Quality Accounts 2014/15
Care | Innovation | Valued | Excellence
1
Contents
Part 1................................................................................... 1
Part 3................................................................................. 23
STATEMENT ON QUALITY FROM THE CHIEF EXECUTIVE.............1
OTHER INFORMATION...............................................................23
Information about this Quality Report........................................2
Review of quality performance 2014/15...................................23
Part 2................................................................................... 3
Patient safety domain................................................................23
Priorities for improvement and statements of assurance from
the Board.....................................................................................3
Reducing falls and reducing harm from falls.............................28
2.1 Priorities for improvement............................................. 3
PRIORITIES FOR 2015/16.............................................................6
Priority 1.............................................................................. 7
To improve the recognition, prevention and treatment of Acute
Kidney Injury in our patients.......................................................7
Priority 2.............................................................................. 8
To structure and organise a formal medical handover process
within Thoracic Medicine .........................................................8
Priority 3.............................................................................. 9
To reduce the incidence of perioperative complications
following complex aortic surgery ...............................................9
Priority 4............................................................................ 10
To improve the physiological assessment in patients with DMD
in line with the American Society recommendations ..............10
Priority 5............................................................................ 11
Medicine safety .........................................................................11
2.2 Statements of assurance from the Board...................... 12
Information on participation in clinical audits and national
confidential enquiries................................................................12
Participation in clinical audits....................................................14
National Confidential Enquiry into Patient Outcome and Death
(NCEPOD) - 100%.......................................................................15
Information on participation in clinical research......................17
CQUIN framework......................................................................18
Care Quality Commission (CQC) registration and reviews........18
Data Quality...............................................................................18
Governance Toolkit Attainment Levels......................................18
Clinical Coding............................................................................18
Performance against the national quality indicators................20
Patient experience domain........................................................33
Clinical effectiveness of care domain........................................37
Overall quality performance against Trust selected metrics,
national priorities and CQC standards.......................................43
A listening organisation.............................................................45
What our patients say about us................................................45
What our staff say about us.......................................................51
Annex 1: What others say about us...........................................57
Annex 2: Statement of Directors’ responsibilities in respect of
the Quality Report.....................................................................59
Annex 3: Limited Assurance Report on the content of the
Quality Report and Mandated Performance Indicators............60
Annex 4: Mandatory performance indicator definitions..........62
Glossary ............................................................................ 64
Part 1
STATEMENT ON
QUALITY FROM THE
CHIEF EXECUTIVE
Everything we do at Papworth Hospital NHS Foundation Trust is
directed at achieving the best quality care and outcomes for patients
that we possibly can. This Quality Account sets out the approach we are
taking to continually improve quality at Papworth and how we are translating
this into improvements in patient care. I am therefore delighted to introduce
the Quality Account for Papworth Hospital - a view of the quality of services we
provided during 2014/15.
The principal quality objectives for Papworth Hospital centre
on patient safety, patient experience and positive outcomes of
care. Performance against national and local quality indicators
in these areas are reported to the Board of Directors and
Council of Governors at every meeting. The commitment
to high quality care will continue through our priorities for
2015/16, which have been developed in consultation with
clinical staff, governors and other stakeholders and reflect
the specialist nature of our work. These priorities will be
addressed later in the quality accounts.
Papworth Hospital is a high-performing Trust, achieving well
against all national indicators. High quality of care for every
patient, every time, is the first objective of Papworth and we
are committed to continuous improvement. Although we
have made great progress against priorities set last year, we
have not made as much progress as we would have wished in
reducing medication errors and this priority is being carried
forward to 2015/16.
Papworth Hospital received a routine inspection by the Care
Quality Commission (CQC) in December 2014. I am pleased
to say that the outcome of the inspection was a positive
one, identifying that Papworth delivers services that are
safe, effective, caring, responsive and well led. We were
delighted with this report and the outcome was testament
to the dedicated hard work of our staff. Further detail is
provided in part three of this document and the full report
can be accessed from the CQC‘s website at: http://papsvriis/
papworthonline/informed/userfiles/files/cgc-results-2015.pdf
Looking forward to the year ahead, our aim is to continue
to gather feedback from our patients to help us not only to
identify opportunities for improvement, and also to highlight
where we have achieved excellence, so that we can celebrate
this and spread the good practice within the
organisation and more widely. We will continue to
focus on the essentials of care, ensuring that no effort is
spared to improve standards and outcomes and, in short, to
realise our vision to provide a positive experience of care for
all our patients and to excel in everything that we do.
In March 2015 Papworth received permission to start building
the state-of-the-art new Papworth Hospital which will offer
cutting-edge facilities for patients requiring heart and lung
treatment in a bespoke building on the Cambridge Biomedical
Campus. This move will allow Papworth to revolutionise
cardiothoracic care and treatment in the UK whilst allowing
Papworth to offer the best possible care and treatment to our
patients and future generations.
The support of all our stakeholders is vital to us in maintaining
and building on our current achievements. I should like to
thank all our staff, governors, volunteers and patient support
groups for their input and support in helping us to progress
against our objectives during the year.
The information and data contained within this report has
been subject to internal review and, where appropriate,
external verification. Therefore, to the best of my knowledge,
the information contained within this document reflects a
true and accurate picture of the quality performance of the
Trust.
Stephen Bridge
Chief Executive
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INFORMATION
ABOUT THIS
QUALITY
REPORT
We would like to thank everyone who contributed to our Quality
Report.
Every NHS Trust, including NHS
Foundation Trusts, have to publish a
Quality Account each year, as required
by the NHS Act 2009, in the terms
set out in the NHS (Quality Accounts)
Regulations 2010.
Part 2.2 Statements of Assurance by the
Board includes a series of statements
by the Board. The exact form of these
statements is specified in the Quality
Account regulations. These words are
shown in italics.
NHS Foundation Trusts are also required
by Monitor to publish a Quality Report
as part of the Foundation Trust’s Annual
Report and Accounts. The Quality
Report includes all the requirements
of the Quality Account regulations but
includes additional requirements as set
out by Monitor in its Annual Reporting
Manual and in the document entitled
Detailed requirements for quality
reports.
Further information on the governance
and financial position of Papworth
Hospital NHS Foundation Trust can be
found in the various sections of the
Annual Report and Accounts 2014/15.
Foundation Trusts are given the option
of either publishing their whole Quality
Report as their Quality Accounts or
removing the additional Monitor
requirements. Papworth publishes
its Quality Report in its entirety as its
Quality Accounts. References to Quality
Report and Quality Account should
therefore be treated as the same
throughout this document. See glossary.
2
To help readers to understand the
report, a glossary of abbreviations or
specialised terms is included at the end
of the document.
Part 2
PRIORITIES FOR IMPROVEMENT AND
STATEMENTS OF ASSURANCE FROM THE
BOARD
2.1 Priorities for improvement
Welcome to Part Two of our report. It begins with a summary
of our performance during the past twelve months compared
to the key quality targets that we set for ourselves in last
year’s quality report.
The focus then shifts to the forthcoming twelve months, and
the report outlines the priorities that we have set for 2015/16,
and the process that we went through to select this set of
priorities.
This will be followed by the mandated section of Part 2,
which includes mandated Board assurance statements and
supporting information covering areas such as clinical audit,
research and development, Commissioning for Quality and
Innovation (CQUIN) and data quality.
Part 2 will then conclude with a review of our performance
against a set of nationally mandated quality indicators.
Summary of performance on 2014/15 priorities
Our 2013/14 Quality Report set out our quality priorities for
2014/15 under the three quality domains of patient safety,
clinical effectiveness and patient experience. See our 2013/14
Quality Account for further detail: www.papworthhospital.
nhs.uk/docs/accounts/Papworth_Hospital_Quality_
Account_2013_2014.pdf
The following table summarises the five quality improvement
priorities identified for 2014/15 along with the outcome.
3
1
2
3
4
To provide high quality
care and follow-up
for patients who have
complex discharge needs
following Pulmonary
endarterectomy surgery
(PEA) [formally PTE]
High quality care for
patients with delirium
Alcohol dependency
management and patient
support
Goals 2014/15
Outcomes
For each PEA patient to experience a timely, safe discharge from
care at Papworth free from unanticipated delays or unmet care
requirements.
All patients accepting surgery to be involved in deciding a realistic date
for their discharge and for this to be documented in the nursing notes.
Introduction of the PEA referral and discharge pathway to facilitate
timely discharge.
Reinstate the PEA checklist with appropriate education and re-audit in
six months. Reported in Part 3.
Understand the patient experience by asking additional questions at
the time of the follow-up telephone call, approximately one week after
discharge from hospital, and develop actions from this where needed.
Ensure that appropriate action is taken in response to patient feedback
and DATIX™ reports.
Achieved
Reduction in the number of complaints in relation to the discharge and
follow-up process post PEA (2 complaints received 2013/14).
No complaints
Goals 2014/15
Outcomes
To ensure patients at risk of delirium are identified.
To ensure appropriate measures are in place to prevent, recognise and
manage delirium for all patients within the Trust.
Agree a Delirium Pathway for patients with, or at risk of delirium from
pre admission to discharge.
Introduce a Delirium Bundle on critical care to ensure best practice in
delirium prevention, monitoring and treatment.
Improve communication between critical care and the wards for
patients who are experiencing delirium.
Introduce a short delirium assessment tool for use by ward staff with a
guide to treatment on the ward for a patient experiencing delirium.
Introduce GP notification on discharge to enable follow up postdischarge if appropriate. (Nursing documentation to be amended in
Q1 15/16 to facilitate this).
Achieved
Achieved
Goals 2014/15
Outcomes
All patients presenting to hospital will be screened for alcohol misuse
using a validated tool such as the Alcohol Use Disorders Identification
Test (AUDIT) as recommended by NICE. (The AUDIT C assessment tool
was introduced to the cardiac pre-admission clinic in Feb 2015. It will
be introduced Trust wide following an audit of its use and subsequent
actions completed).
Introduction of an Alcohol Management guideline for all patients at
risk of alcohol withdrawal to minimise the signs and symptoms of
withdrawal.
All patients presenting to acute services with a history of potentially
harmful drinking, will be referred to alcohol support services for a
comprehensive physical and mental assessment.
Finalise an Alcohol Management Guideline for Papworth Hospital that
is evidence based and adheres to National guidelines (NICE, NCEPOD).
Provide education for all staff to allow the introduction of an Alcohol
Management Guideline for patients at risk of alcohol withdrawal.
Partially achieved
Achieved
Achieved
Partially achieved
Achieved
No negative feedback
or DATIX™ reports
in relation to PEA
discharge
Achieved
Achieved
Achieved
Achieved
Not achieved
Achieved
Achieved
Achieved
Achieved
4
5
Improve the preprocedure pathway for
in-house urgent patients
and reduce their overall
length of stay
Reducing medication
errors (carried forward
from 2013/14)
Goals 2014/15
Outcomes
Introduce a pathway nurse to ensure in-house urgent (IHU) patients’
pathway from referral to procedure is efficient and timely.
Introduce Patient Access/transfer policy to ensure reciprocal
arrangements for transfer of patients across organisations. (The policy
has been written with input from all stakeholders within the East
of England region and it is expected that this policy will be ratified
at their next meeting. The actions described within the policy are
currently being implemented).
Improve IHU patient experience.
Optimise patient clinical work-up to reduce delays in the inhouse
urgent waiting time.
Achieve CQUIN for reducing hospital transfer times to Papworth for
IHU patients.
Achieved
Partially achieved
Goals 2014/15
Outcomes
Reduce the number of *orange medicines related incidents to a
maximum of two per year. We did not achieve this in 2013/14 or
2012/13 (there were three and seven respectively), which we believe
is partly due to an increased awareness and reporting culture.
(*moderate severity harm in which the patient requires significant
intervention and/or may lead to a prolonged length of stay).
Reduce prescribing errors by continuing to encourage the involvement
of consultants/clinical supervisors in the education of junior doctors
and non-medical prescriber’s in relation to prescribing errors.
Reduce the number of omitted doses. Continue monitoring any
incidents that result from omitted doses to be assured that the
impact of additional training has been effective as well as the recently
introduced ‘buddying’ system whereby the prescription charts of
all patients are checked between the nurse handing over and the
receiving nurse.
Continue our focus on reducing incidents that involve high
risk medications - insulin, anticoagulants, anti-epileptics and
immunosuppression, in order to monitor the NPSA rapid-response
action plans as part of an on-going audit plan.
Reduce the number of omitted doses from the chosen therapeutic
groups. Parkinsons medication has been removed from this group
since evidence in the last year has shown that these drugs are not
being omitted. This year, the focus will be on reducing the omission of
glaucoma eye drops which has been highlighted as a problem.
No ‘never events’ in relation to medicines use (none in 2013/14).
Introduce medicines safety champion role.
Not achieved (4
orange incidents this
year)
2013/14 -7
Achieved
Achieved
Achieved
Not achieved
Not achieved (96 this
year)
2013/14 -93
Achieved
Achieved
Achieved
Achieved
5
PRIORITIES FOR
2015/16
Our priorities for 2015/16 reflect the
three domains of quality; patient
safety, clinical effectiveness and patient
experience. Our priorities are:
• To improve the recognition,
prevention and treatment of Acute
Kidney Injury (AKI) in our hospital
patients.
• To structure and organise a formal
medical handover process within
thoracic medicine.
• To reduce the incidence of
perioperative complications
following complex aortic surgery.
• To improve the physiological
assessment in patients with
Duchenne Muscular Dystrophy in
line with American Thoracic Society
recommendations.
• To improve medicine safety by
focusing on reducing prescription
errors and unintentional
medication omissions by 50% by
the end of 2016 on one ward.
To determine our priorities for
2015/16, the Trust reviewed its
clinical performance indicators for
the year and the feedback from ongoing consultation with service users
on the range and quality of services
provided. A wide range of methods are
used to gather information, including
national patient surveys, real-time
patient feedback from the Trust-wide
patient experience data collection
tool, concerns, compliments and
complaints. Having identified some
priorities, the Trust consulted with
clinical teams, Governors, the Quality
and Risk Committee, Patient and Public
Involvement (PPI) Committee before
final priorities were selected.
6
Our Board of Directors and Council of
Governors agreed that, whilst there has
been excellent progress on last year’s
priorities, further improvements could
be made in some areas such as reducing
medication errors which is carried
forward to 2015/16. This priority is an
ongoing challenge for the Trust despite
a number of initiatives which have
been put in place. It is likely that there
is an increase in the reporting culture
at Papworth but there is concern that
none of the measures put in place have
been able to demonstrate a sustained
reduction in medication incidents. For
this reason, the approach to this priority
is changing this year to focus on two
specific wards with clear aims for each
area. It is anticipated that this method
will provide a model for sustainable
improvement which can ultimately be
used across the Trust.
Progress and achievement of goals
in relation to all five priorities will
be reported to and monitored by
the Quality and Risk Committee (a
Committee of the Board of Directors).
Reports will also be presented to
the PPI Committee and Council of
Governors.
Priority 1
TO IMPROVE THE RECOGNITION,
PREVENTION AND TREATMENT OF ACUTE
KIDNEY INJURY IN OUR PATIENTS
Goal
To improve the recognition, prevention and treatment of AKI in our hospital patients.
Rationale
Goals for 2015/16
Acute kidney injury (previously known as Acute Renal Failure)
has recently become a high priority topic amongst medical
and nursing professions within the NHS. In 2009, NCEPOD
(National Confidential Enquiry into Patient Outcome and
Death) published a report entitled ‘Adding Insult to Injury’. The
report highlighted deficiencies in the recognition, prevention
and early detection of AKI in patients admitted to hospital.
•
Most notable findings were that only 50% of patients were
considered to have received good care in relation to AKI and
that 20% of deaths due to AKI were deemed avoidable.
The National Health Service (NHS) has been criticised for its
inability to keep patients hydrated, with the national press
reporting that patients in hospitals have been ‘dying of thirst’.
The National Institute for Care and Excellence (NICE) has
responded by publishing two documents; Fluid Management
in Hospital (CG 174) and Management of Acute Kidney Injury
(CG 169).
•
•
•
•
•
Monitoring
•
Baseline
At Papworth, a task force known as the Fluid Management
& AKI Group was formed at the end of 2013 to assess the
fluid management practices within our organisation and to
fully appreciate the incidence of AKI in our cardiothoracic
population.
The group used CG174 and CG169 to inform the work
undertaken and produce Trust guidelines on fluid
management and AKI patient pathway. These documents
recommend standard practice in relation to the prescription,
administration and consequent management of fluids and
include an AKI Ward Pathway which aims to improve the
awareness, detection and consequent management of
patients who develop AKI as an inpatient. These guidelines
have been implemented across the Trust and an audit cycle is
in progress.
100% of cardiac surgery patients will be assessed using
AKI pathway risk assessment by March 2016.
Establish a baseline of the number of patients who are
managed using the AKI pathway since its introduction at
the end of 2014.
Demonstrate a 50% improvement from baseline in the
number of patients undergoing cardiac surgery who
develop AKI and are subsequently managed using the AKI
pathway.
To measure the incidence of AKI in the PPCI (Primary
Percutaneous Coronary Intervention) patient population.
Implement AKI pathway in PPCI patient population.
Improvements to be made to the pathology systems to
include eGFR (estimated Glomerular Filtration Rate) and
classification of AKI for all inpatients.
•
•
Perform quarterly audit of compliance with the AKI
patient pathway for patients having cardiac surgery.
Feedback and action planning to be provided through the
Fluid Management and AKI Group.
Incidence of AKI will be measured monthly in patients
admitted via the PPCI route.
Monthly review of readmissions to CCA for AKI. Feedback
and action planning to be provided through the Alert
Team Steering Group.
Overall Leads
Executive Lead:
Director of Nursing
Implementation Lead: Consultant Anaesthetist/
Clinical Governance Lead
Programme Leads:
Lead Advanced Nurse Practitioner
The incidence of creatinine rise (an indicator of AKI) in the
cardiac surgical patient has been audited since 2013 and
demonstrated a 20-30% incidence over the last year.
7
Priority 2
TO STRUCTURE AND ORGANISE A FORMAL
MEDICAL HANDOVER PROCESS WITHIN
THORACIC MEDICINE
Goal
To structure and organise a formal medical handover process within Thoracic Medicine at Papworth
Hospital to ensure that the risks involved in the process of transferred clinical responsibility are minimised.
Rationale
Goals 2015/16
Handover of care is one of the most perilous procedures in
medicine, and when carried out improperly can be a major
contributory factor to subsequent error and harm to patients.
Evidence reveals that safe patient handover is imperative with
the introduction of the European Working Time Directive.
•
By having an effective formal handover method it will not only
make the clinical environment safer but also help with the
continuity of patient care. Ultimately this will lead to providing
safe and high quality patient care.
•
Baseline
The recent annual General Medical Council (GMC) survey
highlighted concerns with patient handover amongst
doctors in training within our Trust. This suggests an area of
improvement that is closely linked to the improvement of
patient safety. Doctors and nurses experiences of medical
handover was reviewed using a questionnaire and individual
interviews.
•
•
Formalise medical handover documentation and establish
a secure electronic repository.
Introduce weekly, consultant-led handover sessions each
Friday afternoon to be used as both preparation for the
weekend and as a learning opportunity for junior doctors
by June 2015.
80% of daily shift changes will include a formal written
handover amongst the medical team in thoracic medicine
by March 2016.
Agree programme for roll out of best practice to Thoracic
Directorate by March 2016.
Monitoring
•
•
•
•
•
Monthly audit of medical handover documentation.
Weekly monitoring of attendance at Friday handover
sessions.
Quarterly reporting of incidents relating to medical
handover.
Six monthly questionnaire and interviews with doctors
and nurses within thoracic medicine.
Feedback and action planning to be provided through the
Thoracic Directorate business unit.
Overall Leads:
Executive Lead:
Medical Director
Implementation Lead: Consultant Physician
Programme Leads:
Quality Improvement Lead
8
Priority 3
TO REDUCE THE INCIDENCE OF PERIOPERATIVE COMPLICATIONS FOLLOWING
COMPLEX AORTIC SURGERY
Goal
To measure and reduce the incidence of peri-operative complications following complex aortic surgery by
April 2018.
Rationale
Goals 2015/16
A variety of aortic surgery procedures are performed
at Papworth Hospital and a smaller number of complex
operations are performed on the thoracic aortic arch and
descending thoracic aorta. These operations are associated
with a high risk of mortality, spinal cord injury, stroke, major
bleeding. Whilst the co-morbidities of this small group of
patients may explain the high rates of morbidity and mortality,
further quality work streams need to establish where
improvements can be made.
•
•
Factors which can influence harm associated with a surgical
procedure include procedural complications, breakdown in
communication and team leadership. All these influences
could be associated with human factors, encompassing
the environment, organisation, job factors, and individual
characteristics which influence behaviour at work. The
Clinical Human Factors Group is one of many that recognise
human factors should be at the heart of improving clinical,
managerial and organisational practice, leading to significant
improvements in safety and efficiency.
Baseline
Following a comprehensive clinical audit in 2011 of clinical
outcomes of patients undergoing complex aortic surgery and
a further review in 2013, changes have been implemented to
improve the service for this patient group. A comprehensive
process of multidisciplinary team (MDT) pre-operative
case preparation and postoperative review of all patients
undergoing complex aortic surgery has been implemented.
In addition to this we have identified where further
improvements can be made as listed in our goals for 2015/16.
•
•
•
Establish a list of internationally recognised complications.
Introduce a specific consent form for complex aortic
surgery listing recognised complications to ensure
patients are fully informed about risks involved in the
procedure.
Aortic team to attend Human Factors training.
Consultant anaesthetists involved with complex aortic
surgery to have undergone training in Monitoring of
Motor Evoked Potentials (MEPs).
Introduce an aortic surgery specialist nurse.
Monitoring
•
•
•
•
•
Audit of the number of patients consented using the new
consent form once published.
Quarterly audit of complications.
Audit of monthly Morbidity and Mortality (M&M).
meetings to monitor that protected time is allocated and
used to discuss complications.
Annual measurement of safety culture within perioperative complex aortic team.
Reporting to the surgical business unit and by exception
to the Quality and Risk Management Group.
Overall Leads:
Executive Lead:
Implementation Lead:
Programme Lead
Medical Director
Director of Nursing
Consultant Surgeon/
Consultant anaesthetist
Clinical Audit Manager
9
Priority 4
TO IMPROVE THE PHYSIOLOGICAL
ASSESSMENT IN PATIENTS WITH DMD
IN LINE WITH THE AMERICAN SOCIETY
RECOMMENDATIONS
Goal
To ensure that all patients with Duchenne Muscular Dystrophy (DMD) have access to all appropriate
physiological testing on every occasion that it is required and that appropriate specialist respiratory and
cardiac clinical care is provided.
Rationale
Goals 2015/16
DMD is an inherited condition leading to muscle function
deterioration affecting around 1 in 3,600 boys. Symptoms
typically appear in early childhood with most wheelchair
dependent by age 12. By early adulthood, respiratory and
cardiac problems predominate. Without intervention life
expectancy is 17 years but with early intervention, particularly
with long-term non-invasive ventilation (NIV), patients with
DMD now routinely survive into their thirties and beyond.
•
In 2009, an all Party Parliamentary Group investigated
access to Specialist Neuromuscular Care and published
the Walton Report which highlighted a compelling need
for the NHS to address numerous failings in the care of
patients with DMD and similar conditions. Transition from
paediatric to adult services is a perilous time for these
young people. Unfortunately a significant proportion do
not receive comprehensive care from both respiratory and
cardiac services and usually not in a ‘one-stop’ dedicated
clinic. Evidence from other transitional services for lifelong
conditions has demonstrated that a dedicated clinic can
improve referral rates, patient and carer engagement and
clinical outcomes.
Monitoring
Baseline
An audit in 2014 of DMD care at Papworth has demonstrated
significant challenges in accessing appropriate physiological
tests during patient visits. Whilst blood gas measurement
were achieved in 97% of patients, simple lung function
testing was conducted in less than 60%, specific respiratory
muscle function testing in less than 40%, and annual
echocardiography in only 11%. Factors associated with the
failure to undertake necessary investigations include a lack of
capacity for testing, difficulties in accessing lung function and
cardiology departments, and failure to organise appropriate
testing alongside the clinical appointment. A dedicated
fortnightly DMD clinic has now been established and
standards of care and monitoring strategies are in place.
10
•
•
•
•
•
To ensure all new patients referred with DMD have access
to objective measures of cardiac and respiratory function
within a single clinic visit.
Improve the completion of all tests in more than 90% of
patients who require tests and are willing to undertake
them.
Measure patient experience through use of
questionnaire.
Quarterly monitoring of availability of tests.
Audit of care after each 50 patient episodes (this number
has been set due to the low volume of patients).
Feedback and action planning through the thoracic
directorate business unit meetings with exception
reporting to the Quality and Risk Management Group.
Overall Leads:
Executive Lead:
Implementation Lead:
Programme Leads:
Medical Director
Consultant Physician RSSC/
Consultant Cardiologist
Consultant Physician RSSC
Priority 5
MEDICINE SAFETY
Goal
To reduce prescription errors and unintentional medication omissions by 50% on one ward by April 2016.
Rationale
Since 2008 the numbers of prescribing errors reported
has been increasing. This is likely due to an increase in the
reporting culture at Papworth. It is still felt anecdotally
however that prescribing errors are under reported.
Errors related to the recording and documentation of the
prescription have been audited for many years. The results
of these audits have plateaued with very little variation
seen between audit cycles. This probably reflects the short
term nature of many of the junior doctor contracts and the
limited ability of a paper based prescription chart to prevent
certain errors from occurring. One area of concern has been
amendments to prescriptions and in particular amendments
to doses. The Trust prescribing procedure clearly states
that a medicine should be completely rewritten should an
amendment be required however in practice this seldom
occurs.
In 2010 the National Patient Safety Agency (NPSA) published a
rapid response report called “reducing harm from omitted and
delayed medicines in hospital”. As a result of this Papworth
started to monitor the number of incidents of omitted
medicines in a number of high risk categories. For each
omission of a medication in one of these categories a route
cause analysis is carried out. The contributory causes are
monitored for common themes by the medicines safety group
and examples of good practice in one area of the hospital
shared across the whole site. Over the past few years the
numbers of omissions have gone up and down several times.
A number of different initiatives have been put in place but
none have been able to demonstrate a sustained reduction
in omissions. One ward was chosen to be the focus of a
concerted programme to address these issues to inform the
development of a Trust-wide improvement plan.
Goals for 2015/16
•
•
•
•
•
Complete a detailed prescription chart audit to capture
prescribing errors and omissions not reported through
the DATIX™ system by July 2015.
Introduce and publicise a zero tolerance approach to
amended prescriptions.
Reduce prescription errors by 50% by April 2016 on one
ward.
Reduce unintentional omissions of any medication by 50%
on one ward by March 2016.
Develop a model for sustainable improvement by March
2016 which can be used across the Trust.
Monitoring
•
Monitoring for achievement of these goals will be
through the Medicines Safety Group, and by exception to
the Quality and Risk Management Group and to the Drugs
and Therapeutics Committee. With monthly feedback to
ward sister and matron and lead pharmacist for the ward.
Overall Leads:
Executive Lead:
Director of Nursing
Implementation Lead: Clinical Governance Manager
Programme Lead:
Deputy Chief Pharmacist
Baseline for one ward in focus
2011/12
2012/13
2013/14
Prescribing errors reported through the DATIX™ incident reporting
system
5
8
9
Unintentional medication omissions reported through the DATIX™
incident reporting system
4
5
9
11
2.2 Statements
of assurance from the
Board
This section contains the statutory statements concerning
the quality of services provided by Papworth Hospital NHS
Foundation Trust. These are common to all quality accounts
and can be used to compare us with other organisations.
The Board of Directors is required under the Health Act
2009 and the National Health Service (Quality Accounts)
Regulations 2010 as amended to prepare quality accounts
for each financial year. Monitor has issued guidance to NHS
Foundation Trust Boards on the form and content of Annual
Quality Reports, which incorporate the legal requirements, in
the NHS Foundation Trust Annual Reporting Manual.
Indicators relating to the quality accounts were agreed
following a process which included the input of the Quality
and Risk Committee (a Committee of the Board of Directors),
Governors, the Patient and Public Involvement Committee of
the Council of Governors and clinical staff. Indicators relating
to the Quality Accounts are part of the key performance
indicators reported to every meeting of the Board of Directors
and monthly to Directorates as part of the monthly monitoring
of performance.
Information on these indicators and any implications/risks
as regards patient safety, clinical effectiveness and patient
experience are reported to the Board of Directors, Governors
and Committees as required.
Part 2.2 includes statements and tables required by Monitor
and the Department of Health in every Quality Account/
Report.
The
following
sections
contain
those
mandatory
statements,
using the required
wording, with regard to
Papworth Hospital. These
statements are italicised for the
benefit of readers of this account.
During 2014/15 Papworth Hospital NHS
Foundation Trust provided and/or sub-contracted
six relevant health services. Papworth Hospital NHS
Foundation Trust has reviewed all the data available to them
on the quality of care in six of these relevant health services.
The income generated by the relevant health services
reviewed in 2014/15 represents 100% of the total income
generated from the provision of relevant health services by
Papworth Hospital NHS Foundation Trust for 2014/15.
Full details of our services are available on the Trust’s website:
www.papworthhospital.nhs.uk
Information on participation in clinical audits and national confidential
enquiries
National clinical audits are largely funded by the Department
of Health and commissioned by the Healthcare Quality
Improvement Partnership (HQIP) which manages the National
Clinical Audit and Patients Outcome Programme (NCAPOP).
Most other national audits are funded from subscriptions
paid by NHS provider organisations. Priorities for the NCAPOP
are set by the Department of Health with advice from the
National Clinical Audit Advisory Group (NCAAG).
During 2014/15, 13 national clinical audits and 3 national
confidential enquiries covered relevant health services
that Papworth Hospital NHS Foundation Trust provides.
12
During 2014/15, Papworth Hospital NHS Foundation Trust
participated in 10 of the 13 (77%) national clinical audits and 3
of the 3 (100%) national confidential enquiries of the national
clinical audits and national confidential enquiries which it was
eligible to participate in.
The national clinical audits and national confidential enquiries
that Papworth Hospital NHS Foundation Trust was eligible to
participate in during 2014/15 are as follows:
Audit title
Audit source
Acute
Case Mix Programme
Adult Critical Care
Intensive Care National Audit and Research Centre (ICNARC)
Medical and Surgical Clinical Outcome Review
Programme: National Confidential Enquiry
into Patient Outcome and Death
NCEPOD
National Emergency Laparotomy Audit (NELA)
Royal College of Anaesthetists
Non-invasive Ventilation - Adults
British Thoracic Society. Project was approved to run, but BTS did not have the
capacity to roll out this audit and therefore did not take place in 14/15
Heart
Acute Coronary Syndrome/Acute Myocardial
Infarction (MINAP)
National Institute for Cardiovascular Outcomes Research (NICOR)
Adult Cardiac Surgery (ACS)
National Institute for Cardiovascular Outcomes Research (NICOR)
Cardiac Arrest (NCAA)
Intensive Care National Audit & Research Centre (ICNARC)
Cardiac Rhythm Management
National Institute for Cardiovascular Outcomes Research (NICOR)
Congenital Heart Disease
Papworth was unable to participate in 2014/15 due to data collection problem
Coronary Angioplasty
National Institute for Cardiovascular Outcomes Research (NICOR)
The Heart Failure Audit
Papworth Hospital did not contribute as it was agreed inappropriate with audit
provider as most patients would be ‘tertiary’ rather than ‘secondary’
Pulmonary Hypertension
NHS IC
Long-term conditions
Chronic Obstructive Pulmonary Disease
(COPD)
Royal College of Physicians
Cancer
Lung Cancer (NLCA)
Royal College of Physicians
Blood & transplant
National Comparative Audit of Blood
Transfusion Programme
NHS Blood & Transplant - audit of patient information & consent. It was agreed
that the criteria to obtain appropriate patients was too restrictive
Women’s & children’s health
Maternal, Newborn and Infant Clinical
Outcome Review Programme (MBRRACE-UK)
MBRRACE-UK, National Perinatal Epidemiology Unit
There were three national audits that Papworth did not
participate in. The Heart Failure audit had previously been
agreed with national audit providers as more applicable to
secondary rather tertiary care. There was an issue around
data collection for the Congenital Heart Disease audit, and
therefore Papworth could not participate. The National
Comparative Audit of Blood Transfusion programme 2014
conducted an audit of patient information and consent. It was
agreed that the criteria to obtain appropriate patients was too
restrictive. The Trust did not agree with questioning patients
whilst they were having their transfusion, this was deemed by
the Hospital Transfusion Committee as unethical, therefore
the Trust decided not to participate in this audit.
The national clinical audit and national confidential enquiries
that Papworth Hospital NHS Foundation Trust participated in
during 2014/15 are as follows: (see participation in clinical
audits table).
The national clinical audits and national confidential enquiries
that Papworth Hospital NHS Foundation Trust participated in,
and for which data collection was completed during 2014/15,
are listed below alongside the number of cases submitted
to each audit or enquiry as a percentage of the number of
registered cases required by the terms of that audit or enquiry.
13
Participation in clinical audits
Audit title
Audit source
Compliance with audit terms
Case Mix Programme
Adult Critical Care
Intensive Care National Audit and
Research Centre (ICNARC)
100%
Medical and Surgical Clinical Outcome Review
Programme: National Confidential Enquiry into
Patient Outcome and Death
NCEPOD
See breakdown
National Emergency Laparotomy Audit (Nela)
Royal College of Anaesthetists
100% (at first upload)
Non-invasive Ventilation - Adults
British Thoracic Society
This was not run during 14/15 by BTS
Acute Coronary Syndrome/Acute Myocardial
Infarction (MINAP)
National Institute for Cardiovascular
Outcomes Research (NICOR)
100%
Adult Cardiac Surgery (ACS)
National Institute for Cardiovascular
Outcomes Research (NICOR)
100%
Cardiac Arrest (NCAA)
Intensive Care National Audit &
Research Centre (ICNARC)
100%
Cardiac Rhythm Management (CRM)
National Institute for Cardiovascular
Outcomes Research (NICOR)
100%
Congenital Heart Disease
Papworth was unable to participate
in 2014/15 due to data collection
problems
Papworth was unable to participate
in 2014/15 due to data collection
problems
Coronary Angioplasty
National Institute for Cardiovascular
Outcomes Research (NICOR)
100%
The Heart Failure Audit
Papworth Hospital did not contribute
as it was agreed inappropriate with
audit provider as most patients
would be ‘tertiary’ rather than
‘secondary’
Not Applicable - National Auditors
requested that Papworth withdraw
from this audit
Pulmonary Hypertension
NHS IC
Data collection period closed on
31/03/2015, report publication
expected Mar ‘16
Royal College of Physicians
Organisational questionnaire only
Royal College of Physicians
100%*
NHS Blood & Transplant
2014 Audit of patient information &
consent **
MBRRACE-UK, National Perinatal
Epidemiology Unit
100%
Acute
Heart
Long-term conditions
Chronic obstructive pulmonary disease (COPD)
Cancer
Lung Cancer (NLCA)
Blood & transplant
National Comparative Audit of Blood
Transfusion Programme
Women’s & children’s health
Maternal, Newborn and Infant Clinical
Outcome Review Programme (MBRRACE-UK)
* The National lung cancer audit has few implications for Papworth Hospital as this audit records the patients by the hospital in which they were first seen. Since
almost no patients are referred direct from their GP to Papworth, the data which is completed by Papworth Hospital counts towards the district general hospitals
participation rate.
** It was agreed that the criteria to obtain appropriate patients was too restrictive. The Trust did not agree with questioning patients whilst they were having
their transfusion, this was deemed by the Hospital Transfusion Committee as unethical, therefore the Trust decided not to participate in this audit
14
National
Confidential Enquiry
into Patient Outcome and
Death (NCEPOD) - 100%
A breakdown of the data collection requirement for the national confidential
enquiries that Papworth Hospital participated in is presented below:
Cases included
Cases excluded
Clinical Q
returned
Case notes
returned
Organisational
questionnaire returned
2
5
2
2
1
Gastrointestinal haemorrhage
1
4
1
1
1
Tracheostomy care
11
0
11
2
(2 requested)
1
Title
Sepsis
National audits collect a large volume of data about local service delivery and achievement of compliance with
standards, and about attainment of outcomes. They produce national comparative data for individual healthcare
professionals and teams to benchmark their practice and performance.
The reports of 11 national clinical audits were reviewed by the provider in 2014/15 and Papworth Hospital NHS Foundation
Trust intends to take the following actions to improve the quality of healthcare provided. Examples include: Sample of audits
discussed at relevant group meetings.
Audit Title
Report published
Acute
Adult Critical Care
Yes
Medical and Surgical Clinical Outcome Review Programme: National Confidential Enquiry into Patient
Outcome and Death
Yes
National Emergency Laparotomy Audit (Nela)
No (not yet published)
Heart
Acute Coronary Syndrome/Acute Myocardial Infarction (MINAP)
Yes
Adult Cardiac Surgery (ACS)
Yes
Cardiac Arrest (NCAA)
Yes
Cardiac Arrhythmia (HRM)
Yes
Congenital Heart Disease
N/A
Coronary Angioplasty
Yes
The Heart Failure Audit
N/A
Pulmonary Hypertension
Yes
Long-term conditions
Chronic Obstructive Pulmonary Disease (Copd)
Yes
Cancer
Lung Cancer (NLCA)
Yes
Blood & transplant
National Comparative Audit of Blood Transfusion programme
No (not yet published)
Women’s & Children’s Health
Maternal, Newborn and Infant Clinical Outcome Review Programme (MBRRACE-UK)
Yes
15
Examples of actions include:
Lung cancer (NLCA)
Level of participation not accurately reflected in NLCA
figures due to Papworth being a tertiary centre. New
database in development to allow all fields to be captured,
including performance status, the use of the International
Mesothelioma Interest Group (IMIG) staging system to record
clinical (and where appropriate pathological) stage for all
patients and co-morbidity.
Tracheostomy care (NCEPOD)
The Trust was represented on the East of England Critical
Care Operational Delivery Network which developed a
regional action plan. As recommended by NCEPOD the Trust
introduced a percutaneous tracheostomy insertion checklist
in critical care, this includes a pre-procedure sign in, prior
to start of procedure time out and post procedure sign out
components, including names of staff.
The reports of 66 local clinical audits were reviewed by the
provider in 2014/15 and Papworth Hospital NHS Foundation
Trust intends to take the following actions to improve the
quality of healthcare provided: A sample of actions are listed
below:
Learning from clinical audit - chest x-Rays following
drain removal
An audit was undertaken to establish the necessity of
routine day 1 post-op chest x-Rays following drain removal
for patients in ICU. The audit findings showed that if the
chest x-Rays were administered purely on clinical judgment
this could have resulted in 60% less being performed. It was
also found that only 1% of the chest x-Rays audited resulted
in an intervention. A cost saving was estimated at £36,000
per thousand patients. It was noted that in most cases the
chest x-Rays did not provide any additional information that
changed the management of the patient.
The audit recommended that the routine administration of
day 1 post op chest x-Rays be discontinued and that they
be requested on clinical judgment at the time. This change
should be documented through an amendment of the current
Trust procedures following collaborative discussions with all
parties involved.
16
Learning from clinical audit - blood sciences/
turnaround times
An audit was undertaken to determine how many phone
calls the Blood Sciences department was receiving and the
reasons for these calls. It was also used to determine the
levels of awareness that staff have in relation to the published
turnaround times that are found within the Pathology
Handbook.
The audit recommended that the urgent test protocol should
be reviewed and amended to fully meet the needs of the
service, which has now been completed. It was also decided
that there should be a Trust-wide campaign to increase the
understanding of the urgent test protocol which has just been
implemented with the assistance of Corporate Services.
Recommendations were also made that the junior doctor’s
induction should include learning based around requesting
samples, which is currently in progress.
Re-audit of non-invasive ventilation (NIV) for
motor neurone disease (NICE CG105)
An audit was undertaken to establish compliance with
NICE guidance and to improve assessment of respiratory
impairment in motor neurone disease. NIV improves
symptoms associated with respiratory impairment in motor
neurone disease (MND) patients and extends survival1.
The audit was carried out successfully and showed good
compliance with the standards in the NICE guidelines. Areas
requiring action included:
• Include sleep symptoms and orthopnoea in the yellow
clerking proforma to improve documentation of these
symptoms.
• Consider reintroducing the box for ONSS results or
overnight saturations.
• Include space in the yellow proforma to document
previous PFT results and when PFTs are last done, and
also presence of contraindications.
• Alternative proforma for MND patients to include not
only the suggested investigations but also other questions
e.g. eating/swallowing, bulbar difficulties etc.
• Provision of a checklist for MND patients in the day case
clinic so that investigations are not overlooked.
Information
on participation in
clinical research
The number of patients receiving relevant health services provided or
sub-contracted by Papworth Hospital NHS Foundation Trust in 2014/15
that were recruited during that period to participate in research approved
by a research ethics committee was 4051.
See table below:
Type of research project
No. of participants recruited per financial year
2011/12
2012/13
2013/14
2014/15
NIHR portfolio studies
1,037
2,645
1,363
1,175
Non-NIHR portfolio
studies
366
899
633
367
Tissue bank studies*
1,966
1,719 (1,991)
1,245 (1,450)
2509 (2675)
Total
3,369
5,262
3,241
4051
NIHR = National Institute for Health Research.
* Tissue bank studies includes 2 studies registered on the NIHR portfolio. Total figure given in brackets to avoid double counting as participants are included in
NIHR portfolio studies.
By maintaining a high level of participation in clinical research
the Trust demonstrates Papworth’s commitment to improving
the quality of health care.
During 2014/15 the Trust recruited to 65 studies of which 48
were portfolio studies (2013/14: 68 studies and 39 portfolio
studies), with a greater proportion of these studies being
interventional and more complex in design when compared
to previous years. Participant recruitment figures were down
on the previous year due to the conclusion of a number of
high recruiting studies including the ‘Visenzia study’ which
contributed over 200 participants alone to the 2013/14 total
and the absence of a similar high participation studies in
2014/15.
Quality is at the heart of all our research activities and
Papworth ranked as the top recruiting site in the UK for 30% of
the multi-centre NIHR portfolio studies we supported and was
the 5th highest recruiting NHS Trust within the East of England
for NIHR portfolio research in 2014/15.
The Trust remains committed to improving patient outcomes
by undertaking clinical research that will lead to better
treatments for patients undergoing care in the NHS.
We would like to say thank you to all those who participated
in our research over the past year.
Papworth recruits to a large number of studies in rare disease
groups including pulmonary vascular disease, mesothelioma
and idiopathic pulmonary fibrosis. Research carried out in the
previous year has led directly to the first European DCD heart
transplant.
17
Commissioning for Quality and
Innovation (CQUIN) framework
A proportion of Papworth Hospital NHS Foundation Trust’s
income in 2014/15 was conditional upon achieving quality
improvement and innovation goals agreed between Papworth
Hospital NHS Foundation Trust and any person or body
they entered into a contract, agreement or arrangement
with for the provision of relevant health services, through
the Commissioning for Quality and Innovation payment
framework.
published data. The percentage of records in the published
data which included:
• The patient’s valid NHS number was in excess of 99% for
admitted patient care and in excess of 99% for outpatient
care.
• The patient’s valid General Medical Practice Code (code of
the GP with which the patient is registered) was 99% for
admitted patient care and 99% for outpatient care.
Further details of the agreed goals for 2014/15 and for the
following 12 month period are available electronically at www.
england.nhs.uk/wp-content/uploads/2014/02/sc-cquin-guid.
pdf
Governance Toolkit Attainment
Levels
The amount of income available in 2014/15 conditional upon
achieving quality improvement and innovation goals was
£2,640,439 (2013/14: £2,681,628) and the amount received
was £2,640,439 [100%] (2013/14: £2,649,202 [98.6%]).
Good information governance means keeping the information
that we hold about patients and staff safe. The information
governance toolkit is the way we demonstrate our compliance
with information governance standards. All NHS organisations
are required to make annual submissions to Connecting for
Health in order to assess compliance.
For further information on CQUIN performance for 2014/15
see Part 3 of the Quality Report. For further information on
CQUIN priorities for 2015/16 see Annual Report - Strategic
Report section.
Care Quality Commission (CQC)
registration and reviews
Papworth Hospital NHS Foundation Trust is required to
register with the Care Quality Commission and its current
registration status is ‘registered without conditions’. The Care
Quality Commission has not taken enforcement action against
Papworth Hospital NHS Foundation Trust during 2014/15.
Papworth Hospital NHS Foundation Trust has not participated
in any special reviews or investigations by the Care Quality
Commission during the reporting period.
Papworth Hospital NHS Foundation Trust is subject to periodic
review by the CQC and received an announced inspection
in the first week of December 2014. See Part 3 - Other
information. The report of this inspection is available on the
CQC website at www.cqc.org.uk/sites/default/files/new_
reports/AAAB8932.pdf
Data Quality
It is essential that we produce accurate and reliable data
about patient care. For example, how we ‘code’ a particular
operation or illness is important as it not only allows us to
receive the correct income for the care and treatment we
provide, but it also anonymously informs the wider health
community about illness or disease trends.
Papworth Hospital NHS Foundation Trust submitted records
during 2014/15 to the Secondary Uses Service for inclusion in
the Hospital Episode Statistics which are included in the latest
18
Papworth Hospital NHS Foundation Trust’s information
governance assessment report overall score for 2014/15 was
74% and was graded green. The Trust achieved a minimum of
level 2, with 11 requirements at level 3, on all requirements
in the information governance toolkit. The Information
Governance Toolkit is available on the Connecting for Health
website www.igt.connectingforhealth.nhs.uk
Clinical Coding
Papworth Hospital NHS Foundation Trust was not subject
to the Payments by Results clinical coding audit during the
reporting period by the Audit Commission.
Papworth Hospital NHS Foundation Trust will be taking the
following actions to continue to improve data quality:
• Continued development of the roles of staff that are
responsible for and administer databases;
• Continued refresher training for the clinical coding team;
• Business Support Department to undertake regular
monthly audits to check for consistency and accuracy in
case notes and clinical coding;
• Business Change Team to continue to work with Business
Support to review data quality issues;
• Feedback on data quality will be provided at Directorate
IM&T Strategy meetings;
• Individuals making repeated errors will be identified and
their line manager will be offered re-training for them;
• The above arrangements will be formalised in a Data
Quality Strategy and Policy.
Papworth Hospital was announced as the winner of a
prestigious CHKS award in May 2014. The category was CHKS
Data Quality (Specialist) Award and recognises the importance
of clinical coding and data quality, and the essential role
they play in ensuring appropriate patient care and financial
reimbursement from commissioners.
19
20
The delivery of harm free care is well
established and will continue through
2015/16. VTE prevention and prophylaxis
will continue to be closely monitored
and reported by exception to the Quality
and Risk Management Group. VTE events
which occur within 90 days of discharge
from hospital will continue to be subject
to a route cause analysis.
Trust wide education and
the inclusion of the VTE risk
assessment form within the
drug chart have led to a robust
process for ensuring that
patients are risk assessed. This
is now well embedded in clinical
practice. In addition the Safety
Thermometer has also raised
awareness.
Trust achieved 98.4% for M1 to M11;
2014/15.
Acute Trust average was 95.5% for
M1 to M11; 2014/15.
Highest acute provider 100%.
Lowest acute provider 88.2%.
For Trust internal data on percentage
for M12, 2014/15 see Part 3- Other
Information.
Trust achieved 99.2% for 2013/14.
Acute Trust average was 95.7% for
2013/14.
Highest acute provider 100%.
Lowest acute provider 80.9%.
The percentage of patients
who were admitted to hospital
and were risk assessed for VTE
during the reporting period.
We will continue to act on the comments
from the staff survey to identify areas for
improvement.
See Annual Report - Staff Survey section
for other information on the 2014 Staff
Survey.
This Trust has a solid foundation
of staff who share a sense
of pride in their work and
ownership of the hospital’s
delivery of a quality service.
92% of the staff employed by, or
under contract to, the trust in the
2014 staff survey would recommend
the trust as a provider of care to their
family or friends.
Average for acute specialist trusts
was 87%.
The highest scoring specialist trust
was 93%.
The lowest scoring specialist trust
was 73%.
94% of the staff employed by,
or under contract to, the trust
in the 2013 staff survey would
recommend the trust as a provider
of care to their family or friends.
Average for acute specialist trusts
was 86%.
The highest scoring specialist trust
was 94%
The lowest scoring specialist trust
was 67%.
The percentage of staff
employed by, or under
contract to, the trust during
the reporting period who
would recommend the trust
as a provider of care to their
family or friends
[Data from National Staff
Survey].
We will continue to use data from the
inpatient survey to identify areas for
improvement. See Part 3 for information
on other headline results of the latest
survey (2014) published on 21 May 2015.
Trust achieves results in the top
20% of trusts in the inpatient
survey.
Trust rate was 9.01% for 2011/12
placing the Trust in Band B1.
National average was 11.45%.
Highest rate for an acute specialist
trust was 14.09%.
Lowest rate for an acute specialist
trust was 0.00%.
Trust score was 78.3 in the 2013/14
survey.
National average score was 68.7.
National highest score was 84.2.
National lowest score was 54.4.
Trust score was 76.8 in the
2012/13 survey.
National average score was 68.1
National highest score was 84.4.
National lowest score was 57.4.
The trust’s responsiveness to
personal needs of its patients
during the reporting period
[Data from National Inpatient
Survey].
[Latest national data available
as at 14/5/15].
Note1
Papworth Hospital NHS Foundation
Trust intends to take/has taken the
following actions to improve this score
or rate and so the quality of its services,
by…
We will continue to monitor. Percentages
could be distorted by readmissions
following an inpatient stay for
investigations in which there was no
treatment intended for the underlying
condition.
2014/15
(or latest reporting period available)
Papworth Hospital NHS
Foundation Trust considers that
this score or rate is as described
for the following reasons…
Readmission rates are low due to
the quality of care provided.
Trust rate was 9.46% for 2010/11
placing the Trust in Band B1.
National average was 11.43%.
Highest rate for an acute specialist
trust was 17.10%.
Lowest rate for an acute specialist
trust was 0.00%.
The percentage of patients
aged 16 or over readmitted
to the hospital within 28 days
of discharge from the hospital
Indicator
2013/14
(or previous reporting period to
latest available)
The following core set of indicators applicable to Papworth Hospital on data made available to Papworth Hospital by the Health and Social Care Information centre are required to be
included in the Quality Accounts.
Performance against the national quality indicators
21
(i) Trust number for 2013/14 was
1832.
The Acute Specialist Trust highest
total was 3426, the lowest was 210
and the average was 1727.
(ii) Rate per 100 admissions was
not available.
The highest, lowest and average
Acute Specialist Trust rate per 100
admissions was not available.
(iii) 7 resulted in severe harm/
death equal to 0.4% of the number
of patient safety incidents.
The highest Acute Specialist Trust
% of incidents resulting in severe
harm/death was 3.2%, the lowest
was 0% and the average was 0.5%.
The number and, where
applicable, rate of patient
safety incidents reported
within the trust during the
reporting period, and the
number and percentage of
such patient safety incidents
that resulted in severe harm or
death.
(i) Number
(ii) Rate per 100 admissions
(iii) Number and percentage
resulting in severe harm/death
The number of Clostridium difficile (C. difficile) infections, for patients aged two or over
on the date the specimen was taken. A C. difficile infection is defined as a case where the
patient shows clinical symptoms of C. difficile infection, and using the local Trust C. difficile
infections diagnostic algorithm (in line with Department of Health guidance), is assessed
as a positive case. Positive diagnosis on the same patient more than 28 days apart should
be reported as separate infections, irrespective of the number of specimens taken in the
intervening period, or where they were taken. Acute provider trusts are accountable for all
C. difficile infection cases for which the Trust is deemed responsible. This is defined as a case
where the sample was taken on the fourth day or later of an admission to that trust (where
the day of admission is day one). The Quality Accounts Regulations requires the C. difficile
indicator to be expressed as a rate per 100,000 bed days. If C. difficile is selected as one of
Note 2
Emergency re-admissions within 28 days of discharge from hospital. Percentage of
emergency admissions to a hospital that forms part of the Trust occurring within 28 days of
the last, previous discharge from a hospital that forms part of the Trust.
Note 1
Data is submitted to the National
Reporting and Learning System
in accordance with national
reporting requirements.
Infection prevention and control
is a key priority for the Trust.
The Trust has a positive reporting culture.
All patient safety incidents are subject to
a root cause analysis (RCA) and lessons
leant from incidents, complaints and
claims are available on the Trust’s intranet
for all staff to read.
See Part 3 of report - Other Information.
For Trust internal data on rate for 2014/15
see Part 3 - Other Information.
The indicator is expressed as a percentage of patient safety incidents reported to the
National Reporting and Learning Service (NRLS) that have resulted in severe harm or death.
A patient safety incident is defined as ‘any unintended or unexpected incident(s) that could
or did lead to harm for one of more person(s) receiving NHS funded healthcare’. The ‘degree
of harm’ for patient safety incidents is defined as follows: ‘severe’ - the patient has been
permanently harmed as a result of the incident; and ‘death’ - the incident has resulted in the
death of the patient.
As well as patient safety incidents causing long term/permanent harm being classed as
severe, the Trust also reports ‘Patient Events that effect a large number of patients’ as
‘severe’ incidents to the NRLS.
Note 3
the mandated indicators to be subject to a limited assurance report, the NHS foundation
trust must also disclose the number of cases in the quality report, as it is only this element
of the indicator that Monitor intends auditors to subject to testing. C.difficile was subject to
testing by auditors in 2013/14 but not 2014/15.
(i) Trust number for April 2014 to
September 2014 was 1075.
The Acute Specialist Trust highest
total was 2619, the lowest was 85
and the average was 959.
(ii) Rate per 100 admissions was not
available.
The highest, lowest and average
Acute Specialist Trust rate per 100
admissions was not available.
(iii) 0 resulted in severe harm/death
equal to 0% of the number of patient
safety incidents.
The highest Acute Specialist Trust %
of incidents resulting in severe harm/
death was 4.2%, the lowest was 2.0%
and the average was 0.6%.
Trust rate was 5.6 in 2013/14 for
Trust apportioned patients aged 2
years and over (4 cases).
National average was 14.7.
National highest rate was 37.1.
National lowest rate was 0.
Data source: Health and Social Care Information Centre portal as at 15 May 2015 unless otherwise indicated
[Information on rate not
available on national portal
15/5/15].
Note 3
[2012/13 national figures
updated as at 14/4/15].
Note 2
Trust rate was 9.8 in 2012/13 for
Trust apportioned patients aged 2
years and over (7 cases).
National average was 17.4.
National highest rate was 31.2.
National lowest rate was 0.
The rate per 100,000 bed days
of cases of C.difficile infection
reported within the trust
during the reporting period
22
Part 3
OTHER INFORMATION
Review of quality performance 2014/15
The following section provides a review of our quality
performance in 2014/15. We have selected examples from the
three domains of quality (clinical safety, patient experience
and clinical effectiveness of care). These are not all the same
as in the 2013/14 quality accounts but reflect issues raised
by our patients and stakeholders, which also feature highly in
the agenda from the Department of Health (DH). They include
information on key priorities for 2014/15 where these have
not been carried forward as key priorities for 2015/16.
Pulmonary endarterectomy has been included as Papworth
is the only centre in the country to provide this surgery in the
UK. There is also an update on the Extra Corporeal Membrane
Oxygenator (ECMO) service for which Papworth Hospital is
one of five centres nationally to provide this service for adults.
Other indicators from 2013/14 that have not been included,
such as providing high quality care and follow-up for patients
who have complex discharge needs following Pulmonary
endarterectomy, delirium, alcohol dependency management
and improving the pre-procedure pathway for in-house
urgent patients continue to be monitored but are not listed as
priorities this year as there is ongoing work in place to embed
these priorities within Trust practice.
prevention and control, which needs continuous review. The
Trust is committed to ensuring that appropriate resources are
allocated for effective protection of patients, their relatives,
staff and visiting members of the public. In this regard
emphasis is given to the prevention of healthcare associated
infection, the reduction of antibiotic resistance and ensuring
excellent levels of cleanliness in the hospital.
Hand hygiene remains an important infection prevention and
control measure to reduce the risk of spread of infection,
including MRSA, on the hands of healthcare workers. This was
continuously audited in 2014/15 and the overall hand hygiene
compliance by staff was greater than 95%. In addition, many
other measures are taken to prevent the spread of MRSA
infection including MRSA screening of patients admitted to the
hospital, treatment of MRSA carriers, isolation of patients and
cleaning of both the environment and equipment across the
Trust.
Healthcare associated infections
During 2014/15 the total number of Clostridium difficile cases
was three, against a ceiling of four, and the total number of
MRSA bacteraemias was one, against a ceiling of zero. All
MRSA bacteraemias and cases of C. difficile are reported
to our Commissioners. We perform root cause analysis
on each case to review the events and enable continuous
improvement of practice. Any subsequent lessons learned are
shared with the Commissioners and if the root cause analysis
does not show any avoidable factors in the care of the patient,
the case will not be counted against the ceiling target.
Papworth Hospital places infection control and a high
standard of hygiene at the heart of good management and
clinical practice. The prevention and control of infection was
a key priority at Papworth Hospital throughout 2014/15 and
remains part of the Trust’s overall risk management strategy.
Evolving clinical practice presents new challenges in infection
All actions necessary to reduce the risk of healthcare
associated infection are implemented as required by national
policy and are monitored via the Infection Prevention and
Control Committee. We continue to report all significant
healthcare associated infections monthly to our Board of
Directors and to national surveillance systems.
Patient safety domain
MRSA bacteraemia and C. difficile infection rates
Goals 2012/13
Outcome
2012/13
Goals 2013/14
Outcome
2013/14
Goals 2014/15
Outcome
2014/15
Goals 2015/16
No more
than 1 MRSA
bacteraemia
Total for year
=2
No MRSA
bacteraemia
Total for year
=0
No MRSA
bacteraemia
Total for
year = 1
No MRSA
bacteraemia
No more than 5
C. difficile cases
Total for year
=7
No more than 5
C. difficile cases
Total for year
=4
No more than 4
C. difficile cases
Total for
year =3
No more than 5 C.
difficile cases *
Achieve
100% MRSA
screening of all
patients
Average 99%
Achieve
100% MRSA
screening of all
patients
Average 99%
Achieve
100% MRSA
screening of all
patients
Average
98.5%
Achieve 100%
MRSA screening of
all patients
Data source: Mandatory Enhanced Surveillance System (MESS). *Method for counting changed from 2015/16.
23
Linezolid Resistant Enterococcus in critical care
In July 2013 six patients in the critical care area (CCA) were
identified as being colonised with a multi-resistant organism
called Linezolid Resistant Enterococcus faecium (LRE). This was
found as a result of routine screening for vancomycin resistant
Enterococcus which is carried out weekly in all patients in the
intensive care unit in this Trust.
Since July 2013, there have been no further incidences of
LRE in the CCA. We continue to monitor and screen weekly in
critical care for VRE.
Infection control practices in the Cystic Fibrosis
Unit
In 2012/13 the Trust reported on the increase of infections
caused by the antibiotic-resistant bacterial species
Mycobacterium abscessus (M. abscessus). M. abscessus is
distantly related to the bacterium that causes Tuberculosis
and is usually found in water and soil. This is of concern
particularly in the cystic fibrosis population due to their
susceptibility to serious infections.
The teams at Papworth Hospital, the University of Cambridge
and the Wellcome Trust Sanger Institute have continued with
their research into this area and are linking with other centres
across the world to further understand this species and its
transmission.
As a result of their initial findings a new cystic fibrosis clinic
has been established to further segregate patients with M.
abscessus. Inpatient care has also changed with patients
being cared for in different locations within the directorate.
Investigations into the possible routes of transmission
are being undertaken. New cleaning regimes have been
introduced in both inpatient and outpatient facilities for all
cystic fibrosis patients to reduce the risk of cross infection.
Carbapenemase Producing Enterobacteriacae
(CPE) in CCA
In February/March 2015 one patient in the CCA was identified
as being colonised with a multi-resistant organism called
Carbapenemase Producing Enterobacteriacae (CPE). This was
found as a result of routine weekly screening while on the
critical care unit. As a result of this all contacts of this patient
were isolated and screened as per procedure. No patient
contacts were found to be positive. Increased cleaning was also
implemented, including hydrogen peroxide vapour fogging.
Ebola Preparation
In line with the guidance from Public Health England (PHE)
the Trust have made preparations should a suspected case be
admitted. This includes a ‘walk-through’ exercise with a multiprofessional team.
Influenza A
At the beginning of 2015 the Trust has seen a high number of
24
inpatients with confirmed Influenza A. The total number of
cases from January to mid-March was 21, 18 of these being
in January. During this period of increased incidence cases
were monitored and isolation precautions were put in place to
protect further spread to patients and staff. The high numbers
may be due to the reduced effectiveness of the seasonal flu
vaccine against the main circulating strain of Influenza A strain
this season.
Introduction of the sepsis care bundle in ward
areas
The sepsis care bundle introduced in 2013/14 is now well
established practice within the Trust. Infection in patients is a
potentially life-threatening condition and without treatment
can prove fatal; simple timely intervention can be life saving.
The sepsis bundle has been adapted from the 2008 Surviving
Sepsis Campaign Guidelines for the Management of Severe
Sepsis and Septic Shock (Daniels R, 2009-2010 2nd edition).
The purpose of using the sepsis bundle is to ensure a safe,
standardised approach to the initial assessment of patients
with potential sepsis and their subsequent management
within the ward setting. Introduction of the sepsis care bundle
will equip medical and nursing teams with the knowledge and
understanding to recognise and promptly initiate treatment
to patients and therefore reduce the complications associated
with severe sepsis.
Papworth Hospital took part in the national audit of sepsis
care and management in May 2014 and the findings from this
audit are due to be published in November 2015.
Pressure ulcers
Pressure ulcers (PU) have been defined as ulcers of the skin
due to the effect of prolonged pressure in combination with
a number of other variables; including patient co-morbidities
and external factors such as shear and skin moisture. There
are four grades of PUs, ranging from 1 to 4, with 3 and 4 being
deep tissue injuries.
To facilitate the elimination of all avoidable PUs by the end of
2012, the NHS Midlands and East Strategic Health Authority
Cluster established a Programme Board Steering Group in
September 2011, which incorporated an expert working
group. These groups have now been re-established in 2014
and continue, and Papworth Hospital has representation on
both groups through the Nurse Consultant in Tissue Viability.
As part of this continued initiative, and the national agenda,
there is a requirement that all NHS organisations carry out
a Safety Thermometer harm free care audit every month to
collect prevalence data on any grade 2, 3, 4 PUs in the Trust on
census day. This replaced the quarterly PU prevalence audit
carried out within the Trust. However the Safety Thermometer
does not measure grade 1 PUs, nor does it distinguish if the
PU is avoidable or unavoidable, and it counts PUs twice if the
patient is long stay and is therefore included in subsequent
monthly audits. With this in mind we have reintroduced and
will continue Trust-wide PU prevalence audits, initially every
six months, to run alongside the Safety Thermometer monthly
audits.
Actual numbers of pressure ulcers
Grade
2
3
4 (highest severity
Number reported
2014/15
22
(18 unavoidable, 4 avoidable)
11
(9 unavoidable, 2 avoidable)
0
Number reported
2013/14
24
(13 unavoidable, 7 avoidable, 4 unknown)
4
(3 unavoidable)
0
Number reported
2012/13
32
11
(6 unavoidable)
0
Note for 2013/14: The avoidable/unavoidable decision form for Grade 2 pressure ulcers was new to the Trust during 2013/14
year hence the 4 unknown status number.
It is important to note that unavoidable pressure ulcers will not stay at a standard rate, and it is not appropriate to compare rates
year on year. This is because unavoidable pressure ulcers mainly occur in patients this Trust who have had complex cardiothoracic
surgery with long theatre times, and restrictions on repositioning when they are physically unstable in critical care. We have
looked at the RCA findings in this group of patients and the investigation did not identify any actions that could have prevented
in this sick group of patients. However, we did identify in the ECMO patients that the transfer trolley could be improved with an
overlay pressure redistributing mattress and this is now in place.
Initiatives for 2015/16 include:
•
•
•
•
•
Introduce a scrutiny panel for all avoidable grade 3 or 4
pressure ulcers developed in the Trust
Continue six monthly PU prevalence audits to run
alongside Safety Thermometer harm free care monthly
audits.
Continue the Root Cause Analysis (RCA) process for all
grade 2, 3 and 4 pressure ulcers developed within the
Trust; of note no grade 4 PUs have developed within the
Trust since the PU prevalence audit commenced in 2007.
Continue the Avoidable/Unavoidable decision chart for all
grade 2 PUs developed within the Trust.
Continue DATIX™ reporting for all grade 2, 3, 4 PUs
developed within the Trust, and all grade 2, 3 and 4s
admitted/transferred into the Trust.
•
•
•
•
The 72 hour alert form has now been discontinued by the
CCG, however the Trust has continued to report back (to
the source of the PU) any grade 3 and 4 PUs transferred
into the Trust, as it is recognised as good practice. The
Trust risk department carries out this function in tandem
with the nurse consultant in tissue viability.
Ensure that the rates of PUs developed at Papworth
Hospital continue to be displayed in all clinical inpatient
areas for patients, relatives and staff to see.
Have a standing agenda item in the Quality and Safety
Management meeting to report the PU rates.
Continue education on PU prevention, identification,
reporting and management in Trust-wide mandatory
training days.
Goals 2013/14
Outcome
Goal 2014/15
Outcome
Pressure ulcer prevalence audit
to continue 6 monthly, to run
alongside Safety Thermometer
monthly audits
Achieved and ongoing
To clearly identify in the reporting system
pressure ulcers that are medical device
related or developed on ECMO patients
Achieved and on-going
Continue a Trust wide action
plan for PU prevention based on
RCA learning
Achieved and ongoing
Introduce reporting of Grade 2 pressure
ulcers admitted to the Trust that were
developed outside of the Trust
Achieved and on-going
Introduce RCA learning to stat
and tech training
Achieved Jan
2014, and ongoing
To continue the Pressure ulcer prevalence
audit 6 monthly, to run alongside Safety
Thermometer monthly audits
Achieved and on-going
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Patient Safety Incidents
The number of reported patient safety incidents reported
to the National Reporting and Learning System (NRLS), has
shown an increase in 2014/15. The Trust position in relation
to organisations within its cluster remains average, indicating
a positive safety culture and openness to reporting within the
hospital.
Figure 1 shows a comparison of the actual and near miss
incidents reported by quarter. The trend line for actual
incidents remains upward, demonstrating a positive culture
of reporting incidents, with the total increasing to over 650 in
Quarter 4. This figure should be noted in conjunction with the
impact severity of the incidents detailed at Table 1.
Papworth Hospital has a robust mechanism in place for
reporting, investigating and managing Serious Incidents (SIs).
The Trust reported 7 SI’s in 2014/15 and no Never Events.
Actions arising from SIs are monitored for completion through
the Quality and Risk Management Group.
Figure 2 shows the impact severity of incidents reported and
97% of incidents reported are in the low or no harm category.
All patient safety incidents, where appropriate are reported to
the National Reporting and learning System (NRLS) and from
there to the Care Quality Commission (CQC).
Lessons learned from investigation of patient safety incidents
are published quarterly on the Trust’s web page to share
lessons learnt across the organisation.
700
600
500
Actual Incidents
400
Near Miss
300
Total
Linear (Total)
200
100
0
Q1 2012- Q2 2012- Q3 2012- Q4 2012- Q1 2013- Q2 2013- Q3 2013- Q4 2013- Q1 2014- Q2 2014- Q3 2014- Q4 201413
13
13
13
14
14
14
14
15
15
15
15
Figure 1: Patient safety incidents actual v. near miss (data source: DATIX™ 15/04/2015).
26
Figure 2: Patient safety incidents to Q4 2014-15 (Data source: DATIX™ 15/04/2015).
Patient safety incidents by type & quarter
Number of patient Incidents reported by severity 2014-15
Q2
13/14
Q3
13/14
Q4
13/14
Q1
14/15
Q2
14/15
Q3
14/15
Q4 14/15
Death
1
1
0
0
0
0
0
Severe harm
1
1
4
0
0
0
0
Moderate harm
30
34
20
37
32
22
17
Low, minimal, no harm
409
379
429
508
505
599
633
Total
441*
415
453*
548*
535*
621*
650*
Table 1: Incidents by severity *revalidated figures (data source: DATIX™ 15/04/2015).
27
Reducing falls and reducing harm from falls
Falls prevention remains a top priority for the Trust and
is monitored through incident reporting and the Safety
Thermometer. 96% of the patient falls reported resulted in
no or low harm demonstrating a good reporting culture and
review of falls risks in the Trust. Of the remaining 4% who
suffered harm, one resulted in a fracture and was transferred
to A&E for further assistance; others required medical
intervention and an increase length of stay in hospital. The
table below demonstrates the number of falls per quarter
across the year. There were a total of 195 incidents of patient
falls reported via DATIX™ during 2014/15, an increase on
the previous year. The monitoring of completion of falls risk
assessments continues through the Trust falls group which
meets quarterly.
Quarter 1
Quarter 2
Quarter 3
Quarter 4
Total
2010/2011
51
50
44
40
185
2011/2012
50
39
33
64
186
2012/2013
42
57
44
61
204
2013/2014
54
33
34
35
156
2014/2015*
44
42
46
63
195
Data source: DATIX™ at 6 May 2015.
47 patients suffered harm from falls of which 39 (83%) were graded as green meaning that there was minor injury such as a
bump or bruise. Three were graded as yellow (meaning moderate injury) and five were graded as orange incidents. The definition
of orange incidents in relation to falls is where there is harm which requires further medical intervention, and +/- increased
length of stay. All incidents were subject to full root cause analysis.
Embedding initiatives introduced in 2014/15;
New initiatives and projects in progress are:
•
•
•
•
•
•
•
Physiotherapy review and assessment following all falls to
help prevent further falls.
Physiotherapist are identifying patients at risk of falling
and are educating them in order to minimise falls and
manage risk.
Red blanket alert, to identify patients at high risk of falls.
This blanket then goes with the patient when moving out
of the department, for example to x-ray, alerting staff to
be more vigilant.
Non slip socks introduced.
Estates have upgraded the environment in many problem
areas.
Falls week March 2014; a week of educational
opportunity and development to increase the knowledge
and skills of ward staff in preventing and managing
patient falls and in raising awareness of policies in
practice.
•
•
•
•
•
•
•
•
28
Development of an abbreviated RCA to support
investigation and learning opportunities from patient falls.
The introduction of ‘intentional rounding’ across the Trust
supporting the identification of patients at risk of falls
and implementing care to manage and minimise risk. An
audit of the rounding process in practice was undertaken
and the learning shared with ward teams. Audit results
highlighted areas for improvement in identifying patients
at risk and their care requirements by utilising the
bedside and Patient Status at a Glance board (PSAG) and
magnetic icon system.
An intention to record mobility and falls risk on
the electronic nursing handover sheets to improve
identification of and communication about patients at risk
of falling will be explored.
Review of equipment on the market to alert staff of
patients known to be at risk of falling who are noncompliant in seeking assistance.
Falls group review of patient incidents to share practice
of learning from incidents and so develop as a learning
organisation.
Review of the falls documentation, to simplify process
and improve compliance.
Falls champions have been introduced in each clinical
area.
The specific care needs of patients with delirium and
dementia have been identified through ongoing care
pathway reviews and education of dementia friends
commenced within the Trust as this is known to be a high
risk group for falls.
The development of the clinical customer service
apprenticeship scheme is being planned to start in
2015/16.
Prevention of venous thromboembolism (VTE)
VTE prevention remains a clinical priority for the NHS and is
well established in the daily routine clinical care of patients
within the Trust. Papworth Hospital was previously recognised
in 2013 with a national award from Lifeblood: The Thrombosis
Charity, for best VTE Prevention Programme.
The NHS Standard Contract for Acute Services introduced
the requirement for a root cause analysis (RCA) on all VTE
episodes identified in inpatients and patients discharged
within 90 days. The Trust is compliant with this requirement
and has conducted RCAs on all VTE events known to the Trust
to date since September 2010. In 2014/15, 27 VTE events
were subject to RCA (compared with 28 in 2013/14) and all
were deemed to be unavoidable. The majority of VTE events
in surgical patients were hospital associated as opposed to
those that occurred in medical patients whereby over half
were community acquired. This is not an unexpected finding
due to the additional risks associated with surgery.
RCA findings have contributed to further developments in VTE
prevention including:
•
•
•
A greater awareness about VTE prevention amongst the
multi-disciplinary team
Changes in the nursing documentation to evidence the
use of mechanical prophylaxis
Collaborative working with pharmacists to monitor
chemoprophylaxis
Actions are reported to and monitored quarterly by the
Quality and Risk Management Group.
It is acknowledged nationally that the ability to monitor
hospital acquired thrombosis and identify the critical
underlying reasons is heavily reliant on manual processes.
Furthermore, the lack of standardisation makes national data
collection and interpretation challenging. As an Exemplar
Centre for VTE prevention, Papworth Hospital had been
working with leads at other exemplar sites to develop a
national database to facilitate structured and standardised
RCAs. Although, funding for this has not been possible in light
of stringent financial controls at NHS England, it is possible
that an electronic tool for collection and analysis of RCA data
will be available for Trusts but a licence fee will be required.
The table below illustrates the percentage of patients who were risk assessed for VTE on admission to Papworth Hospital
% of inpatients risk assessed for VTE
April 2014
Q1
98.6
May 2014
98.6
June 2014
97.2
July 2014
Q2
98.4
September 2014
98.8
Q3
98.3
December 2014
98.6
Q4
98.4
98.5
November 2014
January 2015
98.1
98.1
August 2014
October 2014
Quarterly %
98.5
98.3
February 2015
99.1
March 2015
97.7
98.4
Data source: UNIFY database as reported in Quality and Risk Management Group Report.
Monthly prevalence audit of the appropriateness of VTE prophylaxis is ongoing and reported quarterly to the Quality and Risk
Management Group. As illustrated in the table below, 447 patient records have been reviewed since April 2014 to March 2015
and all patients were considered to have received appropriate prophylaxis apart from one patient who had declined to wear antiembolism stockings against the advice of the medical and nursing team.
29
Quarter
1
2
3
4
Month 14/15
% Appropriate prophylaxis
Average over quarter
April
100% (31/31)
Q 1: 88 sets of notes reviewed
100% patients received appropriate prophylaxis
May
100% (28/28)
June
100% (29/29)
July
100% (41/41)
August
100% (42/42)
September
100% (25/25)
October
100% (48/48)
November
100% (52/52)
December
100% (38/38)
January 2015
100% (41/41)
February
97.6% (41*/42)
March
100% (30/30)
Q 2: 108 sets of notes reviewed
100% patients received appropriate prophylaxis
Q3: 138 sets of notes reviewed
100% patients received appropriate prophylaxis
Q4: 113 sets of notes reviewed
99.2% patients received appropriate prophylaxis (*one patient
declined to wear anti-embolism stockings against advice)
Reported in Quality and Risk Management Group Report.
Sign up to Safety
Sign up to Safety is a new national patient safety campaign
that was announced in March 2014 by the Secretary of State
for Health. It launched on 24 June 2014 with the mission to
strengthen patient safety in the NHS and make it the safest
healthcare system in the world. The five Sign up to Safety
pledges are:
1. Put patients first
2. Continually learn
3. Being honesty
4. Collaborative working
5. Being supportive support
The campaign aims to reduce avoidable harm to patients
by 50% in the next three years. All NHS organisations are
encouraged to sign up to the initiative and commit to develop
their own 3 -5 year safety improvement plans.
30
Papworth has signed up to the campaign and the key areas
the Trust will be focussing on for 2016 are:
• Risk assessment for, and management of, acute kidney
injury (AKI).
• Structure a formal handover process within Thoracic
Medicine Directorate.
• Medicines Safety 1 (reducing prescription errors and
unintentional omissions on one ward).
• Medicines Safety 2 (reduce errors related to iv-drugs by
50% by 2017 on one ward).
• Measure and reduce peri-operative complications with a
specific focus on complex aortic surgery.
• Improve physiological assessment in patients with
Duchenne Muscular Dystrophy.
As part of the Sign up to Safety campaign Trusts were invited
to bid for funding from the National Health Service Litigation
Authority (NHSLA) to support the above safety improvement
plan. The NHS LA received 243 bids from 126 members.
The number of bids approved for receiving funding of up to
10% of their contribution was 67. The bids were assessed
against the criteria that all trusts were asked to comply with
to demonstrate that they had prepared a credible bid which
evidenced how they would reduce harm and claims. Papworth
Hospital has been allocated £34, 305 to be used specifically to
support the projects outlined above.
Safe
Care Quality
Commission (CQC)
Inspections
The CQC carried out an announced inspection
on the 3 and 4 December 2014 and following
standard practice, an unannounced inspection took
place on 14 December 2014. The CQC looked at all the
inpatient services, including the Progressive Care Unit and
the outpatients department. The CQC talked with patients
and staff from all the ward areas and outpatients services. The
CQC observed how people were being cared for, talked with carers
and/or family members, and reviewed patients’ records.
Overall
GOOD
Good
Effective
Outstanding
Caring
Outstanding
Responsive
Good
Well-led
Good
The full report is available on the
CQC website at www.cqc.org.uk/
sites/default/files/new_reports/
AAAB8933.pdf
Overall the CQC found that the hospital provided highly effective care
with outcomes comparable with or above expected standards. The service
was delivered by highly skilled, committed, caring staff and patients were
overwhelmingly positive about the care they received at the hospital. However,
there were areas in which Papworth could improve and action plans have been
put in place to address these. The Trust received an overall rating of good with
areas of outstanding practice.
31
32
Patient
experience domain
‘My name is’ campaign
Nurses and other frontline NHS staff are being asked to tell
their patients their name, as part of a national campaign
launched by a terminally ill doctor on the popular social media
website Twitter.
The ‘hello my name is’ campaign was started by Dr Kate
Granger after she became frustrated with the number of staff
who failed to introduce themselves to her when she was an
inpatient with post-operative sepsis. Dr Granger, has terminal
cancer but continues to work as an elderly medicine registrar.
Since leaving hospital, she has started a campaign on Twitter
asking NHS staff to make a pledge to introduce themselves in
future to their patients.
Papworth proudly joined the ‘hello my name is’ campaign in
January, not only to show support but also to highlight the
good work around the hospital as staff pride themselves on
patient centered-care. By the end of March 2015, over 100
staff had taken part and many pictures featuring them holding
their handwritten name are displayed on the Papworth
Hospital Facebook page. All staff new to the Trust now have
‘Hello my name is’ printed above their name on their ID
badge.
Patients and Carer Experience Strategy
The Patients and Carer Experience Strategy has been
developed to be explicit about our ambitions to ensure that
patients are at the heart of everything we do. An action
plan detailing our ambitions has been formulated and will
be monitored through the Patient and Public Involvement
Committee who report to the Council of Governors with
escalation to the Board of Directors if there are concerns. The
actions planned are:
•
•
•
•
•
Increase the use of patient stories by describing a patient
story at ward, business unit and board level meetings in
the future.
Understanding more clearly from our patient experience
why we do what we do well and how we can better hold
to account and action plan when things go wrong.
Increase patient involvement when planning care and
services.
Promote more involvement of patient experience panel
members.
Publish patient experience data (safety, experience
and improvement) in a format that’s understandable
by all. We have signed up to Open and Honest Care,
a programme led by NHS England Midlands and East
to display patient experience in a readable form, two
clicks away from the Hospital public website home page.
Papworth Hospital is an implementation site for this
programme.
New
mobile
diagnostic
equipment
Patients are
benefiting from stateof-the-art diagnostic
equipment that detects
difficulty with swallowing.
The Speech and Language Therapy
team is now able to carry out detailed fibre
optic endoscopic evaluation of swallowing (FEES)
using new kit funded by Papworth Hospital Charity
supporters.
The £50,000 device will improve the assessment of patients’
swallowing abilities and subsequently improve rehabilitation
efforts - giving patients a better quality of life. Traditionally
the team would assess a swallow using detailed observation
of symptoms and occasionally X-raying their swallow. X-ray is
only available to certain patients who are able to get to the
X-ray department but the new equipment is mobile and can
be taken to the patient’s bedside.
The Speech and Language Therapy Lead, said: “This new
equipment will transform the way in which we assess and
rehabilitate our patients as we and our patients can visualise
where the physiology is breaking down and then work
together to manage it effectively. We hope that this service
will also be available to outpatients in the future.”
Cancer - 62-day wait for first treatment from
urgent GP referral
Background
This is the percentage of patients receiving first definitive
treatment for cancer within 62 days of an urgent GP referral
for suspected cancer.
Papworth Hospital is the tertiary centre for lung cancer in
the west half of the Anglia region. Patients seen by their GP
with suspected lung cancer are referred first to their local
district general hospital, and then onto Papworth for further
investigation and treatment if lung cancer seems likely, and
if the recommended treatment is likely to be potentially
curative.
33
Like all other hospital trusts, Papworth is expected to treat
85% of patients referred on a ‘fast track’ pathway with
suspected lung cancer within 62 days of referral. The main
treatment modality delivered at Papworth is thoracic surgery.
Patients who require chemotherapy, radiotherapy or other
treatments are treated at Cambridge University Hospitals or
at their referring trust. In previous years, the target for the
proportion of patients treated within 62 days at Papworth
hospital for lung cancer treatments was 79%. This lower target
was in recognition of the fact that lung cancer is a particularly
complex cancer to treat, and that patients suitable for surgical
treatment require the most complex work-up prior to surgery.
Since 2013/14, Monitor has removed the lower target, and we
are expected to treat 85% of patients within 62 days.
Where patients are referred to Papworth after day 62, the
Network has an agreement that these breaches can be
reallocated to the referring hospital, although these are not
reflected in the nationally reported figures.
Performance against the 62-day target
For the first two quarters of 2014/15, Papworth failed to
achieve its cancer waiting time targets for 62-day patients.
These are shown in the table below. For each patient for
whom the target was breached, a full root cause analysis
was undertaken to understand the reasons for the breach.
Papworth also failed to achieve this target for the first three
quarters of 2013/14 and figures for 2013/14 are therefore
also provided below. The Target was achieved in Q3 and
Q4 of 2014/15, but it is not possible to be confident that
this represents a trend, as the numbers of patients remain
small and the majority of the breach reasons remain outside
Papworth’s control.
For the purposes of cancer waiting times where patients
are seen a multiple hospitals, a patient is spilt between the
‘first seeing’ hospital and the treating hospital. The network
pathway means that Papworth is not the first Trust to see
any patients and therefore Papworth is only accountable for
50% of any pathway. This means the numbers of treatments
Papworth records is very small.
Year to Date Performance - Q4 2014/15.
1. 62 day patients (urgent GP referral)
2. 62 day patients (including re-allocations)
Target = 85%
Target = 85%
Total treated
Breaches
%
Total treated
Breaches
%
Apr-14
4
0.5
87.5%
4
0.5
87.5%
May-14
3
1
66.7%
3
1
66.7%
Jun-14
3.5
1
71.4%
3
0.5
83.3%
Q1*
10.5
2.5
76.2%
10
2
80.0%
Jul-14
6.0
2.0
66.7%
5.0
1.0
80.0%
Aug-14
5.0
1.5
70.0%
4.0
0.5
87.5%
Sep-14
3.5
2.0
42.9%
2.0
0.5
75.0%
Q2
14.5
5.5
62.1%
11.0
2.0
81.8%
Oct-14
5.5
1.5
72.7%
4.5
1.0
77.8%
Nov-14
2.0
0.5
75.0%
2.0
0.5
75.0%
Dec-14
3.5
0.0
100.0%
3.5
0.0
100.0%
Q3
11.0
2
81.8%
10
1.5
85.0%
Jan-15
4.5
1.0
77.8%
4.0
0.5
87.5%
Feb-15
2.0
0.5
75.0%
2.0
0.0
100.0%
Mar-15
4.5
1.0
72.8%
4.0
0.5
87.5%
Q4
11.0
2.5
77.3%
10.0
1.0
90.0%
Year
47.0
12.5
73.4%*
41.0
6.5
84.1%
Data source: Column 1 - Results as reported on Open Exeter (as of 11/5/15). Column 2 reflects reallocations which have been
agreed under the Anglia Cancer Network Inter Provider Transfer Policy, which are not included on Open Exeter.
A This indicator has been subject to independent assurance. PwC’s assurance report can be found in Annex 3. For the
*⃝
definition of this indicator please see Annex 4. 2013/14 Comparative Quarterly data.
34
1. 62 day patients (urgent GP referral)
2. 62 day patients (including re-allocations)
Target = 79% (85% national)
Total treated
Breaches
%
Total treated
Breaches
%
Q1*
17
9
47.1%
17
9
47.1%
Q2
30
7
76.7%
31
8
74.2%
Q3
22
6
72.7%
23
7
69.6%
Q4
20
2
90.0%
19
1
94.7%
Year
89
24
73.0%
90
25
72.2%
Data source: column 1 - Open Exeter as at 9 May 2014. Column 2 reflects reallocations which have been agreed under the Anglia
Cancer Network Inter Provider Transfer Policy, which are not included on Open Exeter.
Safer staffing initiatives
National Care Certificate
Following the reports of the Francis Inquiry and the Berwick
Review into Patient Safety, the Chief Nursing Officer for
England has worked with the National Quality Board (NQB)
to produce a guide to nursing, midwifery and care staffing
capacity and capability.
For over 10 years, Papworth has provided accredited training
for Health Care Support Workers (HCSWs) in the form of a
structured induction and the HCSW Clinical Development
Programme (CDP).
The NQB has set out the immediate expectations of NHS
providers in providing safe staffing levels. The guide brings
together tools, resources and examples of good practice as
a practical guide to help NHS providers and commissioners
ensure that the right people, with the right skills are in the
right place at the right time.
The Trust has successfully completed all returns to Unify
for safer staffing with the compliance target of 90% fill rate
achieved 100% of the time as an average across the Trust.
All areas comply with displaying expected and actual staffing
numbers in public areas and have started to report red flag
events.
The Board of Directors receives a monthly update of the
percentage of vacancies and a report about initiatives to
continuously improve this. The Trust has carried out two
formal establishment reviews as planned this year using the
Nursing Hours per Patient Day (NHPPD) tool and commenced
implementation of continuous monitoring for all ward areas.
Psychiatric support
A dedicated liaison psychiatry service has been launched
this year in the Trust. Patient across the site have access to
the new service led by a consultant in psychiatry. Prior to
this service launching, mental health services were offered
in Cystic Fibrosis and Transplant, however the new service
means that teams can make a referral for any inpatient who
they feel will benefit from the service.
The service is open to inpatients whose mental health is
impacting on their recovery. This can range from adjusting to
major life changing events to living with chronic conditions.
The CDP comprises four modules which form the first year of
the two-year Foundation Degree accredited by Anglia Ruskin
University. Module 1 of the established CDP combined with
the structured induction meets the requirements of the
National Care Certificate and has been mandatory training for
all HCSWs joining the Trust for over five years.
The Trust is able to demonstrate that both the recruitment
and training of HCSWs is both consistent and robust and
exceeds the requirements set out in the Cavendish Report,
which made a number of recommendations on how the
training and support of healthcare assistants could be
improved, including the introduction of a standard ‘certificate
of fundamental care’ before they can care for people
unsupervised.
Patient Led Assessments of the Care Environment
(PLACE) Programme 2014
PLACE was introduced in 2013 as the new system for assessing
the quality of the patient environment, replacing the former
Patient Environment Action Team (PEAT) inspections. The
assessments apply to both the NHS and independent/private
healthcare sector in England.
The PLACE programme aims to promote the principles
and values of the NHS in England established in the NHS
Constitution including:
• Putting patients first;
• Actively encouraging feedback from the public, patients
and staff to help improve services;
• Striving to get the basics of quality of care right;
• A commitment to ensure that services are provided in a
clean and safe environment that is fit for purpose.
The assessments are undertaken on an annual basis focusing
on the areas which patients say matter and encourage the
involvement of patients, Governors, the public and other
bodies with an interest in healthcare (e.g. Local Healthwatch).
35
They go into hospitals as part of a team to assess how the
environment supports patients’ privacy and dignity, food,
cleanliness and general building maintenance. It focuses
entirely on the care environment and does not cover clinical
care provision or how well staff are doing their job. The
assessment took place on 2 May 2014 and the inspection
team consisted of a mix of patient assessors and Trust staff
including Matrons.
The results below show Papworth Hospital’s scores (in blue)
and the national average (in purple). Papworth achieved
improvements in three out of the four areas and all three
were above the national average. Actions identified have
been reported to the Trust’s Operational Executive Group and
monitored through contract meetings.
Source: Health and Social Care Information Centre.
More information can be obtained on the Health and Social Care Information website.
National outpatient survey
There has been no National Outpatient Survey since 2011. Papworth achieved excellent results in this; see previous Quality
Accounts available on the Papworth web site at www.papworthhospital.nhs.uk/content.php?/about/governance/our_
performance_and_annual_report
36
Clinical
effectiveness of
care domain
Respiratory Extra Corporeal Membrane
Oxygenator (ECMO)
Papworth Hospital is one of five centres in the country to
provide the highly specialised Respiratory Extra-Corporeal
Membrane Oxygenation (ECMO) service, including specialised
retrieval of patients from referring hospitals.
ECMO supports adults with severe potentially reversible
respiratory failure by oxygenating the blood through an
artificial lung machine. The extracorporeal life support is used
to replace the function of failing lungs, usually due to severe
inflammation or infection. ECMO is used to support patient
groups with potentially reversible respiratory failure such as
Acute Respiratory Distress Syndrome (ARDS) sometimes seen
in patients with community-acquired pneumonia or seasonal
flu.
ECMO is a technique that oxygenates blood outside the body.
It can be used in potentially reversible severe respiratory
failure when conventional ventilation is unable to oxygenate
the blood adequately. The aim of ECMO in respiratory failure
is to allow the injured lung to recover whilst avoiding certain
recognised complications associated with conventional
ventilation. It is high risk and is only used as a matter of last
resort in difficult cases. The procedure involves removing
blood from the patient, taking steps to avoid clots forming in
the blood, adding oxygen to the blood and removing carbon
dioxide, then pumping the blood back in the patient.
ECMO is a complex intervention, which is only performed
by highly trained specialist teams including intensive care
specialists, cardiothoracic surgeons, and specialists in
perfusion as well as ECMO-trained nurses.
ECMO is a form of support rather than a treatment and its aim
is to maintain physiological homeostasis for as long as it takes
to allow the lung injury or infection to heal. This usually means
a support time between five and 14 days but sometimes
ECMO support is required for longer.
As a tertiary cardiothoracic centre, Papworth Hospital has
been providing specialist ECMO services (both respiratory
and cardiac) for a number of years to patients such as those
undergoing heart or lung transplantation. The hospital is
registered with the international Extracorporeal Life Support
Organisation (ELSO) and is renowned for its experience using
ECMO.
This
long
experience
in providing
a high-quality
ECMO service
is recognised in
the success of the
residential Papworth
ECMO course that attracts
national and international
delegates, with more than 200
delegates from 5 continents having
attended to far.
From December 2011 the service provided by
Papworth became part of the national network of
services across England, and now provides a year-round
ECMO service, including the retrieval on ECMO of patients
from the referring hospital by a dedicated team.
Papworth works very closely with the other 4 national ECMO
centres to ensure all patients in England have immediate
access, all week long and at any time of the day or night,
irrespective of their location. The consultant Intensivist
provides specialist advice by phone to referring centres when
patients are not deemed suitable for ECMO. To ensure best
practice across many hospitals, Papworth is now inviting team
members of all referring intensive care units to attend a yearly
meeting to review indications and outcomes, and share areas
of best practice.
The first meeting of this kind was held in December 2014
in Cambridge and allowed the multi-disciplinary teams
to comment on the service offered at Papworth. The day
generated much discussion will improve the ongoing
collaboration between the Papworth ECMO team and
referring hospitals.
In 2014 the service expanded to include a follow up clinic. All
patients are seen 6 months after discharge from Papworth
by a consultant in respiratory medicine or intensive care, and
an ECMO specialist nurse. The aim of the clinic is to provide
ongoing support where required, evaluate their respiratory
function to ensure best treatment is offered and measure
quality of life after ECMO to allow us to refine how we deliver
the service.
37
Summary of ECMO activity at Papworth Hospital since December 2011 - March 2015
Year
Referrals
Accepted
Supported
with ECMO
Survival to
discharge*
(ECMO)
Survival to
discharge* (all
accepted)
30 day survival
(ECMO)
30 day survival
(all accepted)
Dec 2011/12
25
15
10
50%
66%
50%
66%
2012/13
111
28
22
68%
75%
64%
71%
2013/14
116
35
32
75%
77%
71%
71%
2014/15
148
40
37
80%**
79%**
77%
76%**
*Discharge from Papworth
**Excludes 2 patients still supported on ECMO
Whilst difficult to compare due to the multiple conditions
treated and the absence of risk stratification, survival is in
keeping with international figures (ExtraCorporeal Life Support
Organisation registry shows in January 2015 a survival of 65%
for patients supported with respiratory ECMO).
The Lead ECMO nurse who has been instrumental in setting
up the service, including establishing pathways and protocols
for receiving and collecting patients, as well as ensuring
consistent standards for infection control, has recently been
announced as the winner in the Nursing Standard Awards
2015 in the category for Innovations in Respiratory care.
Following short-listing she was invited to present her work
which included explaining how family liaison has improved
significantly since the service began, helping patients and
their families to come to terms with their experience through
access to nurse-led follow-up clinics.
Pulmonary endarterectomy
Pulmonary Hypertension (PH) is a rare disease of the lungs
in which the blood pressure in the pulmonary artery, the
large blood vessel carrying blood from the right side of the
heart to the lungs, is raised above the normal level. It is a
serious disease that leads to right heart failure and premature
death. Patients usually present with symptoms of exertional
breathlessness and as there are no specific features, the
diagnosis is usually made late in the disease process.
Chronic thromboembolic pulmonary hypertension (CTEPH) is
one type of PH and is important to recognise as it is the only
form of PH that is potentially curable.
The disease begins with blood clots, usually from the
deep veins of the legs or pelvis moving in the circulation
and lodging in the pulmonary arteries (this is known as a
pulmonary embolism). In most people these blood clots
dissolve and cause no further problems. In a small proportion
of people the blood clots partially dissolve or don’t dissolve at
all and leave a permanent blockage in the pulmonary artery
leading to CTEPH.
The pulmonary endarterectomy operation removes the inner
lining of the pulmonary arteries to clear the obstructions and
to reduce the PH back to normal levels. This allows recovery
of the right side of the heart with a dramatic improvement
in symptoms and prognosis for the patient. The operation is
38
complex and requires a long time on the heart lung machine
with the patient cooled to half normal body temperature, and
periods of circulation arrest when the blood volume is drained
out to give a clear view inside the pulmonary arteries.
Since 2000 Papworth hospital was commissioned to provide
this surgery for the UK, and since 2001 it was also designated
as one of the seven adult specialist PH medical centres. With
better understanding of the disease, CTEPH is increasingly
recognised in the UK, but still probably remains under
diagnosed.
Over the last few years there has been a large increase in
pulmonary endarterectomy surgery at Papworth and the
hospital has been at the forefront of developments in this
field with multiple research publications and participation in
international conferences. Doctors from all over the world
visit regularly to learn the operation and Papworth Hospital
surgeons have also travelled to assist surgeons in their own
hospitals.
A change has been successfully introduced to the patient care
management in the critical care setting post operatively with
those patients who are stable being weaned from sedation
and ventilation so allowing return to the progressive care unit
within a day of surgery.
The introduction of a progressive care unit (PCU) within
the surgical care pathway has benefited the PEA patients in
providing an environment where there is a high dependency
care provision but in a less intimidating and less intensive
care area which has been of benefit to the experience of both
patient and their families.
In 2014/15 Papworth performed 148 PEA operations and has
maintained the operative mortality between 2-3%, only just
higher than that for standard cardiac surgery in the UK.
A Papworth development that has been of benefit to patients
nationally is the status of Papworth as a specialist centre for
ECMO. Within the last year two patients has been retrieved on
ECMO from other centres with severe CTEPH, undergone PEA
surgery and experienced uneventful post-operative recoveries
and subsequent discharge home.
The PEA specialist nurses in conjunction with AHP colleagues
and the discharge co-ordinator meets one to three monthly to
A Patient Reported Outcome Measure (PROM) has been
completed within the PEA service in the last year, the collated
report will now be shared with service stakeholders and
information used to drive service improvement further for
users of the service.
Transcatheter Aortic Valve Implantation (TAVI)
Innovation and expertise has meant that a specialist valve
replacement service at Papworth is treating people more
effectively than ever before. Just over a year after Papworth’s
TAVI team was given national recognition, the service
continues to evolve. TAVI is a procedure to replace a diseased
aortic valve without open heart surgery via a minimally
invasive approach, ideally via the leg arteries. It offers an
alternative to conventional heart valve surgery for patients at
high or prohibitive risk.
When the program started, every patient had a general
anaesthetic but it is now becoming routine for patients to
have the procedure whilst awake using conscious sedation and
regional anaesthesia. This approach shortens the operation,
reduces risk and recovery time, accelerates mobilisation
and allows earlier discharge. Some patients have same-day
admission with discharge just two days later. As the service
develops, it is becoming increasingly similar to coronary
angioplasty.
State-of-the-art CT scanner
A new generation of CT scanner which captures 4D images of
the heart and lungs was officially opened on 18 December by
Cambridge MP Dr Julian Huppert. The £1.5 million Siemens CT
scanner, called the SOMATOM Force is the first of its kind in
the UK - enhancing diagnostic services for cardiac patients.
The scanner, which is one of only a few in the world, will not
only improve diagnostic care at Papworth Hospital with stateof-the-art scanning technology but also dramatically reduces
the level of radiation patients are exposed to - just a fifth of
the average CT scanner. This will open up the use of the CT
scanner to more patients including those with shortness of
breath, who would otherwise have been deemed unsuitable
for such a scan.
One of the Trust’s Consultant Radiologist’s said: “This exciting,
cutting-edge scanning technology will enhance diagnosis
in a wide range of patients with significantly decreased
radiation dose and with much shorter scanning times, further
increasing the utility of CT in patients who were previously
unsuitable for CT.” The time required for scanning is reduced
considerably and therefore this increases the number of
patients who can be seen during clinics at Papworth. Both the
speed and definition of this new scanner allows it to capture
high definition images of the heart while it beats making it
perfect for cardiothoracic diagnostics and research. It will be
used for a variety of cardiac procedures including coronary
artery bypass grafts, pre-TAVI and pre-ablation and will also
be used for thoracic procedures such as thoracic oncology and
pulmonary vascular diseases.
Cambridge International VATS Symposium
Papworth Hospital’s thoracic
team became the first in the UK
I N T E R N A T I O N A L
to perform a new anaesthetic
technique in major thoracic
surgery together with a visiting
surgeon from Spain. The procedure was a minimally invasive
video assisted thoracic procedure (VATS) using just local
anaesthetic and sedation allowing the patient to recover
more quickly with minimal post-operative risks. Traditionally
patients are given a general anaesthetic for this minimally
invasive procedure and have a breathing tube inserted to
ventilate both lungs.
CAMBRIDGE
VATS
SYMPOSIUM
review patient feedback and refresh the care pathway for PEA
patients. The pathway was analysed and new opportunities
for early referral and engagement of specialists recognised.
An algorithm for assessment and use in identifying complex
elements of care including; physical, psychological and social
needs has been developed. This development has helped
the MDT to recognise and anticipate delays in discharge
and has improved the patient experience through better
communication. This learning has informed the development
of the PEA check list which is expected to be implemented
early in 2015/16.
A live case was streamlined to delegates at the Cambridge
International VATS Symposium with ongoing commentary. The
Consultant Thoracic Surgeon explained how this demonstrated
‘the way in which staff at Papworth Hospital embrace
innovation and push the boundaries to continue improving
the way we treat and care for our patients as well as sharing
knowledge and expertise with colleagues all over the world’.
A dedicated nursing course was run in parallel to the
symposium which attracted nurses from across the world.
It involved interactive sessions on enhanced recovery, preoperative preparation, assisting with minimally invasive
surgery, advanced communication skills, potential postoperative complications and management and pulmonary
rehabilitation post thoracic surgery.
More information about the next symposium can be found at
www.cambridgevats.com
Delivery of harm free care
Harm free care is defined by the absence of pressure ulcers,
falls, venous thromboembolism (VTE) and catheter-associated
urinary tract infections (CAUTI) and uses the NHS Safety
Thermometer (a point of care survey instrument) whereby
teams measure and report harm and the proportion of
patients that are ‘harm-free’ during one day each month.
The table below show the percentage of inpatients at
Papworth Hospital over the last year who were harm-free
Patient Safety Thermometer
The NHS Safety Thermometer continues to feature in the
national CQUINS this year but the emphasis is on reducing
the number of avoidable grade 2, 3 and 4 pressure ulcers. The
Trust will continue the monthly report of the delivery of harm
free care via the UNIFY database.
39
Health and Social Care Information Centre as at 22/04/2015.
Monitoring mortality
Monitoring of mortality among patients in hospital is
important, as this is an indicator of care standards and other
patient outcomes. Non-specialist Trusts rely on mortality
indicators such as the Summary Hospital Mortality Rate
(SHMR) but these are inappropriate for a specialist cardiac
hospital such as Papworth Hospital. Nevertheless, there are
areas of our clinical practice in which good, validated and riskadjusted benchmark data exist against which our results can
be compared. This applies particularly in the areas of adult
cardiac surgery and interventional cardiology.
Heart attack is common and remains a major cause of death
and ill health. Prompt appropriate treatment reduces the
likelihood of death and recurrent heart attack. Specialist
treatment, combined with cardiac rehabilitation, leads to
better outcomes and optimal quality of life. Heart attack, or
myocardial infarction, is part of the spectrum of conditions
known as acute coronary syndromes (ACS). This term includes
both ST-elevation myocardial infarction (STEMI), for which
emergency reperfusion treatment, with primary percutaneous
coronary intervention (primary PCI) or thrombolytic drugs,
is beneficial, and non-ST-elevation myocardial infarction
(nSTEMI), which represents the majority, and for which a
different approach is required. (Source: MINAP Annual public
report April 2013 - March 2014.)
30 day unadjusted mortality rates for STEMI patients admitted to hospital between 2011-14
Primary PCI capable centres
Number
30 day mortality (%)
All
63,408
7.2%
Papworth Hospital
1,569
6.3%
In all specialties, mortality and morbidity among patients is reviewed at regular mortality and morbidity meetings, so that, where
appropriate, lessons can be learned from each case and action plans developed. The action plans are followed up through the
Quality and Safety Management Group.
40
Adult Cardiac Surgery
Figures, published in January 2015, from the Society for
Cardiothoracic Surgery (SCTS) in Great Britain and Ireland
revealed that Papworth Hospital have carried out the largest
number of major heart operations in the country with the
lowest mortality rate over the last three years. More than
5,500 heart surgery cases have taken place at Papworth
Hospital between 1 April 2010 and 31 March 2013. This
figure does not include heart transplants and implantation of
artificial heart devices which also take place at Papworth.
The figures on the SCTS website also show that Papworth
has the best cardiac surgery outcomes in the country
while treating some of the highest risk patients - with a
1.54% risk adjusted mortality rate for 5,504 procedures.
The most recent hospital figures also show that mortality
for coronary artery bypass at Papworth Hospital is now
below 1%, and that includes repeat, emergency and salvage
operations (http://scts.org/patients/hospitals/centre.
aspx?id=5&name=papworth_hospital_foundation_trust).
The Director of Surgery at Papworth Hospital said: “These are
excellent figures of which we are truly proud. Heart surgery at
Papworth Hospital is a world-leading service and our results
reflect the very high standards not only of our surgeons and
anaesthetists, but also the nurses and other staff groups
involved in delivering care to our patients.”
The Interim Medical Director of Papworth Hospital said:
“I am delighted that the team working between our heart
surgeons, operating theatre staff, anaesthetists, intensive care
unit and ward staff has led to these excellent outcomes for
our patients. While there is no room for complacency, the
mortality from heart surgery at Papworth is significantly lower
than the national average.”
Data for period April 2010 - March 2013
Risk adjusted in-hospital mortality rate
41
42
Overall quality
performance
against Trust selected
metrics, national priorities and
CQC standards
Performance of Trust against selected metrics
Throughout 2014/15 we have continued to measure our quality performance
against a number of metrics. Table A sets out our performance against those
national targets Monitor requires Foundation Trusts to report against on a quarterly
basis, for ease of reference all indicators applicable to Papworth Hospital are included
even if referred to elsewhere in the Quality Report. Table B below sets out our performance
against other Department of Health national priorities and a range of local priorities.
Table A
Performance
2012/13
Performance
2013/14
Ceiling target
2014/15
Performance
2014/15
Maximum 18 weeks from referral to treatment for
admitted patients
92.4%
91.3%
>90%
90.93%
Maximum 18 weeks from referral to treatment for
non-admitted patients
97.9%
98.1%
>95%
97.87%
Maximum 18 weeks from referral to treatment for
incomplete pathways*
93.8%
93.5%
>92%
93.5%
Cancer - 62 day wait for first treatment from GP
referral**
82.1%
72.2%
85%
84.1% (following
reallocations)
Cancer - 31 day wait from diagnosis to first
treatment
98.7%
98.5%
96%
95.8%
Cancer - 31 day wait for second and subsequent
treatment***
100%
94.6%
94%
93.9%
Clostridium difficile - year on year reduction
7
4
4
3
Compliance with the requirements regarding
access for people with learning disability
Achieved
Achieved
Compliance
Achieved
Acute Targets - national requirements
A This indicator has been subject to independent
*⃝
assurance. PwC’s assurance report can be found in Annex 3.
For the definition of this indicator please see Annex 4.
**Prior to 2013/14, Papworth had a reduced target of 79% as
a single site cancer centre. This figure includes re-allocations.
The indicator is expressed as a percentage of patients
receiving first definitive treatment for cancer within 62 days
of an urgent GP referral for suspected cancer. An urgent GP
referral is one which has a two week wait from date that the
referral is received to first being seen by a consultant.
***This figure is stated for second and subsequent surgery
only (as requested by Monitor). Monitor do not consider a
cancer target to be failed where there has only been 1 breach
per quarter. There were only 3 breaches of this target during
the year, but due to the small numbers involved this did not
enable achievement of the 96% target.
The indicator only includes GP referrals for suspected cancer
(i.e. excludes consultant upgrades and screening referrals
and where the priority type of the referral is National Code
3 - two week wait). The clock start date is defined as the
date entered onto the national database, Open Exeter, for
recording cancer waiting times by the third party referring the
patient to Papworth Hospital. The clock stop date is the date
of first definitive cancer treatment. In summary, this is the
date of the first definitive cancer treatment given to a patient
who is receiving care for a cancer condition or it is the date
that cancer was discounted when the patient was first seen or
it is the date that the patient made the decision to decline all
treatment.
43
Table B: examples of Trust performance against other national and local priorities
Performance
2012/13
Performance
2013/14
Target
2014/15
Performance
2014/15
Operations cancelled for nonmedical reasons
1.5%
1.8%
<1.5%
1.7%
Percentage not readmitted within
the 28 day guarantee
7%
12.2%**
<5%
12.3%
Inpatients waiting over 26 weeks
(highest number from monthly
snapshots)*
35 patients,
(March 2013)
111 patients,
(March
2014)**
-*
123 patients (April
2014) reduced
significantly over
the year
Outpatients waiting over 13 weeks
(highest number from monthly
snapshots)*
1 patient
3 patients
-*
12 patients
(September)
52 week referral to treatment
Not monitored
4
0
0
Number of patients risk assessed
for VTE on admission
>97%
>98%
>90%
98.4%
MRSA - meeting the MRSA
objective (no longer included in
the Monitor framework from 1
October 2013)
2
0
0
1
Patient
Experience
Rate of harm as assessed using the
Patient Safety Thermometer
Set up
year, use of
thermometer
established
0.4% - 3.4%
<5%
Range 0.5%-5.0%
(5.0% Dec only)
Average 2.1%
Effectiveness
of Care
Domain
Cardiac surgery in-hospital
mortality within statistical limits
using 50% of Euroscore (a method
of identifying risks to our patients)
>95% (97%
achieved for
11/12 months)
>97.6%
>95%
>97.5% achieved
for all 12 months
Domain
Metric
Patient
Experience
Patient
Safety
*The Trust experienced significant capacity issues during 2013/14 and early 2014/15 resulting in a longer waiting list for surgery
and an increase in the length of time on the waiting list for some patients. A range of measures was put in place to alleviate this.
44
A listening
organisation
What our patients say about us
2014 National Adult Inpatient Survey
Papworth Hospital performed very well in the National Inpatient Survey.
The 2014 survey was published by the Care Quality Commission on 21 May
2015.
2014
2013
2012
2014 Comparison with other Trusts
(Better/worse/about the same)
The Emergency/A&E Department
No A&E
No A&E
No A&E
Not applicable
Waiting list and planned admissions
9.3
9.1
9.3
Better
Waiting to get to a bed on a ward
9.4
9.6
9.3
Better
The hospital and ward
9.1
8.9
8.8
Better
Doctors
9.3
9.2
9.2
Better
Nurses
9.2
9.2
9.1
Better
Care and treatment
8.8
8.5
8.3
Better
Operations and procedures
8.9
8.3
8.4
Better
Leaving hospital
8.2
8.3
8.0
Better
Overall views of care and services
6.5
6.2
5.8
Better
Overall experience
9.0
-
-
Better
Source: Survey of adult inpatients 2014, Care Quality Commission www.cqc.org.uk/inpatientsurvey.
Scores are out of 10. Please note that comparison between years is not advised due to variations in the questions asked to
patients.
NHS ‘friends and family’ test to improve patient experience and care in hospital
From 1 April 2012, a new question was added to the patient experience survey that is conducted amongst a sample of patients
admitted to Papworth Hospital. The question is ‘how likely is it that you would recommend this services to a friend or family?’
using an ‘extremely likely’ to ‘not at all likely’ scale. The question is used in other organisations and industries and is believed by
the Department of Health to give a real time reflection of standards within a hospital. It allows hospitals to compare themselves
and learn from the best performing Trusts. Hospitals are required to ask the question to a minimum of 10% of their inpatients
and the responses are fed back to the Board. Scores are publicly available, alongside other measures of clinical quality.
In this Trust, the responses are reviewed at the weekly Matrons meeting, led by the Director of Nursing and actions monitored.
These are reported to every meeting of the Board.
45
Friends and Family inpatient results 2014/15
100
97
97
96
97
97
98
98
96
97
98
98
98
0.9
0.4
1.9
1
0.7
0.5
0.5
1.8
1.2
0.5
0.4
0.6
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
90
80
Percentage
Percentage
70
60
50
40
30
20
10
0
Patients who would recommend our service %
Patients who would not recommend our service %
‘Neither’ or ‘don’t know’ excluded from numerator.
Response rate: the average response rate for all eligible inpatients for 2014/15 was 60%
www.england.nhs.uk/statistics/statistical-work-areas/friends-and-family-test/
National Cancer Patient Experience Programme
The fourth National Cancer Patient Experience Survey was
published in September 2014 and was, as in previous years,
very positive for Papworth.
The survey includes all patients with a primary diagnosis of
cancer who had been admitted to Papworth between 1/9/13
and 30/11/13. 91 patients who had attended Papworth were
sent a questionnaire, 59 people responded representing a
response rate of 70%, which was higher than the national
average of 64%.
The survey asks 60 questions, responses by Trust are then
categorised into the highest 20% of performance (green), the
lowest 20% (red) and the remaining 60% (amber). Papworth
scored 38 as green, 15 as amber and 7 as red.
Not all the questions relate to a patient’s experience in
hospital, some are related to experience of primary care and
social care. In addition, the majority of patients attending
Papworth will have attended at least one other hospital
on their cancer pathway and therefore it is not possible to
determine which hospital the patient may be referring to.
Questions where Papworth scored green included; the
46
explanation of diagnostic tests, breaking bad new sensitively,
keeping the patient informed, access to information about
research, information and explanation about operations, ward
nursing care and hospital care and environment.
The areas where Papworth scored as red were about patients
receiving an understandable explanation about side effects
and receiving written information about side effects and
that patients did not recall they had been given information
on financial help. This was a disappointing result for the
team as the team spend a lot of time giving information to
patients and feel that side effects and financial advice is well
covered in this. However, the team are now investigating
closer collaboration with Macmillan in developing a potential
‘Information Manager’ post which might facilitate access to
cancer information for patients.
It was reassuring to see that scores for the questions where
Papworth had scored red in the previous year had improved.
In addition to the individual questions, patients are able to
provide additional comments. These provided some very
positive feedback about patients’ experiences and the contact
they had had with Papworth staff.
The One Show
A special piece looking at how Ventricular Assist Devices
(VADS) implanted at Papworth Hospital transform people’s
lives featured on the BBC One Show in October 2014. The
feature included a pre-recorded piece that followed the
journey of a Papworth patient from pre- to post-surgery
and included filming within theatres and numerous clinical
settings. The patient and her family were invited to be
interviewed live on the programme which was aired on the 8
October 2014.
Patient support groups
Papworth has several patient support groups, which include:
‘Pulmonary Hypertension Matters’ Support Group continues
to be run by patients with the support of specialist staff
from the PH team and the Patient Advice and Liaison Service
(PALS). Voluntary speakers this year have presented topics
from their different specialist areas such as Specialist Nurse
Q&A sessions, an excellent presentation from a Consultant on
the tests and investigations carried out at routine follow up
appointments, a senior Respiratory Physiologist gave a talk on
Pulmonary Function Tests and Six Minute Walks and a patient
talked about her transplant journey. For the coming year
there will presentations from the Chairman of the Pulmonary
Hypertension Association-UK and the Clinical Psychologist
attached the Pulmonary Hypertension team at Papworth.
The group meetings are well attended with 35-40 members
at most meetings and twice as many at the Christmas party
in November. Approximately four to five new members are
welcomed each year to the group. Young adults transitioning
their care from Great Ormond Street Hospital are encouraged
to attend the support group as a way of finding out about
the Pulmonary Vascular Diseases Unit prior to attending the
hospital for the first time.
The group is advertised in several ways; members produce
a four page quarterly newsletter and information on the
support group can be found on the Pulmonary Hypertension
Association UK forum website and social media Facebook
page. A small number of patients from other specialist centres
such as Sheffield and London also attend the support group.
The group is friendly and sociable and offers support to
individuals and their families; members have reported that
meeting other patients with the same condition has helped
them enormously, for example patients considering PTE
surgery have had the opportunity to meet members and their
families who have already gone through this procedure. One
of the members still comes to the meetings following their
transplant surgery and has shared their experience of this
aspect as well.
Fundraising this year has enabled staff to be provided with
CD Players to facilitate patient education about treatment
options. The group is always receptive to ideas on how this
money can be spent.
The Mesothelioma Patient Support Group (www.
mesopapworth.co.uk) meet every month. This group is for
patients and their carers to talk freely about their concerns.
The first half of the meeting is based around a talk on subjects
such as relaxation, new treatments, nutrition, breathlessness
and complementary therapies. The second half of the meeting
provides an opportunity to talk to group members informally
over refreshments. There is also a separate monthly meeting
specifically for carers so they can share their concerns and
experiences with others in a similar situation.
The group has developed and funded a DVD for mesothelioma
patients and carers entitled ‘Mesothelioma - the journey’
which is offered free of charge to new patients and
their carers at the time of diagnosis. The DVD has been
professionally filmed and includes specialist doctors and
nurses talking about the disease, treatment options and help
available. The DVD includes inspirational patients and carers
taking about their personal experiences of living with this
condition. The DVD has been very well received and patients
have said they wished it had been available when they were
diagnosed. New patients have found the DVD ‘extremely
helpful’.
The group is planning a Papworth mesothelioma awareness
day in July 2015 at Papworth Village Hall which will provide
information, education and includes the release of doves.
Cream teas will be served to those attending.
New members of the group have said the group helps them to
feel ‘Less alone’ and they have found the support provided as
‘a great help’.
The Papworth Pulmonary Fibrosis Support Group was
established in 2010 to provide information for individuals
with pulmonary fibrosis, to give them support and to establish
regular opportunities for the patients and their carers to meet.
Meetings are held every other month at The Hub in
Cambourne and are regularly attended by an average of 60
participants. The meetings are planned and managed by a
small committee who organise speakers and refreshments and
give participants plenty of time to socialise.
An annual picnic is now part of the programme and has
been successful in bringing together the families of the
members as a way to thank them for their support. Recently
communication with Interstitial Pulmonary Fibrosis (IPF)
sufferers has been widened with the development of a
website accessed through the Trust’s public homepage,
a Facebook page and a newsletter. A Pulmonary Fibrosis
Patient Day is organised annually (the last one being held at
Newmarket Race Course) during IPF Awareness Week and
attended by over 100 patients and carers.
The inaugural chair of the group stepped down to help
establish a national charity - ‘Action for Pulmonary Fibrosis’
and the Papworth Support Group retains strong links with this
organisation. The current Chair has facilitated collaborative
working with staff at The British Lung Foundation a link which
our patients are benefiting from enormously.
Many of the members are regular attenders and find the
meetings invaluable.
47
Transplant patient support
Examples of what our patients have said:
We have continued to hold three to four Mechanical
Circulatory Support Device (MCSD) Patient Forums a year for
all patients with a device. These are held on Saturdays and
are well received by our patients and their families. Wherever
possible patients who have recently had their device
implanted are buddied up with a longer term patient to act as
a mentor; also, any patient who is still an inpatient on the day
the group meet is invited to attend with their family.
The Pulmonary Hypertension Support Group
A web-based support forum has also been launched and work
is underway to develop this in a way that patients will be
able to communicate with each other irrespective of where
they are in the UK. This is a password protected support
forum which allows patients to share their stories and discuss
topical issues as they arise. So far there are approximately 200
patients registered and the numbers continue to increase as
patients become more aware of this facility.
The Transplant Patients Representatives Group has been
formally convened this year to ensure that the needs of the
patients are being met and that their voice is heard during
a time of very rapid change within the organisation. The
intention of the group is to ensure that patients’ needs are
met in the New Papworth site as well as now. The group has
joined the National cardiothoracic transplant support group
and taken an active part in the Transplant Peer review process.
In the future, it is hoped that the group will assist at the
patients support meetings and facilitate the buddy system.
We are planning to hold our first patient support event for
patients on the transplant waiting list later this year and it is
hoped that patients will benefit from this opportunity and
that the occasion will complement our annual support event
in July 2015.
“I came to the Papworth PH Matters Support Group shortly
after I was diagnosed with severe PH. My husband and I didn’t
know anyone else with PH and found that most of our friends
and family didn’t really understand much about it or what
it was like to have to live with it. It has been great to meet
others who have gone through the same and understood
what we were going through. The meetings are always
helpful and informative too - with various professionals and
speakers attending helping us to understand more about all
the different aspects of living and coping with PH. Above all,
we have made many new friends - who will be friends for life they have supported us through all the ups and downs.”
“After years of feeling isolated with my PH, it was most
refreshing to finally meet fellow PHers at the Papworth
Support Group. A friendly, welcoming and relaxed
environment away from the hospital where new friendships
are established.”
“With a rare illness it is great to be able to regularly meet
with other patients and chat, not just about health issues but
socially too.”
Mesothelioma Patient Support Group
“The help of the support group enabled us to enjoy those last
special years together.”
“The support group has helped us to feel less isolated and has
helped us to cope.”
“Attending the support group has been a fantastic help and we
have met lots of lovely people.”
Papworth Pulmonary Fibrosis Support Group
“Thanks for all you do - I find these meetings really helpful.”
“It is so good to have a chance to meet others in the same
position as me.”
Transplant patient support
“Really enjoyable and informative session.”
“Great to meet other people who have gone through the
same thing and come out the other side.”
“Having time with the Transplant Nursing team outside our
normal clinic is really useful and the ability to practice our
device changes is also really good.”
48
49
What
our staff
say about us
Staff survey 2014
The Operating Framework lists a series of ‘Vital signs’
indicators within the NHS staff survey to determine job satisfaction
scores and Trusts are expected to demonstrate year-on-year progress.
There are 8 staff satisfaction questions. The score is based on a 5 point
scale (with 1 being the lowest and 5 being the highest) and the result is
published annually. For any year it cannot easily be calculated, although a 0.1
point increase equates to approximately achieving a 2% improvement on every
question in the 8 question matrix.
A national staff survey has found that 92% of Papworth staff would recommend the
hospital to friends and family - this is the highest score in the NHS. The annual survey,
which had an above average response rate, found that Papworth staff are receiving training
and development opportunities relevant to their job and have had well-structured appraisals in the
past 12 months. They also feel that their roles are making a difference to patients.
The results for the Trust are shown below as follows:
Subject questions
2008
2009
2010
2011
2012
2013
2014
% change
Recognition for good work
51%
53%
48%
50%
55%
57%
57%
No change
Satisfied with support from their
immediate manager
63%
66%
61%
65%
68%
71%
70%
-1%
Satisfied with the support from
their work colleagues
76%
76%
74%
74%
79%
81%
81%
No change
Freedom to choose their own
methods of working
71%
61%
61%
63%
63%
67%
67%
No change
Satisfied with the amount of
responsibility given
74%
68%
73%
72%
75%
79%
78%
-1%
Satisfied with the opportunities to
use their skills
70%
68%
64%
71%
73%
76%
74%
-2%
Satisfied with the extent to which
the Trust values their work
41%
41%
42%
44%
55%
55%
54%
-1%
-
-
-
38%
41%
40%
34%
-6%
Satisfied with level of pay
Overall staff job satisfaction was 3.72 and average when
compared to other acute specialist trusts. This was an increase
from last year’s score of 3.71.
•
•
•
Whilst the overall results are extremely encouraging against
a background of significant change and workload pressures
during the year, it has to be noted that the following areas
have been identified for improvement:
The percentage of staff experiencing physical violence from
patients is not unexpected. Our incident reporting system
highlights that in all reported cases, the incident has occurred
whilst the patient has been receiving treatment/under
medication.
Percentage of staff:
• Witnessing potentially harmful errors, near misses or
incidents.
• Experiencing physical violence from patients, relatives or
the public .
50
Experiencing discriminatio.n
Experiencing harassment, bullying or abuse from staff.
Receiving support from immediate managers.
The above areas will be included in the Trust’s action plan and
progress will be monitored through the Operational Executive
Group and Health and Safety Committee.
51
Papworth People Staff Achievement Awards/Long
Service Awards
Papworth staff were honoured for their dedication and hard
work at the Papworth People Annual Staff Achievement
Awards in September 2014. A total of 43 awards were
given out in seven categories judged by the Patient and
Public Involvement Committee. The awards honoured both
individuals and teams in categories that included Caring for
Patients, Achieving Excellence and the Chairman’s award
for Outstanding Achievement. The event was hosted by the
hospital Chief Executive.
At the same event, more than 90 of Papworth Hospital’s
longest serving members of staff were commended for their
dedication to patients at the Trust. The awards ceremony saw
staff being honoured with awards for 15, 20, 25 and 30 years
of service. This included members of staff across all disciplines
and included one of the Trust switchboard operators who was
celebrating 30 years of service at Papworth. Staff received
pin badges, awards and certificates marking their years of
services.
Investors in People
The hospital retained the joint Investors in People and NHS
Health and Wellbeing award after specialists visited the
hospital and spoke to staff about their roles.
Valuing volunteers
We continue to be indebted to our volunteers, approximately
120 at present. They give their time, energy and experience
to aid patients and staff and contribute greatly to the ‘patient
experience’. It has been found that volunteers enrich the
lives of patients and their families, contributing significantly
to the overall success of patient care. All the staff and
patients at Papworth are extremely grateful for the hard work
and commitment which our volunteers provide. For more
information see the Foundation Trust section of our Annual
Report.
Health and wellbeing
The Papworth Musculoskeletal Staff Injury Clinic has
helped staff get back to work and contributed to reducing
sickness absence during 2014/15. The service is run by a
Sports Therapist who visits staff in their actual workplace
to intervene at the earliest opportunity and prevent further
injury. She advises on different tools and techniques and
is finding that staff are requiring less time off work and
experiencing speedier recovery time.
Open and transparent/duty of candour
Openness when things go wrong is fundamental to the
partnership between patients and those who provide their
care. There is strong evidence to show that when something
goes wrong with healthcare, the patients who are harmed,
their relatives or carers want to be given information about
what has happened and would like an apology. Being open
about what has gone wrong and discussing the problem
52
promptly and compassionately can help patients come to
terms with what has happened and can help prevent such
incidents becoming formal complaints or clinical negligence
claims. The Trust aims to promote a culture of openness and
transparency, which it sees as a prerequisite to improving
patient safety and the quality of a patient`s experience.
The new statutory duty of candour was introduced for NHS
bodies in England (Trusts, Foundation Trusts and special
health authorities) from 27 November 2014 and applies to
organisations, not individuals though it is clear from CQC
guidance that it is expected that an organisation’s staff will
cooperate with it to ensure the obligation is met.
A notifiable patient safety incident has a specific statutory
meaning: it applies to incidents where a patient suffered (or
could suffer) unintended harm that results in death, severe
harm, moderate harm or prolonged psychological harm.
Papworth’s policies and procedures have been update to
reflect the new statutory duty.
Throughout 2014/15 we have continued to be open and
transparent in all aspects of the quality of our care. As part of
Papworth Hospital’s monitoring and assurance framework a
Quality and Safety Report is produced each quarter detailing
the quality and safety activity across the organisation.
This information is presented to the Quality and Risk
Management Group and the Quality and Risk Committee to
provide notification of trends, actions and assurance of our
continual drive for quality and safety. Learning from incidents,
complaints and claims is shared across the organisation and is
available on our website.
Quality and safety information is presented in the quarterly
reports under headings, which include: patient safety, patient
experience and effectiveness of care. Our duty of candour
requirements is also monitored through this process and we
can confirm that we are fully compliant with this requirement.
Listening to patient experience and complaints
Listening to the patient experience and taking action following
investigation of complaints is an important part of our quality
improvement framework. In 2014/15 Papworth Hospital
received 43 formal Complaints requiring investigation (24
inpatient and 19 outpatient complaints). Subsequently, 1
complaint was withdrawn from the formal complaints process
by the complainant leaving 42 in total. 36 were relating to
NHS provided services with 7 complaints relating to private
patient services at Papworth Hospital. The overall numbers of
complaints received is down on the numbers received during
the previous year when 56 complaints were received (23%
decrease).
Where a patient/ family member does not wish to register
their concern as a formal complaint we log these concerns
as “Enquiries”. Investigation of the issues raised follows the
same robust process as a formal complaint and a written
response, including any actions identified as a result of raising
their concern, is provided. The Trust received 22 Enquiries in
2014/15.
All formal complaints received have been subject to a full
investigation, and throughout the year service improvements
have been made as a result of analysing and responding to
complaints.
Not all complaints are upheld following investigation and
the table below shows the number of complaints received
per 1,000 patients and of those, the numbers upheld or part
upheld.
Number of complaints reported and upheld per 1,000 patient episodes
Number of patient episodes (includes
inpatients, outpatients and private patients)
Number of
complaints
received
Complaints
received per 1000
patient episodes
Complaints
upheld
Q1
25,683
11
0.4
8
Q2
26,694
9
0.3
6
Q3
26,499
13
0.5
8
Q4
27,570
23
0.8
15
Total
106,446
56
0.5
37
Q1
27,554
6
0.2
3
Q2
28,236
18
0.6
14
Q3
28,139
5
0.2
5
Q4
28,232
14
0.5
5*
Total
112,161
43*
0.4
22*
0.3
16*
1.5
7
2013/14
2014/15
NHS patients only (inpatients and outpatients
Total 14/15
107,483
36
Private patients only (inpatients and outpatients)
Total 14/15
4,678
7
* Some of the complaints received in Q4 have not been fully investigated at the time of this report - Data source: DATIX™ as at
12/04/2014.
53
Out of the 43 complaints received in 2014/15, 48% were upheld or partly upheld following investigation (2013/14: 57% and
2012/13: 52%). There has been a 23% decrease in complaints received over the year and as the overall number remains low, it is
difficult to extract meaningful trends from the data. Below is a comparison of complaints raised by primary subject by quarter.
Complaints received by primary subject
2014/15
2013/14
2012/13
2011/12
Verbal or physical abuse
0
1
0
0
Admission arrangements
1
4
1
1
Staff attitude
4
4
6
5
Clinical care
20
16
24
23
Nursing care
2
2
1
1
Catering
1
0
1
5
Patient charges
1
0
1
2
Communication/information
8
12
4
8
Delay in diagnosis/treatment or referral
6
8
10
9
Discharge arrangements
0
4
4
2
Equipment issues
0
3
2
1
Parking
0
0
1
0
Lost Property
0
0
1
0
Environment - external
0
0
0
1
Medication issues
0
1
0
1
Medical records
0
0
0
1
Transport issues
0
0
0
1
Totals
43
56
56
61
Complaints by primary subject (data source DATIX™ as at 12/04/2014).
Summary of actions taken as a result of upheld and part upheld complaints - 2014/15
We have increased the operational hours of the Cardiac Day ward to accommodate patients who require over-night stay
following pacemaker insertion.
We have reviewed our patient letters for admissions to highlight the possibility of cancellation for operational reasons.
We have reviewed the check-in list for patients who are undergoing a CT scan to include a patient signature following
explanation and risk assessment. This will reinforce and confirm patients understanding.
We have undertaken an MDT review of the management of Hickman line removal in theatres and a new procedure has been
agreed.
A communication and escalation strategy has been developed and agreed with the cardiac nursing team.
Training has been arranged for radiology staff by the Tissue Viability team.
We have undertaken a review of the Nil by Mouth Guidelines.
Laminated printed explanation of how to control the individual room temperature have been placed in rooms on Varrier-Jones
ward.
We have developed a pre-admission flow chart for new patients with known learning or physical disabilities to ensure the
patient/carer is contacted in advance of admission and reasonable adjustments are planned according to the needs of the
patient.
We have developed a care plan ‘contract’ for patients who are accompanied by a carer outlining which care will be provided
by whom so that all concerned are aware of their roles and responsibilities.
We have updated the patient information leaflet for Stress Echo to include potential complications and percentage risk. This
will be added to a procedure specific consent form.
We have improved documentation in patient letters regarding the distance to walk from main reception.
Further information is available in our quarterly Quality and Safety Reports which are on our web site at www.papworthhospital.
nhs.uk/content.php?/clinical_quality/healthcare_professionals/clinical_governance
54
Figure below shows the trend of formal complaints and enquiries received by quarter.
Complaints Vs Enquiries received by quarter
25
20
15
Complaints
10
Enquiries
5
0
Q1_1314 Q2_1314 Q3_1314 Q4_1314 Q1_1415 Q2_1415 Q3_1415 Q4_1415
Figure below shows the primary subjects of complaints received by quarter.
9
8
7
Q4 14/15
Q41415
Q3 14/15
Q31415
6
Q2 14/15
Q214/15
5
Q114/15
Q1 14/15
4
3
2
1
0
55
Summary of CQUIN performance 2014/15
%
weighting
Performance
in 2014/15
Friends & Family Test - implementation of staff friends and family test
10%
Achieved
Friends & Family Test - early implementation
10%
Achieved
Friends & Family Test - increased or maintained response rate
10%
Achieved
Friends & Family Test - increased response rate in acute inpatient surveys
10%
Achieved
NHS Safety Thermometer Test - reduction in number of avoidable pressure ulcers
15%
Achieved
NHS Safety Thermometer Test - support for nursing homes
15%
Achieved
Dementia - find, assess, investigate and refer
10%
Achieved
Dementia - clinical leadership
10%
Achieved
Dementia - supporting carers of people with dementia
10%
Achieved
Smoking cessation - brief interventions for smoking cessation - training
9%
Achieved
Smoking cessation - brief interventions for smoking cessation - delivery of brief advice
8%
Achieved
Smoking cessation - brief interventions for smoking cessation - delivery of level 2
advice
8%
Achieved
Weight management - brief interventions for weight management - training
12.5%
Achieved
Weight management - brief interventions for weight management - delivery of brief
interventions
12.5%
Achieved
National CQUINs (20% of all contracts)
1
2
3
CCG CQUINs (80% of the non-specialist contract)
4
5
6
Hospital transfers - reduction in waiting times for cardiology hospital transfers to
Papworth
30%
Achieved
7
Community IV antibiotic - expand IV antibiotic pathway
20%
Achieved
The CQUIN (Commissioning for Quality and Innovation) payment framework enables commissioners to reward excellence, by
linking a proportion of English healthcare providers' income to the achievement of quality improvement goals. Since the first year
of the CQUIN framework (2009/10), many CQUIN schemes have been developed and agreed.
The two main commissioning contracts at Papworth have different CQUIN targets in place. Nationally determined CQUINs cover
both contracts, with the remainder down to local negotiation between the Trust and commissioner. The individual CQUIN targets
are weighted resulting in the final financial value paid for achievement of each area. Non-achievement of a particular CQUIN
results in a reduction of income equivalent to the CQUIN weighting multiplied by the overall CQUIN value.
56
Annex 1: What
others say about us
NHS England - Midlands and East (East of England)
- Specialised Commissioning
It was reassuring that the CQC review confirmed the
Specialised Commissioning impression that Papworth is
a provider of high quality services rating good for safety,
responsiveness and leadership and outstanding for providing
effective care and caring. CQC concerns around governance
and risk management systems, and improvements to risk
registers have been noted and will be taken forward with the
Trust.
Waiting times at the Trust were a significant area of focus
for both commissioners and the Trust during 2014/15. A
combination of Trust led system redesign and additional
capacity supported by significant investment from
commissioners enabled the Trust to achieve and maintain the
18 week waiting time standard from November 2014. We will
work with the Trust to ensure that this is maintained during
2015/16.
NHSE England commissions all cardiac surgery at the Trust.
The well established and respected Society for Cardiothoracic
Surgery (SCTS) data base on clinical outcomes continues to
indicate that Papworth has the best cardiac surgery outcomes
in the country.
The following Key Performance Indicators continue to require
improvement and are routinely discussed at the monthly
contract review meetings with the Trust, cancer 62 day waits,
operations cancelled for non-medical reasons and cancelled
operations not readmitted within 28 days. The cancer waiting
standard is challenging given the very low numbers of patients
seen which can mean that a single patient may typically
represent 20% of that month’s activity. However even a single
patient breach is cause for concern and we will continue to
explore with the Trust opportunities to expedite this complex
care pathway. As the waiting list back log has been cleared
and additional capacity brought on stream there has been a
steady improvement in the numbers of cancelled operations
during the latter half of the year. A trend which we will work
with the Trust to ensure is continued.
Overall this report demonstrates that the Trust continues to
provide high quality, timely, safe and effective healthcare.
As responsible commissioner for specialised services we
will continue to work with the Trust to address those areas
requiring improvement.
Cambridgeshire
and Peterborough
Clinical Commissioning
Group (CGC)
The CCG has reviewed the Quality
Account produced by Papworth Hospital
NHS Foundation Trust (Papworth) for 2014/15.
The main commissioner for Papworth is the Specialist
Commissioning Group (SCG) at NHS England Midlands and
East of England, with the CCG commissioning the District
General Hospital elements of Papworth’s services. The SCG
lead on performance meetings with the Trust where quality
and performance is reviewed throughout the year, with the
CCG feeding in any local quality issues that arise.
The Care Quality Commission (CQC) is the national regulator
of quality in the NHS and carries out inspections across all
health and social care organisations. The CQC inspected
Papworth in December 2014 and rated the Trust as Good
overall, with Outstanding ratings given for effective and caring
services. There were some areas requiring improvement in
relation to Medical Care, and the Trust is implementing an
action plan to address these.
Papworth has achieved Green ratings against the CCG Quality
dashboard for all areas of quality except the percentage of
staff having up-to-date appraisals. However, the level of staff
engagement is high as evidenced by the CQC report and the
results of the NHS 2014 national staff survey. The CCG will
continue to monitor performance to ensure Papworth is
taking action to increase the level of staff appraisals.
Performance against the quality priorities set for 2014/15 was
good although some outcomes have not been fully achieved
and there is a gap in the Quality Account, as it does not give
details of the continued work required. Papworth has set four
new priorities for 2015/16. The initiative to improvement
medication safety has been taken forward for a third year
The Papworth Quality Account is clearly written, with a wide
range of quality initiatives included. Complex issues are
explained well and goals set out clearly.
57
Healthwatch Cambridgeshire
As a world leader in many fields the Trust is to be commended
for its outstanding performance in cardiothoracic (heart and
lung) transplants.
The Trust continues to deliver a high level of good quality care
for patients and has effective systems in place to regularly
assess and monitor the quality of service that people receive.
As evidenced by the actions log they have taken prompt
action, with audits being undertaken to improve service
provision and protect people.
We were pleased to note the Trust has made many
improvements on the length of stay project and reduction
of medication errors and we look forward to seeing further
achievements in all areas in the coming year and we support
the priorities outlined for 2015/16.
Following the announcement in March 2015 that Papworth
Hospital has received permission to commence building a new
Hospital on the Cambridge Biomedical Campus site, we will be
interested to see how staff inputs and patient experiences are
involved in the development of the site and the re-location of
services.
58
Patient and Public Involvement Committee (PPI)
Committee of the Council of Governors
The PPI Committee congratulate Papworth on another year
of excellent quality results including the outcome of the Care
Quality Commission (CQC) inspection.
The committee notes that the Trust has continued to
experience capacity issues during 2014/15 and the Committee
supports the actions being taken on the current site to remedy
this and are pleased that approval was received in March 2015
to proceed with building the new Papworth Hospital on the
Cambridge Biomedical Campus.
The Committee would like to thank everyone involved
with delivering the performance priorities for 2014/15
and supports the work that is still ongoing to achieve the
outstanding goals relating to medicines safety. The Committee
support the priorities for 2015/16 which align Papworth’s sign
up to safety pledges.
Annex 2: Statement of Directors’ responsibilities in respect of the Quality
Report
The Directors are required under the Health Act 2009 and
the National Health Service (Quality Accounts) Regulations to
prepare Quality Accounts for each financial year.
Monitor has issued guidance to NHS Foundation Trust
boards on the form and content of annual Quality Reports
(which incorporate the above legal requirements) and on the
arrangements that Foundation Trust boards should put in
place to support the data quality for the preparation of the
Quality Report.
In preparing the Quality Report, directors are required to take
steps to satisfy themselves that:
• The content of the Quality Report meets the
requirements set out in the NHS Foundation Trust Annual
Reporting Manual 2014/15 and supporting guidance.
• The content of the Quality Report is not inconsistent with
internal and external sources of information including:
»» Board minutes and papers for the period April 2014
to 21 May 2015.
»» Papers relating to quality reported to the Board over
the period April 2014 to 21 May 2015.
»» Feedback from NHS England – Midlands and East
(East of England) - Specialised Commissioning dated 5
May 2015.
»» Feedback from Cambridge and Peterborough Clinical
Commissioning Group dated 14 May 2015.
»» Feedback from the Patient and Public Involvement
Committee (PPI) Committee of the Council of
Governors dated 14 May 2015.
»» Feedback from Healthwatch Cambridgeshire dated 7
May 2015.
»» The Trust’s ‘Quality and Safety Report: Quarter 4 and
annual Summary 14/15’;
»» The 2014 National Inpatient Survey.
»» The 2014 National Staff Survey.
»» The Trust’s Annual Governance Statement 2014/15.
»» The Head of Internal Audit opinion on the
effectiveness of the system of internal control for the
year ended 31 March 2015.
»» CQC Inspection Reports published 27 March 2015.
»» CQC Intelligent Monitoring Report dated December
2014.
There are proper internal controls over the collection and
reporting of the measures of performance included in the
Quality Report, and these controls are subject to review to
confirm that they are working effectively in practice.
The data underpinning the measures of performance
reported in the Quality Report is robust and reliable,
conforms to specified data quality standards and prescribed
definitions, is subject to appropriate scrutiny and review and
the Quality Report has been prepared in accordance with
Monitor’s annual reporting guidance (which incorporates
the Quality Accounts regulations - published at www.gov.uk/
annualreportingmanual - as well as the standards to support
data quality for the preparation of the quality report (available
at www.monitor.gov.uk/annualreportingmanual).
The directors confirm to the best of their knowledge and
belief they have complied with the above requirements in
preparing the Quality Report.
By order of the Board
Date: 21 May 2015
Chairman
Date: 21 May 2015
Chief Executive
The Quality Report presents a balanced picture of the NHS
Foundation Trusts performance over the period covered.
The performance information reported in the Quality Report is
reliable and accurate.
59
Annex 3: Limited Assurance Report on the content of the Quality Report
and Mandated Performance Indicators
Independent Auditors’ Limited Assurance Report to the
Council of Governors of Papworth Hospital Foundation Trust
on the Annual Quality Report.
We have been engaged by the Council of Governors of
Papworth Hospital Foundation Trust NHS Foundation Trust to
perform an independent assurance engagement in respect of
Papworth Hospital Foundation Trust NHS Foundation Trust’s
Quality Report for the year ended 31 March 2015 (the ‘Quality
Report’) and specified performance indicators contained
therein.
The indicators for the year ended 31 March 2015 subject to
limited assurance (the ‘specified indicators’), marked with
A in the Quality Report, consist of the following
the symbol ⃝
national priority indicators as mandated by Monitor:
Specified Indicators
Specified indicators criteria
Percentage of incomplete pathways within 18 weeks
for patients on incomplete pathways at the end of the
reporting period.
Details of the criteria for the indicator can be found at Annex 4
of the Quality Report.
Maximum waiting time of 62 days from urgent GP referral
to first treatment for all cancers.
Details of the criteria for the indicator can be found at Annex 4
of the Quality Report.
Respective responsibilities of the Directors and
auditors
The Directors are responsible for the content and the
preparation of the Quality Report in accordance with the
specified indicators criteria referred to on the pages of the
Quality Report as listed above (the ‘Criteria’). The Directors
are also responsible for the conformity of their Criteria
with the assessment criteria set out in the NHS Foundation
Trust Annual Reporting Manual (‘FT ARM’) and the ‘Detailed
requirements for quality reports 2014/15’ issued by the
Independent Regulator of NHS Foundation Trusts (‘Monitor’).
Our responsibility is to form a conclusion, based on limited
assurance procedures, on whether anything has come to our
attention that causes us to believe that:
•
•
•
The Quality Report does not incorporate the matters
required to be reported on as specified in Annex 2 to
Chapter 7 of the FT ARM and the ‘Detailed requirements
for quality reports 2014/15’;
The Quality Report is not consistent in all material
respects with the sources specified below; and
The specified indicators have not been prepared in all
material respects in accordance with the Criteria and the
six dimensions of data quality set out in the ‘2014/15
Detailed guidance for external assurance on quality
reports’.
We read the Quality Report and consider whether it addresses
the content requirements of the FT ARM and the ‘Detailed
requirements for quality reports 2014/15’; and consider
the implications for our report if we become aware of any
material omissions.
60
Scope and subject matter
We read the other information contained in the Quality
Report and consider whether it is materially inconsistent with
the following documents:
Board minutes for the financial year from April 2014 and up to
21 May 2015;
• Papers relating to quality report reported to the Board
over the period April 2014 to 21 May 2015;
• Feedback from the Commissioners NHS England Midlands and East (East of England) - Specialised
Commissioning dated 5 May 2015;
• Feedback from Cambridge and Peterborough Clinical
Commissioning Group dated 14 May 2015;
• Feedback from the Patient and Public Involvement (PPI)
Committee of the Council of Governors dated 14 May
2015;
• Feedback from Healthwatch Cambridgeshire dated 7 May
2015;
• The Trust’s ‘Quality and Safety Report: Quarter 4 and
annual Summary 14/15’;
• The 2014 National Inpatient Survey;
• The 2014 National Staff Survey;
• The Trust’s Annual Governance Statement 2014/15;
• The Head of Internal Audit opinion on the effectiveness
of the system of internal control for the year ended 31
March 2015;
• CQC Inspection Reports published 27 March 2015;
• CQC Intelligent Monitoring Report dated December 2014.
We consider the implications for our report if we become
aware of any apparent misstatements or material
inconsistencies with those documents (collectively, the
‘documents’). Our responsibilities do not extend to any other
information.
We are in compliance with the applicable independence
and competency requirements of the Institute of Chartered
Accountants in England and Wales (‘ICAEW’) Code of Ethics.
Our team comprised assurance practitioners and relevant
subject matter experts.
This report, including the conclusion, has been prepared solely
for the Council of Governors of Papworth Hospital Foundation
Trust NHS Foundation Trust as a body, to assist the Council
of Governors in reporting Papworth Hospital Foundation
Trust NHS Foundation Trust’s quality agenda, performance
and activities. We permit the disclosure of this report within
the Annual Report for the year ended 31 March 2015, to
enable the Council of Governors to demonstrate they have
discharged their governance responsibilities by commissioning
an independent assurance report in connection with the
indicators. To the fullest extent permitted by law, we do not
accept or assume responsibility to anyone other than Council
of Governors as a body and Papworth Hospital Foundation
Trust NHS Foundation 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 in
accordance with International Standard on Assurance
Engagements 3000 ‘Assurance Engagements other than Audits
or Reviews of Historical Financial Information’ issued by the
International Auditing and Assurance Standards Board (‘ISAE
3000’). Our limited assurance procedures included:
• Reviewing the content of the Quality Report against the
requirements of the FT ARM and ‘Detailed requirements
for quality reports 2014/15’;
• Reviewing the Quality Report for consistency against the
documents specified above;
• Obtaining an understanding of the design and operation
of the controls in place in relation to the collation
and reporting of the specified indicators, including
controls over third party information (if applicable) and
performing walkthroughs to confirm our understanding;
• Based on our understanding, assessing the risks that
the performance against the specified indicators may be
materially misstated and determining the nature, timing
and extent of further procedures;
• Making enquiries of relevant management, personnel
and, where relevant, third parties;
• Considering significant judgements made by the
NHS Foundation Trust in preparation of the specified
indicators;
• Performing limited testing, on a selective basis of
evidence supporting the reported performance indicators,
and assessing the related disclosures; and
• Reading the documents.
A limited assurance engagement is less 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.
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 Report in the
context of the assessment criteria set out in the FT ARM the
‘Detailed requirements for quality reports 2014/15’ and the
Criteria referred to above.
The nature, form and content required of Quality Reports
are determined by Monitor. This may result in the omission
of information relevant to other users, for example for the
purpose of comparing the results of different NHS Foundation
Trusts, organisations or entities.
In addition, the scope of our assurance work has not included
governance over quality or non-mandated indicators in
the Quality Report, which have been determined locally by
Papworth Hospital NHS Foundation Trust.
Conclusion
Based on the results of our procedures nothing has come to
our attention that causes us to believe that for the year ended
31 March 2015,
• The Quality Report does not incorporate the matters
required to be reported on as specified in Annex 2 to
Chapter 7 of the FT ARM and the ‘Detailed requirements
for quality reports 2014/15’;
• The Quality Report is not consistent in all material
respects with the documents specified above; and
• The specified indicators have not been prepared in all
material respects in accordance with the Criteria and the
six dimensions of data quality set out in the ‘Detailed
guidance for external assurance on quality reports
2014/15’.
PricewaterhouseCoopers LLP, London
The maintenance and integrity of the Papworth Hospital
NHS Trust’s website is the responsibility of the directors; the
work carried out by the assurance providers does not involve
consideration of these matters and, accordingly, the assurance
providers accept no responsibility for any changes that may
have occurred to the reported performance indicators or
criteria since they were initially presented on the website.
61
Annex 4: Mandatory performance indicator definitions
The following indicator definitions are provided by Monitor
and are based on Department of Health guidance, including
the ‘NHS Outcomes Framework 2013/14 Technical Appendix’.
Monitor does not set definitions for indicators but, for
convenience and to address potential inconsistencies between
sources, Monitor has provide definitions for the mandated
quality report indicators and has required that these are used
for 2014/15 quality reports.
Maximum waiting time of 62 days from urgent GP
referral to first treatment for all cancers
In order to improve the consistency in indicator definitions,
the Health and Social Care Information Centre (HSCIC) has
published an Indicator Portal available at https://indicators.
ic.nhs.uk/webview/
Data definition
Where relevant this is referred to in the definitions provided
below but where the HSCIC Indicator Portal does not provide
a detailed definition of the indicator older sources of indicator
definitions are used.
Percentage of incomplete pathways within 18
weeks for patients on incomplete pathways
Source of indicator definition and detailed guidance
The indicator is defined within the technical definitions that
accompany Everyone counts: planning for patients 2014/15
- 2018/19 and can be found at www.england.nhs.uk/wpcontent/uploads/2014/01/ec-tech-def-1415-1819.pdf
Detailed rules and guidance for measuring referral to
treatment (RTT) standards can be found at www.england.
nhs.uk/statistics/statistical-work-areas/rtt-waiting-times/rttguidance/
Detailed descriptor
E.B.3: The percentage of incomplete pathways within 18
weeks for patients on incomplete pathways at the end of the
period.
PHQ03: Percentage of patients receiving first definitive
treatment for cancer within 62 days of an urgent GP referral
for suspected cancer.
All cancer two-month urgent referral to treatment wait.
Numerator
Number of patients receiving first definitive treatment for
cancer within 62 days following an urgent GP (GDP or GMP)
referral for suspected cancer within a given period for all
cancers (ICD-10 C00 to C97 and D05).
Denominator
Total number of patients receiving first definitive treatment
for cancer following an urgent GP (GDP or GMP) referral for
suspected cancer within a given period for all cancers (ICD-10
C00 to C97 and D05).
Accountability
Performance is to be sustained at or above the published
operational standard. Details of current operational
standards are available at: www.england.nhs.uk/wp-content/
uploads/2013/12/5yr-strat-plann-guid-wa.pdf (see Annex B:
NHS Constitution Measures).
Numerator
Cancer referral to treatment period start date is the date the
acute provider receives an urgent (two week wait priority)
referral for suspected cancer from a GP and treatment start
date is the date first definitive treatment commences if the
patient is subsequently diagnosed.
The number of patients on an incomplete pathway at the end
of the reporting period who have been waiting no more than
18 weeks.
For further detail refer to technical guidance at www.
dh.gov.uk/en/Publicationsandstatistics/Publications/
PublicationsPolicyAndGuidance/DH_131880
Denominator
The total number of patients on an incomplete pathway at the
end of the reporting period.
Accountability
Performance is to be sustained at or above the published
operational standard. Details of current operational
standards are available at: www.england.nhs.uk/wp-content/
uploads/2013/12/5yr-strat-plann-guid-wa.pdf (see Annex B:
NHS Constitution Measures).
Indicator format
Reported as a percentage.
62
Detailed descriptor1
1
63
Glossary
A
Acute Respiratory Distress
Syndrome (ARDS)
Acute respiratory distress syndrome (ARDS) is a life-threatening lung condition that prevents
enough oxygen from getting to the lungs and into the blood.
Adults Wellbeing
and Health Scrutiny
Committee (OSC)
Purpose is to exercise the powers conferred by Section 21 of the Local Government Act 2000 and
Section 7 of the Health and Social Care Act 2001 by co-ordinating the effective scrutiny of adult
social care, health services and other related services and making reports to relevant local NHS
bodies and local authorities.
C
Cardiac surgery
Cardiovascular surgery is surgery on the heart or great vessels performed by cardiac surgeons.
Frequently, it is done to treat complications of ischemic heart disease (for example, coronary artery
bypass grafting), correct congenital heart disease, or treat valvular heart disease from various
causes including endocarditis, rheumatic heart disease and atherosclerosis.
Care bundles
A collection of interventions (usually three to five) that may be applied to the management of a
particular condition.
Care Quality Commission
(CQC)
The independent regulator of health and social care in England. The CQC grants licences to practice
healthcare in England. The CQC only issues licences to organisations that can rigorously prove they
can offer safe quality healthcare.
www.cqc.org.uk
Catheter associated
urinary tract infections
(CAUTI)
A catheter-associated urinary tract infection (CAUTI) occurs when germs (usually bacteria) enter the
urinary tract through the urinary catheter and cause infection.
Central Venous Catheter
Bloodstream Infections
(CVC-BSI)
A central venous catheter related-bloodstream infection (CVC-BSI) is a bloodstream infection most
likely caused by the presence of a central venous catheter (CVC). CVCs disrupt the integrity of the
skin, making infection with bacteria or fungi possible. Infection may spread to the bloodstream.
Clinical audit
A quality improvement process that seeks to improve patient care and outcomes by measuring the
quality of care and services against agreed standards and making improvements where necessary.
CDAD
C. difficile-associated disease.
Clostridium difficile (C.
difficile or C. diff)
Clostridium difficile (C. difficile) are bacteria that are present naturally in the gut of around twothirds of children and 3% of adults. C. difficile does not cause any problems in healthy people.
However, some antibiotics that are used to treat other health conditions can interfere with the
balance of 'good' bacteria in the gut. When this happens, C. difficile bacteria can multiply and
produce toxins (poisons), which cause illness such as diarrhoea and fever.
There are ceiling targets to measure the number of C. difficile infections which occur in hospital.
Coding
An internationally agreed system of analysing clinical notes and assigning clinical classification codes
Commissioning for Quality A payment framework that enables commissioners to reward excellence by linking a proportion of
Innovation (CQUIN)
the Trust’s income to the achievement of national and local quality improvement goals.
Controls
In the research sense, the control ‘arm’ of the study or patients in the control group are patients
who receive standard care, rather than the intervention that is being researched.
Coronary artery bypass
graft (CABG)
A type of heart surgery where the blocked or narrowed arteries supplying the heart are replaced
with veins or arteries taken from another part of the patient’s body.
Cystic Fibrosis (CF)
Cystic fibrosis is a genetic condition in which the lungs and digestive.
D
64
Data Quality
The process of assessing how accurately the information we gather is held.
DATIX™
Incident reporting system and adverse events reporting.
Delayed transfers of care
A national indicator. Assesses the number of patients who are delayed when being transferred
from one health organisation to another e.g. from one hospital to another, or from hospital to
community care.
Delirium
Delirium is a state of mental confusion that can happen if you become medically unwell. It is also
known as an 'acute confusional state'.
Medical problems, surgery and medications can all cause delirium. It often starts suddenly and
usually lifts when the condition causing it gets better. It can be frightening - not only for the person
who is unwell, but also for those around him or her.
Dementia
Dementia is a general term for a decline in mental ability severe enough to interfere with daily life.
Department of Health
(DH)
The government department that provides strategic leadership to the NHS and social care
organisations in England.
www.dh.gov.uk/
E
End of life care
The General Medical Council considers that patients are approaching the end of life when they are
likely to die within the next 12 months. This includes patients who are expected to die within the
next few hours or days, and those with advanced incurable conditions. End of life care may last a
few days, or for months or years. End of life care begins when you need it, and will continue for as
long as you need it.
Equality Delivery System
(EDS)
The NHS Equality Delivery System (EDS) is designed to help NHS organisations improve equality
performance, embed equality into mainstream NHS business and is one of the key products to
come out of the Equality and Diversity Council (EDC).
Extracorporeal membrane ECMO is a technique that oxygenates blood outside the body (extracorporeal). It can be used in
oxygenation (ECMO)
potentially reversible severe respiratory failure when conventional artificial ventilation is unable to
oxygenate the blood adequately. The aim of ECMO in respiratory failure is to allow the injured lung
to recover whilst avoiding certain recognised complications associated with conventional artificial
ventilation. The procedure involves removing blood from the patient, taking steps to avoid clots
forming in the blood, adding oxygen to the blood and pumping it artificially to support the lungs.
F
Foundation Trust (FT)
NHS Foundation Trusts were created to devolve decision making from central government to local
organisations and communities. They still provide and develop healthcare according to core NHS
principles - free care, based on need and not ability to pay. Papworth Hospital became a Foundation
Trust on 1 July 2004.
G
Governors
Foundation Trusts have a Council of Governors. For Papworth the Council consists of 18 Public
Governors elected by public members, seven Staff Governors elected by the staff membership and
four Governors nominated by associated organisations.
H
Health and Social Care
Information Centre
The Health and Social Care Information Centre is a data, information and technology resource for
the health and care system.
Healthcare acquired
infection (HCAI)
HCAI are infections that are acquired as a result of healthcare interventions. There are a number of
factors that can increase the risk of acquiring an infection, but high standards of infection control
practice minimise the risk of occurrence.
Healthwatch
Healthwatch is the consumer champion for health and social care, gathering knowledge,
information and opinion, influencing policy and commissioning decisions, monitoring quality, and
reporting problems to inspectors and regulators.
Hospital episode statistics
(HES)
The national statistical data warehouse for the NHS in England. HES is the data source for a wide
range of healthcare analysis for the NHS, government and many other organisations.
Hospital standardised
mortality ratio (HSMR)
A national indicator that compares the actual number of deaths against the expected number of
deaths in each hospital and then compares Trusts against a national average. This, along with a
similar system more recently introduced, the Summary Hospital-level Mortality Indicator (SHMI),
are both not applicable to Papworth Hospital as a specialist Trust due to casemix.
65
I
Indicator
A measure that determines whether the goal or an element of the goal has been achieved.
In-house urgent (IHU)
The term applied to a category of patient where the patient is not medically fit for discharge and is
required to stay in hospital until an intervention has been performed
Inpatient
A patient who is staying in hospital.
Inpatient survey
An annual, national survey of the experiences of patients who have stayed in hospital. All NHS
Trusts are required to participate.
Intentional rounding
Intentional rounding is the timed, planned intervention of healthcare staff in order to address
common elements of nursing care, typically by means of a regular bedside ward round that
proactively seeks to identify and meet patients’ fundamental care needs and psychological safety.
Intensive Care Unit (ICU)
A special ward for people who are in a critically ill or unstable condition and need constant medical
support to keep their body functioning.
L
Licence
The NHS provider licence is Monitor’s main tool for regulating providers of NHS services.
Local clinical audit
A type of quality improvement project that involves individual healthcare professionals evaluating
aspects of care that they themselves have selected as being important to them and/or their team
M
Methicillin-resistant
Staphylococcus aureus
(MRSA)
Staphylococcus aureus (S. aureus) is a member of the Staphylococcus family of bacteria. It is
estimated that one in three healthy people harmlessly carry S. aureus on their skin, in their nose or
in their mouth, described as colonised or a carrier. Most people who are colonised with S. aureus
do not go on to develop an infection. However, if the immune system becomes weakened or there
is a wound, these bacteria can cause an infection. Infections caused by S. aureus bacteria can
usually be treated with meticillin-type antibiotics. However, infections caused by MRSA bacteria are
resistant to these antibiotics. MRSA is no more infectious than other types of S. aureus, but because
of its resistance to many types of antibiotics, it is more difficult to treat.
Monitor
Previously the independent regulator of NHS Foundation Trusts, from April 1 2013 Monitor took on
new powers as the sector regulator for health, with a duty to protect and promote the interests of
patients. www.monitor-nhsft.gov.uk/
Multi-disciplinary team
meeting
(MDT)
A meeting involving health-care professionals with different areas of expertise to discuss and plan
the care and treatment of specific patients.
N
66
National clinical audit
A clinical audit that engages healthcare professionals across England and Wales in the systematic
evaluation of their clinical practice against standards and to support and encourage improvement
and deliver better outcomes in the quality of treatment and care. The priorities for national audits
are set centrally by the Department of Health and all NHS Trusts are expected to participate in the
national audit programme.
National Institute for
Health and
Care Excellence (NICE)
NICE is an independent organisation responsible for providing national guidance on promoting
good health and preventing and treating ill health. www.nice.org.uk/
National Institute for
Health Research (NIHR)
The National Institute for Health Research (NIHR) is a UK government body that coordinates
and funds research for the National Health Service It supports individuals, facilities and research
projects, in order to help deliver government responsibilities in public health and personal social
services. It does not fund clinical services.
National Institute for
Health Research (NIHR)
Portfolio research
The National Institute for Health Research Clinical Research Network (NIHR CRN) Portfolio is a
database of high-quality clinical research studies that are eligible for support from the NIHR Clinical
Research Network in England.
National Patient Safety
Agency
(NPSA)
An arm’s length body of the Department of Health which leads and contributes to improved, safe
patient care by informing, supporting and influencing organisations and people working in the
health sector. www.npsa.nhs.uk/
Never events
Never events are serious, largely preventable patient safety incidents that should not occur if the
relevant preventative measures have been implemented. Trusts are required to report if a never
event does occur.
NHS Innovation and
Improvement
Assists the NHS in transforming healthcare for patients by developing and spreading new work
practices, technology and improved leadership.
NHS Safety Thermometer
The NHS Safety Thermometer is a local improvement tool for measuring, monitoring and
analysing patient harms and 'harm free' care. From July 2012 data collected using the NHS
Safety Thermometer is part of the Commissioning for Quality and Innovation (CQUIN) payment
programme.
NHS number
A 12 digit number that is unique to an individual, and can be used to track NHS patients between
organisations and different areas of the country. Use of the NHS number should ensure continuity
of care.
O
Operating Framework
An NHS-wide document which outlines the business and planning arrangements for the NHS.
Outpatient
A patient who goes to a hospital and is seen by a doctor or nurse in a clinic, but does not stay
overnight.
Outpatient survey
A national survey of the experiences of patients who have been an outpatient. All NHS Trusts are
required to participate.
P
PALS
The Patient Advice and Liaison Service (PALS) offers confidential advice, support and information on
health-related matters. They provide a point of contact for patients, their families and their carers.
Papworth Hospital
Papworth Hospital NHS Foundation Trust.
PEA (formally PTE)
Pulmonary Thromboendarterectomy.
PLACE
Patient-led assessments of the care environment (PLACE) is the system for assessing the quality of
the hospital environment, which replaced Patient Environment Action Team (PEAT) inspections from
April 2013.
Pressure ulcer
A pressure ulcer is localised injury to the skin and/or underlying tissue usually over a bony
prominence, as a result of pressure, or pressure in combination with shear and/or friction.
Primary coronary
intervention (PCI)
The term percutaneous coronary intervention (sometimes called PTCA, angioplasty or stenting)
describes a range of procedures that treat narrowing or blockages in coronary arteries supplying
blood to the heart.
Priorities for improvement There is a national requirement for Trusts to select three to five priorities for quality improvement
each year. This must reflect the three key areas of patient safety, patient experience and clinical
effectiveness.
Productive Ward
‘The Productive Ward’ - releasing time to care, focuses on lean methodology to improve ward
processes and environments thus enabling staff to spend more time on direct patient care.
PVDU
Pulmonary Vascular Diseases Unit.
Q
Quality Account
A Quality Account is a report about the quality of services by an NHS healthcare provider. The
reports are published annually by each provider, including the independent sector, and are available
to the public. The Department of Health requires providers to submit their final Quality Account
to the Secretary of State by uploading it to the NHS Choices website by June 30 each year. The
requirement is set out in the Health Act 2009. Amendments were made in 2012, such as the
inclusion of quality indicators according to the Health and Social Care Act 2012. NHS England or
Clinical Commissioning Groups (CCGS) cannot make changes to the reporting requirements.
Quality, Innovation,
Productivity and
Prevention (QIPP)
Department of Health QIPP targets are the basis on which the NHS is expected to contain rising
costs and stay solvent.
Quality Report
Foundation Trusts are required to include a quality report as part of their annual report. This
quality report has to be prepared in accordance with our annual reporting guidance, which also
incorporates the quality accounts regulations. All Trusts have to publish Quality Accounts each year,
as set out in the regulations which came into force on 1 April 2010. The quality account for each
Foundation Trust (and all other types of Trust) is published each year on NHS Choices.
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R
Risk Assessment
Framework
Monitor’s document sets out how it will oversee NHS Foundation Trusts’ compliance with the
governance and continuity of services conditions of the NHS provider licence. This replaced the
Compliance Framework.
Root Cause Analysis (RCA)
Root Cause Analysis is a structured approach to identify the factors that have resulted in an
accident, incident or near-miss in order to examine what behaviours, actions, inactions, or
conditions need to change, if any, to prevent a recurrence of a similar outcome. Action plans
following RCAs are disseminated to the relevant managers.
S
Safeguarding
Safeguarding means protecting people’s health, wellbeing and human rights, and enabling them to
live free from harm, abuse and neglect. It is fundamental to creating high quality health and social
care.
Secondary Care
Care typically provided in a hospital setting or following referral from a primary or community
health professional.
Secondary Uses Service
(SUS)
A national NHS database of activity in Trusts, which is used for performance monitoring,
reconciliation and payments.
Serious incidents (SIs)
Previously known as Serious Untoward Incidents (SUIs). An incident requiring investigation that
results in one of the following:
Unexpected or avoidable death
Serious harm
Prevents an organisation’s ability to continue to deliver healthcare services
Allegations of abuse
Adverse media coverage or public concern
Never events, as updated on an annual basis
Sepsis
Sepsis is a life-threatening illness caused by the body overreacting to an infection.
Sepsis bundle
Using bundles in health care simplifies the complex processes of the care of patients with severe
sepsis. A bundle is a selected set of elements of care distilled from evidence based practice
guidelines that, when implemented as a group, have an effect on outcomes beyond implementing
the individual elements alone. Each hospital's sepsis protocol may be customised, but it must meet
the standards created by the bundle.
Septic shock
Septic shock is a life-threatening condition that happens when your blood pressure drops to a
dangerously low level. The fall in blood pressure is a reaction to a serious infection that develops in
the blood. This causes a response from the body known as sepsis. If sepsis is not treated, it will lead
to septic shock.
T
Tertiary Care
Specialised consultative care, usually on referral from primary or secondary medical care personnel,
by specialists working in a centre that has personnel and facilities for special investigation and
treatment.
Tuberculosis
Tuberculosis (TB) is a bacterial infection spread through inhaling tiny droplets from the coughs or
sneezes of an infected person.
V
Venous thromboembolism VTE is the term used to describe a blood clot that can either be a deep vein thrombus (DVT),
(VTE)
which usually occurs in the deep veins of the lower limbs, or a blood clot in the lung known as a
pulmonary embolus. There is a national indicator to monitor the number of patients who have
been risk assessed for VTE on admission to hospital.
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A member of
Papworth Hospital NHS Foundation Trust
Papworth Everard | Cambridge | CB23 3RE
Tel: 01480 830541 | Fax: 01480 831315 | www.papworthhospital.nhs.uk
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