Qua
alitty Rep
R porrt
20
010
0 – 201
11
Part 1: Chief executive’s statement
Although production of a formal Quality Report only became a statutory
requirement in April 2011, this is the third consecutive year in which our
Foundation Trust has produced such a report.
It allows us to demonstrate our commitment to giving each patient the best
possible care and treatment; report our progress on the priorities identified last
year; and set out the areas that we, our stakeholders and partners have
identified as priorities for improvement in the coming year.
I am pleased to report that we achieved many of the priorities for improvement
that we identified for 2010-2011, thereby improving patients’ experience of
care and, particularly, improving end of life care. There is more information
about our performance last year in Part 3 of this quality report (see page 69).
We also made progress during 2010-2011 in a number of other areas:
• electronic prescribing was implemented successfully with a positive
impact on patient safety and medicines management.
• the annual patient safety culture survey results for 2010-2011 confirmed
that the Foundation Trust has a positive approach to effective team work,
incident reporting, and support for patient safety and improvement.
• executive and non-executive directors walk-rounds are identifying
patient safety issues, with consequent benefits for patients (e.g. an audit
prompted by patient comments about noise at night led to the Foundation
Trust providing telephones that flash at night rather than ring).
• the Foundation Trust introduced ‘hourly rounding’ to ensure that patients
receive regular, timely attention and intervention from nursing staff. The
Patient and Public Involvement Group has worked with us on
benchmarking so that we can measure the resulting improvements.
• staff were presented with an award at the Junior Doctor of the Year
Conference for their audit work on airway care in the Intensive therapy unit
which helped ensure patient safety in the critical care environment.
• in addition the Foundation Trust met requirements for same sex
accommodation to maintain patients’ privacy and dignity; reduced the
number of patient falls that resulted in an injury; maintained its
commitment to staff training because of the evidence that effective
teamwork improves patient safety; and shared learning from incidents to
reduce the chance of reoccurrence.
I congratulate staff on the quality of care that they have once again provided
to patients during the past year. We will continue to support them in their drive
to innovate and improve. I confirm that to the best of my knowledge the
information provided here about the quality of services we provided in 20102011 is correct.
Signed ............................
Quality Report 2010 – 2011
Mary Edwards,
Chief executive
2
3 June 2011
Part 2: performance against 2010-2011 quality improvement
priorities
Priority 1 – patient experience of care
• Customer care
We pledged to establish a care and values framework. This has been
completed and underpins customer care training delivered through induction
courses, customer care workshops and frontline training sessions. This will
remain a priority for the Foundation Trust in 2011-2012.
• Inpatient survey
We pledged to do better in the national inpatient survey, and the 2010-2011
results showed significantly better performance in the percentage of patients
who reported receiving copies of letters sent between hospital doctors and
GPs. There was no significant change for a further 63 indicators whilst
performance worsened in relation to:
• nurses always answering patients’ questions clearly;
• doctors and nurses working together; and
• the percentage of patients wanting to complain about their care.
• Privacy and dignity
We comply with national requirements about same-sex accommodation and
have not breached them since January 2011.
The inpatient survey and walk-rounds showed that more patients reported
being disturbed by noise at night. This issue has been audited by a
multidisciplinary group of students. A number of actions have been identified;
implementing these will be a priority for 2011-2012.
Priority 2 – controlling and preventing infection
• Hand hygiene audits
We pledged to exceed a 90 per cent positive score in hand hygiene and
cleaning audits. Hand Hygiene audits (monitored monthly by the Board)
showed an average score for the year of 90 per cent, whilst the average
environmental cleaning audit score for the year was 97 per cent.
• Reducing MRSA Bacteraemia and Clostridium Difficile infection rates
We pledged to reduce MRSA Bacteraemia cases. There have been no cases
at all in 2010-2011.
The Foundation Trust had a period of increased incidence of Clostridium
Difficile cases in the summer of 2010. This was a high priority for the
Foundation Trust and in January 2011 we invited the Health Protection
Agency (HPA) to review our actions and advise on any other measures that
we might take. The following chart shows the improvement achieved in 2011;
work will continue in 2011/12.
Quality Report 2010 – 2011
3
A chart showing the number of hospital acquired cases of
Clostridium Difficile since April 10
No. of cases
Mar-11
Feb-11
Jan-11
Dec-10
Nov-10
Oct-10
Sep-10
Aug-10
Jul-10
Jun-10
May-10
Apr-10
12
10
8
6
4
2
0
Goal
Significant bacteraemia
We pledged to establish a baseline for significant bacteraemia by monitoring
and analysing infection rates. We achieved this and the Board can now use
this to monitor bacteraemia trends.
We also conduct Root Cause Analysis (RCA) on significant bacteraemia to
identify any common themes and/or learning, and share the results with front
line staff.
Priority 3 – care at the end of life (EOL)
• Improving end of life care
We pledged to improve the quality of end of life care. We assessed our
success using feedback from EOL quality of care surveys.
Surveys showed that 85 per cent of families and carers felt their relatives were
well looked after by doctors and nurses. Typical comments were:
“The care my brother received was excellent. All staff were caring and very
supportive to both my brother and family. Thank you.”
“A big thank you to all staff who cared for my mother during her many periods
of illness at the hospital. Thank you for all your patience and support.” • Reduce the Hospital Standardised Mortality Rate (HSMR):
We pledged to reduce the HSMR to less than 85 and began by reviewing the
notes of patients who had died and conducting in-depth mortality reviews in
collaboration with the NHS South Central Patient Safety Federation.
These reviews and associated work revealed that our avoidable mortality rate
is lower than other hospitals in our peer group, but our coded data does not
properly reflect our patient population and therefore gives an inaccurate
predicted mortality rate. A clinical data quality group has been set up to
address this complex issue.
Our HSMR increased in 2010-11 through a combination of co-morbidity
coding problems and a change in coding policy following national guidance on
palliative care coding.
Quality Report 2010 – 2011
4
• Improving communications with patients, their families and GPs
We pledged to improve communications with patients, their families and GPs
as measured through the national inpatient survey. We achieved this, and the
2010-2011 survey showed that a significantly higher percentage of patients
reported receiving copies of letters sent between hospital doctors and GPs.
Quality improvement priorities 2011-2012
Seven quality improvement priorities for 2011-2012 have been selected by the
Board in partnership with members, governors, patients, staff, and other
stakeholders including commissioners.
The seven priorities cover patient safety, clinical effectiveness and patient
experience. Each one has been developed using SMART (Specific,
Measurable, Achievable, Realistic, Time-limited) principles.
Those priorities associated with contractual requirements for quality
improvement will be monitored and reported through established quality
review meetings with the appropriate commissioning organisation(s).
Others will be monitored through the Trust’s existing governance structures,
with staff who deliver care involved in the measuring and monitoring. The
monitoring results will be shared with stakeholders including staff, the Patient
and Public Involvement Group/Patient Experience Group, Local Involvement
Networks (LINks) and Overview and Scrutiny Committees (OSCs).
Patient safety priorities for 2011-2012
Priority
outcome
Reduce the
number of cases
of C Diff.
Measurement and
monitoring
Infection Control
Team provides
monthly data for
monitoring at
divisional and
organisational level
Reduce the
number of
medication
errors for high
risk drugs
Audited by the
Medicines
Management Team
and monitored at
the Drugs and
Therapeutic
Committee
Quality Report 2010 – 2011
Reporting
Rationale
Infection Control
Committee,
C Diff Task
Force,
PPIG/PEG,
Governors
meetings,
Executive
Committee
Drugs and
Therapeutic
Committee,
Board of
Directors,
Executive
Committee
Infection rates are an
important factor in
patient experience and
the quality of care
provided, and require
further improvement.
5
Stakeholders chose
this as an important
priority, and we can
build on the good
results achieved in
2010-2011
Clinical effectiveness priorities for 2011-2012
Priority outcome
Improve the
quality of End Of
Life (EOL) care
Implement
learning from
clinical audits
Measurement and
monitoring
EOL survey results
monitored at the EOL
Strategy Group
All clinical audit
recommendations will
be risk-rated. High
risks will be monitored
through divisional
structures.
Venous
Monitor compliance
Thromboembolism with VTE risk
(VTE) reduction
assessment and carry
out root cause analysis
of VTE events
Reporting
Rationale
Board of
Directors,
Executive
Committee
Selected by
stakeholders as an
important priority.
Also a CQUIN
priority.
Selected by
stakeholders as an
important priority.
Clinical
Effectiveness
Group
Board of
Directors,
Executive
Committee
Thrombosis
Committee,
Board of
Directors,
Executive
Committee
National priority and
part of our CQUIN
target.
Patient experience priorities for 2011-2012
Priority Outcome
Improve percentage
of in-patient survey
respondents giving
a positive response
in the 5 agreed
priority areas
Reduce noise on
wards at night
Measurement and
monitoring
Develop key
performance
indicators (KPIs) for
teams. Patient
Experience Manager
will provide monthly
feedback that will be
monitored at
divisional and
corporate level
Audit in 2012 and
compare against the
baseline audit
conducted in 2011
Reporting
Rationale
PPIG/PEG,
Governors
meetings,
Executive
Committee
This is a recognised
area for ongoing
improvement. It is also
part of our CQUIN
target.
PPIG/PEG
Governors
meetings,
Patient
Safety
Group,
Board of
Directors,
Executive
Committee
Patients told of their
poor experience and
an audit illustrated the
extent of the problem.
Review of services
During 2010-2011 Basingstoke and North Hampshire NHS Foundation Trust
provided and/or sub-contracted 67 NHS services.
Quality Report 2010 – 2011
6
The Foundation Trust has reviewed all the data available to it on the quality of
care in all 67 of these NHS services.
The income generated by the NHS services reviewed represents 100 per cent
of the total income generated in 2010-2011 from the provision of NHS
services by the Foundation Trust.
National audits and confidential enquiries
During 2010-2011, 40 national clinical audits and two national confidential
enquiries covered NHS services that Basingstoke and North Hampshire NHS
Foundation Trust provides.
During that period, the Foundation Trust participated in 85% of national
clinical audits and 100% of national confidential enquiries of the national
clinical audits and national confidential enquiries which it was eligible to
participate in.
The following table shows:
- the national clinical audits and national confidential enquiries that the
Foundation Trust was eligible to participate in during 2010-2011;
- the national clinical audits and national confidential enquiries that the
Foundation Trust participated in during 2010-2011; and
- the national clinical audits and national confidential enquiries that the
Foundation Trust participated in, and for which data collection was
completed during 2010-2011. These are shown alongside the number of
cases submitted to each audit or enquiry expressed as a percentage of the
number of registered cases required by the terms of that audit or enquiry.
The reports of 18 national clinical audits were reviewed by the provider in
2010-2011 and the Foundation Trust intends to take the actions listed in the
table to improve the quality of healthcare provided.
Is BNHFT
participating?
% submission
of number of
registered
cases
required
External
audit reports
published in
2010 and
reviewed
Perinatal mortality (CEMACH)
Yes
100%
1
No actions identified for the Foundation
Trust
Neonatal intensive and special care
(NNAP)
Yes
100%
0
Report not due
Paediatric pneumonia (British
Thoracic Society)
No
N/A
N/A
The Foundation Trust intends to
participate in 2011/12 audit
Paediatric asthma (British Thoracic
Society)
No
N/A
N/A
The Foundation Trust intends to
participate in 2011/12 audit
National audit / confidential
enquiry title
Action taken as result of
external report
Perinatal and neonatal
Children
Quality Report 2010 – 2011
7
Is BNHFT
participating?
% submission
of number of
registered
cases
required
External
audit reports
published in
2010 and
reviewed
Paediatric fever (College of
Emergency Medicine)
Yes
100%
0
Childhood epilepsy (RCPH
National Childhood Epilepsy Audit)
Yes
N/A
N/A
N/A
Diabetes (RCPH National
Paediatric Diabetes Audit)
Yes
N/A
N/A
N/A
Emergency use of oxygen (British
Thoracic Society)
Yes
100%
1
No actions identified for the Foundation
Trust
Adult community acquired
pneumonia (British Thoracic
Society)
Yes
100%
0
Report not due
Non invasive ventilation (NIV) adults (British Thoracic Society)
Yes
100%
0
Report not due
Pleural procedures (British
Thoracic Society)
No
N/A
N/A
N/A
Cardiac arrest (National Cardiac
Arrest Audit)
No
N/A
N/A
The Foundation Trust will begin submitting
data in 2011-2012
Vital signs in majors (College of
Emergency Medicine)
Yes
100%
0
Report not due
Adult critical care (Case Mix
Programme)
Yes
100%
4
No actions identified for the Foundation
Trust
Potential donor audit (NHS Blood &
Transplant)
Yes
100%
1
Report reviewed by the Organ Donation
Committee and action plan developed
Yes
100%
2
Actions to improve the insertion and
management of central venous catheters
have been completed
Diabetes (National Adult Diabetes
Audit)
Yes
100%
0
Report not due
Heavy menstrual bleeding (RCOG
National Audit of HMB)
Yes
N/A
N/A
Chronic pain (National Pain Audit)
Yes
100%
0
Report not due
Ulcerative colitis & Crohn’s disease
(National IBD Audit)
Yes
100%
0
Report not due
Parkinson’s disease (National
Parkinson’s Audit)
No
N/A
N/A
COPD (British Thoracic
Society/European Audit)
Yes
100%
0
Report not due
Adult asthma (British Thoracic
Society)
Yes
100%
0
Report not due
Bronchiectasis (British Thoracic
Society)
No
N/A
N/A
National audit of dementia
Yes
100%
1
Identified actions include improving
access to memory clinics
Yes
100%
1
Quarterly mortality and morbidity meetings
have been established by the Orthopaedic
team
National audit / confidential
enquiry title
Action taken as result of
external report
Report not due
Acute care
NCEPOD confidential enquiries
including peri-operative care and
cardiac arrest studies
Long term conditions
N/A
N/A
N/A
Elective procedures
Hip, knee and ankle replacements
(National Joint Registry)
Quality Report 2010 – 2011
8
Is BNHFT
participating?
% submission
of number of
registered
cases
required
External
audit reports
published in
2010 and
reviewed
Elective surgery (National PROMs
Programme)
Yes
77%
2
No actions identified for the Foundation
Trust
Coronary angioplasty (NICOR
Adult cardiac interventions audit)
Yes
100%
1
No actions identified for the Foundation
Trust
Yes
100%
0
Report not due
Acute Myocardial Infarction & other
ACS (MINAP)
Yes
100%
5
Ongoing monitoring and action is
decreasing door to balloon times
Heart failure (Heart Failure Audit)
Yes
100%
1
Acute stroke (SINAP)
Yes
N/A
N/A
Stroke care (National Sentinel
Stroke Audit)
Yes
100%
1
Yes
100%
0
Report not due
Lung cancer (National Lung Cancer
Audit)
Yes
100%
1
A multidisciplinary proforma has been
developed to improve communication and
data collection
Bowel cancer (National Bowel
Cancer Audit Programme)
Yes
100%
0
Report not due
Head & neck cancer (DAHNO)
Yes
100%
1
The Foundation Trust participates in this
audit as part of the regional cancer
network. Actions are identified and
implemented through the network
Hip fracture (National Hip Fracture
Database)
Yes
100%
1
Improved liaison between orthopaedic
surgeons and the anaesthetic team is
helping the identification of high risk
patients
Severe trauma (Trauma Audit &
Research Network)
Yes
>65%
4
A review of the pathway of care of patients
with a head injury is underway
Yes
90%
0
Report not due
Yes
100%
1
No actions identified for the Foundation
Trust
Yes
100%
1
No actions identified for the Foundation
Trust
National audit / confidential
enquiry title
Peripheral vascular surgery
(VSGBI Vascular Surgery
Database)
Cardiovascular disease
Action taken as result of
external report
Action continues to develop pathways for
the identification and follow up of inpatients with heart failure
The Foundation Trust is registered for this
audit and anticipates data submission to
commence in 2011-2012
An action plan has been developed and
includes actions to improve access to the
Stroke unit
Renal disease
Renal colic (College of Emergency
Medicine)
Cancer
Trauma
Falls and non-hip fractures
(National Falls & Bone Health
Audit)
Blood transfusion
O negative blood use (National
Comparative Audit of Blood
Transfusion)
Platelet use (National Comparative
Audit of Blood Transfusion)
•
The list above is based on one provided by the National Clinical Audit
Advisory Group. The Foundation Trust also participates in other national
and regional audits. Decisions about participation in national clinical audits
are made at a speciality level and reflect consultants’ view of their clinical
priority.
Quality Report 2010 – 2011
9
Local clinical audits
The reports of 98 local clinical audits completed in 2010/11 were reviewed by
the provider in 2010/11 and the Foundation Trust intends to take the following
actions to improve the quality of healthcare provided:
• A re-audit showed improved care and fewer adverse outcomes after a new
protocol for managing acute chest pain was introduced in the Medical
Assessment Unit. All cardiology patients now have an exercise tolerance
test within 72 hours of attendance. This has more than halved the number
of patients re-presenting with heart attacks. The cardiology team leading
the project were finalists at the annual Health Service Journal National
Patient Safety Awards. Further development work is ongoing.
• An audit of analgesia for Emergency Department patients with a suspected
fracture of neck of femur resulted in patients getting faster pain relief and
pre-operative hydration. The department is building on these
achievements.
• Following an airway care audit, critical care staff have improved the care of
patients who are having their airway managed through more staff training
and daily decision making about sedation hold.
• An audit of the measurement of head circumference in children under two
led to the introduction of disposable measuring tapes on the Children’s
Day Unit.
• An organ donation audit highlighted the need for further teaching and
information for staff on the organ donation process. An action plan is in
place and is being monitored by the organ donation committee.
• An orthopaedic ward audit looking at patients’ ability to express their
opinions about inpatient care led to all patients now receiving PALS
leaflets on discharge.
Clinical audit activity is monitored by the Trust’s Clinical Effectiveness Group
which meets quarterly and provides regular reports to the Board. The Group
also holds an annual audit conference, chaired by the Medical Director, which
enables best practice to be shared across the Trust.
Research during 2010-2011
The Foundation Trust supports clinical research as a means of improving
patient care, and contributing to wider health improvement. The Foundation
Trust is a member of the Hampshire and Isle of Wight Comprehensive Local
Research Network.
The number of patients receiving NHS services provided or sub-contracted by
Foundation Trust in 2010-2011 who were recruited during that period to
participate in research approved by a research ethics committee was 512.
This was 18 per cent above the target set for the year.
Clinical staff participated in 108 clinical research studies approved by the
Trust’s research ethics committee during 2010-2011, as shown in the table
below, and 159 clinical staff completed Good Clinical Practice training to
enable them to participate in research studies.
Quality Report 2010 – 2011
10
Specialty
Anaesthetics
Cardiology
Child Health
Dermatology
Emergency Dept
Gastro/Hepato
Gynaecology
Haematology
Neonatology
Nursing
Obstetrics &
Gynaecology
Oncology
Number of
studies
2
6
4
1
1
5
2
15
2
2
5
25
Specialty
Orthopaedics
Pathology
Physiotherapy
Radiology
Respiratory
Rheumatology
Stroke
Support services
Surgery
Uro-Gynaecology
Urology
Tissue bank
Number of
studies
3
1
1
1
2
12
6
2
6
1
2
1
During 2011-2012 the Trust’s Research & Development Department will:
• increase the number of Foundation Trust clinicians engaging in research
and commercial trials;
• increase the number of specialties represented in research studies;
• improve the quality of research applications and reduce the burden of
gaining research approvals; and
• overcome barriers to recruitment to clinical research studies.
Information on the use of the CQUIN framework
A proportion of Basingstoke and North Hampshire NHS Foundation Trust’s
income in 2010-2011 was conditional upon achieving quality improvement and
innovation goals agreed between the Foundation Trust and organisations with
which it had a contract, agreement or arrangement for the provision of NHS
services, through the Commissioning for Quality and Innovation payment
framework.
The total amount of income in 2010-2011 conditional upon achieving quality
improvement and innovation goals was £2.08 million. The Foundation Trust
received £1.42 million (68 per cent of this total) in 2010-2011. Further details
of the CQUIN goals for 2010-2011 are available on request from the Head of
Governance at the Foundation Trust.
Care Quality Commission
Basingstoke and North Hampshire NHS Foundation Trust is required to
register with the Care Quality Commission. Its current registration status is
licensed and the Foundation Trust is fully compliant with the requirements of
registration.
The Care Quality Commission has not taken enforcement action against the
Foundation Trust during 2010-2011.
Quality Report 2010 – 2011
11
Basingstoke and North Hampshire NHS Foundation Trust is not subject to
periodic review by the Care Quality Commission, nor has it participated in
special reviews or investigations by the Care Quality Commission during the
reporting period.
Information on data quality
Basingstoke and North Hampshire NHS Foundation Trust submitted records
during 2010-2011 to the Secondary Uses service for inclusion in the Hospital
Episode Statistics which are included in the latest published data (at the
month 10 inclusion date).
The percentage of records in the published data which included the patient’s
valid NHS Number was 97.7 per cent for admitted patient care; 99.6 per cent
for outpatient care; and 89.9 per cent for accident and emergency care.
The percentage of records in the published data which included the patient’s
valid General Medical Practice Code was 100 per cent for admitted patient
care; 100 per cent for outpatient care; and 100 per cent for accident and
emergency care.
Basingstoke and North Hampshire NHS Foundation Trust’s Information
Governance Assessment Report overall score for 2010-2011 was 65 per cent
and was graded red.
Basingstoke and North Hampshire NHS Foundation Trust was subject to the
Payment by Results clinical coding audit during the reporting period by the
Audit Commission. Error rates reported in the latest published audit for that
period for diagnoses and treatment coding (clinical coding) are shown below:.
Percentage of primary procedures coded incorrectly - 3.1%
Percentage of secondary procedures coded incorrectly - 1.7%
Percentage of primary diagnoses coded incorrectly - 8.3%
Percentage of secondary diagnoses coded incorrectly - 6.9%
Percentage of episodes changing HRG - 3.0%
Percentage of spells changing HRG - 2.8%
In total 72 procedures and diagnoses were coded incorrectly, an error rate of
5 per cent. The net impact of these changes was that the Foundation Trust
overcharged its commissioners by £538,352.
The services reviewed were orthopaedics, obstetrics and midwife led
obstetrics. Please note that the results should not be extrapolated further than
the actual sample audited.
Quality Report 2010 – 2011
12
Part 3 - Other information
The Foundation Trust has chosen a range of measures reflecting patient
safety, clinical effectiveness and patient experience for inclusion in this
section. The measures were chosen after consultation with a range of
stakeholders including patient groups and Foundation Trust members. The
Board of Directors has reviewed the measures and believe they best reflect
the quality of the services we deliver.
There have been two changes to the measures selected for last year’s quality
report. The ‘average length of stay’ measure has been replaced with one
showing the percentage of patients who have a ‘long length of stay’. This new
measure is more accurate and allows us to monitor by diagnosis group. In
addition four patient experience measures have been added so that the
patient experience section includes those measures selected as a national
priorities through the CQUIN scheme.
No. of medication errors per 1000 bed days
(low numbers indicate better performance)
Data source: staff incident reporting
No. of patient falls resulting in injury per 1000 bed days
(low numbers indicate better performance)
Data source: staff incident reporting
Hospital acquired pressure ulcer rate(% inpatients)
(low % indicates better performance)
Data source: surveillance
No. of cases of MRSA bacteraemia
(low numbers indicate better performance)
Data source: surveillance
No. of cases of hospital acquired Clostridium Difficile
(low numbers indicate better performance)
Data source: surveillance
Hand hygiene rates
(high % indicates better performance)
Data source: audit
No. of patient safety walk-roundsTM
(high numbers indicate better performance)
Data source: patient safety programme
2007 – 2008
(low numbers indicate better performance)
Data source: staff incident reporting
2008 – 2009
No. of serious incidents requiring investigation
2009 – 2010
Measure
2010-2011
Patient Safety
14
15
14
6
4.1
5.9
7.0
7.7
1.6
1.9
2.0
1.9
2.0
2.7
2.6
NA
0
4
3
5
59
46
69
100
90%
85%
75%
NA
30
27
5
0
(NA = data not available)
The Foundation Trust continues to perform well on a range of patient safety
measures; in particular medication errors, patient falls and pressure ulcers all
showed reductions in 2010-2011. The Foundation Trust continues to report
serious incidents requiring investigation and the figure for 2010-2011 reflects
this reporting culture. The number of cases of Clostridium Difficile in 20102011 was higher than the previous year; more information about this is
contained within the main annual report.
Quality Report 2010 – 2011
13
Clinical Effectiveness and Outcomes
(low % indicates better performance)
Hip fracture – in hospital mortality rate (%)
(low % indicates better performance)
Acute myocardial infarction – in hospital mortality rate
(%) (low % indicates better performance)
Readmission rates (%) within 28 days (following
elective admission) (low % indicates better performance)
Readmission rates (%) within 28 days (following nonelective admission) (low % indicates better performance)
Long length of stay (% of patients)
(low % indicates better performance)
Day case rate (% for all elective procedures)
(high % indicates better performance)
Peer
(2010 – 2011)
Stroke – in hospital mortality rate (%)
2007 – 2008
(low numbers indicate better performance)
2008 – 2009
Hospital standardised mortality ratio (HSMR)
2009 – 2010
Measure
2010 – 2011
The Foundation Trust continues to monitor a range of clinical effectiveness
and outcome measures. All of them showed improving or stable results for
2010/11, as shown in the following table:
93.0
91.7
115.4
107.7
90.4
18.1
22.8
22.3
22.5
19.1
9.4
15.4
11.7
18.8
8.6
12.0
8.0
8.9
13.3
8.3
2.7
2.7
2.6
2.8
3.5
8.9
9.1
9.4
9.1
8.7
10.7
11.1
10.3
10.6
11.6
72.0
73.1
74.1
73.4
77.5
Data source: Dr Foster RTM. For 2010/11 timescales see data quality notes
Patient Experience
Measure (% of patients)
2010 – 2011
2009 – 2010
2008 – 2009
2007 – 2008
Peer
(2010 – 2011)
Although these results do not show statistical improvement in 2010-2011, the
Foundation Trust continues to perform well in the annual inpatient survey with
results that are comparable to its peer group. This will be an area of continued
development in 2011-2012.
Rating care as fair or poor
9
7
5
10
8
19
18
16
22
20
2
2
3
5
4
22
22
21
23
22
45
47
42
43
46
56
50
53
58
57
26
26
29
30
28
(low % indicates better performance)
Not treated with respect or dignity
(low % indicates better performance)
Room or ward not very or not at all clean
(low % indicates better performance)
Did not always have confidence and trust in doctors
and nurses (low % indicates better performance)
Wanted to be more involved in decisions
(low % indicates better performance) CQUIN
Could not always find staff member to discuss
concerns with (low % indicates better performance) CQUIN
Not always enough privacy when discussing
condition/treatment (low % indicates better performance) CQUIN
Quality Report 2010 – 2011
14
2008 – 2009
2007 – 2008
Peer
(2010 – 2011)
(low % indicates better performance)
2009 – 2010
Not fully told side-effects of medication upon
discharge (low % indicates better performance) CQUIN
Not told who to contact if worried after leaving
hospital (low % indicates better performance) CQUIN
Did not always get enough help from staff to eat
meals (low % indicates better performance)
Wanted to complain about care received
2010 – 2011
Measure (% of patients)
47
47
45
47
46
20
19
20
22
21
23
26
27
34
31
11
7
7
8
8
Data source: annual inpatient survey 2010
Performance against key Monitor and Care Quality Commission targets
Measure
2010 – 2011
Target
(2010 – 2011)
Performance
The Foundation Trust has met all of the Monitor service performance targets
and Care Quality Commission targets. The thrombolysis target is not
applicable as this is not the preferred treatment method of the Foundation
Trust.
Clostridium Difficile year on year reduction
59
<60
Met
MRSA Bacteraemia
0
<3
Met
Cancer 31 Days decision for subsequent treatment (surgery)
99.5%
94%
Met
Cancer 31 Days decision to Treatment (subsequent treatment - drug
therapy)
100%
98%
Met
Cancer 62 Days wait for first treatment (from urgent GP referral)
93.8%
85%
Met
Cancer 62 Days wait for first treatment (from consultant screening
service referral)
94.1%
90%
Met
Maximum waiting time of 18 weeks form point of referral to treatment
in aggregate and by speciality for admitted patients
90.9%
90%
Met
Maximum waiting time of 18 weeks from point of referral to treatment
in aggregate and by speciality for non-admitted patients
98.1%
95%
Met
All cancers: 31 day wait from diagnosis to first treatment
99.6%
96%
Met
Time in A&E - Maximum 4 hours waiting time in A&E from arrival to
admission, transfer or discharge
97.7%
>95%
Met
Yes
Yes
Met
MRSA screening for all elective and emergency admissions
Quality Report 2010 – 2011
15
2010 – 2011
Target
(2010 – 2011)
Performance
Maximum 2 week wait from urgent GP referral to 1st OP appointment
for all urgent suspected cancer referrals
95.4%
>93%
Met
Maximum 2 week wait from GP referral to 1st OP appointment for all
urgent breast symptomatic patients
94.3%
>93%
Met
Thrombolysis (for myocardial infarction)
N/A
>68%
Met
Access to healthcare for people with a learning disability
Yes
Yes
Met
Measure
Notes on data quality
Data has been taken from national data sources where available. Where local data is used the following should be
noted:
•
The Foundation Trust’s incident reporting policy requires all adverse events, near misses and hazards to be
reported. The organisation encourages an open reporting culture in accordance with national guidance but
acknowledges that there may still be under-reporting of incidents.
•
The Foundation Trust carries out monthly audits to collect data. These audits use specifically designed audit
tools and a set methodology.
•
Hand hygiene rates are measured using regular surveillance to determine the percentage of staff who clean
their hands in accordance with the recommended ‘five moments of hand hygiene’ which specify the points at
which staff should routinely clean their hands.
•
The Trust uses Dr Foster Real Time Monitor (RTM) tool to monitor mortality, re-admission, long length of stay
st
st
and day case rates. Mortality rate, long length of stay and day case rate timescales are 1 April 2010 until 31
st
st
December 2010. Re-admission rate timescales are 1 April 2010 until 31 October 2010
•
Monitor did not measure compliance with 18 weeks waiting times from Quarter 2 2010-2011
Data changes from the 2009/10 Quality Report
Data taken from Dr Foster RTM has been updated to report full year data and to reflect changes in the Dr Foster
baseline.
Peer groups
Basingstoke and North Hampshire NHS Foundation Trust has chosen to compare metrics against a peer group in
clinical effectiveness and patient experience.
The peer group for clinical effectiveness features hospitals that have a similar case mix by percentage volume.
Hospitals in this peer group are:
•
Basingstoke and North Hampshire NHS Foundation Trust
•
Frimley Park Hospital NHS Foundation Trust
•
Oxford Radcliffe Hospitals NHS Trust
•
Royal Berkshire NHS Foundation Trust
•
Salisbury NHS Foundation Trust
•
Surrey and Sussex Healthcare NHS Trust
•
West Hertfordshire Hospitals NHS Trust
The peer group for patient experience features hospitals that use Picker Institute Europe to undertake the national
inpatient survey on their behalf. This group is known to produce an accurate reflection of the national picture.
Performance against other Operating Framework priorities
Keeping children well, improving health and reducing health inequalities
• The Foundation Trust is an active member of Hampshire Safeguarding
Children Board and is assessed annually by it for compliance with Section
11 of the Children Act 2004.
The Foundation Trust complies with the Section 11 requirements and with
the additional safeguarding requirements set out in July 2009 by the NHS
Chief Executive (following up children who missed appointments, a clear
Quality Report 2010 – 2011
16
role and sufficient allocated time for Named Professionals, a lead Board
Director for Safeguarding, regular audits, and at least one Board review a
year of Safeguarding Children arrangements across the organisation).
The safeguarding children team supervises staff working with complex
families, and the Foundation Trust also provides a specialist service for
children and young people who have been sexually abused or assaulted.
• Our school nurses measured 93.4 per cent of year 6 children in 20102011, exceeding the 88 per cent target set by the National Child
Measurement Programme. This work informs local service planning and
delivery, and enables analysis of trends in growth patterns and obesity.
• School nurses also vaccinated more than 1,400 local girls and young
women against Human Papilloma Virus, in line with the national
programme, through sessions in schools plus catch-up clinics.
• A self-assessment by our sexual health clinic showed that the clinic meets
the ‘You’re Welcome’ quality criteria which support health service
providers to improve their services and be more young people friendly.
Emergency preparedness
The Foundation Trust’s business continuity plan, which was approved in
September 2010, was rolled out during the year. All clinical and non-clinical
areas have been issued with core business continuity action cards, and more
than 100 senior managers, matrons and medical staff attended workshops in
September 2010 and March 2011 where a range of business continuity
scenarios were rehearsed. The next step is to improve business continuity
awareness among staff in general and we are encouraging local workshops to
develop local plans.
Workshops about the hospital management of mass casualties and ballistic
trauma took place in December 2010 and January 2011 for senior clinicians
and managers, and we have reviewed our clinical equipment to better support
ballistic trauma management.
Foundation Trust emergency preparedness staff attended Local Resilience
Forums for health during the year and contributed to local, regional and
national emergency planning for the Department of Health and Home Office.
They also represented the Foundation trust at Exercise Longbarrow, a
regional mass casualty exercise.
Quality Report 2010 – 2011
17
Statements from stakeholders
The following statement was provided by NHS Hampshire, the Foundation
Trust’s primary commissioner, giving their comments on the content and
accuracy of the Quality Report.
NHS Hampshire response to Basingstoke and North Hampshire NHS Foundation Trust
Quality Account April 2010 – March 2011
NHS Hampshire has reviewed Basingstoke and North Hampshire NHS Foundation Trust
(BNHFT) 2010/2011 Draft Quality Account.
Report Structure
The Quality Account provides information across the three areas of quality as set out by Lord
Darzi. These are patient safety, patient experience and clinical effectiveness. The account
largely incorporates the mandated elements required. There is evidence that the Trust has
relied on both internal and external assurance mechanisms, for example through audit and
national surveys.
Priorities
BNHFT outlines seven priorities for 2011/12, two patient safety, two patient experience and
three clinical effectiveness. They are continuing engagement with staff, governors, patients
and members to work towards these.
The BNHFT’s 2010/11 Quality Account outlined the Quality Improvement Priorities identified
in the 2009/10 report as goals for improvement to 31 March 2010. Updates on these priorities
have been highlighted; however, outcomes achieved may have been presented more clearly.
The seven priorities set out for quality improvements in 2011/12 give general reference to the
expected outcomes, but greater clarity on specific quality measurements are not included.
The report assumes a well informed and knowledgeable understanding of items outlined
within it, with the result of the possibility of a lack of clarity of understanding of the content.
Background information with definitions on specific items would be beneficial – for example
defining ‘same sex accommodation’.
Clinical Audit And Research
The Trust participated in 40 (85%) of national audits, and 2 (100%) of national confidential
enquiries. The Trusts has identified actions for 2011/12, particularly in care pathways for
inpatients with heart failure and severe trauma. In addition the Trust has participated in 98
local audits from which actions are being implemented to improve quality of healthcare, for
example protocols for managing acute chest pain in the Medical Assessment Unit (MAU).
Clinical staff participated in 108 clinical research studies and the Trust has demonstrated
commitment to clinical research as it has supported a number of staff through training to
enable participation in research studies. The Trust intends to increase the numbers of staff
engaged in Research and Development during 2011/12.
Quality Report 2010 – 2011
18
Data Quality
Where information permits, the Commissioners are largely in agreement with the accuracy of
the data contained in the Quality Account. Some elements are not possible to comment upon
due to the variation in reporting mechanisms.
The account states that BNHFT will be taking forward actions to improve data quality. The
Trust has indicated that their coded data does not properly reflect their patient population and,
for example, an inaccurate predicted mortality rate is given.
The Trust’s Information Governance Assessment report reported an overall score for 2010-11
as 65% and graded red. A clinical data quality group has been set up to address coding
issues.
Patient Safety
The priority for patient safety has resulted in the Trust reaching their targets for Hand
Hygiene, environmental audit and infection control targets for MRSA bacteraemia, with no
cases for the year. The clostridium difficile target was achieved and the Trust has been
monitoring other bacteraemias, which will form the baseline targets for 2011/12.
Improvement in medication errors have been progressed through an electronic prescribing
project. The patient safety culture survey results showed a positive approach to patient safety
and improvement.
Patient Experience
The BNHFT has rightly addressed the challenges around delivering the Same Sex
Accommodation agenda and have had no breaches since January 2011.
BNHFT has rightly identified the improvements required against the national Inpatient Survey
and specifically to those areas categorised against responsiveness to personal needs of
patients. This is in conjunction with improving noise reduction at night. There is limited detail
on any further patient experience monitoring methods which will be utilised in year.
Patients receiving stroke care at BNHFT receive, on discharge, a pack which enables
feedback to be sent to the Stroke Association. Increased participation rates will support the
ongoing quality improvement in the Stroke Service.
Clinical Effectiveness
BNHFT have identified three priorities under clinical effectiveness for 2011/12. The inclusion
of improvements to be made against Stroke care may have been beneficial. The account has
not provided data on the Trust's Stoke or Transient Ischaemic Attack (TIA) performance. They
have not achieved the mandatory target of 80% for the Stroke Vital Sign Service. The
Commissioners have highlighted this area of concern and an initial action plan has been
provided to address the issues. Further discussions are scheduled to review the action plan
with time-scales for implementation.
The account references Commissioning for Quality and Innovation Schemes and provides an
opportunity to access more information.
Commissioner Summary
There have been many positive developments in 2010/2011. BNHFT continues to perform
well on a range of patient safety and experience measures, including same sex
accommodation and electronic prescribing to reduce medication errors. Projects, including
reviewing reducing the noise at night on wards, have initially produced good patient outcomes
and are being taken forward for 2011/12.
Quality Report 2010 – 2011
19
However the Quality Account needs to give more clarity on patient outcomes, and measures
of how outcomes will be achieved.
These developments are important considerations in the assurance around the quality of
services offered to patients and need to be commended alongside the continuing challenges.
NHS Hampshire will continue to work in partnership with Basingstoke and North Hampshire
NHS Foundation Trust to support the improvements outlined in this account.
The following draft statement was provided by the Foundation Trust’s
Governors, giving their comments on the content and accuracy of the Quality
Report.
The Governors of BNHFT congratulate the Board for the production of another excellent
Quality Report; we recognise and are fully supportive of all the efforts put in by staff to provide
and maintain the very best quality patient care at our Hospital, achieving consistently high
standards of performance.
Quality Report 2010 – 2011
20
Statement of Directors’ responsibilities in respect of the quality report
The directors are required under the Health Act 2009 and the National Health
Service (Quality Accounts) Regulations 2010 to prepare Quality Accounts for
each financial year. Monitor has issued guidance to NHS foundation trust
boards on the form and content of annual quality reports (which incorporate
the above legal requirements) and on the arrangements that 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 2010-11;
• the content of the Quality Report is not inconsistent with internal and
external sources of information including:
o Board minutes and papers for the period April 2010 to June
2011;
o papers relating to Quality reported to the Board over the period
April 2010 to June 2011;
o feedback from the commissioners dated 1 June 2011;
o feedback from governors dated 1 June 2011;
o the Foundation Trust’s complaints report published under
regulation 18 of the Local Authority Social Services and NHS
Complaints Regulations 2009;
o the CQC 2010 patient survey report;
o the CQC 2010 national NHS staff survey;
o the Head of Internal Audit’s annual opinion over the Foundation
Trust’s control environment dated 20 May 2011;
o CQC quality and risk profile dated February, March and April
2011;
• the Quality Report presents a balanced picture of the NHS Foundation
Trust’s performance over the period covered;
• the performance information reported in the Quality Report is reliable and
accurate;
• there are proper internal controls over the collection and reporting of the
measures of performance included in the Quality Report, and these
controls are subject to review to confirm that they are working effectively in
practice;
• the data underpinning the measures of performance reported in the Quality
Report is robust and reliable, conforms to specified data quality standards
and prescribed definitions, is subject to appropriate scrutiny and review;
and
• the Quality Report has been prepared in accordance with Monitor’s annual
reporting guidance (which incorporates the Quality Accounts regulations)
(published at www.monitornhsft.gov.uk/annualreportingmanual) as well as
the standards to support data quality for the preparation of the Quality
Report (available at www.monitornhsft.gov.uk/annualreportingmanual)).
Quality Report 2010 – 2011
21
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
3 June 2011
..............................Date.............................................................Chairman
3 June 2011
..............................Date..........................................................Chief Executive
Quality Report 2010 – 2011
22
Independent Auditor’s Report to the Council of Governors of Basingstoke and
North Hampshire NHS Foundation Trust on the Annual Quality Report
We have been engaged by the Council of Governors of Basingstoke and North
Hampshire NHS Foundation Trust (“the Trust”) to perform an independent assurance
engagement in respect of the content of the Trust’s Quality Report for the year ended
31 March 2011 (the “Quality Report”).
Scope and subject matter
We read the Quality Report and considered whether it addresses the content
requirements of the NHS Foundation Trust Annual Reporting Manual, and
considered the implications for our report if we become aware of any material
omissions.
Respective responsibilities of the Directors and auditors
The Directors are responsible for the content and the preparation of the Quality
Report in accordance with the criteria set out in the NHS Foundation Trust Annual
Reporting Manual 2010/11 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 content
of the Quality Report is not in accordance with the NHS Foundation Trust Annual
Reporting Manual or is inconsistent with the documents (defined below).
We read the other information contained in the Quality Report and considered
whether it is inconsistent with:
•
Board minutes from April 2010 to April 2011 (the period);
•
Papers relating to quality reported to the Board over the period;
•
Feedback from NHS Hampshire dated 1 June 2011;
•
Feedback from governors 1 June 2011;
•
The Trust’s complaints report;
•
CQC 2010 Patient Survey Report;
•
CQC 2010 National NHS Staff Survey;
•
The Head of Internal Audit’s annual opinion over the Trust’s controls
environment dated 16/05/2011; and
•
CQC Quality and Risk Profile dated February, March and April 2011.
We considered the implications for our report if we became aware of any apparent
misstatements or material inconsistencies with those documents (collectively, the
“documents”). Our responsibilities do not extend to any other information.
This report, including the conclusion, has been prepared solely for the Council of
Governors of the Trust as a body, to assist the Council of Governors in reporting the
Trust’s quality agenda, performance and activities. We permit the disclosure of this
report within the Annual Report for the year ended 31 March 2011, to enable the
Council of Governors to demonstrate they have discharged their governance
responsibilities by commissioning an independent assurance report in connection
Quality Report 2010 – 2011
23
with the Quality Report. To the fullest extent permitted by law, we do not accept or
assume responsibility to anyone other than the Council of Governors as a body and
the 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 (Revised) – ‘Assurance Engagements
other than Audits or Reviews of Historical Financial Information’ issued by the
International Auditing and Assurance Standards Board (‘ISAE 3000’). Our limited
assurance procedures included:
•
Making enquiries of management;
•
Comparing the content requirements of the NHS Foundation Trust Annual
Reporting Manual to the categories reported in the Quality Report; 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
It is important to read the Quality Report in the context of the criteria set out in the
NHS Foundation Trust Annual Reporting Manual.
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 2011, the content of the
Quality Report is not in accordance with the NHS Foundation Trust Annual Reporting
Manual.
PricewaterhouseCoopers LLP
Chartered Accountants
London
3 June 2011
Quality Report 2010 – 2011
24