement Group are that the Trust could engage
more positively and pro-actively with patient groups
in addressing these issues.
The Panel is, however, encouraged by the Trust’s
recruitment of a Director of Engagement and by its
positive and constructive response to concerns raised
by a North Somerset Council officer about disabled
access through the lobby at the Brunel building.
Safety
Members are impressed with the Trust’s excellent
record on reducing hospital-acquired infections,
noting that there were no MRSA cases and no
norovirus related ward closures in 2014/15.
The panel also welcomes the work undertaken by
the Trust to improve the monitoring of patients in the
single bed rooms at the hospital but still has concerns
about the risk of falls and is encouraged that further
work is planned in 2015/16 to improve monitoring
further, including the use of sensors.
90
Account of the Quality of Clinical Services 2014/2015
Another area of on-going concern are issues around
clinical risks associated with the Sterile Services
Department (operation packs) but Members note
that measures are being put in place to improve
communication and the tracking of kit between SSD
and theatres.
Clinical effectiveness
Members are impressed with the Trust’s achievement
of Centre of Excellence status in a range of
services and specialities including Neurosciences,
Orthopaedics and Breast Care Centre Services.
From a local perspective, the Panel is also encouraged
that the Trust is working more effectively with GPs
in North Somerset. Members nevertheless seek
assurance that the 24 hour summary discharge
letters are sent to GPs electronically and that the
information is being shared in a coordinated and IT
compatible manner. It is noted that improving the
quality and timeliness of information provided to GPs
is a priority for 2015/16.
Priorities for 2015/16
The Panel supports the Trusts priorities for 2015/16:
■■
Improving care for patients with dementia
■■
Reduction in Pressure ulcers
■■
Improving the recognition, diagnosis and
treatment of Acute Kidney Injury
■■
Improving the quality and timeliness of
information provided to GPs
Roz Willis
Chairman, Health Overview & Scrutiny Panel
North Somerset Council
Commentary from NHS South Gloucestershire
Clinical Commissioning Group,
Commentary from NHS Bristol Clinical
Commissioning Group and
NHS North Somerset Clinical Commissioning Group
The CCGs welcome the opportunity to comment on
the draft Quality Account for NBT for 2014/2015, and
acknowledge that this has been a significant year
for the Trust following the move into the new Brunel
building and the consolidation of services from
Frenchay and Southmead onto one site. There are
some good areas of quality improvement within the
report and we acknowledge the impact the hospital
move has had on services. However, we would like
to have seen more detail and recognition relating to
the areas of patient safety and quality that we have
focused on with the Trust throughout the year and
which have had significant external scrutiny.
The document itself is easy to read and it was good to
see how patient stories have been used to highlight the
quality of services. We note the very good performance
against infection control targets and positive
Standardised Hospital Mortality Indicator (SHMI) rate
during the year. We also noted the positive introduction
of the iCare programme in 2014/15.
We understand the need for a balanced and positive
report but it also needs to be rounded in its content.
The inspection by the Care Quality Commission (CQC)
in November 2014 highlighted areas of good care and
areas of concern. There is an acknowledgement of
the need to improve ‘flow ‘ and privacy and dignity
of patients within the Emergency Department and
actions are being taken to address these. Nevertheless
from a quality perspective there is no reference to the
impact that the overcrowding and long trolley waits
have had on patient safety and experience.
There is also little reference to some of the other areas
of patient safety concern raised by the CQC where
improvement is required. In line with this, we would
have expected to see more focus in the 2015/16
priorities around the fundamentals of care and
reducing the number of inpatient falls and pressure
ulcers. The CCGs saw a significant increase in falls in
the first half of 2014/15 and whilst strategies have been
put in place to minimize this risk and we are pleased to
see the falls rate reduce, the Trust will need to maintain
this focus into 2015/16 and beyond. We also noted
that there was no reference to improving performance
against the constitutional standards in 2015/16.
Within the Quality Account the Trust has
acknowledged the significant increase in complaints
and concerns since the move to the new building in
May 2014 and the steps they are taking to address this.
The CCGs were pleased to see the partnership with
the Patients Association in implementing a strategy
to improve the quality and timeliness of response.
The CCG’s look forward to the impact of this work in
improving the response times to patient complaints
and meeting agreed timescales going into 2015/16.
The CCGs would have liked to engage more with the
Trust on the management of sepsis during 2014/15,
particularly as this was a local CQUIN priority. Whilst
we recognise the work that has taken place within
the Trust the CCG’s require assurance that all patients
diagnosed with sepsis receive antibiotics within
an hour of presentation. We are pleased that this
will continue to be a quality priority for the Trust in
2015/16 as well as being a national CQUIN.
NBT have demonstrated areas of good quality
improvement and the CCGs look forward to working
with the Trust in 2015/16. However, the CCGs feel
that the Trust has missed an opportunity to clearly
state where standards fell below an acceptable level
and how they are focusing on the actions needed to
improve these in 2015/16.
Anne Morris
Nurse Director and Head of Quality
and Safeguarding
South Gloucestershire CCG
Alison Moon
Transformation and Quality Director
Bristol CCG
Bridget James
Head of Quality
Bristol CCG
Jacqui Chidgey-Clark
Chief Nurse
North Somerset CCG
June 2015
Account of the Quality of Clinical Services 2014/2015
91
Commentary from
North Bristol NHS
Trust’s Patient Panel
Once again the Patient Panel are pleased to receive
the Quality Account and make a comment.
The Quality Account is very informative and easy to
read which makes it more user friendly.
The new hospital has had its teething problems
but is working to resolve the problems when seen
internally and when brought to its attention by
patients and members of staff.
Patient Panel members have again been involved in
numerous clinical groups and committees where they
have been part of the debates and decision making,
ensuring that the patient voice is heard and that the
patient experience is the best it can be in what is to
be achieved. The Panel is being consulted on new
initiatives and informed on progress on the Quality
issues ongoing within the Trust, making comments
and giving its views to ensure that the patients are at
the forefront of any decisions.
92
Account of the Quality of Clinical Services 2014/2015
The new hospital has bought the Trusts services
to one point of delivery which has enhanced the
patient experience. There is still work to be done
regarding the outpatient experience but this area
is being addressed with regards to appointments,
waiting times and clinics.
Members of the panel have been involved with
some inspections within the hospital which has
been useful in that it can follow up the things that
have been observed and ensure yet again that the
patient is at the forefront of care.
The North Bristol Trust was one of the first Trusts
in the country to create a Patient Panel and has
allowed it to continue to have a voice within the
Trust and to have an input and influence in the day
to day working practices of the hospital.
Commentary from
Bristol Healthwatch
No comments received.
Commentary from
South Gloucestershire
Healthwatch
No comments received.
Account of the Quality of Clinical Services 2014/2015
93
Commentary from
North Somerset
Healthwatch
Healthwatch North Somerset is pleased to have the
opportunity to comment on the North Bristol NHS
Trust Quality Account.
The Statement on Quality from the Chief Executive
provides a good overview and an insight to
initiatives undertaken during the year. We note and
recognise the challenges faced by the new Hospital
termed as the MOVE in the document.
Part 1
The Quality Account identified 4 priorities for
improvement but it is not clear whether the priority
objectives were achieved although all indicate that
progress has been made in each of the identified
areas. The report would benefit from more detail
about measured outcomes. We also note that
Priority 2 is included in the list of 2015/16 priorities.
Part 2
Healthwatch North Somerset notes that there were
no cases of avoidable deaths during 2014/15 and
a new screening system was implemented. It is not
clear from the narrative what percentage the 600
patient deaths recorded and reviewed were of the
total number of deaths.
We note the PROMS and that most outcomes are
within expected national averages and consider
the complex data would benefit from a narrative
analysis to assist lay interpretation of the data. It is
also difficult to understand the readmissions data
without narrative or comparison data.
Healthwatch North Somerset notes and commends
the year on year overall reduction in infection
and commitment to continuing the reduction.
The increase in serious incidents compared to
the previous year is disappointing and we note
the specific attention and action plan in place to
minimise the occurrence.
We are disappointed with the results of the 2014
National NHS Staff Survey, the low rate of response
and the Staff Satisfaction rate which was lower
than the previous year and lower than the national
average. We are pleased however that the Trust is
committed to improving the rate of response and
the level of staff satisfaction.
94
Account of the Quality of Clinical Services 2014/2015
We note the Friends and Family Test data however
without national comparative data it is difficult to
relate the data effectively. We do note however
the increase in response rates through the year
although the Emergency Department response
rates appear to be quite volatile.
Part 3
Health North Somerset commends the Trust on its
approach to placing Safeguarding as a high priority.
We are pleased to note that a new electronic
tool has been implemented to identify those at
increased risk of falls however we have concerns
that this has not resulted in a decrease in falls, but
rather an increase in falls compared to the previous
year of 9.6%. We note the decrease in serious falls
and the commitment during 2015/16 to reduce the
level of falls.
It is disappointing to note that the cancer targets
are not achieved consistently and there was
insufficient consultant support identified in two
MDT/Topic areas and capacity pressure challenges.
We would like the narrative to identify how it is
planned to improve these issues.
Part 4
Healthwatch North Somerset values the feedback
of the patient experience and engagement through
the Patient Experience Group and Patient Panel.
It would be useful for the complaints narrative
to identify the number complaints resolved
satisfactorily for the patient and the time scales for
dealing with the complaints.
We commend the high number of compliments
recorded and would welcome narrative to explain
what issues were commended.
An ‘easy read’ version of the Quality Account
would ensure greater accessibility of the Quality
Account for the general public.
This response was completed with the support of
Healthwatch North Somerset volunteers.
8. Appendices
Account of the Quality of Clinical Services 2014/2015
95
96
Account of the Quality of Clinical Services 2014/2015
0.40%
4.2%
1.12%
0.49%
0%
Apr14-Sep14
Apr14-Sep14 Apr14-Sep14 Apr14-Sep14
Percentage of patient safety incidents
resulting in severe harm or death
Responsiveness to inpatients’
personal needs
29.6
Oct 13Mar 14
Comparative data for 2014/15 will not be available from the Health &
Social Care Information Centre until August 2015).
NBT score 76.5 (91.0); England median 68.1 (67.4); low 54.4 (57.4);
high 84.2 (84.4).
Comparative data for 2013/14 (2012/13 in brackets):
20.2
97%
30.9
35.38
94.84
0.24
Apr14-Sep14 Apr14-Sep14 Apr14-Sep14 Apr14-Sep14
87.7%
Apr-Dec14
Rate of patient safety incidents
reported per 1,000 bed days
100%
Apr-Dec14
14.8
15.0
0
60.5
Apr14-Jan15 Apr14-Jan15 Apr14-Jan15 Apr14-Jan15
96.0%
Apr-Dec14
Clostridium difficile rate per 100,000
bed days (patients aged 2 or over)
NBT
2013/14
95%
Apr-Dec14
National
worst
2014/15
Venous thromboembolism risk
assessment
National
best
2014/15
NBT
2014/15
Mandatory indicator
National
average
2014/15
Appendix 1 Mandatory Indicators Table
The Trust will act to improve this percentage, and so the quality of
its services by continuing to collect feedback from patients, carers
and relatives through a range of different sources co-ordinated by
the Head of Patient Experience and utilising the Patient Panel and
Experience Group as outlined in this report.
The Trust considers that this data is as described for the following
reasons as this rate is as described as is the latest as available on the
HSCIC website.
The Trust will act to improve this percentage, and so the quality of
its services by continuing to review all Serious Incidents through
Root Cause Analysis investigation and actions to identify lessons and
improvements to practice.
The Trust considers that this data is as described as it is supplied by
the National Reporting & Learning System (NRLS) and is consistent
with internal data reviewed on a monthly basis during the year.
The Trust will act to improve this rate, and so the quality of its
services by continuing to review incident data to encourage open
and transparent reporting and to identify improvements to practice
and learning.
The Trust considers that this data is as described as it is supplied by
the National Reporting & Learning System (NRLS) and is consistent
with internal data reviewed on a monthly basis during the year.
The Trust will act to improve this percentage, and so the quality of its
services by continuing to focus on a range of improvement actions to
reduce C.Difficile infection through as outlined in this report.
The Trust will act to improve this percentage, and so the quality of
its services by ensuring our patients are risk assessed for VTE on
admission and improving VTE prevention as detailed in the report.
This is a priority for review through the Quality Committee.
The Trust considers that this data is as described as it is the latest
available on the HSCIC website and is validated closely on a case by
case basis by the Trust’s Infection Control Team.
The Trust considers that this data is as described as until 2013/14 NBT
had consistently performed above the national average and the reduced
performance has attracted significant scrutiny through the Trust’s Quality
Committee and the information team that supplies the data.
Comment
Account of the Quality of Clinical Services 2014/2015
97
100
Jul13-Jun14
97.0
(Band 2 “As
Expected”)
Jul13-Jun14
29.04%
Jul13 – Jun14
Summary Hospital-level Mortality
Indicator (SHMI) value and banding
Percentage of patient deaths with
specialty code of ‘Palliative medicine’
or diagnosis code of ‘Palliative care’
0%
54.1
Jul13-Jun14
92.8%
2014 Staff
Survey
Apr-Dec 2014 NBT score 74.0% (national average 81.4%)
North Bristol NHS Trust PROM data for these three procedures does
not meet the publication threshold of at least 30 returned PROM
Questionnaires.
Knee Replacement Primary EQ 5D
Varicose Veins, Groin Hernia and Hip
Replacement Revision
Emergency readmissions within 28
days of discharge: age 16 or over
Comparative data is not currently available for 2012/13, 2013/14 or
2014/15 from the Health & Social Care Information Centre.*
Comparative data for 2011/12: NBT score 10.9%; England average
11.4%; low 0%; high 17.1%.
Comparative data is not currently available for 2012/13, 2013/14 or
2014/15 from the Health & Social Care Information Centre.*
Comparative data for 2011/12: NBT 10.2%; England average 10.0%;
low 0%; high 47.6%.
Apr-Dec 2014 NBT score 55.2% (national average 56.1%)
Knee Replacement Primary EQ-VAS
Emergency readmissions within 28
days of discharge: age 0-15
Apr-Dec 2014 NBT score 89.8% (national average 90.2%)
Hip Replacement Primary EQ 5D
40.39%
Apr13Mar14
The Trust will act to improve this percentage in relation to its by
monthly review with clinical directorates of its own monitoring data
within the Performance Assurance Framework. This will identify
adverse trends and agree actions to reduce unplanned readmissions
The Trust considers that this data is as described as it is obtained
directly from the national Information Centre site
The Trust will act to improve this percentage, and so the quality of
its services by analysing the outcome scores and continuing to focus
on participation rates for the preoperative questionnaires.
The Trust considers that this data is as described as it is obtained
directly from the national PROMs information site.
its services by continuing with the approach detailed in this account
to improve quality and safety. The Trust does not specifically target
a reduction in mortality but has more robust processes in place for
monitoring mortality. Including the implementation during 2014-15
of a robust system to review all Hospital deaths. It is important to
note that palliative care coding has no effect on SHMI.
The Trust will act to improve this percentage, and so the quality of
its services by revitalising the approach taken to patient feedback
to broaden its range and target improvement actions rapidly to
address themes. This includes a significant improvement programme
in relation to the management of queries, concerns and complaints.
The Trust considers that this data is as described as it is directly
97.93
(Band 2 “As extracted from the Dr Foster system and analysed through the
Expected”) Trust’s Quality Surveillance Group, the medical Director and within
specialties. The rate is also consistent with historic trends.
Apr13Mar14
The Trust will act to improve this percentage, and so the quality of
61.3%
2014 Staff
Survey
Apr-Dec 2014 NBT score 64.4% (national average 66.3%)
49.0%
119.8
Jul13-Jun14
38.2%
2014 Staff
Survey
Hip Replacement Primary EQ-VAS
Patient Reported Outcome Measures – No. of patients reporting an improved score;
24.8%
67.5%
2014 Staff
Survey
51.9%
2014 Staff
Survey
Percentage of staff who would be
happy with standard of care provided
if a friend or relative needed treatment
The Trust considers that this data is as described as it is directly
extracted from National Survey data and the trend variation from
previous year is consistent with internal surveys intended to inform
ongoing improvement actions.
Appendix 2 2014/15 CQUINS
A proportion of North Bristol NHS Trust’s income in 2014-15 was conditional
on achieving quality improvement and innovation goals agreed between North Bristol NHS Trust and local
Clinical Commissioning Groups or NHS England for the provision of NHS services, through the Commissioning
for Quality and Innovation (CQUIN) payment framework.
Further details of the agreed goals for 2014-15 and for the following 12 month period are available
electronically at http://www.england.nhs.uk/wp-content/uploads/2014/02/sc-cquin-guid.pdf
2014-15 CQUINS - National Schemes
Title
Friends and
Family Test
NHS Safety
Thermometer
Dementia
98
Description
Q1
Q2
Q3
Q4
Comment
Staff Friends and Family Test from April
2014
Questionnaires sent out to all staff
Early implementation in Outpatients
and Day Case by October 2014
Rolled out FFT to outpatients and day
case by target date of 1st October 2014
Increase response rates in Emergency
Dept (ED) and Inpatients (IP)
Further increase to response rates in
Inpatients (IP) only in March 2015
Achieved in March 2015
Reduction in number of pressure ulcers
for Nov 2014 - March 2015 compared
to Nov 2013 - March 2014
February and March performance
resulted in a non - achievement of
this target
To identify, assess and refer on
dementia patients
All 3 targets were met in December
2014 and for Q3 in total. Based on
January and February’s results, it is
expected that Quarter 4 results will
also be achieved
Confirmation of clinical lead and
implementation of training programme
Achieved
Provision of support for dementia
carers
Action plan in place: Pilot questionnaires
posted, awaiting response
Account of the Quality of Clinical Services 2014/2015
2014-15 CQUINS - Local Schemes
Title
Description
Q1
Q2
Q3
Q4
Comment
Maternity
Increase quality of post - natal care and
improvement of breast feeding rate at
handover of community services
n/a
Cancer
Treatment
Summaries
To produce cancer summaries
following successful completion of
surgical treatment
Achieved
Discharge
Summaries
To improve timeliness and quality of
discharge summaries
Achieved
End of Life care
To improve identification of end of life
patients and increase level of support to
the patient and carer
Achieved
Personalised
Care Planning
To increase the number of personalised
care plans agreed with patients with
long term conditions
Not achieved
Sepsis
Reduction in incidence of Sepsis
Not achieved
7 day working
Emergency admissions to be assessed
by an appropriate consultant within 14
hours of admission
Method of reporting not robust
System wide
with Sirona
Implementation of Sirona model
relating to virtual wards
Achieved
Revised questionnaire assessed and
improvement demonstrated in Q4
2014-15 CQUINS - NHS England Specialist Services Schemes
Title
Description
Q1
Q2
Q3
Q4
Comment
Genetics
Access to array Comparative Genomic
Hybridisation (GCH) for prenatal diagnosis
Not achieved
CAMHS
CAMHS 5 day review of unplanned
admission
Achieved
Specialised
cancer
Use of remote monitoring for the support
of prostrate cancer patient follow up
Achieved
Achieved
NICU
The % of babies born <34+0 weeks
gestation receiving some of their
mother’s breast milk at final discharge
home from neonatal care
% of babies born <29+0 weeks gestation
and/or <1000g who start intravenous
nutrition (TPN) by day 2 of life
Achieved
Orthopaedics
Develop network for adult services
including regional audits and MDTs for
complex cases
Achieved
Critical care
Increase effectiveness of rehabilitation
following critical care stay
n/a
Not Achieved
Increase GP registration and
communication
n/a
Achieved
HIV
Development of IT system to support
implementation of antiretroviral system
Green = met target
Achieved
Yellow = CQUIN being finalised
Red = not met target
Account of the Quality of Clinical Services 2014/2015
99
Appendix 3
List of services provided by NBT
Directorate
Specialities
Medical Directorate
A&E
Care of the Elderly
Day Care (Medicine)
General (Acute)
Medicine
Cardiology
Dermatology
Clinical Haematology
Respiratory Medicine
Palliative Care
Clinical Immunology
HIV/AIDS Service
Oncology
Clinical Psychology
GI Services (Medicine)
Diabetes &
Endocrinology
Musculoskeletal
Directorate
100
Orthopaedics
Trauma Services
Rheumatology
Paediatric Rheumatology
Orthotics
Disablement Services
Directorate
Specialities
Renal &
Outpatients
Directorate
Hospital Services
Renal Medicine
Renal Surgery
Transplantation Surgery
Hospital Haemodialysis
Community Renal Services
Home Haemodialysis
Peritoneal Dialysis
Satellite Haemodialysis
Renal Technical, Diagnostic
& Treatment Services
Outpatient Clinics
Day Case Suite
Minor Operations and
Procedures Theatre
Women’s and
Children’s
Directorate
Gynaecology
Fertility Services
Integrated Maternity Services
Neonatal Intensive Care Unit
(NICU)
General Paediatrics incl.
Outpatients
Peri-operative Acute Care
Unit
School Nurses
Community Paediatrics
Children’s Speech Therapy
Child & Adolescent Mental
Health
Family Therapy
Psychotherapy
Children’s Occupational
Therapy
Child Psychology
Riverside Unit
Account of the Quality of Clinical Services 2014/2015
Directorate
Specialities
Surgical Directorate
Core Clinical
Services Directorate
Directorate
Specialities
General (Acute) Surgery
Vascular Surgery
Breast Services
Urology
Plastics and Burns
Surgery
GI Services Surgery
Endoscopy
Pigmented Lesion Clinic
Audiology
Orthodontics
Neurosciences
Directorate
Neurology
Neurosurgery
Neurophysiology
Neuropathology
Neuropsychiatry
Neuropsychology
Frenchay Centre for Brain
Injury Rehabilitation (FCBIR)
Head Injury Therapy Unit
(HITU)
Ophthalmology
Stroke Service
Anaesthetics
ITU
HDU
Theatres
Clinical Equipment
Services
Pain Management
Back Pain Services
Resuscitation Training
Day Case Unit
Pathology
Genetics
Clinical Biochemistry
Dietetics
Outpatient Facilities
Management
Cellular Pathology
Haematology
Immunology
Microbiology
Pharmaceutical Services
Radiology
Medical/Radiation Physics
Regional Quality Control Lab
Infection Control
Phlebotomy
Medical Illustration
Adult Speech Therapy
Occupational Therapy
Physiotherapy and associated
Musculo-skeletal rehabilitation
Account of the Quality of Clinical Services 2014/2015
101
Appendix 4
Auditors Opinion
Independent Auditor’s Limited Assurance Report to the Directors of North Bristol NHS Trust on the
Annual Quality Account.
We are required to perform an independent
assurance engagement in respect of North Bristol
NHS Trust’s Quality Account for the year ended 31
March 2015 (“the Quality Account”) and certain
performance indicators contained therein as part
of our work. NHS trusts are required by section 8
of the Health Act 2009 to publish a quality account
which must include prescribed information set out
in The National Health Service (Quality Account)
Regulations 2010, the National Health Service
(Quality Account) Amendment Regulations 2011
and the National Health Service (Quality Account)
Amendment Regulations 2012 (“the Regulations”).
Our responsibility is to form a conclusion, based on
limited assurance procedures, on whether anything has
come to our attention that causes us to believe that:
■■
the Quality Account is not prepared in all material
respects in line with the criteria set out in the
Regulations;
■■
the Quality Account is not consistent in all material
respects with the sources specified in the NHS
Quality Accounts Auditor Guidance 2014-15 issued
by DH in March 2015 (“the Guidance”); and
■■
the indicators in the Quality Account identified
as having been the subject of limited assurance
in the Quality Account are not reasonably stated
in all material respects in accordance with the
Regulations and the six dimensions of data quality
set out in the Guidance.
Scope and subject matter
The indicators for the year ended 31 March
2015 subject to limited assurance consist of the
following indicators:
■■ Percentage of reported patient safety incidents
resulting in severe harm or death; and
■■ Friends and Family Test: patient element score.
We refer to these two indicators collectively as
“the indicators”.
Respective responsibilities of
directors and auditors
The directors are required under the Health Act 2009
to prepare a Quality Account for each financial year.
The Department of Health has issued guidance on
the form and content of annual Quality Accounts
(which incorporates the legal requirements in the
Health Act 2009 and the Regulations).
In preparing the Quality Account, the directors are
required to take steps to satisfy themselves that:
■■ the Quality Account presents a balanced picture of
the Trust’s performance over the period covered;
■■ the performance information reported in the
Quality Account is reliable and accurate;
■■ there are proper internal controls over the
collection and reporting of the measures of
performance included in the Quality Account, and
these controls are subject to review to confirm
that they are working effectively in practice;
■■ the data underpinning the measures of
performance reported in the Quality Account is
robust and reliable, conforms to specified data
quality standards and prescribed definitions, and is
subject to appropriate scrutiny and review; and
■■ the Quality Account has been prepared in
accordance with Department of Health guidance.
The Directors are required to confirm compliance
with these requirements in a statement of directors’
responsibilities within the Quality Account.
102
Account of the Quality of Clinical Services 2014/2015
We read the Quality Account and conclude whether it
is consistent with the requirements of the Regulations
and to consider the implications for our report if we
become aware of any material omissions.
We read the other information contained in the
Quality Account and consider whether it is materially
inconsistent with:
■■
■■
■■
■■
■■
■■
■■
■■
■■
■■
■■
Board minutes for the period April 2014 to June 2015;
papers relating to quality reported to the Board over
the period April 2014 to June 2015;
feedback from the Commissioners dated June 2015;
feedback from Local Healthwatch dated June 2015;
the Trust’s complaints report published under
regulation 18 of the Local Authority, Social
Services and NHS Complaints (England)
Regulations 2009, dated 29 April 2015;
feedback from other named stakeholder(s)
involved in the sign off of the Quality Account;
the latest national patient survey dated 2014;
the latest national staff survey dated 2014;
the Head of Internal Audit’s annual opinion over
the trust’s control environment dated May 2015;
the annual governance statement dated 4 June
2015; and
the Care Quality Commission’s Intelligent
Monitoring Report dated May 2015.
We consider the implications for our report if we
become aware of any apparent misstatements
or material inconsistencies with these documents
(collectively the “documents”). Our responsibilities
do not extend to any other information.
This report, including the conclusion, is made solely
to the Board of Directors of North Bristol NHS Trust.
We permit the disclosure of this report to enable
the Board of Directors to demonstrate that they
have discharged their governance responsibilities by
commissioning an independent assurance report in
connection with the indicators. To the fullest extent
permissible by law, we do not accept or assume
responsibility to anyone other than the Board of
Directors as a body and North Bristol NHS Trust for
our work or this report save where terms are expressly
agreed and with our prior consent in writing.
Assurance work performed
We conducted this limited assurance engagement
under the terms of the guidance. Our limited
assurance procedures included:
■■ evaluating the design and implementation of
the key processes and controls for managing
and reporting the indicators;
■■ making enquiries of management;
■■ testing key management controls;
■■ analytical procedures;
■■ limited testing, on a selective basis, of the
data used to calculate the indicator back to
supporting documentation;
■■ comparing the content of the Quality Account
to the requirements of the Regulations; and
■■ reading the documents.
A limited assurance engagement is narrower in
scope than a reasonable assurance engagement. The
nature, timing and extent of procedures for gathering
sufficient appropriate evidence are deliberately limited
relative to a reasonable assurance engagement.
Basis for qualified conclusion
The indicator reporting the percentage of reported
patient safety incidents resulting in severe harm or
death did not meet the six dimensions of the data
quality in the following respects:
■■ Completeness, Accuracy and Timeliness - The
Trust has provided us with a full list of incidents
recorded on its own incident reporting system
during the reporting period. However, it has
not fully submitted all incident data for the
reporting period to the National Reporting and
Learning Service (NRLS) through its periodic
data uploads, which forms the basis for the
reported indicator. In total there were 120
incidents included within the Trust incident
system that were not reported as part of its
NRLS submission for the period 1 April 2014
to 30 September 2014.
■■
Qualified conclusion
Based on the results of our procedures, with the
exception of the matters reported in the basis for
qualified conclusion paragraph above, nothing has
come to our attention that causes us to believe that,
for the year ended 31 March 2015:
■■
the Quality Account is not prepared in all
material respects in line with the criteria set out
in the Regulations;
■■
the Quality Account is not consistent in all
material respects with the sources specified in
the Guidance; and
■■
the indicators in the Quality Account subject
to limited assurance have not been reasonably
stated in all material respects in accordance
with the Regulations and the six dimensions of
data quality set out in the Guidance.
Limitations
Non-financial performance information is subject to
more inherent limitations than financial information,
given the characteristics of the subject matter and
the methods used for determining such information.
The absence of a significant body of established
practice on which to draw allows for the selection
of different but acceptable measurement
techniques which can result in materially different
measurements and can impact comparability. The
precision of different measurement techniques may
also vary. Furthermore, the nature and methods
used to determine such information, as well as the
measurement criteria and the precision thereof, may
change over time. It is important to read the Quality
Account in the context of the criteria set out in
the Regulations.
The nature, form and content required of Quality
Accounts are determined by the Department
of Health. This may result in the omission of
information relevant to other users, for example for
the purpose of comparing the results of different
NHS organisations.
In addition, the scope of our assurance work has not
included governance over quality or non-mandated
indicators which have been determined locally by
North Bristol NHS Trust.
Accuracy and Timeliness - Based on the
evidence available at the time of our review,
our sample testing of 27 incidents identified
five incidents which were incorrectly classified
in the indicator.
Grant Thornton UK LLP
Hartwell House
55-61 Victoria Street
Bristol
BS1 6FT
30th June 2015
Date.............................................................................
Account of the Quality of Clinical Services 2014/2015
103
If you require a summary of this information
in another language or format please contact:
Emily Holloway
Communications Officer
0117 414 3887
www.nbt.nhs.uk/quality