BOARD OF DIRECTORS
MEETING IN PUBLIC
29 May 2014
PAPERS
Board of Directors’ Meeting
In Public
29 May 2014
The Education Centre, Birmingham Children’s Hospital
AGENDA
Item
Outcome
Time
Item
No.
14.70
Apologies for absence
Note
14.71
Declarations of interest
Note
Verbal
14.72
Minutes of public Board meeting 30 April 2014
Approve
Enclosure 01
14.73
Matters arising from public Board meeting 30 April 2014
Note
Verbal
14.74
Chairman’s Report
Note
09.05
10 mins
Verbal
14.75
Chief Executive’s Report
Note
09.15
10 mins
Verbal
09.25
20 mins
Enclosure 02
14.77
Strengthening the Voice of Young People Michelle Approve
McLoughlin, Chief Nurse, and Janette Vyse
Infection Control Annual Report Michelle McLoughlin, Chief Approve
Nurse and Dr Jim Gray
Quality & Resources
09.45
10 mins
Enclosure 03
14.78
Quality Account Vin Diwakar, Chief Medical Officer
09.55
10 mins
Enclosure 04
14.79
*Quality Report - Vin Diwakar, Chief Medical Officer and
Michelle McLoughlin, Chief Nurse
*Performance Report - David Melbourne, Chief Finance
Officer & Deputy Chief Executive
*Resources Report - David Melbourne Chief Finance Officer
& Deputy Chief Executive, Phil Foster, Director of Finance &
Procurement and Theresa Nelson, Chief Officer for
Workforce Development.
Use of the Trust Seal – David Melbourne, Chief Finance
Officer & Deputy Chief Executive
AOB
10.05
15 mins
Enclosure 05
09.00
Allocated
time
05 mins
Report type
Verbal
Strategy
14.76
14.80
14.81
14.82
14.83
Questions from members of the public
Approve
Note
Note
Enclosure 06
Note
Enclosure 07
Approve
10.20
05 mins
Enclosure 08
10.25
05 mins
None
BREAK
*For note, unless item becomes unstarred at the commencement of the meeting.
UNCONFIRMED
Item 14.77
Enc 01
BOARD OF DIRECTORS MEETING
Minutes of the meeting held in public on 30 April 2014 at 09.00
in the Education Centre, Birmingham Children’s Hospital
Present
Attending
Ref.
14.75
14.76
14.77
14.78
14.79
Keith Lester
Sarah-Jane Marsh
Tim Atack
Vin Diwakar
Michelle McLoughlin
David Melbourne
Theresa Nelson
Roger Pearce
Elaine Simpson
KL
SJM
TA
VD
MM
DM
TN
RP
ES
Interim Chairman
Chief Executive Officer
Chief Operating Officer
Chief Medical Officer
Chief Nursing Officer
Deputy CEO and Chief Finance Officer
Chief Officer for Workforce Development
Non-Executive Director
Non-Executive Director
Matthew Boazman
Christine Braddock
Simon Crooks
Georgina Dean
Phil Foster
MB
CB
SC
GD
PF
Director of Strategy and Planning
Chairman elect
Executive Office Manager (minutes)
Deputy Chief Officer, Contracting and Performance
Director of Finance and Procurement
Item
Apologies
Apologies for absence were received from Deborah Bannister, Jon Glasby and Colin Horwath.
Declarations of Interest
None
Minutes of the Board meeting held in public on 27 March 2014
The minutes were agreed as an accurate record.
Matters arising from the Board meeting held in public on 27 February 2014
There were no matters arising not covered by the agenda.
Chairman’s Report
Non-Executive Director
The Council of Governors at their meeting on 8th April 2014 approved the appointment of Judith
Smith, currently Head of Policy at Nuffield Trust as a non-executive director.
Joint Board and Council of Governors
On the same evening the joint Board and Council of Governors discussed risks and demands
arising from the 5 year plan.
Annual Memorial Service
Would be held on 11th May at St Chad’s Cathedral.
The Board noted the verbal report
Page 1 of 7
Action
UNCONFIRMED
Item 14.77
Ref.
14.80
Enc 01
Item
Chief Executive’s Report
SJM reported verbally as follows:
A visit at the end of March (at our request) by the CQC CEO David Behan and the
National Patients Safety Adviser James Titcombe had included a review of the Trust’s
approach to quality and safety, a tour of ward 5 and the PICU had resulted in a very
impressive response. The QCC commented positively on our open culture and the way
we handled complaints.
The ‘Big Discussion’ event facilitated by the Trust but managed and operated by the
Young People’s Advisory Group had been held at the Orange Studio and hosted by
Radio 1’s Aled Jones. Items discussed included communication, transition to adult care,
mental health and a feeling that care for the 16-24 age group should be given more
priority by the NHS in general. They queried how health professionals shared
information (they were irritated at having to repeat themselves), and asked whether
our IT systems were good enough to cope with its increased reliance upon by
healthcare professionals.
An organ donation event had been held at the Council House by the Trust chaired by Dr
Fiona Reynolds, provided a forum to stress the importance of donation and remove the
myths that existed within certain faith communities. The audience however didn’t
include as many faith representatives as had been hoped. The next steps were being
considered but could include taking this message out into the communities.
CB suggested the Trust consider promoting this direct to Colleges were the interest of
younger people could be captured.
VD also suggested promoting the service to staff in the Trust.
Louise McCathie, the Trust’s Fundraising Director had been awarded the ‘future face of
business’ award by the Birmingham Chamber of Commerce, recognising her role and
commitment to fundraising by the Trust.
The Big White Wall project had been launched by the Trust, bringing together health
and well being support for staff, by a link up services the Trust provided or had access
to.
The Board noted the verbal report.
STRATEGY
14.81
National & Local Staff Workforce
TN presented an update a summary of the findings of the 2013 national survey.
Page 2 of 7
Action
UNCONFIRMED
Item 14.77
Ref.
Enc 01
Item
The survey had gone out to all staff and had resulted in the highest return rate ever recorded of
59% compared to 46% the previous year. A better engagement with medical groups had also
been achieved.
TA suggested a comparison with other large specialist DGH for children would be useful rather
than large acute specialists.
Improvement based on the staff engagement score was based on five categories, seeing the
Trust rating increase from 3.74 to 3.84, an improvement not seen by many Trusts. In addition
staff motivation had increased from 3.73 to 3.83, this was good when understanding the
pressure on staff.
The survey also highlighted how the Trust could help staff with the pressure staff experienced
in trying to meet performance targets. DM asked if further work had been done on recovery
strategy when in a difficult environments. MM confirmed feedback and debrief was now being
encouraged.
CB asked whether the problem was with bullying also, inadvertently, encouraged by the
terminology – the continued use of the word ‘bullying’ in communication could well lead staff
to feel that everything is related to this. Instead the enabling more ‘positive behaviour’ rather
than the reduction of bullying behaviour should be encouraged.
National positives were highlighted and discussed, particularly reporting of errors. Again
however comparisons with general acute hospitals were not as relevant – bench marking with
specialist Children hospitals would be better.
In terms of national improvement areas CB asked if they would trigger action by Monitor.
Should we be paying more attention to this and prepared to address? Particularly staff stress
with the ongoing NHS demands.
BCH local engagement scores reported that 61% are positive about working at BCH, with 23%
sitting in the middle (neither agree nor disagree) and 16% giving negative feedback.
CB asked if there was a suggestion scheme whereby staff could provide comments. TN
confirmed the availability of the intranet and staff engagement exercises. SJM added that
further work was being done on this, including social media outlets.
The Board noted the report and the results of the survey.
14.82
Updated People Strategy
TN presented the above strategy which was a refresh of the 2012 strategy.
Page 3 of 7
Action
UNCONFIRMED
Item 14.77
Ref.
Enc 01
Item
Three specific priorities underpinned our strategy going forward, specifically;
Caring for our people
Leadership culture & development - we need to establish the right culture to find the
right leaders
Well being – looking after our staff
Managing our people
People systems – need to ensure our people management systems are better
Recognition and reward of staff – ensure there is a visible link
Developing our people
Workforce redesign and education – developing our staff for the challenges that lie
ahead, for example the Next Generation project and workforce supply issues.
Support & Guidance – regular meetings between managers and staff.
CB suggested a partnership approach, the expectation of the Trust – what the Trust expects
from staff. It was agreed that this should be emphasised more.
MM also mentioned our responsibility for training of staff before they join the Trust.
TN continued to explain the drivers behind the strategy specifically the workforce requirements
of the strategic priorities and where we are following the Francis report. Furthermore the new
hospital project impacted not only recruitment but the retention of staff.
All of this was against a worsening financial background.
A further slide demonstrated the supply and demand model for the nursing workforce. Based
on predicted leavers it demonstrated the challenges the Trust faced in attracting new nurses. It
was noted that the Next Generation impact wasn’t included. If the skill mix was changed by 2%
year on year we could overcome the supply deficit.
Finally some of the achievements were listed, specifically improved staff survey response,
better engagement and improved team development opportunities.
The Board received and accepted the contents of the report.
QUALITY & RESOURCES
14.83
Quality Report
Page 4 of 7
Action
UNCONFIRMED
Item 14.77
Ref.
Enc 01
Item
VD introduced the report containing a range of issues that had been reviewed and investigated
during the month. Items of note included;
Complaints in the last quarter had increased, key themes were
o
Communication – mainly applying to medical staff. Advance training had taken
place but more was intended on training and attitude.
o
Waiting times, delays and cancellations
o
Quality of treatment
There had been no Never Events during the month but four new SIRI’s had occurred.
There were no worrying trends in mortality statistics
MM reported on feedback from communication specifically cardiac cancellations. Discussed
who should give the message, not necessarily the individual carrying out the operation and
subsequent discussions with the family
Birmingham City Council Ofsted review had taken place at the end of March and early April.
Results had not yet been received but it was believed they had been told services were seen as
inadequate. In response to a question from SJM, MM wasn’t sure whether Lord Warner had
stared in his role as a commissioner. CB mentioned that in this respect there was a national
drive to change this perception of Birmingham which included the social services operated by
the Council.
National guidance was expected on female genitalia mutilation and how it should be dealt with
by emergency departments and clinical teams.
Finally co production of the SCAN safety Thermometer was proceeding with our partner Haelo
it was hoped it would be ready for the national launch in March/April 2015.
The Board noted the report.
14.54
Performance Report
GD presented the report, which contained a review of March and year to date.
March continued to be a busy month with high levels of elective activity, nearly 15% higher
than March 2013, and ED attendances were the highest since December 2010. In addition a
higher proportion of children were staying in the hospital longer. This impacted on the
availability of beds.
In March there were 43 patients or 2% of all operations were cancelled on the day due to
hospital reasons.
Diagnostic waits saw 146 patients waiting more than 6 weeks for an MRI test. This represented
13.46% of all diagnostic waits and was well above the 1% NHS standard. It was still hoped to
eliminate this list by June, but this was dependant on a mobile scanner on site in April, May and
June.
Page 5 of 7
Action
UNCONFIRMED
Item 14.77
Ref.
Enc 01
Item
It was noted that the Emergency Department continued to record a green rating, despite
March being the busiest month on record. CAMHS continued to achieve their 18 week wait
target with 100% of their patients being seen within target.
Cancelled operations continued to be a problem receiving a red rating. RP mentioned that a
further review had been undertaken at the FRC earlier in the week, looking at actions that
could be taken, in particular how the Trust responded to concerns raised by the
Commissioners. This included governance and whether another structure would help. Did the
Trust accept that there would be a level of cancellations or make other changes to other
elective treatment?
MM and VD were reviewing the clinical aspect, SJM stressed the problems of mandating
priorities but had agreed that the chief medical officers view would take priority over
optimising patient priorities. She felt that pressure to reduce the number of cancellations must
continue but not at the risk of care for other patients.
KL suggested this matter should be reviewed separately by the chief officers SJM agreed but
stressed that pressure to improve the problem should continue rather than look at alternatives
that could impact on other patients.
TA mentioned that in February the NHS missed the 18 week target – this could well be seen as
a national priority.
The Board noted the report.
14.55
Resources Report
DM reported a very successful year end saw the Trust improve on its financial performance
plan finishing the year £3,556k above target with an overall Trust surplus of £8.209m. Once the
Trusts trading subsidiary’s accounts were incorporated, the year end surplus was slightly lower
at £8.1m.
However despite this the Trust had failed to meet our efficiency targets in the year.
Cash balance stood at £48.6m ahead of plan by 69.1%., £8m would now be invested back in
hospital services.
The Continuity of Service Risk Rating for March is a 4 (the highest level), but DM stressed the
dangers of complacency.
The danger of our Commissioners running out of money was a concern with a major deficit for
specialised services in the West Midlands. This would be covered before the election but
afterwards the position remained uncertain.
SJM stressed the need for relationships being maintained with the commissioners, particularly
important in times of pressured and at the same time the importance of the Trust remaining
proactive.
TN reported on two specific concerns, namely;
The impact of operational issues such as cancellations on staff, particularly sickness
Page 6 of 7
Action
UNCONFIRMED
Item 14.77
Ref.
Enc 01
Item
levels; these had reduced in the month but were still above the 3% target.
The use of bank and agency staff had increased in March to 182.92 WTE, an increase of
23.67 WTE compared to February, principally due to people taking leave.
A ward breakdown slide showing nursing skill mix figures was referred to as part of the
Trusts commitment to transparency of workforce figures. In addition a further slide
showing the levels of nursing staff by skill mix was also presented. MM advised that this
was the first time we had to report nursing levels – for March the Trust recorded a
98.1% of actual against plan. SJM confirmed that if there was a problem in nursing
levels the Board needed to know.
The Board noted the report
OTHER
14.56
Questions from the Public
In response to a question from Carl Harris regarding the CAMHS tender for the 0-25 age group,
KH confirmed that due to the sensitivity of this item, it would be discussed in more detail in the
private session of the Meeting.
Next Board Meeting: 29 May 2014, The Education Centre, BCH
Page 7 of 7
Action
Board of Directors
29 May 2014
Item 14.76
Strategic Objective/ Enabler
Report Title
Sponsoring Director
Enc 02
Strengthening the voice of children and young people
Strengthening the voice of children and young people
Michelle McLoughlin, Chief Nurse
Author(s)
Janette Vyse, Lead Nurse for Participation & Patient
Experience
Previously considered by
Trust Leadership Team
Situation
Engaging and listening to children and young people is what we do at Birmingham Children’s
Hospital (BCH). Our Trust priorities reflect this and our strategic objective is that ‘every child and
young person cared for by us to be provided with safe, high quality care, and a fantastic patient and
family experience’.
Within the context of patient experience and participation we strive to continue the campaign in
recognising the importance, for the organisation, our staff and the children, young people and
families we care for, to invest and strengthen the voice of children and young people at every
opportunity.
Background
We know there is a clear link between patient experience and how it influences clinical effectiveness
and safety and we also know that a fantastic patient experience goes well beyond the health
outcomes.
The care we provide meets not only physical needs but emotional ones too. Compassion should be a
part of all health care services, making quality of care as important as quality of treatment. This is
something we aspire to for each and every child and young person in our care.
Alongside the clinical care there is a gravitas that has developed greatly in recent years in engaging
with children and young people on health care policy. The development of the Young Person’s
Advisory Group has been testimony to this, along with the value and benefits to health care
professionals of working in partnership with young people. There is much evidence that
demonstrates that young people value their role in participation and the clear benefits that can be
realised from doing this.
We have learnt much from our own experiences over the last few years and we are in an ideal
position at BCH to continue to build and develop this work.
Over the last few years we have developed a quality framework that puts children and young people
at its heart. Some of this has been through local drive and enthusiasm such as the setting up of our
Young Persons’ Advisory Group (YPAG) and the innovative feedback app, whilst others have been
driven by the National agenda and our Commissioners eg implementation of the Friends and Family
Test.
Several years ago saw a redesign of the organisation approach to patient experience with the
development of a ‘toolkit approach’ to patient feedback. This included the development of the
Patient Experience Database (PED) and a move from a ‘clunky’ paper based process to an electronic
one with more emphasis on real time and improving outcomes immediately.
We have introduced an increase in the use of more qualitative approaches to try and gain a better
understanding of the experiences of children, young people and families "trying to see the
experience through their eyes" through the use of shadowing, mystery shopper and patient stories.
Patient stories have been a feature more consistently at strategic level.
Assessment
We have worked hard to incorporate active participation into our overall patient experience and
participation agenda and we have actively engaged with children, young people and families, who
have been consulted on and participated in numerous activities.
Externally Birmingham Children’s Hospital is seen as a current leader in children and young people’s
engagement; our participation agenda and its influence has received national recognition.
The patient experience agenda has this year seen the successful development of a new more
accessible database to provide improved collection and analysis of feedback. There has been
identification of key themes with resultant action leading to change and improvement.
We have maintained the successful implementation of the friends and family test with a greater
focus on the young person response for this year. As is required within our CQUIN objectives we
have also introduced the process in to ED.
We have developed and launched the feedback app, the first of its kind within the NHS which has
received recognition for its innovation with a Guardian Public Service Award for Digital Excellence, a
PR Week Public Sector communications award and Birmingham Chamber of Commerce Excellence in
Innovation award. The app has brought a level of honesty and transparency that goes some way to
supporting recommendations within The Francis Report, 2013.
We have seen some investment in resources with the addition of a support role to the Patient
Experience & Participation Lead.
However this is an important and ever increasing agenda which requires us to bring in further
resources and investment. This would mean we can also provide developmental opportunities for
young people beyond a voluntary role. This year will be the second time we have seen a young
person progress from patient, to member of YPAG to Council of Governor representative through to
paid employment. There is scope for this to become an on-going opportunity we could advertise for
young people to apply for as a ‘gap-year’ initiative.
There is room to improve through the development of a more collaborative approach between
patient experience, PALS and complaints. This will ensure a thematic approach with better analysis
of what our children, young people and families are telling us about their experiences with early
recognition of emerging themes and issues and the opportunity to develop a more cohesive
strategic approach and action plan to address them.
Recommendations
The Trust Board is asked to note the developments that have been made in this area, the existing
good practice and leadership.
It is asked to support the recommendations and provide on-going support in strengthening the voice
of children and young people.
Key Risks
Risk Description
Risk Description:
Failure to meet strategic
objective
Would not be a centre of
choice
Failure to meet the
expectations of patients
Not meet CQUIN
requirements
Key Impacts
Strategic Objectives
CQC Registration (state
outcome)
Controls
Assurances
Patient feedback mechanisms –
toolkit approach
YPAG
Regular patient feedback report
via Quality Report
YPAG
Birmingham Children’s Hospital NHS Foundation Trust mission is
to provide outstanding care and treatment to all children and
young people who choose and need to use our services, and to
share and spread new knowledge and practice, so we are always
at the forefront of what is possible.
Key Trust Strategic objective is for every child and young person
cared for by us to be provided with safe, high quality care, and a
fantastic patient and family experience
The essential standards of quality and safety consist of 28
regulations (and associated outcomes) that are set out in two
pieces of legislation: the Health and Social Care Act 2008
(Regulated Activities) Regulations 2010 and the Care Quality
Commission (Registration) Regulations 2009. Providers must have
evidence that they meet the outcomes.
This report provides assurance of compliance against QC Core
Essential standards of quality and safety. In particular, Regulation
17 Respecting and involving people who use services and
Regulation 10 Assessing and monitoring the quality of service
provision.
NHS Constitution
Other Compliance (e.g. NHSLA,
Information Governance,
Monitor)
Equality, diversity & human
rights
In relation to equality or discrimination, this report should capture
any potential sources of dissatisfaction or problems and bring
them to the attention of the organisation. Therefore the impact in
relation to equality should only be a positive one.
UN Conventions on the Rights of the Child (1989), Article 12
includes children's freedom to express opinions, to have a say in
matters affecting their own lives; every child has a right to be
heard.
Trust contracts
Other
Strengthening the voice
of children & young people at BCH
Engaging and listening to children and young people is what we do at Birmingham Children’s Hospital (BCH). Our Trust priorities
reflect this and our strategic objective is that ‘every child and young person cared for by us to be provided with safe, high quality
care, and a fantastic patient and family experience’ Within the context of patient experience and participation we strive to
continue the campaign in recognising the importance , for the organisation, our staff and the children, young people and families
we care for, to invest and strengthen the voice of children and young people at every opportunity.
At BCH we care for children and young people every day to provide the best clinical experience possible, we know there is a clear
link between patient experience and how it influences clinical effectiveness and safety and we also know that a fantastic patient
experience goes well beyond the health outcomes.
The care we provide meets not only physical needs but emotional ones too. Compassion should be a part of all health care
services, making quality of care as important as quality of treatment. This is something we aspire to for each and every child and
young person in our care.
Alongside the clinical care there is a gravitas that has developed greatly in recent years in engaging with children and young people
on health care policy. The development of the Young Person’s Advisory Group has been testimony to this, along with the value and
benefits to health care professional of working in partnership with young people. There is much evidence that demonstrates that
young people value their role in participation and the clear benefits that can be realised from doing this.
We have learnt much from our own experiences over the last few years and we are in an ideal position at BCH to continue to build
and develop this work.
As a Trust, we have launched our mission, vision and strategic goals. Through the active and meaningful participation of children and
young people across all areas of health care will afford children and young people greater life opportunities and really will make BCH
champions for children and young people.
Underpinning all we do we are mindful of the United Nations Convention on the Rights of the Child (UNCRC)
U.N. Convention on the Rights of the Children 1981 (UK 1991)
Article 12 . Every child and young person has the right to express his or her views freely – about everything that affects him or her.
The child’s or young person’s views must be given ‘due weight’ depending on his or her age and maturity.
Article 3. All organisations concerned with children should work towards what is best for each child.
Improving local accountability and public engagement in the NHS is currently seen as key by all political parties. The Labour party, looking to
create a distinctive election strategy, in their draft consultation paper on health states that people should be "not mere consumers of
services but genuine and active partners in designing and shaping their care and support".
The national friends and family test, introduced by the Conservative Government from 1 April 2013 to ask patients if they would
recommend their ward or A&E department to friends and family if they needed similar care or treatment is to be rolled out for Children’s
services to all areas by March 2015.
As part of the Midlands and East network we were part of the Friends and Family pilot from April 2012 and have continued the initiative as a
locally agree patient experience CQUIN.
We were the first Children’s Hospital to introduce a paediatric variant of the question and BCH are represented on the ‘Accessibility for All’
programme helping define the National paediatric guidance.
Working in partnership with clinicians and carers in decisions about healthcare is one of the guiding principles set out in the NHS
Constitution 2013 it states people who use health and care services have the right to be treated with respect, dignity and compassion by
staff who have the skills and time to care for them.
Our young persons’ advisory group (YPAG) provided feedback on the NHS Constitution to DH with a recommendation that there be a young
person friendly version – NCB has now been commissioned to undertake this as a piece of work.
YPAG have undertaken a piece of research on compassion.
The Health and Social Care Act 2012 set duties for the NHS Commissioning board, clinical commissioning groups (CCG), Monitor, and health
and well being boards with regard to involvement of patients carers and the public.
A member of YPAG presented their work at the first meeting of our CCG
The Act also established Healthwatch England as a national body representing the views of users of health and social care services, other
members and local Healthwatch organisations.
It is early days in the development of Healthwatch Birmingham but we have the starting of a good relationship upon which we hope to
build. Members of our Young Persons Advisory group sat on a young person’s panel in the recruitment process of the Chief Executive
Officer.
The Children and young people health outcome forum (YPHOF) report 2014 has welcomed progress but has challenged the health system
and children’s sector on where further improvements are needed. They first of 6 themes is ensuring useful engagement with children and
young people so that their views are asked for, listened to and acted upon.
Trust Values
We must be brave and address the
organisational culture to ensure children
and young people can participate in many
different ways, including commissioning
services, designing the built healthcare
environment, recruiting and selecting staff,
governance of health services and
developing healthcare research.
Participation has the potential to reduce
health inequalities; however this requires
courage and an understanding of existing
power imbalances, barriers affecting the
involvement of children and young people
from diverse backgrounds and a range of
experience.
Better shared
understanding
of what is
meant by a
‘good patient
experience’
Patient
experience now
sits within heart
of quality
agenda
The participation of children and young
people should be evaluated systematically
and the outcomes shared with key
stakeholders. We should be committed to
ensuring the contribution that children and
young people make should be valued and
any successes celebrated.
Senior and
executive
engagement
Increased focus on
improving patient
experience through
education and
training
We have a responsibility in partnership
with parents and other organisation to
respect and maximise the potential of
children and young people. It is important
that children and young people can trust
us to demonstrate compassion and
courage, avoiding the pitfalls of nonparticipation such as tokenism,
manipulation and decoration.
Listening to children, young people and families at BCH
There is no one right way, which is why we use a toolkit approach to ensure we offer as many ways as
possible for as many people to tell us about their experience
Mystery
shoppers
Face to face
feedback
Surveys
Graffiti
walls &
creative
arts
Focus
groups
Shadowing
Patient
experience
walkabouts
Texts
Patient and
family
feedback
app
Feedback
cards
Patient
stories
Young Person’s Advisory Group (YPAG)
Friends &
Family Test
And
much
more!
Patient
Experience
Database
(PED)
In 2013/14 we asked 21% (13% in 12/13) of parents and 19% of children and young people, over the age of 8 years whether
they would recommend our hospital.
Out of 2930 parents, 2895 were either likely or extremely likely to recommend BCH to Friends and family.
Our overall net promoter score was an impressive and improved 82% (73% 12/13).
Social media
This past year has seen the increase of the use of social media by staff. Providing an opportunity for direct access to
many staff including increasing numbers of the Executive team.
It provides a direct line of communication to the head of the organisation any time of the day or night.
We have a strong presence on Facebook with 26,000 followers, one of the largest social media profiles of all children's
hospitals.

Patient Feedback App
Since it was launched in 2013 we have received over 1,200 messages for 55 different areas from children, young people
and parents. The vast majority have been positive, with many leading to changes and improvements. It has also been
recognised nationally with a Guardian Public Service Award for Digital Excellence, a PR Week Public Sector
communications award and Birmingham Chamber of Commerce Excellence in Innovation award.
.
It was really easy to download the
app and give our feedback and I got
a message back from the ward
manager within an hour, which was
great…
It’s good to know that
someone’s taking what
you say seriously and is
there to act on your
feedback straight away,
from Lola’s dad Paul
Thematic approach…......
In 2013 /2014 we identified from patient experience feedback the following issues as themes upon which we could
improve our children, young people and families’ care
Patient stories have influenced changes within each of these services and helped to define the success of the
developments within them.
Each of the projects has a defined lead for example the Associate Director of Nursing, Patient Experience and
Participation or Palliative & End of Life. However all of the projects benefit from inter team working. Information is
freely shared to improve patient safety, quality of care and improve outcomes
We have introduced
information & activity
books for all children
who come in to ED
We have secured charitable
funding to continue to provide
singing medicine, giggle doctors
and rhythm time – improving
health and well being through
music and laughter!
“The only problem we have
now is that children do not
want to go home from the
waiting room in ED as they are
having too much fun!” - Lead
Nurse
The Play and Recreational Facilitators
Play and activities are important for the wellbeing of all children and young people who spend time in hospital. They provide an essential
distraction from distressing aspects of care.
Improving normalising play and activities was a key objective for 2012/2013 and the introduction of play and recreational facilitators was
critical in helping to achieve this.
The Play and Recreational Facilitators have been in post since October 2013. The role of the Play and Recreational Facilitators is to
provide normalising play not specialised play. Many of the successful candidates have a nursery nurse background and also help with
Health Promotion, feeding advice etc. The facilitators have one to one sessions with children and young people who require more input
but also run larger craft sessions etc. to encourage interaction with peers particularly useful in long stay areas. There have been many
patient comments collected about the positive impact they are having on their experience. Within 2 months of the new role one of our
Facilitators were nominated for a star of the month for Outstanding Patient Care.
Continuing the improvement
Play and activities will remain high on the agenda for 2014/15 and we have recently recruited a new Play Project Manager for play for a
6 month secondment that is reviewing both specialised and normalising play provision in the trust. The aim will be to provide a fuller
service that will cover more out of hours activities for children and young people and also to help raise the profile of play, raise
awareness of what facilities are available and define roles within the team.
“Heather is Autistic, she has been diagnosed with ADHD, severe learning difficulties and a number of other difficulties such as
anxiety. She came in for surgery and the experience was traumatic for all involved. Due to Heather’s inability to understand her
situation and surroundings her anxieties immediately kicked in. There had been preparation beforehand in the form of a play
worker and, even though staff were outstanding, there was a definite lack of understanding of Heather’s condition. Heather
would occasionally hear the odd word “cut”, “needle”, etc. inducing even more anxieties from her.
Heather was suddenly confronted with staff she hadn’t previously met or had 5 minutes to talk with. All these new faces
bombarding her overwhelmed her. Eventually she was given a pre-med and taken down for her surgery. We had been told how
important this surgery was, not only for her hearing but also for her to, hopefully, move forward in her education so we were
eager for her to have the operation. As she started to receive anaesthetic she panicked and attempted to run, so we had to hold
her. It left both nurses and surgery staff unfairly shaken up by the experience which is, unfortunately, something Heather’s Mum
and I have had to deal with on numerous occasions. We were all confronted with a repeat of these events when Heather was to
receive her second Myoplasty surgery sometime in the near future.
Now we move on…
Having had some support from CAMHS we were assigned a Care Worker to work with Heather toward her upcoming surgery. The
Care Worker was introduced and spent time getting to know Heather and attempt to help the next surgery be a much less
traumatic event. J worked with Heather until we had a date for the surgery. J also worked with staff at the hospital to make
Heather’s surgery go as smooth as possible and even put together a short book, with pictures, that Heather could use to
understand her surgery a little better as well as tick off the various stages as they happened so nothing was a surprise to her.
We arrived at the hospital early and were immediately introduced to a fantastic young Staff Nurse who was outstanding at
making Heather feel relaxed in an environment that she was absolutely terrified of being in. Heather was introduced to the
surgery staff also and a Doctor, who introduced herself by name and spent a few minutes chatting with Heather, importantly
about the items she would see when entering the anaesthetic room.
Heather was fast tracked through, and other than a slight panic going under (Heather thought she was having a seizure) the
whole process was a breeze compared to last time.
I believe the work pre-empting problems and the hospital staff taking time getting to
understand both Heather’s difficulties and Heather herself really helped. I wanted to
pass on my sincere thanks to everyone involved in making this the smoothest possible
experience for Heather and putting her previous experience somewhat out of her mind.
Heather’s dad.
A gastroenterology consultant and MHDU make contact to discuss a 6 month old twin who they consider is palliative. They are asking for support in terms of
how to manage her. Lily is receiving CPAP ventilation, mum and dad are commuting long distances each day, dad is struggling to maintain his business, he
already has a child from a previous relationship who died 10 years ago, there are two older siblings and a healthy twin to consider.
A meeting is arranged including;
•Local specialist community nurses, Paediatrician and hospice
Complex care lead, BCH
Specialist nurse for gastroenterology, BCH
Respiratory consultant, BCH
Gastroenterology consultant, BCH
Ward manager
The meeting decides who is the key professional, who will lead difficult conversations, additional roles and a plan for future care i.e. what can and what can’t be
achieved. The possibility of changing ventilation is discussed in order to allow family to take Lily out of hospital in a pushchair, something mum has always
wanted to do. I support the gastroenterologist and MHDU to write an advance care plan. The Gatroenterologist shares the plan with medical colleagues to
ensure it is followed in his absence. Community nurses investigate local support for siblings, support for dad and funeral arrangements for Lily. The Local
paediatrician and community nurses arrange to meet regularly with mum at BCH and at home. The ventilation is changed to allow greater visibility of Lily’s face
and increase the likelihood that she might be able to spend time outside of BCH. Mum meets with the Lead Nurse for discussions that include taking Lily home
to die in the last hour’s/ day of her life, how she will die, how to care for her body at home and symptom control.
“The nurses are fantastic, they will never know how much they have helped….talking to you (lead nurse) and the community nurses is different though…you
know about the dying part and what we need to do….i can ask you things that it’s difficult to ask them…it’s obvious you have done this before!” Mum
The ward and Dr’s are supported in planning Lily’s care over the next month. The family are helped to take Lily out in a pushchair (she has never been in the
fresh air before) with her twin and spend a day at home supported by BCH and community staff. Family are able to take photographs of Lily and her twin in
their bedroom and the whole family in the garden which dad had landscaped in preparation for their birth.
When Lily deteriorated on MHDU suddenly, the plan was clear and the family were able to spend time with her. She was not resuscitated and died naturally.
Feedback from family was exceptional in terms of the support they had. Staff on MHDU were delighted with their feedback.
What is participation?
Participation is a way of working and an essential principle that should be applied at all times in all arenas.
In the context of BCH it is about children, young people and families having the opportunity to express
their views, influence decision making and bring about change.
As adults we have a responsibility to safeguard and protect children and young people from nonparticipation, avoiding manipulation, decoration and tokenism
Engagement & Participation can be considered at 3 Levels :
The following table shows examples of how each level might work in practice
Individual
The relationship between children,
young people their parents / carers and
health care professional or member of
staff
•Engaging and building relationships
•Individual feedback - including PALS and complaints
•Patient stories - used at staff away days, ward based training
•All induction (currently not included in new staff induction)
•Ward based surveys
•Use of volunteers
•Quality walkabouts
•Making the complaints process child friendly
Level 2 - Directorate or speciality levelImprovements or changes to services
and care pathways
•Engaging children and young people in service improvement projects eg ED pathway
redesign
•Speciality support groups eg IBD
•Specific work streams eg CAMHS web site design
•Quality and safety walkabouts
•Patient and parent representation at recruitment
•Focus groups
•Closer working relationships with PALS & complaints
Level 3 - Organisational or Trust wide
strategic issues
•Patient stories at Trust Board
•Triangulation of patient feedback with PALS and complaints to identify emerging themes and
issues.
•Listening events eg in tent
•Consultation - new hospital build
•Parent advisory group - actual/ virtual
•Commissioning
•Make 'strategic' relevant and meaningful
•High level participation - CYP initiated and led
•You’re Welcome assessment
Participation projects
Events: The Big Discussion
The Young Persons’ Advisory Group (YPAG) hosted a unique event
which brought together local youngsters and healthcare
professionals from all over the UK, to discuss important health
topics. The Big Discussion was supported by the Royal College of
Paediatrics and Child Health, the National Children’s Bureau and
Healthwatch Birmingham.
The Big Discussion welcomed health professionals from hospitals
and councils across the country. Representatives from the Care
Quality Commission, NHS England, The Department of Health and
the National Institute for Health and Care Excellence were in
attendance to hear about the important areas faced by young
people in the NHS.
Hosted by BBC Radio 1's Aled Haydn-Jones, there were also
keynote speeches from Children’s Commissioner of England
Maggie Atkinson and NHS England Head of Patient Experience
Kath Evans.
The four key topics of the day were transition from paediatric to
adult care, mental health, health education/health promotion and
communication between healthcare professionals and young
people.
Key points raised included the need for more adolescent wards
and a request that transition be renamed ‘graduation from
paediatric care’.
"I’m so excited to be part of this event, especially as the day is being
led by young people. I think it’s important to allow young voices to
be heard especially when it’s about bridging the gap between them
and the health care professionals. I hope the day will help influence
health care to suit young people’s needs and that we’ll be
successful in bringing about the change they’re looking for.”
Aled Haydn-Jones
Everyone was asked to fill in a pledge postcard outlining something they will start doing differently and pledges included:
•Provide the space and support for four young people led projects, discussions, events that will influence health and care changes in
services in Birmingham in 2014/15.
•Continue to raise the voices of children and young people by not being afraid to ask questions or voice my opinion!
The voices of parents and carers are just as important!
Whilst it is essential to increase the voice of children and young people, they should not be heard in isolation and
it is important to continue to empower the voices of parents and carers too. Older children do not exist in
isolation and parents play a crucial role in speaking for those children who are unable to through age or disability.
A review of the evidence suggests key themes emerging from parents in this context are:
•Help for young people to gain independence in managing their own care
•Services to be child orientated
•More co-ordination, integration and consistency of care
•Improved transition and for this to occur later (up to age 24)
•Schools to be more supportive of young people with long term conditions
Initiatives such as Tea@3 have been introduced to strengthen the voice of parents (and therefore children and
young people), this needs to be further developed through 1 or 2 parent member representation at PE and
Participation Committee - potentially the new carer Governor as one.
Early discussion is in place with the Carer Governor to look at setting up a parent advisory group - actual and
virtual.
A hospital without walls....
There has been a level of engagement not only at Birmingham Children’s Hospital, but across the NHS and we
already have a strong national network of contacts. BCH is influential and represented in NHS England's current
work stream to prioritise capturing and responding to Children and young peoples experiences of care across
organisations - through the development of the F&F test for children's services and the development of children
and young people's survey.
NHS England held their first meeting for the newly formed Young Peoples Health Forum in February 2014, the
anticipation is to develop opportunities for joint work with YPAG.
The Big Discussion is another example of national networking for the benefit of young peoples health outcomes.
Strengthening our local community Links will be a key patient experience and participation objective for 2014 /
15, this will be in close liaison with the Health Promotion agendas. This will include health and educational
organisations.
We will continue to build on the excellent participation and successful engagement with children and young
people across community CAMHS in the development of the fabulous resource - CAMHS website:
www.lotson yourmind.org.uk
We will build on the early relationship started with Healthwatch Birmingham and look at strengthening young
peoples role in commissioning.
Recommendations – objectives for 2014/15
1.
Build on toolkit approach to patient experience and explore more technical options eg ipads, screens etc.
2. Build on the thematic approach and triangulation of patient experience feedback with
PALS and complaints.
3. Multi-professional education and training – the challenge is to engage more with medical
colleagues
4. Further development of YPAG – explore accountability between Council of Governors and
YPAG and vice versa
5. Review role of young people on Council of Governors
6. Formalise development of ‘gap year’ opportunity from YPAG to paid position
7. Development of Parent Advisory Group
8. Strengthen our local community Links
9. Encourage more child/ young person led initiatives and projects
10. Build on from and keep ‘The Big Discussion’ going!
Conclusion
The Trust Board is asked to note the developments that have been made in
this area, the existing good practice and leadership.
It is asked to support the recommendations and remain committed to
strengthening the voice of children and young people through meaningful
engagement and participation.
Board of Directors
29 May 2014
In Public
Item 14.77
Enc 03
Strategic Objective/ Enabler
Infection, Prevention Control Annual Report
Report Title
Delivering Excellent Care Today: Infection Prevention
and Control Team Annual Report 2013/2014
Sponsoring Director
Michelle McLoughlin, Chief Nurse
Author(s)
Previously considered by
Jim Gray, Consultant Microbiologist
Selina Reay, Infection Prevention & Control Nurse,
Julie Suviste, Infection Prevention & Control Nurse
Specialist.
Infection Prevention & Control Committee
Quality Committee
Situation
This is the Annual Report of the Infection Prevention & Control Team. The production of such a
report, and its public release, is a requirement under The Health & Social Care Act 2008 (‘Hygiene
Code’)
Background
Although the national focus on healthcare-associated infections (HAI) has abated somewhat, HAI
continue to cause potentially avoidable patient morbidity and disruption to clinical care in every
hospital. There is therefore no room for complacency. Moreover, there are always opportunities to
improve, for example by learning from adverse events, and by harnessing new products and
technologies. The Annual Report this year consists of the usual mix of data showing the current state
of infection prevention & control within the Trust, and reports from many different disciplines across
the organisation describing their innovatory approach to improving infection prevention & control at
Birmingham Children’s Hospital.
Assessment
We have maintained our excellent performance in mandatorily reportable HAIs, and performance
remains satisfactory against extensive programme of audits of infection control standards.
Much of the focus of the report this year is around new ways of working in and between the
Infection Prevention & Control and Microbiology Teams.
Working hours have been extended, and there has been greater integration of the two teams;
infection and prevention control nurses now attend the microbiology department bench round
every day to identify potential issues as soon as possible, whist the creation of a new Advanced
Laboratory Practitioner role has been extremely successful.
The availability of new laboratory technologies has been put to good use, and during the year we
were able to introduce on-site testing for norovirus (the main cause of hospital outbreaks of
diarrhoea & vomiting); the value of this test in minimising or preventing disruption to the running of
the hospital is already being felt. We have exciting plans to use new technologies to radically
overhaul the investigation of children with viral respiratory infections next winter.
Recommendations
The Board is asked to approve the Report.
After approval the report will be released publically.
Key Risks
Risk Description
Controls
Failure to maintain good
infection and prevention
control standards carries risks
of avoidable harm to patients;
reputational and operational
risks to the hospital; risk to CQC
registration.
Infection prevention & control
is everyone’s responsibility. The
Infection Prevention & Control
Team oversees maintenance of
good standards and measures
the clinical impact of controls
Assurances
Series of regular reports to
Trust Board, CRAQ, Infection
Prevention & Control
Committee
Key Impacts
Strategic Objectives
Avoidance of HAI is integral to every child and young person
cared for by Birmingham Children’s Hospital being provided
with safe, high quality care, and a fantastic patient and family
experience.
The Hygiene Code requirement that infection prevention &
control is everybody’s responsibility is congruent with our
objective that every member of staff working at Birmingham
Children’s Hospital will be looking for, and delivering better
ways of providing outstanding care, at better value
CQC Registration (state
outcome)
NHS Constitution
Other Compliance (e.g. NHSLA,
Information Governance,
Monitor)
Equality, diversity & human
rights
Trust contracts
Other
ITEM 14.77
ENC 03
Delivering Excellent Care Today
Infection Prevention and Control Team
Annual Report
2013/2014
Contents
1. Executive Summary
2. Message from the Director of Infection Prevention and Control
3. Statement by the Trust Board
4. How did we do in 2013/14
5. Working towards NO Hospital Acquired Infections at BCH
6. How have we worked with others
Clean Team Development
Influenza Promotion Campaign
Engagement with Staff
Engagement with Patients and Families
IC Link & Lead Nurse Programme
7. What have we achieved
Hand hygiene Compliance
HII
Use of Antimicrobial stewardship
8. A word from the Directorates and Departments
Three successes, challenges and overcoming of challenges from:
The Heads of Nursing
Estates
Facilities
Decontamination
Occupational Health
9. External Assurance
PLACE
10. What we will do next
Targets for 2014/15
How we will achieve these
Page 2 of 21
1. Executive summary
Excellent performance in the Department of Health mandatory infection surveillance schemes:
No cases of MRSA bacteraemia for the third year.
A further reduction in MSSA bacteraemia.
One case of Clostridium difficile (which was a pre-48 hour case).
Successful infection prevention and control awareness week which prepared Departments for the
winter season.
Real progress in implementing more rigorous environmental inspections to ensure that the highest
infection prevention and control standards are maintained.
Adoption of new technologies to improve infection prevention and control.
Excellent performance in hand hygiene audits has been sustained.
Best staff flu vaccination rate in the country.
Page 3 of 21
1. Message from the Director of Infection Prevention and
Control
As I write this, NICE has just published new Quality Standards that remind us that healthcareassociated infections are still a very real threat to patients, their families and carers and staff.
When children, young people and families come to us, we want them to have the best experience
possible. This means ensuring our hospital is clean and they are protected from infections.
We work tirelessly to ensure that every member of staff understands and embraces our infection
prevention and control practices and takes every step possible to make improvements and share
best practice.
This approach has had a real impact again this year. For the second year running we’ve had no
cases of MRSA bacteraemia, only one case of C-difficile and can report on further improvements in
all measures of blood culture performance. We’ve also been able to get our MSSA rates down
further.
We ran our flu campaign again this year with 87% of front line staff taking up the vaccine to help
protect our children, young people, families and colleagues. This is the best rate in the country!
We encourage every member of staff to have the jab, no matter whether they are front-line or
not, and we have some robust plans in place for next year to ensure that we can improve on this
year.
But none of this would be possible without the Infection Prevention and Control Team and
support of our workforce. The team delivered a number of engagement initiatives across the
hospital to prepare staff for the winter season, and has made good use of the training film that
was made last year; all of this has vastly improved awareness amongst staff, patients and families
too.
I am really pleased to be able to report on another really positive year
of improvements but we won’t stop until all our rates are down to zero.
We’ve set ourselves some tough targets for 2014/15, and we will be
working hard to make sure we achieve them so we can make sure our
children, young people and families get the highest quality care they
deserve.
Michelle McLoughlin
Chief Nursing Officer
Page 4 of 21
3. Statement by the Trust Board
Public concern about healthcare associated infections remains at a high level. Once
again we are pleased to note that this year’s report demonstrates the maintenance of
high standards of infection prevention and control at all levels within the Trust.
The Trust is registered with the Care Quality Commission, and the Trust’s Quality and
Risk Profile has identified no concerns in relation to Standard 8 (Cleanliness and
Infection Control). This report should be seen as providing assurance of compliance
with each provision of the Health and Social Care Act 2008 (the Hygiene Code).
We replicated the previous year’s best ever performance in Department of Health
mandatory surveillance schemes during 2013/14, and indeed saw a further reduction in
MSSA bloodstream infections.
The Trust continues to invest in infection prevention and control, and this report shows
how that investment is helping to deliver improved care for the children under our
care.
Page 5 of 21
4. How did we do in 2013/14?
Our main objectives for 2013/14 fell within four key areas. The outcomes of many of these are
described in more detail throughout the report, but progress in each area is summarised below.
What we said we would do
What we achieved
1. To devise a new internal inspection programme based on the best practice of
external agencies
Establish a CLEAN Team to inspect all clinical
areas at least once per year to ensure that safe
and high quality care is delivered throughout
the organisation.
The Inspection process has been agreed and
trialled.
A training programme for key assessors has
been developed and delivered and a new
inspection reporting framework has been
agreed.
A CLEAN Team inspection programme for
2014/15 has been published
2. Getting our messages right when communicating with patients and families
Provide information and improved
communication on Infection Prevention and
control that meets the needs of
patients/families and visitors.
We have developed communication links with
patients and families by visiting patients who
are at high risk of infection or are nursed in
isolation.
Our feedback questionnaire has captured
positive comments regarding this input.
3. Utilise technology to provide accessible advice and information to clinical staff
Develop an ‘Infection APP’ which will
include antibiotic guidelines, blood culture
taking guidelines and any other relevant
clinical guidelines.
The ‘BCH Infection App’, is being
developed with a technical team from Coventry
University Innovation Park and will be available
soon on Apple and Android mobile phones. The
App contains trust antimicrobial guidelines,
blood culture collection guideline and sepsis
pathway. It will make these documents available
at patient’s bedside to the medical staff who
manage infection and regularly prescribe
antibiotics.
Develop user friendly algorithms for
common infections. These will be
incorporated into an infection control
intranet portal which will contain all
relevant infection control guidelines and
policies.
Three algorithms have been developed:
Diarrhoea and Vomiting, chickenpox and MRSA.
These are currently being trailed on several
wards and we are awaiting feedback.
4. Focus on best practice to prevent Surgical Site Infections
Review practices in our operating theatres, and
Observations were undertaken in Theatres,
Page 6 of 21
departments in line with NICE guidance.
following which an action plan was developed
by the Infection Control Nursing Team and the
Lead Nurse in Theatres to further improve
practice.
Our patient information resources pre surgery
were reviewed and updated with advice about
pre-washing.
Review the use of antibiotic prophylaxis to
ensure that patients receive the right agents at
the right time.
A re-audit of antibiotic use for surgical
prophylaxis was undertaken. This showed an
improvement in choice and duration and in
documentation on prescription charts.
Instigate a programme of surgical site infection
surveillance.
During Quarter 4 we participated in the
neurosurgical surveillance programme. Patients
are still being monitored but to date no patients
were identified to have infections.
Page 7 of 21
5. Working towards NO hospital acquired infections
MRSA Bloodstream Infections: another year with no cases
For the third consecutive year no child at BCH has had a bloodstream infection with MRSA. The
Infection Prevention and Control Team played an important role in maintaining this performance,
because we saw a number of patients colonised with MRSA who had multiple risk factors for
bloodstream infection and ensured that they received affective and timely treatment.
MRSA Screening: vigilance still required
The Department of Health MRSA guidance requires that we screen all-high risk children for MRSA
on admission. PICU and Cardiac services are specialities where the risk of MRSA is high. We
monitor our screening compliance, and are pleased to say that all our areas reached our 95%
external screening target throughout the year.
Speciality
External Screening
Target
Overall performance
during 2013/2014
Number of patients
identified as culture
positive
PICU
98%
97%
8
Ward 11
98%
99%
5
Ward 12
98%
99%
6
Nineteen MRSA cases were identified in our high risk patients; all of these could have got a serious
infection if we hadn’t known that they had MRSA.
Throughout the year 77 cases of MRSA were detected, 33 from children screened outside the high
risk screening programme, 19 cases were identified from clinical samples from in-patients and 25
cases were identified from clinical samples taken during clinic appointments, attendance at the
Emergency Department or as a day case.
Due to a cluster of MRSA positive patients (who proved to be unrelated) we looked at our current
MRSA screening policy to see where we can improve it. We found that if we increase the amount
of MRSA swabs from nose to nose, throat and groin/perineum then the detection of MRSA
increases by 33%.
Clostridium difficile: maintaining excellence
For the third year running we saw only one mandatorily reportable case; the onset of symptoms in
this case was within 48 hours of admission to hospital. The introduction of two-stage testing for C.
difficile three years ago has made us recognise the potential infection risk from patients who have
C. difficile but do not have diarrhoea as a consequence. We now undertake PCR on GDH-positive,
toxin-negative stools, and manage any PCR-positive toxin-negative with the same infection
preventuion and control precautions as confirmed cases of C. difficile infection.
Page 8 of 21
Preventing MSSA Bloodstream Infections: further progress
We continue to learn from carefully reviewing every case of MSSA bacteraemia that we see.
Measures that have been put in place over the past three years include:
Increasing the dose of Flucloxacillin used as prophylaxis for cardiac surgery.
Working closely with the Nutritional Care Team.
New Central Venous Catheter ongoing care document being developed with operational
lead nurses.
Improved observation of Central Venous Catheter exit sites for early signs of infection.
Work to reduce the number of contaminated blood cultures (MSSA is an important
contaminant of paediatric blood cultures).
During 2013/14 we saw a further 14% reduction in the number of MSSA BSI, from 28 to 24, and we
have plans to introduce further preventative measures based on a review of all the cases we have
seen in the past three years.
MSSA BSI data over the years
45
40
35
30
2010-2011
25
2011-2012
20
15
42
31
28
24
2012-2013
2013-2014
10
5
0
2010-2011
2011-2012
2012-2013
2013-2014
Further progress in reducing contaminated blood cultures
Because it is more difficult to take blood cleanly from children, we see a higher rate of blood
culture contamination. This can be a problem, because patient management can be affected
during the period of a day or more between a blood culture signalling positive and enough
information being available to determine whether the culture is a true positive or not.
In 2011/12 we reduced the number of contaminated blood cultures by 20% compared with the
year before. In the subsequent two years the improvement has continued, albeit at a slower rate.
In 2013/14 contaminants accounted for 52.6% of all positive blood cultures, meaning that we are
edging closer to our initial target of getting the proportion of all positive blood cultures that
represents contamination to under 50%.
Page 9 of 21
Contaminated blood culture numbers over the years
300
250
200
150
100
50
0
2010-2011
2011-2012
2012-2013
2013-2014
Winter Viral Season
A vaccine for rotavirus was introduced into the routine immunisation programme in July 2013.
The vaccine is given orally at two months and three months of age. We are monitoring the impact
of this programme on patients presenting to our Trust with rotavirus. Numbers of cases seen
nationally have been low so far this season, which compares to the lower numbers we have also
seen to date.
Once again, norovirus was controlled during the winter with no ward closures required. We have
been able to introduce polymerase chain reaction (PCR) testing for norovirus, meaning that results
are available within one hour compared with two or three days when they were referred to
another laboratory for testing. This has assisted greatly in the early assessment of children with
diarrhoea.
We saw a large number of patients presenting with respiratory illnesses over the winter period. A
total of 253 patients had Respiratory Syncytial Virus (RSV): these were predominantly patients
presenting to the Trust with symptoms, however we did see 23 hospital acquired RSV Infections.
This year the influenza season was again later in the year than expected, and we saw an increased
number of cases (15 cases of influenza A).
We are currently reviewing what went well, and opportunities to have done things differently to
prevent hospital acquisition of respiratory virus infections during the winter period. We anticipate
being able to recommend changes in practice (e.g. improved speed of diagnosis) before next
winter.
Page 10 of 21
6. How we have worked with others
The Microbiology Laboratory
The Microbiology Department has always played an important role in supporting the Infection
Prevention and Control service. However, during the past two years we have introduced many
important organisational and technological developments that have directly benefited the
prevention and control of infections. The Infection Prevention and Control Nurses’ offices are now
within the Microbiology Department, which makes communication more efficient and effective,
whilst the new Advanced Laboratory Practitioner role has provided an important link between the
laboratory and the nurses.
Microbiology laboratory technology is developing at an unprecedented pace, and we are
increasingly able to provide highly accurate results within an hour or two, rather than a day or
two. In the final quarter of the year we were able to introduce testing for norovirus for the first
time, which assisted greatly in the management of patients with suspected norovirus infection.
We also evaluated a new PCR test for a panel of respiratory viruses that detected infection in
almost 7X more patients than conventional diagnostic tests. Although expensive, we believe that
this test has considerable potential to assist in the management of winter pressures, and we are
now working on a business case ahead of next winter.
Infection Prevention and Control fun week
In October the Infection Prevention and Control Team took to the wards and set up an interactive
stall in the conservatory to promote all things Infection Prevention and Control related. Staff
participated in the many competitions being held and expand their knowledge.
Hand hygiene quiz with a prize for the winner.
‘How clean are your hands competition’ with a prize for the member of staff with the
cleanest hands.
Prize for the ward or department with the best Infection Prevention and Control board.
Raising awareness of antimicrobial stewardship.
Taking all the competitions to wards and departments so
everyone can get involved.
Posters, information, fun facts and freebees.
Flu Campaign 2013/14
At Birmingham Children’s Hospital we believe that all staff should
be entitled to the flu vaccine, regardless of whether they are
frontline staff or not as all staff are only one step away from a
vulnerable child or young person.
Our flu campaign centred on 48 known and publicised Nurse
Champions who were available on wards and departments to
promote the importance of the vaccination. With the help of
Page 11 of 21
managers and the Trust Board we were able to vaccinate staff in their workplace, making it
quicker and easier for people to get protected.
Our ‘Jab-a-thon’ was the launch event, which commenced in October with several successful
events in our busy communal staff areas. In the launch week alone 1,123 staff members were
vaccinated with this number reaching a massive 2,817 over the course of the campaign.
We are proud to say that we reached 87% of front line staff vaccinated, making us the top
children’s hospital and the top Trust in the country.
Providing a safe and clean environment Our programme of routine multidisciplinary
inspections has continued in all our clinical areas, with team representatives from the Infection
Prevention and Control Team, Senior Nursing Staff, Facilities and Estates. These focus on:
Cleanliness
Environmental standards
Good infection prevention and control practice
We found things that needed attention, but we are pleased to report that none of our areas were
deemed as putting our patients at risk of infection.
Throughout the year we have redeveloped this internal inspection programme to ensure that safe
and high quality care is continued to be delivered throughout the organisation. Our new CLEAN
Team inspection process assesses all aspects of infection prevention and control including
Cleanliness, Education of staff and ANtimicrobial prescribing during inspections to all clinical areas.
A training programme has been completed for the key assessors and a new observation and
reporting format has been developed. This will be fully implemented for all inspections throughout
the coming year.
Engagement with staff, patients and families
The Infection Control Nursing Team hav introduced routine visits to patients and their families to
provide advice and information to patients who have a high risk of infection or are admitted with
infections and require nursing in isolation. A written questionnaire has been developed to capture
feedback and comments from families. Feedback so far has been very positive. We are exploring
ways of capturing the information electronically, which will also allow us to generate reports of
the information captured.
Link Workers and Lead Nurses
The Infection Prevention and Control Link Champions (IPCLC) are invited to bi-monthly meetings.
At these meetings we update them on new developments within Infection Prevention and Control
and we also deliver educational presentations, interactive sessions and discussions. All
information given to the IPCLC is then disseminated to ward staff.
To ensure that they are updated monthly, on the months that we do not have a meeting they are
sent out an e-brief. We also circulate quarterly newsletters that go on display in the ward and
department areas.
Page 12 of 21
As well as giving information to the IPCLC we also have monthly meeting with the Lead Nurses. In
these meetings we discuss current issues and ways of improving care, we also discuss outcomes of
any Root Cause Analysises that took place over the month. Work groups have been set up within
the Lead Nurse meetings to look at Central Venous Cather ongoing care, enhanced cleaning and
the flooring within the hospital. The Lead Nurses are also provided with training to participate in
the CLEAN team.
Page 13 of 21
7. Our achievements
Directorate Hand hygiene audits 2013/14
For the sixth year in a row we have beaten our 95% hand hygiene target. Throughout the year we
have had consistently excellent performances reported to the Infection Prevention and Control
Committee.
Non-Clinical
100%
Clinical
support
services
100%
CAMHS
Medical
100%
100%
Surgical
100%
Specialised
services
100%
High Impact Interventions
Throughout the year we audited our High Impact Interventions. These detail key steps that will
reduce the risk of infection when inserting or caring for a medical device and could be devices
such as lines, urinary catheters or tubes which provide a pathway between the external
environment and the patient’s blood stream or body systems.
We looked at several care bundles across the directorates and we are pleased to say that our
performance target of 90% was reached in all bundles. If a department or ward did fall below the
90% target, we would help them reach it through extra training, education and demonstrations of
the correct procedures.
Effective use of Single Rooms
During the winter period the requirement for single rooms increases due to the numbers of
patients admitted with seasonal viral illnesses. Single rooms enable us to isolate the infection so it
doesn’t spread to other patients.
This year, the Infection Control Nursing Team actively monitored the effective use of single rooms
on a daily basis. An electronic cubicle database was developed which improved the access to
information on isolation requirements for individual patients. This was available to the Bed
Management Team, Department Managers and Lead Nurses, helping them to prioritise or identify
single rooms for patients when required.
Page 14 of 21
Antimicrobial Stewardship
This year there a big push to re-promote antimicrobial stewardship by re-establishing the
antimicrobial management committee, with new specialities invited to take part and to promote
better stewardship across the trust. We met more frequently and shared work done in the
specialities by presenting audits undertaken.
We took part in the Infection Prevention and Control week and European antibiotic awareness day
to promote stewardship and discovered that a bigger education drive is needed for stewardship
across the trust.
It was driven across the Trust to improve training targets for safe and effective antimicrobial
prescribing and 82.6% of staff completed this mandatory training.
In 2013/14 we were set a target to score 85% in the Antimicrobial Self Assessment Toolkit for
Trusts (a nationally recognised audit of antimicrobial stewardship arrangements in hospitals). This
was exceeded with a score of 90% (118/131), an improvement from 84% (110/131), last
year,demonstrating our robust antimicrobial stewardship arrangements.
Following 2012/13’s development of surgical antibiotic prophylaxis guideline, a re-audit was done,
which demonstrated good adherence to the guidelines, although some work for better
documentation is still needed.
After the launch of the much awaited new drug charts, with a dedicated section for antibiotics,
review of antibiotics being colour coded and area for indication and special instructions. It has
shown better documentation of this information, in the snap shot audits done quarterly, which
followed the Department of Health, Advisory Committee on Antimicrobial Resistance and
Healthcare Associated Infection (ARHAI), “start smart then focus” guidance.
Page 15 of 21
8. A word from our Directorates and Departments
Head of Nursing - Clinical Support Service Directorate
Highlights
Medical Day Care (MDC) has redesigned their ward to increase capacity by redeveloping
their playroom and one of their bathrooms into an infusion bay for young people. This
improved the patient experience and overall ambience of the department.
The development of the CLEAN team to replace environmental audits using the same way
of working as the CQC. There has been excellent engagement with the lead nurses who feel
this will improve the monitoring and cleanliness of their ward areas.
Radiology and the infection control team has worked closely during the rebuild in radiology
to accommodate the new CT scanner ensuring the patient journey was not affected.
Challenges
Maintaining an acceptable level of infection prevention and control training compliance
has been challenging, however we have addressed this through monthly monitoring of
figures, with each department liaising closely with Education and Training to ensure
improvements.
The screening of patients for MRSA going for a Central Venous Catheter insertion on
Surgical Day Care (SDC), as patients don’t always start their journey on SDC. A process has
been put in place to improve this.
Ensuring the patient journey was smooth with no interruptions during building work on
MDC.
Head of Nursing - Specialised Services Directorate
Highlights
Containment of an MRSA cluster on Ward 12, the whole team was commended by
Commissioners for the robust approach to managing and containing the outbreak.
Amending the data capture forms in KIDS; scores were down due to incorrect capturing of
data. The team redesigned their forms to make completion easier and compliance has
improved since the redesign.
Standardising the cleaning checklists in anaesthetic rooms. Previously each Theatre team
had different variations which led to some confusion when staff moved between Theatres
and also during inspections. A standardised form is now in place in all anaesthetic rooms;
this is being rolled out across all Theatre rooms.
Challenges
Norovirus outbreak on Ward 8 - this was challenging to manage for a number of reasons.
Segregating patients who needed isolating was very difficult as a number of patients on the
ward required isolation for other reasons which meant that cubicles were not available to
isolate patients affected by the virus. Symptom recognition was also a challenge due to the
nature of the underlying illnesses of the patients. This was overcome by all team members
working closely together, communicating well and supporting each other through the
challenges.
Page 16 of 21
Ventilator-associated pneumonia (VAP) compliance in our Paediatric Intensive Care Unit compliance with the VAP HII has historically never really achieved the required KPI so we
introduced the ‘Zap the VAP’ campaign in January 2014. This included lots of posters and
communications in staff newsletters and meetings to raise the profile and awareness with
staff. Since the campaign compliance is starting to improve.
Introduction of Infection Control Dashboard; demonstrating compliance with standards
whilst moving to a new monitoring system was a challenge, as was ensuring that the
reports provided information in a format that was helpful to the clinical and Directorate
teams to overcome this the DSS HoN acted as operational link with IT and Infection
Prevention and Control team to ensure a workable solution that provided assurance that
standards were being met and that the system provided the information needed for the
clinical, Directorate and Infection Prevention and Control teams.
Head of Nursing - Medical Directorate
Highlights
A reduction of MSSA bacteraemia across the Directorate
Ward 15 won the best board for Infection Prevention and Control in its fun week
competition.
Multidisciplinary approach to the challenges which include team working between the
Emergency Department and stakeholders.
Challenges
During the building work in the Emergency Department the Infection Prevention and
Control measures put in place caused a significant challenge for the staff on duty, those
managing the project and neighbouring stakeholders. By holding daily meetings with the
Emergency Department, Infection Prevention and Control, estates and
haematology/oncology we were able to manage the building works whilst reducing the risk
to the patients.
On Ward 15 there has been a cyclical occurrence of infections. We reinforced
accountability and developed action plans with the ward managers. We continue to
monitor and place interventions to reduce risk of infection, which include heightened
cleaning regimes and working closer with multidisciplinary team including non-clinical staff.
Containment of winter respiratory illnesses across Ward 2. We raised awareness with
families and staff on infection prevention especially during periods of outbreaks we did this
by giving out information leaflets, letters, face to face discussions, posters and training
both formal and on the spot.
Head of Nursing - Surgical Directorate
Highlights
Bare below the elbows (BBE) non-compliance has been dealt with on the Neonatal Surgical
Ward with one to one meetings with persistent offenders and Directorate wide reminder
from the Clinical Director to all Medical Staff.
Increased number of housekeepers in clinical areas to improve the overall cleanliness of
patient areas and to support the nursing team.Lead Nurses have received CLEAN team
Page 17 of 21
training, which is also helping them to ensure standards are maintained in their own
clinical areas .
Challenges
Norovirus has been a challenge, however it was contained and attended to promptly
without the need to cancel any surgery.
Head of Nursing - Child and Adolescent Mental Health Services
Highlights
Consistently scored 100% in hand hygiene results throughout the year.
Continued to have the same dedicated link workers for the wards maintaining their role
resulting in a small group of staff who are very knowledgeable and experienced in their link
role.
Maintained our local Link Workers meetings, continued with daily cleaning/checklist and
have notably set up a system around the maintenance of the environment of the wards.
Units conduct weekly community groups in which the patients report to the staff
(nursing/managerial/facilities) about the environment (i.e. what needs repair or
replacement) which the ward clerk processes with estates. We also undertake regular
walkabouts where the environment is checked, issues reported to the relevant department
and jobs are tracked.
Challenges
A problem on Irwin Ward with access to showers for young people. To overcome this
bathrooms were converted into shower rooms.
During work to improve the safety of the units by reducing the availability of potential
ligature points around the wards we found that the paper towel and toilet roll holders
were unsafe, we are currently using freestanding holders and are awaiting agreement for
holders to be fitted to the wall by magnet so as not to withstand the weight of a person.
Inadequate premises. Despite making minor improvements to the environment we have
long noted the out-dated nature of our current premises. During 2013 agreement was
reached for a £9 million overhaul and major redesign of our current premises.
Estates Department
Highlights
Four Responsible Persons for water now trained, ensure that we meet our legal obligations.
Infection Prevention and Control Policy developed for Estates works.
To minimise the risk to patients a dust risk assessment procedure (known as Q711) has been
introduced to accompany all Estates works.
Challenges
The Q711 dust risk assessments resource is intensive therefore an additional team leader will
be recruited.
Responsible Persons for water has not been appointed. An authorising Engineer for water is
being commissioned, they will complete assessments and appointments.
Page 18 of 21
The water written scheme to ensure that water in the Trust s always safe is incomplete.
The scheme is being reviewed and revised by appointed specialists in conjunction with and
across the Shared Estates Management Service.
Facilities
Highlights
Staff, through the training undertaken within Facilities, are progressing relatively quickly to
Healthcare Assistant and Housekeeper positions within the Trust and other NHS providers.
Patient Led Assessment of the Environment (PLACE) inspection results over the last five
years have indicated improved standards in all areas.
The team is continuing to work closely with ward and departmental leads to respond to
any issues that the ward may have especially to any infection outbreaks within the Trust in
a timely and professional standard.
Challenges
Retention of our staff due to the high level of training that staff receive as they are able to
apply for positions as healthcare assistants and housekeepers and are being very
successful. We are working in partnership with Birmingham Metropolitan College to recruit
the long term unemployed once they have undertaking training in NVQs to support them
back into the work place.
Storage for waste and cleaning equipment on wards and departments causing issues for
staff trying to maintain high standards of cleanliness around the Trust. These areas have
been reduced due to the pressure on space as clinical services expand and move to a 24/7
service. Facilities are working closely with Heads of Nursing and the Infection Control Team
to find ways of working more productively on Wards and Departments where space is at a
premium.
Maintaining a high standard of cleaning that is within budget yet continually improving the
service offered. Research and introducing cleaning equipment that may save time that can
be reinvested to increase cleaning times of higher risk areas have helped us overcome this.
This includes floor machinery for corridor cleaning and wet and dry pick up machine to
scrub hard non-slip floors such as toilets, bathrooms and the art rooms at Parkview.
Decontamination
Highlights
Onsite decontamination facilities remain compliant with statutory regulations.
Challenges
Plans to upgrade our decontamination facilities in R-Block theatres as part of the Theatres
development have been subject to a delay. However, this is not putting patients or staff at
risk.
Page 19 of 21
Occupational Health
Highlights
The Trust’s sickness absence average was low at 3.48% in 2013/14. This was partly
attributable to timely Occupational Health referrals and employees and their line managers
following advice to enable employees to return to work gradually.
The Trust has continued to build a productive relationship with Heart of England NHS
Foundation Trust (HEFT), its Occupational Health provider, in 2013/14. This has resulted in
a more efficient referral process. During 2013, HEFT agreed to implement a referral triage
service at no additional cost to BCH. Consequently, all new Occupational Health referrals
are now triaged when they are received by HEFT to ensure that the referral is appropriate,
i.e. the employee needs to be seen by an Occupational Health practitioner rather than a
Counsellor. Where a Counsellor is more appropriate, the employee is referred to the
Trust’s Counselling Service, thereby shortening the time for the employee to be seen by a
trained counsellor and freeing up Occupational Health appointments for employees that
need to be seen.
Trust staff experienced 58 sharps injuries in 2013/14 compared to 61 in the previous year.
Education continues to be undertaken with staff across the Trust to decrease the risk of
staff suffering sharps injuries. The volume and geographical location of sharps injuries will
continue to be reported to the Infection Prevention and Control Committee meetings.
Challenges
BCH staff did not attend their Occupational Health appointments on 564 occasions in
2013/14, a year-on-year increase of 26%. To reduce this in 2014/15, the Trust’s Human
Resources department will disseminate quarterly Occupational Health reports to individual
directorates to highlight this issue and to ascertain the reasons that staff did not attend.
Currently, Human Resources is exploring solutions with Directorates to reduce
Occupational Health spend, whilst ensuring an effective service is provided to our staff. A
quick-win to reduce Occupational Health expenditure is to reduce the numbers of those
who don’t attend their appointments.
A measles immunisation testing programme for the relevant Trust staff was carried out in
2013/14 however the uptake was lower than expected. A plan is being formulated to
address this and a decision will be made if the measles immunisation testing will be
undertaken by Occupational Health or internally by the Trust’s Phlebotomy service.
Page 20 of 21
9. External Assurance
We are still awaiting the final report from the PLACE inspection that took place this year, however
the initial feedback we received was extremely positive.
10. What are we planning to do in 2014/15?
As part of our goal to continually improve infection prevention and control we have identified
some key objectives for this financial year:
Increase, promote and engage with staff patients and families. Encourage staff to take
ownership in the prevention of infections. We will action this by arranging drop in sessions
for staff to attend, using postcards with clear simple messages which will to go to wards
and departments. e will encourage wards/departments/the Trust to make an Infection
Prevention and Control pledge or commitment to promote individual ownership of
Infection Prevention and Control and improve links with managers by developing an
education and communication programme.
We want to improve Antimicrobial Stewardship engagement with the clinical teams and
public. To do this we will produce posters, send postcards and promote the use of the
newly developed antibiotic app. We will also undertake ward visits and attend team
meetings.
Due to an increase in the presence of carbapenemase-producing organisms the
Department of Health and Public Health England recommends that all trusts screen
patients that are admitted from high risk areas for these organisms. To do this we are
going to update our existing Multi Resistant-Gram Negative Bacteria (MR-GNB) policy,
identify the at risk patients group and work closely with the Lead Nurses to ensure that the
screening is undertaken appropriately and correctly.
Future Fit Workforce
Following a review of the nursing workforce and the increasing clinical/operational demand on the
infection control team, we will be expanding our team by 2.8wte. This will provide us with the
resource to expand our cover during the week and to include weekends, which were of benefit
over this winter season.
11. Contacts
If you have any questions about what you have read here, or would like to find out more about
how we are tackling and preventing infections at Birmingham Children’s Hospital, please contact
Chief Nursing Officer, Michelle McLoughlin, on 0121 333 9999 or email
michelle.mcloughlin@bch.nhs.uk.
Page 21 of 21
Board of Directors
In Public
29th May 2014
Item 14.78
Enc 04
Report Title
Final draft Quality Account and Quality Report 2013/14
Sponsoring Director
Author(s)
Previously considered by
Chief Medical Officer
Chief Medical Officers Senior Projects Manager
Trust Board/Governors Scrutiny Committee/Council of Governors
Situation
The annual mandatory Trust Quality Report and Quality Account are required to be published in May
2014 and June 2014 respectively.
Background
The Quality Account and Quality Report are both annual reports to the public on the quality of services
we provide.
They are intended to demonstrate Boards and leaders of NHS organisations are assessing the quality
of services they provide and are committed to quality improvement. They also are intended to allow
scrutiny of our approach to quality and assurance that Board understand where improvement is
needed in the quality domains of safety, patient experience and clinical effectiveness.
The documents are very similar in terms of content but there are some key differences between them
which can be summarised as:
The Quality Report is mandated by Monitor and is published as a section of the overall Annual Report
in May. It is distinct from the Quality Account for the following reasons:
- Trusts are only obliged to publish three locally selected indicators under each quality domain
(though more can be published if the Trust wished to remain in line with their Quality
Account document);
-
It’s content is audited against Monitor issued guidance by our external auditors;
- Monitor mandates that external auditors audit data quality underlying two nationally
mandated indicators and one locally selected indicator contained in the quality account on
and annual basis.
The Quality Account is mandated by the Department of Health/NHS England and is published by
submission to the NHS Choices website in June. This is deemed to meet the requirement that all
quality accounts should be laid before the Secretary of State for Health. It is also a ‘stand alone’
document.
Assessment
In order to proceed to final publication of the 2013/14 Quality Account and Report Trust Board are
requested to review the final draft of the document.
Recommendations
Trust Board are asked to:
APPROVE: the contents of final draft Quality Account/Report for submission to Monitor (as
part of the Annual Report) and publication to the NHS Choices website as mandated.
Key Risks
Risk Description
Controls
Assurances
Key Impacts
Strategic Objectives
CQC Registration (state
outcome)
NHS Constitution
Other Compliance (e.g.
NHSLA, Information
Governance, Monitor)
Equality, diversity & human
rights
Other
Mandatory requirement to publish both and annual Quality
Account and Quality report.
ITEM 14.78
ENC 04
Birmingham Children’s Hospital NHS Foundation Trust
Quality Account 2013-14
1
Chief Executive’s Statement on Quality
Chief Executive’s Statement on Quality
At Birmingham Children's Hospital, we pride ourselves on placing quality and safety at the heart of
all we do. In that context, I am pleased to report that 2013/14 has been another great year, where
we have not only further embedded our quality focus, but have also worked on a range of safety
projects, helping us develop even better ways of doing things, and ensuring we deliver the very
highest standards our children, young people and families deserve.
Our Hospital Handover Project is vastly improving the quality and consistency of information our
doctors and nurses exchange about a patient’s condition between shifts, in the specialties where we
have piloted it. This is part of a Health Foundation funded initiative, which we plan to implement
across our hospital over the coming months, and we hope will benefit other hospitals too.
We are also leading the way on the development of the first NHS wide tool to measure harm done to
children whilst they are in hospital. The national Safety Thermometer, which measures things like
urinary tract infections, blood clots and falls is not really sensitive to the potential risks in children
and young people’s healthcare. Our tool, called SCAN - Safer Children Audit No Harm, has been
endorsed by NHS England, and we are working with them to support a roll out to other children’s
units across the UK.
These, and our many other systems for assessing and monitoring the quality and safety of care, were
reviewed this year by the Care Quality Commission (CQC), who visited us in November as part of a
routine inspection. In addition, its inspectors observed how we treat children and young people, and
spoke to staff, patients and families who said that they “cannot fault the care” we provide and in
their really positive inspection report, confirmed that we had met all five of the essential CQC
standards they were considering.
But the quality and safety improvement journey is never over, there are always areas where we can
do better, and this year is no exception. The numbers of operations we have to cancel, the length of
time children and young people have to wait for an MRI scan, and our staff satisfaction score in the
National NHS Staff Survey are all things we desperately want to improve on. There can surely be
nothing worse than preparing your child and family for major surgery, only for it not to go ahead, or
to wait too long for an MRI scan when the results determine next steps in your child's treatment. It is
equally important that we keep an eye on how happy our staff are, and to make sure they are fully
supported, so that they are able to deliver the very best services. Put simply, happy staff means
happy patients. We have significant plans to make improvements in each of these areas, which you
can read more about in the following pages.
None of our day to day work, or improvement activity, would be possible without listening to, and
engaging with our children, young people, families and staff, to really understand what is most
important to them, and what we need to do to improve. We do this in many ways - through our
patient and family feedback app, mystery shoppers, surveys, events and more. Our Young Person’s
Advisory Group has continued to provide the perfect sounding board for many of our decisions at
the hospital, whilst also setting out its own agenda, and quite rightly holding us to account for its
delivery.
We have many challenges, and exciting times ahead, and will be doing all we can to achieve our
objectives of delivering safe, high quality care to every child and young person, alongside a fantastic
2
patient and family experience. It is what we are here for, and if we cannot get this right, then
nothing else we do really matters.
To the best of my knowledge the information contained in this Quality Account is accurate.
Sarah-Jane Marsh
Chief Executive
Priorities for Improvement
‘Every child and young person cared for by BCH will be provided with safe, high
quality care and a fantastic patient experience’.
It is a key priority for the Trust to ensure that the care we give is of the highest quality and safe and
that when children are with us the experience they have when they’re here is a good one.
Our clinical and quality strategy helps us focus on ensuring that we continually monitor our and
improve our systems for promoting and enhance patient safety and reducing avoidable harm.
We do this by working in partnership with our children, young people, families and staff to ensure
their opinions are heard, feedback is acted on and lessons are learned. Our Participation and Patient
Experience Strategy ensures that we engage and involve children, young people and families in the
planning, provision and evaluation of all aspects of our services as outlined in section 242 of the NHS
Act.
In the last year we have moved to a more real time data collection and responsiveness. This has
been enhanced by a new communications tool – the feedback app - and is also increasingly being
supported by the use of social media including Facebook and Twitter. The app has provided an
opportunity for parents, children and young people to let us know about their experience, both
positive and not so good, in real time and for staff to respond directly in real time too.
There are many other ways we gather information so we can understand where we need to improve
to make our quality of care better:
Listening to the children, young people and families that use our services There are lots of ways
they can tell us what they think, and we take account of it all to work out what’s most important to
them:
Complaints, comments and concerns
Feedback cards
Surveys
Patient stories
Feedback App
Websites like NHS Choices and Patient Opinion
Consultations
Mystery Shoppers
Listening to our staff The views of the staff who work in our hospital every day are vital and
we encourage them to tell us what they think through surveys, consultations and feedback
events. It’s also really important that we keep an eye on their happiness and make sure
they’re fully supported so that they are able to deliver the best services they can.
3
Listening to others The views of BCH groups like the Young Person Advisory Group help us
focus on how to make the improvements that are needed.
Analysing information about the quality of services, such as patient safety incidents and
clinical audits.
Using best practice examples, national targets and learning from and benchmarking with
other organisations.
Using this information has helped us to identify Quality Priorities, which are the main areas we want
to focus on to improve quality. Each priority has a goal and a way of measuring our progress in
reaching t which will be detailed on the forthcoming pages. This is however not an exhaustive list of
priorities. These relate to the three elements of quality: Patient Experience, Clinical Effectiveness,
and Safety. The priorities we are reporting on this year are:
Patient Experience
Food and Nutrition
Play and Activities
Tertiary Inpatient Referrals
Cancelled operations
MRI scan waits
Clinical Effectiveness
Staff Survey
Nursing Care Quality Indicators
Asthma Care
Health Promotion
CAMHS User Service
Satisfaction
Safety
Extravasation injuries
Pressure Ulcers
Healthcare Acquired Infections
in PICU
Reducing Rates of Clostridium
Difficile
Preventing MRSA
Reducing MRSA
Reducing Medication Incidents
Resulting in Harm
Reducing Life Threatening
Events, Cardiac and Respiratory
Arrests
Mortality –Zero Avoidable
Deaths
Some of the key projects and highlights of our quality strategy planned for 2014-16 are outlined
below:
-
Implement and embed the Safer Clinical Systems Handover Project Trust wide.
Pilot and review the use of the Safety Case approach as a method for embedding quality
review of service delivery across the organisation.
Support the development of the national Paediatric Safety Thermometer building upon the
SCAN work
Re-launch the Sepsis Care Pathway.
Implement SHINE 12 – ‘Listening to You’ – a tool to measure parental concerns and
standardise the format for handing over care between a parent and a nurse.
Improving situational awareness by introducing the proven ‘huddle’ model to improve
communication and address underlying cultural causes for safety failures.
4
We can map our quality indicators into the wider priorities of the NHS for Children and Young People
based on the NHS Outcomes Framework as outlined below:
QUALITY
STRAND
QUALITY DOMAIN
(NHS OUTCOMES FRAMEWORK)
Effectiveness
Preventing people from dying
prematurely
Enhancing quality of life for
people with long-term conditions
Safety
Patient Experience
Helping people to recover from
episodes of ill health or following
injury
BCH QUALITY INDICATOR
Nursing Care Quality Indicators
Asthma Care
Health promotion
Nursing Care Quality Indicators
Asthma care
Health Promotion
Food and Nutrition
Nursing Care Quality Indicators
Health promotion
CAMHS Service User satisfaction
Food and nutrition
Play and activities
Tertiary inpatient referrals
Cancelled operations
Friends and Family Test
Ensuring that people have a
positive experience of care
MRI waits
Treating and caring for people in
a safe environment; and
protecting them from avoidable
harm
Pressure ulcers
Reducing Healthcare Acquired Infections in PICU
Reducing rates of C.Difficile
Preventing MRSA
Reducing MRSA
Medication Incidents
Acute life threatening events, Cardiac Arrests and
Respiratory Arrests
Zero avoidable deaths
Extravasation injuries
These priorities and what we’ve achieved in 2013/14 are set out over the next few pages of this
Quality Account.
In 2014/15 we will also develop indicators report on some additional priorities that we have been
developing during 2013/14:
Safety:
Patient Experience:
Paediatric Safety Thermometer
Learning disabilities
Palliative and End of Life Care
Clinical Effectiveness: Implementing the Sepsis Care Bundle
5
Listening to Patients and Families
Food and Nutrition
Good quality and tasty food helps our children and young people get better more quickly and
improves their experience of hospital.
We previously measured how well we were doing with the food we provide by asking children,
young people and their families two questions which were ‘I can choose what I want from the menu’
and ‘I am happy with the choice I am given at mealtimes’.
We have changed the way we collect feedback on food in 2013/14 so can’t make a comparison
against previous years for these two questions. We have begun assessing our food provision for the
first time using the new PLACE assessment. This involves patient and volunteers from outside the
hospital assessing and giving feedback about the quality of food that we provide
How have we done?
This year we are showing information about and PLACE assessments and the percentage of positive
and need to improve comments received and captured in our patient experience database both of
which are shown below:
Figure 1: Positive v need to improve comments relating to food in 2013/14
“Please ensure
portions are big
enough for
teenagers”
“Chips are on the menu too much
I would like pasta and wraps to be
added on”
“A lot of variety
on the dinner
menus and we
like the MAPLE
system”
PLACE assessments are undertaken by local volunteers and children/young people work as a team to
assess how the environment supports patient’s privacy and dignity, food, cleanliness and general
building maintenance.
6
The assessors score questions which are then used to give a percentage score indicating the
assessment of quality by the review team. Our PLACE food assessment scores for our Child and
Adolescent Health facility at Parkview and the main city centre hospital site are outlined below:
Figure2: PLACE assessment scores for Parkview and BCH sites 2013
Parkview (CAMHS)
87.1 %
Steelhouse Lane Site
86.9%
While we have received more positive patient experience feedback about our food than need to
improve comments its clear the percentage of need to improve comments is still too high.
The average PLACE score for food across England 2013 was 85%. We have scored above the average
rating for food at both Parkview and the main hospital site at Steelhouse Lane. We are pleased with
our PLACE food assessment scores but know based on feedback that we still have a lot to do to make
things better.
What are we doing to improve?
Continuing to work with our partners to reduce the amount of sugar and salt in the food we
provide.
Changed how we receive patient experience feedback about food. We continue to receive
comments into our Patient Experience Database, children young people and families can
also send us comments via our real time feedback app.
Trained our staff to deliver health promotion advice about health diets through our Making
Every Contact Count initiative.
Our catering partner Sodexo has also employed a Patient Experience and Food Service
Manager
We will continue to analyse how we’re doing throughout the year but will report on our annual
performance in our 2014/15 Quality Account.
7
Listening to Patients and Families
Play and Activities
Ensuring children and young people have enough to do in terms of play opportunities remains a very
important quality indicator for us. We know play is important for development and can also be
distraction from some of the stressful and unpleasant aspects of clinical care.
It’s important that we know that play opportunities are easily accessible, age appropriate and that
toys and equipment are in good condition. We categorise feedback about play and activities as
either ‘positive’ or ‘need to improve’.
How have we done?
Figure3: Play and Activities: Positive v Need to Improve Feedback 2012/13 and 2013/14
“There isn’t enough choices
for all ages and it’s mainly
for young children”
“The DVD
player on our
bedside TV
was not
working”
“Your colouring
books are great can I
take this one home
please?”
We have seen a swing from a majority of positive comments in 2012/13 to a majority of ‘need to
improve’ comments in 2013/14. Looking at the comments received a significant number of the ‘need
to improve’ comments related to the provision of TVs for children and young people. We know this
is an area of concern for a lot of families and carers and we have a specific project in place to make
this better. It’s disappointing our feedback isn’t better but we have a number of improvements we
are going to be working on which are outlined below.
8
What are we doing to improve?
As well as the project to look at better access to TVs we are doing a lot of work to make sure we get
better at providing the right play and activities.
Improving normalising play and activities was a key objective for 2012/2013 and the introduction of
play and recreational facilitators was critical in helping to achieve this.
The Play and Recreational Facilitators have been in post since October 2013. The role of the Play
and Recreational Facilitators is to provide’ normal ‘play
Many of the successful candidates have a nursery nurse background and also help with Health
Promotion advice. The facilitators have one to one sessions with children and young people who
require more play support but also run larger craft sessions to encourage interaction with other
children (which particularly useful where children have a long stay in hospital). There have been
many patient comments collected about the positive impact they are having on their experience.
Within two months of the new role one of our Facilitators were nominated for a star of the month
for Outstanding Patient Care.
Other things we are doing to improve include:
Our Play Charter sets out our vision for play and recreation and aims to be a catalyst for
everyone at the hospital to continually examine, review and improve their provision for
babies, children and young people’s play and informal recreation and leisure time.
Promoting the Play Centre and James Brindley School – a weekly timetable has been
produced detailing what activities run throughout the hospital (school, youth club and play
centre). ‘Activity ward boards’ are being produced to raise awareness of these activities.
Stay and Play – held weekly in the Play Centre. Parents are encouraged to bring their child,
where during facilitated play, health promotion messages are shared. This has received very
positive feedback from parents.
Rhythm Time - music and singing classes for babies, toddlers and preschool children which
help develop confidence, creativity and coordination, accessible twice a week to all wards
and departments.
Activity Packs – available for children and young people on admission, ensuring their first
contact is a ‘play’ contact.
Learning Disability Booklet – a specialist booklet has been designed which helps children
with learning difficulties and autistic patients understand their hospital journey.
DITTO Distraction Device – each ward has been provided with a hand held device which
reduces anxiety related pain in children by engaging them in fun and games, whilst
undergoing medical procedures.
Standardised Playroom Project - underway with funding for eight rooms available which to
create better play spaces and allow better access to play
We will report on this indicator again in our 2014/15 Quality Account to let you know how we have
got on.
9
Listening to Patients and Families
Tertiary Inpatient Referrals
Tertiary inpatients are patients who care needs to be transferred from a medical team in another
hospital to BCH because we have a specific set of skills and expertise to treat them. When a child or
young person needs to come to BCH for urgent inpatient care from home or from another hospital,
it’s important that their admission is not delayed as this could have a negative impact on their care.
In 2010/11 we put processes in place to meet our goal.
How have we done?
Figure 4: Trend – tertiary referrals waiting over 24 hours for a bed October 2012 – March 2014
Trend - Tertiary Referrals Waiting Over 24 Hours for a
Bed
50
45
40
35
30
25
20
15
10
5
0
Mar-14
Feb-14
Jan-14
Dec-13
Nov-13
Oct-13
Sep-13
Aug-13
Jul-13
Jun-13
May-13
Apr-13
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Making sure we admit children and young people who urgently need a bed within 24 hours
remained a challenge in 2013/14 as we continued to see more demand for our clinical services.
March 2014 has been an extremely busy month for us (including our busiest ever month in terms of
children and young people coming to our emergency department). We have also been admitting a
lot of children whose illness means they stay a long time in hospital. All of these factors put pressure
on our beds and we know this remains a bit challenge for the hospital.
We have begun to measure tertiary inpatient waits in a slightly different way. Some of our clinicians
tell us that getting a child or young person needing a bed at BCH can sometimes need to be in a BCH
bed in less than 24 hour or could wait for 48 hours and this still be appropriate and safe. Therefore
we have started to look at a better measure of tertiary waits which measures whether we have got a
patient into a BCH bed within the timescale specified by our clinical teams (the ‘clinical target time’).
10
We have only just started measuring this indicator in this way. Below is an example of this
information from our March 2014 Board quality Report:
Figure5: Tertiary referrals - Performance v Clinical Target Time March 2014
Performance vs clinical tgt time for patients who required a bed
100
90
80
70
60
50
40
30
20
10
0
85%
79%
76%
within 12 hours
12-24 hours
86%
84%
82%
80%
78%
76%
74%
72%
70%
Up to 48 hours
Target Time
Met
Not met
% patients meeting tgt time
We will continue to report on our tertiary referral waits but will look to report the percentage of
patients who were given a BCH bed within the defined clinical timescale (as above) when we report
back in our 2014/15 quality account.
What are we doing to improve?
We are doing lots of work to make sure that our capacity is managed well and we make the best use
of all our beds.
Our Hospital Operations Centre (HOC), a clinically led centre which oversees the day to day use of
capacity, has really helped us improve our outcomes. We have been working hard to make sure that
the HOC helps us to manage the demand for our beds and prioritises our children and young people
into the right beds in a the right clinical timeframe.
11
Listening to Patients and Families
Cancelled Operations
There are times when we have to cancel operations because of emergencies like transplants which
can’t wait, or when another operation is more complex than expected, so it takes longer than
planned. Sometimes an operation can’t go ahead because there aren’t enough beds that day on
PICU to care for the patient after the operation. This can be very stressful and inconvenient for
children, young people and families as it can disrupt work, travel and child care arrangements. It is
also difficult and stressful for our staff to explain to anxious children, young people and their families
that an operation has had to be cancelled.
How have we done?
We have been working extremely hard over the past year to reduce the number of operations we
cancel. However it remains a significant challenge for us and we know we must do more to make
things better for our families and staff.
Figure 6: Cancelled operation national definition – comparative performance 2011/12, 2012/13 and 2013/14
The graph above outlines patients who were cancelled on the same day based on a national
definition of ‘Cancelled by a hospital for non medical reasons on the day of admission or after
admission’. This is a figure we report nationally.
12
However this definition doesn’t include all patients who have their operations cancelled. There have
been 840 operations cancelled by the hospital in 2013/14 of which 510 fit the criteria for national
reporting
The graph below shows the reasons for cancellation of the total 840 patients cancelled by the
hospital in 2013/14:
Figure 7: Cancelled operation2013/14 by reason for cancellation
The single largest reason for the Trust having to cancel operations by far is the absence of PICU beds,
which accounts for 24% of all cancellations
We also have some patients whose operation has been cancelled more than once, outlined below:
13
Figure 8: Patients cancelled more than once (same specialty) 2013/14
“My daughter was due an operation
last week at the Birmingham
Children's Hospital which was
cancelled the day before. Then I was
given a call 5 days later asking us to
come in 2 days' time at 4pm. On that
day at 10am I got a phone call
cancelling this operation too. This is
a lot of stress for an 8 year old”
We have not met our 2013/14 target, with the percentage of operations cancelled on the day at 1.1
% compared to our target of 0.8%. The total number of cancelled operations remains high and we
have a number of patients who have had their operations cancelled more than once. This is largely
due to the increasing numbers of children and young people that we see each year, which
increasingly complex conditions, plus availability of our Paediatric Intensive Care (PICU) beds and
capacity in our theatres,
What are we doing to improve?
PICU capacity
Last year we expanded our PICU to provide capacity for 31 beds, however to open a bed we need to
ensure that we have the right number of skilled staff to care for each child or young person. Like
other hospital across the country, we find it hard to recruit staff to work in our PICU, so we have
been working with colleagues at other hospitals and NHS England to review PCIU capacity and find a
way to overcome these challenges.
Bed capacity
Between October and March we see many more patients who get ill because of the winter weather.
Our Winter Plan includes the opening of an additonal 17 ward beds as we know that increases in
number of emergency admissions impacts on our ability to find a bed for a child or young person
who needs an operation. We have also provided a dedicated unit for infants and launched our ‘What
are we waiting for?’ project to look at the reasons why patients can’t go home sooner, which has
started to speed up discharge to free beds more quickly
Theatre capacity
We have recruited more anaesthetists to ensure we don’t cancel operations because a member of
staff isn’t available.
14
We have plans to convert an existing plaster room to create up to an additional half a theatre of
operating slots. Similarly we have developed a case to expand our interventional radiology capacity
equivalent to an additional theatre of capacity.
We have also agreed a significant improvement project to look at how we can use our theatres more
efficiently.
Improving processes
We are in the process of changing the way our surgical pathways work to ensure processes are
designed to reduce duplication and improve communication between staff and families.
We will continue to do everything we can to reduce our cancelled operations and report back on
progress in our 2014/15 Quality Account.
15
Listening to Patients and Families:
MRI Scan Waits
Coming to hospital for a test such as a MRI scan can be a key step in a child or young person’s
pathway and understanding their treatment needs. Waiting for these tests can be an anxious time
for children, young people and families.
A real challenge has been providing MRI scans within six weeks of referral. This is because of the
availability of staff with the right skills which is also a problem for hospitals across the country. In
addition, children often need a general anaesthetic to have an MRI scan and it can be difficult to find
the capacity amongst our anaesthetists to staff the increasing numbers of list we require to keep
waiting time down.
Often we have dealt with this issue by doing more ‘waiting list initiative’ work at the weekends but
this hasn’t been sustainable and we need better solutions as we recognise this is a real issue for our
children and families.
Patients, families and staff have told us that the waits for MRI scans cause anxiety and we, and our
Commissioners (who pay for our services), see it as a key challenge for us to address.
This is new indicator for 2013/14.
How are we doing?
The graph below shows the number of children and young people who were waiting over six weeks
for an MRI scan (the purple bars on the graph). This is based on a ‘snap-shot’ census date at the end
of each month. The bars in blue show how we are planning to reduce the number of patients waiting
over six weeks at the end of the month to zero by June 2014.
Figure 9: Number of patients waiting over 6 weeks at month end for MRI scans (based on DMO1 census dates)
16
A significant number of children and young people have waited over six weeks for an MRI scan. We
know this isn’t good enough and are aiming to make sure no child or young person waits more than
six at the end of each month weeks by June 2014
What are we doing to improve?
Recruiting more Consultants
We have recruited two more Radiology Consultants who started in September and November 2013.
We have been planning to make sure their skills and capacity are used well by planning new rotas
which will commence in April 2014.
Changing the way we work
The radiographers who support the Consultants in carrying out the MRI scans have worked hard to
change the way they work to provide more time and capacity to carry out MRI scan lists.
Creating more capacity
We have continued to do additional work at weekends but have begun to extend the amount of
work we do during the day. From the beginning of 2014 Saturday working has become part of our
radiographers standard working hours.
Using a mobile scanner
We have tried to find capacity at other hospitals to do MRI scans but this hasn’t been possible, so we
have been using a mobile scanner which has helped speed up access. This will continue in 2014/15.
Making the most of the capacity we have
We have been using a tool to help us predict how much scanning capacity we will need. We have
introduced weekly reviews of the MRI lists to ensure capacity is used fully. We have also introduced
a second reminder phone call to families two days before their appointment to make sure they will
be attending. Also we have changed the letter about preparation for the anaesthetic which goes to
families to make sure children and young people are properly prepared and can be given sedation.
We will continue to make these changes and improvements so that no child or young person waits
over six weeks for their scan by June 2014. We will report on this in our 2014/15 Quality Account.
17
Listening to our Staff:
Staff Survey
Our staff are critical in all that we do at the hospital and without them we wouldn’t be able to
provide the high quality care that we do. Knowing how our staff really feel about our services is a
really important indicator of quality. There is also a lot of evidence that shows that staff satisfaction
and motivation has a real impact on the quality of care that they deliver.
The NHS Staff Survey is one important way that we can understand how our staff feel about the
quality of care we give and how they feel about working here.
How have we done?
Figure 10: 2013 Staff survey results based on responses to ‘care of patients is my Trusts top priority’ and ‘if a friend or
relative needed treatment, I would be happy with the standard of care provided by the Trust’
18
Figure 11: 2013 Staff survey results – Staff satisfaction scores 2012, 2013 and comparative Acute Specialist comparison
score for 2013
59% of our staff completed the staff survey in 2013 compared to 46% in 2012.
There has been a small improvement in our results in 2013/14 but we would like to do much better.
Our overall satisfaction score has increased but is still slightly lower than the average for Acute
Specialist Trust elsewhere in the NHS.
What are we doing to improve?
We have a number of initiatives in place to support our staff and take care of their well being. Many
of these have been shaped by our annual ‘In-Tent’ event where we invite staff to a week of events
aimed at helping us understand how we can make things better for our children, young people,
families and staff, including:
•
Launch of a number of team building initiatives under the theme ‘Building Team BCH’.
•
Launch of our ‘InTent2Listen’ events for staff to discuss issues they think are important with
our Chief Executive and other Senior Executives.
•
Star of the Month scheme to acknowledge staff that demonstrate commitment to our Trust
values.
•
New Medical Directorate Team monthly award scheme to recognise the exemplary work of
their staff.
•
New ‘Team maker’ leadership training for managers to improve their leadership skills.
•
Development of conflict resolution officers to work with staff to amicably resolve any
tensions or disputes within the workplace.
•
Increased mentoring opportunities.
•
Values based staff appraisal process with greater focus on personal development and clarity
of objectives.
19
•
New ‘paired learning’ scheme to increase understanding and develop relationships between
clinical staff and management colleagues.
•
Several staff health and wellbeing activities, such as new counselling services and a slimming
club.
We have a lot of work we want to do to improve and we will report on these indicators again in our
2014/15 quality account.
20
Providing Even Better Nursing Care
Nursing Care Quality Indicators (NCQIs)
Our Nursing Care Quality indicators help us to understand if we are delivering excellent high quality
nursing care for our children and young people. Since they were launched we have added new
indicators (such as cannula care) and will continue to review them to make sure we are measuring
the things that are most important for our patients.
How have we done?
The graph below shows how we did for each of the care quality indicators in since we started
capturing the data electronically in September 2013
Figure 12: % Compliance NCQI performance September 2013 –March 2014
21
As in 2012/13 we have continued to perform well against our Nursing Care Quality Indicators. We
will continue to monitor and report on our NCQI’s which are reviewed regularly by our Trust Board
via the monthly Trust Quality Report.
What are we doing to improve?
Our electronic system is up and running and that allows our ward nurses managers and Clinical Lead
Nurses to view data in real time and make any changes to improve quality and safety much more
quickly. We are planning to roll out the Nursing Care Quality Indicator Process to the other non
ward based nursing services such as Hospital at Home and our KIDS retrieval and transport service.
In 2013 we changed from quarterly collection of data to monthly. We will continue to report on our
NCQI’s comparing our performance in 2013/14 with 2014/15 in our next Quality Account. We have
more detail about two specific measures linked to our NCQI’s relating to pressure ulcers and
extravasation which are outline below.
22
Providing Even Better Nursing Care:
Asthma Care
When children and young people with asthma use an inhaler, it’s essential that they use it properly
to get the full benefits.
It’s also important that we ensure that they are involved in decisions about their care and we do this
by agreeing their care plan with them and giving them a copy.
Figure 13: BTS National Paediatric Asthma Audit 2012 and 2013 – Comparative BCH and National performance
How have we done?
During 2013/14 we have worked hard to embed adherence to the asthma care pathway in normal
clinical practice. We will have also amended our asthma care pathway to reflect the new NICE
Asthma Quality Standards.
We have done well and improved our performance in 2013 compared to 2012 for both assessing
inhaler device technique and making sure a written care plan is in place. We continue to do really
well compared to the national figure from the Paediatric Asthma Audit.
23
What are we doing to improve?
We will continue to develop Asthma Integrated Care Pathway to include latest national
recommendations and to improve quality of asthma care. There is ongoing reinforcement of asthma
care standards by regular training and education sessions for all members of the multi disciplinary
team.
We will update you again on how we are doing with asthma care in our 2014/15 quality account.
24
Improving Health Outcomes
Health Promotion
We know we have a really important role to play in improving the general health of children and
young people and reducing health inequalities in addition to helping then when they are ill. We
have continued to work to support and advise children, young people and families on how to stay
healthy and see this as a real priority;
How have we done?
We met all of our goals for the second year running.
We have also provided Making Every Contact Count and BMI training to 197 targeted staff and are
looking to train 70 more (this is part of a scheme agreed with our Commissioners). We have
reviewed, updated and re-launched the smoking and alcohol awareness information shown on
screens in our outpatients department
What are we doing to improve?
We have employed a Public Health Consultant to support and advise our clinical staff on health
promotion and develop our health promotion strategy. This post is unique amongst hospitals in the
West Midlands. We are bringing our smoking referral pathway ‘in house’ as we believe it will deliver
a better service this way and we will continue to train our staff in health promotion/Making Every
Contact Count.
We will continue to report on how we are doing in our 2014/15 account.
25
Improving Health Outcomes:
Child and Adolescent Mental Health Service (CAMHS)- User ssatisfaction
Measuring the difference our services make to the people who use them helps us to understand
what we are doing well and where we might need to make improvements.
How have we done?
Figure 14: CAMHS questionnaire ‘helpful’ and ‘improvement’ scores 2012/13 and 2013/14
We have not only met but improved our performance against the national target of 61% of people
feel that they have a better health outcome as a result of using CAMHS. Our children and young
people particularly have found the service has been helpful and they feel a bit better/much better
since being treated in CAMHS.
We have worked hard to improve our access for families with the average waiting time for first
appointment four weeks and 11.4 weeks to start treatment. We have redesigned our services to
improve clinical pathways so that children and young people get the right support, from the right
person with the right skills at the right time. We are pleased that the improvements that we have
made are reflected in the feedback from our families.
26
What are we doing to improve?
As with all of our services we will continue to improve the way that we engage with young people to
gather feedback and support our service redesign over the coming year, including:
We have now launched our new webs site www.lotsonyourmind.org.uk This was named by
one of our young people and the designed with the input from young people and their
families. This contains information about CAMHS but also self-help information for young
people.
One of our young people designed our new feedback cards and posters so that we can
encourage users to feedback views about our service.
We are running regular focus groups that are supporting specific projects including a new
web based portal.
We are developing new care plans with the support of young people.
Young people are supporting our recruitment of consultant psychiatrists.
27
Providing Even Better Nursing care:
Extravasation harm
When medicine is given into a vein, it can leak into and damage the surrounding tissue and cause a
potentially serious injury. This can be a particular problem for children. We have developed a
Nursing Care Quality Indicator (NCQI) for cannula care which focuses on accurate observations,
dressing changes and observations of early signs of an injury.
How are we doing?
We began measuring our extravasation harm rate using a tool called SCAN (Safer Children No Harm)
in November 2013 and we have been better able to monitor how often extravasation harm occurs .
The graph below shows the numbers of harms caused by extravastion we have picked up from the
audits we do using the SCAN tool.
Figure 15: Number of extravasation harms detected v number of patients surveyed November 2013 – March 2014
What are we doing to improve?
Monthly data has shown where incidents have occurred and we have targeted education via
specialist nurse into those areas. We will be using the data we are gathering to understand what
measures and goals we can define to reduce harm from extravasation.
We will report on this indicator in our 2014/15 Quality Account, outline the numbers of
extravasation harms we have been reporting, the steps we are taking to reduce them and how we
will look to measure if we are making things better.
28
Providing Even Better Nursing Care
Pressure Ulcers
Some of our patients - in particular the sickest patients on PICU - are at risk of developing pressure
ulcers which, if left untreated, can become very serious. We are working toward the complete
eradication of pressure ulcers, in line with the ambition of the whole NHS.
How have we done?
Figure 16: Point prevalence of Grade 2 and above pressure ulcers 2012/13 and 2013/14
For the past two years we have monitored the prevalence of pressure ulcers on a monthly basis
using the adult Safety Thermometer.
On average we find between two and four Grade 2 pressure ulcers per month. In the months where
there have been peaks we have reviewed each patients care to ensure that it was appropriate. The
peak in May 2013 was due to two patients who were admitted from home with pressure ulcers and
the increase in January and February 2014 was due to the addition of data from another patient
group which was predominately complex care. We provided education and training from the tissue
viability team to the ward nurses which effectively dropped the prevalence in March.
29
What are we doing to improve further?
As of April 2014 we will use the Paediatric Safety Thermometer pilot to collect data about pressure
ulcers and in addition moisture lesions. Our initial test data has demonstrated that moisture lesions
are a particular problem in children and young people in hospital.
We will continue to monitor our pressure ulcers (and also moisture lesions) using the Paediatric
Safety Thermometer). Using the thermometer we will identify any areas where we need to target
education and training to make sure we improve. We will report again on pressure ulcers in our
2014/15 account and also update you on how we have been doing in terms of moisture lesions.
30
Reducing Infection
Reducing Healthcare Acquired Infections in PICU
Our Paediatric Intensive care unit (PICU) cares for our sickest children and young people. They are
particularly vulnerable to acquiring infections which can complicate there care, extend their time in
hospitals and create worry and stress for their families. It’s important we do all we can to protect
them from infections. Many patients on PICU have Central Venous Catheter (CVC) lines and are on
ventilators and these can be sources of infection.
How have we done?
Figure 17: PICU CVC and VAP infection rates per 1000 CV patient days/1000 ventilator days 2012/13 and 2013/14
31
We are doing really well in maintaining low rates of Central Venous Catheter (CVC) infection. In
2013/14 we reduced our target rate for CVC infection to less than 1.2 infections per 1,000 catheterpatient-days and we have met this target. We have also recently introduced the use of specially
designed antimicrobial dressings for use with CVC lines in order to help reduce our infection rates
still further.
We have though, seen an increase in our Ventilator Associated Pneumonia rates over the last year,
and although these are still lower than when we first started measuring them, we have been looking
closely to see what we can do to improve this again.
We continue to monitor how well we comply with practices to prevent VAP infections and we are
putting into place a number of measures to improve this further. From the data we collect, we have
been able to determine certain groups of patients that are more at risk from VAP infections than
others, and we are therefore looking at how we can reduce the risk of these infections in these
particular groups of patients.
What are we doing to improve?
We will continue to develop the practices we have put in place and we now look at every infection in
detail to determine any preventable factors that we can learn from, so that we can continue to
reduce the rate of infections in PICU and across the hospital to a minimum level.
As outlined under our section on MSSA infections on page xx we are also trialling a new skin
antiseptic for use with CVC lines which may help reduce infections in children and young people with
CVC lines even further. We will continue to report on CVC and VAP infections in PICU in our 2014/15
quality account.
In addition to measuring CVC and VAP infections, in 2013/14 we have started measuring urinary
tract infections that may be associated with the use of urinary catheters (UCA-UTI) and infections in
surgical wounds (SSI). Over the next year we will set targets for reducing the rates of these infections
and will report how we have done in our 2014/15 account
32
Reducing Infection:
Reducing Rates of Clostridium Difficile
Clostridium difficile are bacteria present naturally in the gut of around two-thirds of children and 3%
of adults. C.difficile does not cause any problems in healthy people. However, some antibiotics used
to treat other health conditions can interfere with the balance of 'good' bacteria in the gut. When
this happens, the bacteria can multiply and produce toxins, which cause illness such as diarrhoea
and fever. As C.difficile infections are usually caused by antibiotics, most cases happen in a
healthcare environment. Reducing rates of C.difficile in hospitals is a national priority.
How have we done?
Figure 18: Clostridium Difficile infections 2011/12, 2012/13 and 2013/14
We haven’t had any cases of C-difficile in 2013/14 that have been attributed to care at BCH so we
have met our target, which is really good news. One case of a cancer patient in December 2013 was
looked at by the Health Protection agency and was not attributed to care at BCH. This case was also
investigated at BCH which raised no concerns about care given.
However we know infection remains a key area of concern for our children, young people and
families and we always have to be vigilant to ensure we perform well, therefore we will report on
how we did in 2014/15 in our next quality account.
What are we doing to improve?
We are currently evaluating a new cleaning product called Virusolve which in place of our traditional
cleaning products which we believe may be more effective help us continue to maintain our low rate
of C-difficile. We will report on the results of this evaluation in our next quality account.
33
Reducing Infection
Preventing MRSA
Blood stream infections with MRSA can be very serious for people who are unwell and can result in
additional treatment and an increased length of stay.
Figure 19: Number of MRSA infections 2008-2009 to 2013/14
How have we done?
For the third year in a row we have had no MRSA blood stream infections at all. This is very positive
but we will continue to report on MRSA infections in our 2014/15 quality account.
How will we maintain this?
In May 2013 we detected a cluster of patients with MRSA colonisation on one of our wards that
weren’t attributable to the clinical care received at BCH. This did suggest however that our current
screening policy and techniques may not have been effective enough.
In order to continue protecting our children and young people we are trialling new ways to increase
our detection rate of MRSA. The pilot is ongoing and we will report on the outcome in our next
quality account.
34
Reducing Infection
Reducing MSSA
MSSA is a common bacteria carried on the skin of 30% of the population. MSSA bloodstream
infection is a risk for some of our patients, especially those who have a central venous catheter
(CVC), surgical site infections and patients on Home Parenteral Nutrition.
How have we done?
Figure 20: Post 48 hours MSSA bloodstream infections 2011/12 to 2013/14
It has continued to be challenging to reduce the number of post 48 hours MSSA infections by 10%
with a similar number of infections to 2012/13 and we haven’t met out target. By studying each
infection we understand that CVC’s remain the commonest cause of infection and that 40% of
infections are present within three weeks of line insertion and 90% affect children aged 1 and under.
What are we doing to improve?
Using the knowledge we have gained from looking at each infection we have introduced a series of
actions to reduce CVC related infections.We have also introduced series of guidelines for taking
blood cultures We have continued to review and analyse every MSSA infection in order to
understand how they occur and how we can prevent them.
We introduced a multi disciplinary group (Doctors/Nurses/infection Control and Nutritional care
teams) to look at all aspects of administering Home Parenteral Nutrition to reduce infection.
35
We are currently part of a study involving other hospitals looking at the use of a skin antiseptic called
Octenidine for use with CVC lines. Initial results are very encouraging and we will report on this trial
in our 2014/15 quality account as part of our MSSA indicator
36
Providing the Safest Possible Care:
Medication Incidents
We encourage staff to report every incident, from the most serious to near-misses. At BCH we use a
lot of medicines so there are many opportunities for errors to occur, and medication incidents are
the most frequently reported incident type. We want to see a high number of reported medication
incidents at a low level of harm, as this shows a good safety culture.
How have we done?
Figure 21: Number of medication incidents and levels of harm 2013/14
We have achieved our target of no medication errors resulting in serious harm. During the course of
the year we have reviewed our safety strategy and have redefined our targets around medications
incidents to:
Reduce the number of incidents of omitted doses resulting in more than minor/temporary
harm to zero.
Reduce the number of incidents involving incorrect dosage calculations resulting in more
than minor/temporary harm to zero.
37
What are we doing to improve?
We have revised our Drug Chart so that this is clearer and so that safety prompts, such as
review of antibiotics are included.
Changed from using codeine to oral morphine as this is believed to be safer. This has
involved a change in our practice as well as changing documents such as the Discharge
Prescription on our Day Surgery unit
Plans to move to stocking only one concentration of intravenous morphine across the Trust.
This is important because our incident investigations have shown that the act of diluting the
drug is the stage at which errors are often made
Develop guidance to our ward staff investigate medication incidents more thoroughly and
this will help us to identify trends in incidents more effectively.
This remains an important indicator relating to safety and quality and we will report on our new
safety strategy targets outlined above in our 2014/15 quality account.
38
Providing the Safest Possible Care:
Acute Life-Threatening Events (ALTEs), Cardiac Arrests and Respiratory Arrests
Good monitoring on wards means that we will pick up deteriorating patients more quickly and avoid
preventable emergency and life- threatening events.
How have we done?
The graph below show the total number of emergency events per 1000 admissions between
February 2013 and February 2014. We look at all these events to decide if they were
predictable and preventable. This helps us understand if there are things we can do better and
help us improve the care we give.
Figure 22: Incidents of emergency events per 1000 admissions February 2013 to February 2014
We have continued to perform well with low levels of cardiac arrests, respiratory arrests and acute
life threatening events (ALTEs) means that we are monitoring and escalating clinical deterioration in
a timely manner.
39
We have had no ALTEs, respiratory or cardiac arrests that were seen to be both predictable and
preventable in 2013/14
What are we doing to improve?
We will continue to review each event to identify any learning that could prevent or help predict
events in the future.
40
Providing the Safest Possible Care:
Mortality
We have relatively low numbers of deaths at Birmingham Children’s Hospital and continue to review
every single death that occurs to make sure there were no avoidable factors and check that the
clinical care we are delivering is of the best quality.
We continue to look at our overall death rate per 1,000 admissions. Also we have specific ways of
looking at the deaths in some of our most complex and high risk areas with some of the sickest
children and young people (such as our PICU and cardiac surgery departments) to understand if the
numbers of deaths are within the expect numbers given the complexity of our patients.
How have we done?
Figure 23: Deaths per 1000 admissions February 2013 to March 2014
In 2013/14, deaths per 1,000 admissions has remained at a very similar level to the previous year.
In January 2014, we had significant concerns with the death of one of our patients who died very
quickly after developing an overwhelming infection. We investigated this in depth and although we
cannot say for certain, it is possible that had we recognised and treated this sooner, the patient may
not have died. We are deeply sorry that this happened and have learnt from it, making a number of
significant changes to the way in which we manage children with severe infections.
41
Figure 24: PICU CUSUM monitoring
We continue to monitor deaths on our PICU using the CUSUM method outlined in figure 24 above.
This is a statistical way of helping us identify early when deaths occur when they are not expected.
Using the CUSUM method we haven’t identified any systemic care failings on PICU which have
contributed towards any of the deaths. Using this monitoring method in 2013/14 we did notice a
trend in deaths amongst patient who had illnesses being cared for by our Haematology and
Oncology teams. However, when each of the deaths were reviewed, no avoidable factors or care
failings were found.
Our PICU team also submits data to a database called PICANT which enables them to benchmark our
unit against other PICUs. This information continues to indicate we are well within the expected
range for deaths within our PICU given the range of conditions of the children and young people we
care for
42
Figure 25: Cardiac Surgery CUSUM monitoring
Our cardiac surgery team also uses a CUSUM methodology to analyse the deaths which occur under
their care. There continues to be no concerns that any of the deaths in cardiac surgery were
avoidable in 2013/14. The team also submits data to the national Cardiac Clinical Audit Database
(CCAD) and use a further method called Variable Life Adjusted Display (VLAD) to look at mortality.
Using this method, outcomes continue to be better than expected given the complexity of the
chlidren and young people the team treat.
What are we doing to improve?
We will continue to monitor mortality rates in a number of different ways to ensure that any
concerns are identified and that we learn from every death in case there was anything we could
have done differently.
Our safety team has been working to ensure the process for reviewing every death is completed and
reported quickly.
We have been studying some of the national measures to measure mortality such as Hospital
Standardised Mortality Ratios (HSMR) and Relative Risk, which are used to compare deaths rates in
adult hospitals. These two methods use statistical techniques to adjust the risk of a patient dying for
factors such as their age and their diagnoses. Unfortunately, these methods don’t adjust risk well for
children and young people, since the diseases, illnesses and statistical methods used are all based on
adults, therefore aren’t useful in helping us compare our death rates with other children’s hospitals.
We have raised this with NHS England and will be looking to work with them and other hospitals to
develop a better risk adjustment method which is more meaningful to compare hospitals that
provide care for children and young people.
We will report on our mortality rates in our 2014/15 Quality Account.
43
New Priorities to be developed in 2014/15
1. Sepsis Care
The rate of mortality from Septic Shock in children is approximately 10%. Survival is significantly
increased if antibiotics are given within an hour of diagnosis (as well as other treatment such as
intra-venous fluids). Lots of the children we treat are at high risk of sepsis, such as oncology patients
or those who are immune system is compromised. Our complex patients sometimes need unusual
antibiotics and sepsis can be difficult to detect.
What have we been doing?
We have developed a sepsis care pathway called Paediatric Sepsis 6 (based on the adult Sepsis 6)
which describes what must be done when a patient is suspected to have sepsis. This has been
piloted in PICU and has been introduced to the Emergency Department before a complete roll-out to
other areas of the hospital in 2014/15. We will report on this as a key indicator in 2014/15.
Measure
We previously said we would measure compliance with the sepsis care pathway, monitored by way
of audit. Auditing of our previous pathway was very challenging and we have recently introduced the
Paediatric Sepsis 6 as we believe that this will both be more effective in identifying and treating
children with sepsis, and be more straightforward to audit. We will report on our progress in our
2014/15 Quality Account.
2. Learning difficulties
It is known nationally that children and young people with learning difficulties can
face significant challenges in accessing and care and getting appropriate care.
Many aspects of care can be stressful for children and young people without learning difficulties and
even more so for those with learning difficulties. Families can also face challenges in unfamiliar
environments such as outpatients when bringing their children and young people to hospital.
We know we need to do our very best for this group of children and young people to make sure they
get the right care at the right time.
Measure
We will be working to develop measures relating to the quality of care we provide for children and
young people with learning difficulties in 2014/15 and will report on these in our 2014/15 Quality
Account.
44
3. Palliative and End of Life Care
It is always important that we provide high quality care but at end of life we only get one
opportunity to make sure this is delivered to the best of our abilities. Our families and young people
have told us that they value open and honest conversations about their care at this difficult time.
Since 2012 we have worked with our partners, the West Midlands Paediatric Palliative Care Network
to improve upon palliative and end of life care and produced the following,
The Purple pages are an extensive resource for staff packed with information about all aspects
of Palliative care which is also available as an app.
Advanced Care Pathway – a way of recording the detailed information that has been discussed
about what children, young people and families want in relation to end of life care.
Rapid Discharge Pathway and kit which supports children and young people to leave hospital
quickly so that they can spend whatever time they have left in the place that they choose,
usually either at home or a hospice.
Education – We have provided targeted education about palliative and end of life care, we have
priorities Advanced Communication training to staff who have these difficult conversations with
families so that they are better able to deliver the messages with sensitivity.
We are also providing clinical supervision to staff so that they can debrief, reflect and internalise
what they have experienced and continue to care.
In 2013 we recruited a small team to specifically focus upon children, young people with
palliative care need or at end of life.
Measure
During 2014 we will consider how to sensitively measure the impact of this work and will be
reporting on these measures in our 2014/15 Quality Account.
4. Paediatric Safety Thermometer
During the past two years we have used the national Safety Thermometer to measure harm in our
hospital.
We have demonstrated that this tool is not sensitive to the harms in children and young peoples’
healthcare and have been working with other providers of acute children and young people’s
healthcare to design and test a prevalence tool which we named SCAN - Safer Children Audit No
Harm. This work focused upon extravasations, pain management, deteriorating patients and skin
integrity.
In 2013 this pilot work was endorsed by NHS England which has commissioned Haelo (the team who
produced the original Safety Thermometer) to develop this into a national paediatric safety
thermometer.
Measure
At this point the measures are still being tested and so the detail is not available. However it is
anticipated that the areas of nursing care that the tool will focus upon will be deteriorating patients,
skin integrity, extravasations, pain management and drug omissions. We will report on this in our
2014/15 Quality Account.
45
STATEMENTS OF ASSURANCE ON THE QUALITY OF OUR SERVICES
Review of Services
During 2013/14 Birmingham Children’s Hospital NHS Foundation Trust provided and/or subcontracted 37 NHS services.
Birmingham Children’s Hospital NHS Foundation Trust has reviewed all the data available to them on
the quality of care in all of these NHS services.
The income generated by the NHS services reviewed in 2013/14 represents 100 per cent of the total
income generated from the provision of NHS services by Birmingham Children’s Hospital NHS
Foundation Trust for 2013/14.
On a regular basis, the Board reviews the following data which enables a comprehensive
understanding of the three dimensions of quality – patient safety, clinical effectiveness and patient
experience across every service provided by the Trust:
Quality Report – this report includes details of the following:
Incident analysis
Mortality
Serious Incidents
Emergency clinical events
Never Events
Patient Feedback
Quality walkabouts
Formal complaints
PALS concerns
Surveys
Resources Report – in addition to financial performance this report includes the following:
Activity
Performance against our objectives relating to access to our services
Workforce indicators including:
- Rates of appraisals
- Mandatory training attendance
- Sickness rates and analysis
- Turnover
- Use of temporary staff
Consideration of these reports together provides an overview of areas in the Trust where there
might be concerns about the quality of care.
Members of the Board, senior hospital staff, Governors and members of the Young People’s
Advisory Group undertake regular Quality Walkabouts to the wards, where the focus is on either
safety or patient experience. The walkabout involves ward observations and discussions with
members of the ward multi-disciplinary teams, patients and families to identify any safety or patient
experience issues or concerns. The outcome of the walkabout is fed back to the ward staff with a
requirement to take action where improvements are necessary.
46
The Clinical Risk and Quality Assurance Committee has delegated responsibility from the Board for
reviewing risks to safety and quality and identifying and monitoring actions to address these risks
and improve quality. This Committee reports to the Quality Committee which is responsible for
driving the Trust’s quality strategy, bringing the three elements of quality together, allowing
integrated reporting to the Board of Directors.
In 2010/11 we developed a Safety Dashboard, which acts as an early warning system. It allows an
aggregated comparison of safety metrics against each ward and department and incorporates a
series of defined ‘triggers’ which, in combination, may indicate problems with safety or quality in a
specific area. The dashboard approach allows us to really focus on the areas where potential for
harm is the highest. Whenever the dashboard identifies a potential concern a more detailed analysis
is provided for the area in question and this is considered in depth at the Clinical Risk and Quality
Assurance Committee. During 2013/14 we expanded the range of metrics to include a range of
workforce metrics. This has allowed us to assess the potential impact of workforce challenges on
safety and acts as an early warning system.
Participation in Clinical Audit and National Confidential Enquiries
During 2013/14, 13 national clinical audits and one national confidential enquiry covered NHS
services that Birmingham Children’s Hospital NHS Foundation Trust provides.
During 2013/14 Birmingham Children’s Hospital NHS Foundation Trust participated in 100% of
national clinical audits and 100% national confidential enquiries of the national clinical audits and
national confidential enquiries that it was eligible to participate in.
The national clinical audits and national confidential enquiries that the Trust was eligible to
participate in during 2013/14 are as follows: (see table below).
The national clinical audits and national confidential enquiries that Birmingham Children’s Hospital
NHS Foundation Trust participated in, and for which data collection was completed during 2013/14,
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.
47
Table 1: National Clinical Audits and National Confidential Enquiries 2013/14 – eligibility, relevance,
participation and percentage cases submitted
NATIONAL CLINICAL AUDITS AND NATIONAL CONFIDENTIAL ENQUIRIES IN WHICH THE TRUST
WAS ELIGIBLE TO PARTICIPATE IN 2013/14
Audit
Relevant
Participation
% Cases
submitted
Paediatric asthma (British Thoracic Society)
Childhood epilepsy (RCPH National Childhood Epilepsy
Audit)
Paediatric intensive care (PICANet)
Paediatric cardiac surgery (NICOR Congenital Heart Disease
Audit)
Diabetes (RCPH National Paediatric Diabetes Audit)
Inflammatory Bowel Disease (IBD)
Cardiac arrhythmia (Cardiac Rhythm Management Audit)
Renal replacement therapy (Renal Registry)
Severe trauma (Trauma Audit & Research Network)
Maternal, infant and newborn programme (MBRRACE-UK)*
Mental Health programme: National Confidential Inquiry
into Suicide and Homicide for people with Mental Illness
(NCISH)
Yes
Yes
Yes
Yes
95%
100%
Yes
Yes
Yes
Yes
Ongoing
100%
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
99.8%
100%
100%
100%
82%
Yes
Yes
100%
100%
The reports of 4 national clinical audits were reviewed by the Trust in 2013/14 and the Trust intends
to take the following actions to improve the quality of healthcare provided:
Paediatric cardiac surgery (NICOR Congenital Heart Disease Audit)
It has been agreed that monthly reports will be sent to the Consultants highlighting where
there may be any missing data or coding errors.
The congenital data manager will circulate a subsequent list of cases to be signed off
accepting that they are happy with the data and it can be submitted, this will ensure that
there is a greater level of clinical engagement.
Extra training for new starters to ensure that they are aware of the importance of the
NOCOR data and know what the definitions are and where they can find the online help
within HeartSuite.
BCH are currently adhering to NICOR submissions criteria with quarterly submissions of
data.
Data is extract4ed for reverse validation and any amendments needed are made to both
the local and NICOR data.
It has been agreed to update the discharge summary process to add in NICOR outcomes.
Changes are being made in the PICU data collection system to aid with the calculation of the
intubation days.
Severe trauma (Trauma Audit & Research Network) (2012)
No recommendations.
48
PICANet
Emergency readmission rates are being monitored closely as a key quality indicator. All unplanned
readmissions to PICU within 48 hours of discharge are subject to case note review and discussion at
the monthly departmental Morbidity & Mortality meeting.
Patient Suicide: the impact of service changes
Removal of ligature points on in—patient wards
Community services include an assertive outreach team
Community services include 24 hour crisis teams as a point of access
Follow up within 7 days of discharge from inpatient care
Written policy on management of patients who refuse treatment
Written policy on patients with a “dual diagnosis”
Written policy on sharing information about risk with criminal justice agencies
Written policy on multidisciplinary review and information sharing with families after a
suicide
Front-line clinical staff receive training in the management of suicide risk at least every 3
years
The reports of 23 local clinical audits were reviewed by the Trust in 2013/14 and the Trust intends to
take the following actions to improve the quality of healthcare provided:
Emergency Department Documentation Audit
We have adapted Observation Unit documentation and approved via Health Records
Committee.
Care of Open Fractures in the Emergency Department
Complete a one page guideline for the management of open fractures to be included with
department guidelines.
Daily Documentation on PICU
Developed training on how to perform I-PASS based handover.
Audit of the surgical protocol for patients with congenital adrenal hyperplasia
Guidelines to be updated :
Endocrine team to see patient prior to surgery and be responsible for prescription of
corticosteroids and IV fluids pre and post operatively
Importance of IV fluid prescription to be highlighted in guidelines
Signs/symptoms of adrenal crisis and management plan in guidelines
Guidelines to be printed and attached to patient notes when requiring surgery
Surgical clerking of patients
New generic clerking sheet to be designed and used Trustwide.
Audit on antiemetic prescribing in oncology
Guidelines to be changed for the route of ondansetron for antimetix px and to review
course length.
Further Education for trainees.
49
Participation in Clinical Research
The number of patients receiving NHS services provided by Birmingham Children’s Hospital NHS
Foundation Trust that were recruited during that period to participate in research approved by a
research ethics committee was 2400.
Figure 26: Participation in clinical research. Number of patients recruited into research approved by a research ethics
committee 2010/11 – 2013/14
The number of patients recruited to participate in research by a research ethics committee has fallen
in 2013/14. A large recruiting portfolio PICU study has closed which as expected has had an impact
on the recruitment for this year. We are due to open another large home grown portfolio study in
the May/June 2014 which should once again see an increase in recruitment.
Additionally we will continue to work to increase recruitment into clinical research in 2013/14 by:
Based around National Clinical Trials day is on 20th May and BCH Research Team are
planning an exciting day to encourage staff, patients and parents to ask about research;
The Research and Development Manager is working with our communications team to
improve the BCH Research and Development intranet page and website to increase the
profile of Research and Development at BCH and encourage recruitment.
One of our strategic objectives is to strengthen Birmingham Children’s Hospital’s position as a
provider of specialised and highly specialised services, so that we become the leading provider of
Children’s Healthcare in the UK. To help us achieve this, we are implementing a Research &
Development Strategy towards becoming a leader in paediatric clinical research.
Clinical research is important as it helps us to understand conditions and improve and discover new
treatments, resulting in improved quality of care for patients. A key priority for 13/14 was to
reconfigure our Research Team to best support development of research at BCH.
50
In 2013/14 we have also been working with University Hospitals Birmingham NHS Foundation Trust
on the development of the Institute of Translational Medicine. This will be a major development and
crucial to moving research into evidence based clinical practice.
An important indicator of research quality is the impact factor of the journals in which the research
is published, which reflects the number of times the journal is cited by other researchers and the
number of citations of particular publications over a period of time.
A good way of finding out how well we are doing on clinical research is to monitor the number of
peer reviewed research publications - excluding abstracts and letters - that we deliver each year.
When a research publication is reviewed by other professionals, or ‘peers’, this ensures that it is of a
high enough standard to be used to help develop treatments for patients. The number of peer
review publications in 2013 is outline below:
Figure 27: Number of peer reviewed publications2009 to 2013
Use of the CQUIN Framework
A proportion of Birmingham Children’s Hospital NHS Foundation Trust’s income in 2013/14 was
conditional upon achieving quality improvement and innovation goals agreed between Birmingham
Children’s Hospital NHS Foundation Trust and any person or body they entered into a contract,
agreement or arrangement with for the provision of NHS services, through the Commissioning for
Quality and Innovation (CQUIN) payment framework.
The exception to this is the Quality Improvement Development Innovation Scheme (QIDIS) used by
the National Specialised Commissioning Team to support Trusts to improve the quality of care and
clinical outcomes for nationally designated services, replacing CQUIN arrangements for those
services.
51
Table 2: Schemes agreed for Quality Improvement and Innovation (CQUIN) 2013/14
Goal
Goal Name
1
2.a
2.b
3
4.a
5
6
Total
SCAN (Safety Children Audit No Harm) (Paed Safety Therm)
Friends and Family Test - Increased response rate
Friends and Family Test - Improved performance on the staff FFT
Safety Thermometer
CAMHS - PBR
Pharmaceutical Risk Assessment
Childhood Obesity
Weight
Value
23%
12%
8%
5%
10%
20%
23%
100%
£285,167
£148,783
£92,989
£61,993
£117,786
£247,971
£285,167
£1,239,857
End of year
performance
Targets met
Targets met
Targets met
Targets met
Targets met
Targets met
Targets met
Table3: Schemes agreed for Quality Improvement Development Innovation Scheme (QIDIS) 2013/14
Goal
Goal Name
1a
1b
2
3
4
5
6
7
8
Total
Friends and Family Test - Increased response rate
Friends and Family Test - Improved performance on the staff FFT
SCAN (Safety Children Audit No Harm) (Paed Safety Therm)
Quality Dashboards
Highly specialised services - audit
Preventing unplanned readmissions to PICU within 48 hours
Haemtrack Monitoring
Highly specialised services - other
CAMHS Care Plans
Weig
ht
6%
4%
10%
10%
10%
10%
15%
20%
15%
100%
Value
£200,536
£133,691
£334,227
£334,227
£334,227
£334,227
£501,341
£668,454
£501,341
£3,342,270
End of year
performance
Targets met
Targets met
Targets met
Targets met
Targets met
Targets met
Targets met
Targets met
Targets met
The monetary total for the amount of income conditional upon achieving CQUIN and QIDIS goals in
2013/14 is detailed below:
Table 4: CQUIN and QIDIS income data 2012/13 and 2013/14
Percentage of income conditional upon achieving goals (total value £4.58m)
Income not achieved
2012/13
2.5%
0
2013/14
2.5%
0
Further details of the agreed goals for 2013/14 and for the following 12 month period are available
online at: https://commissioning.supply2health.nhs.uk/eContracts/Documents/cquin-guidance.pdf
Care Quality Commission
Birmingham Children’s Hospital NHS Foundation Trust is required to register with the Care Quality
Commission (CQC) and its current registration status is Green and is currently registered without any
conditions.
Birmingham Children’s Hospital NHS Foundation Trust is registered to carry out the following legally
regulated services:
Transport services, triage and medical advice provided remotely
Treatment of disease, disorder or injury
Assessment or medical treatment for persons detained under the Mental Health Act 1983
Surgical procedures
52
Diagnostic and screening procedures
Management of supply of blood and blood derived products
The Care Quality Commission has not taken enforcement action against Birmingham Children’s
Hospital NHS Foundation Trust during 2013/14.
Birmingham Children’s Hospital NHS Foundation Trust has not participated in special reviews or
investigations by the Care Quality Commission during 2013/14
On 20th, 22nd and 25th of November 2013 the CQC undertook a routine, unannounced inspection of
the Trust’s services at our main site at Steelhouse Lane, to assess compliance with the following
standards:
Care and welfare of people who use services
Cooperating with other providers
Safeguarding people who use services from abuse
Supporting workers
Assessing and monitoring the quality of service provision
Birmingham Children’s Hospital NHS Foundation Trust was found to be meeting all the standards
outlined above.
On 13th and 22nd of August 2013 the CQC undertook a routine, unannounced inspection of the
Trust’s Tier 4 (inpatient) Child and Adolescent Mental Health Service at Parkview to assess
compliance with the following standards:
Respecting and involving people who use services
Care and welfare of people who use services
Management of medicines
Staffing
Assessing and monitoring the quality of service provision
The inspection identified action was needed against the standard ‘respecting and involving people
who use services’ and ‘management of medicines’. The service was compliant against all other
standards.
Specifically the inspection identified minor concerns about the management and safe storage of
young people's medicines. The inspection also identified that young people had to ask to use toilet
facilities as they were sometimes locked. A compliance action was issues asking for improvements to
be made.
53
Birmingham Children’s Hospital has taken the following actions to the Tier 4 (inpatient) Child and
Adolescent Mental Health Service at Parkview improve against these two standards
•
A standardised care plan template for the use of non-psychiatric medicine has been devised
•
Standardised care plans for as required psychiatric medicines have been developed
•
Monitoring of compliance with care plans has been built into the monthly cycle of audit of
Nursing Care Quality Indicators
•
New thermometers, recording documentation and spot checks have been introduced for drugs
fridges
•
Spot checks and reminders have been put in place for expired medicines
•
A consistent approach has been put into place relating to locking toilet doors which are now
only locked in exceptional circumstances, this arrangement is subject to regular spot checks
•
The Temporary Locking Policy has been updated
•
Each young person at risk of self harming has a care plan in place which includes any
environmental controls that may be required.
Data Quality
Birmingham Children’s Hospital NHS Foundation Trust submitted records during 2013/14 to the
Secondary Uses service for inclusion in the Hospital Episode Statistics which are included in the latest
published data.
The percentage of records in the published data which included the patient's valid NHS Number was:
99.21 %for admitted patient care;
99.71% for outpatient care; and
99.23% for accident and emergency care
The percentage of records in the published data which included the patient's valid General
Practitioner Registration Code was:
100% for admitted patient care;
100% for outpatient care; and
100% for accident and emergency care
Birmingham Children’s Hospital NHS Foundation Trust’s Information Governance Assessment Report
overall score for 2013/14 was 91% and was graded green (satisfactory).
Birmingham Children’s Hospital NHS Foundation Trust will be taking the following actions to improve
data quality:
Missing NHS numbers are checked daily;
Missing Ethnicity is monitored daily;
A pilot of a follow up waiting list has been running to ensure no patient is lost to follow up;
A regular report is run to capture outpatient appointments which have been recorded
incorrectly;
In patient clinical coding validation meetings with specialties held monthly with clinician input
All Admissions, discharges and transfers are checked daily on all wards for any missing data
items
54
Long stay report checked for any incorrect admissions or delays in discharge
A GP distance report is produced monthly to ensure we trace on the spine and capture the
correct GP for patients who may have moved house
Coding for outpatients is being monitored for some specialties and regular audits are carried
out
A 30 day readmission report is run weekly in order to rectify in admissions recorded
incorrectly
The recording of definitive diagnosis and co morbidities is being monitored for patients
admitted to the OBS unit
Birmingham Children’s Hospital NHS Foundation Trust was subject to the Payment by Results clinical
coding audit during the reporting period by the Audit Commission and the error rates reported in
the latest published audit for that period for diagnoses and treatment coding (clinical coding) were:
Diagnoses
% Error rate
Treatment (procedure)
Primary
Secondary
Primary
Secondary
20.5
29.9
6.6
22.6
191 cases (spells) were reviewed within the sample. The local focus for this sample of 191 spells was
Paediatrics as selected by our host Commissioner.
Note: the results of the audit should not be extrapolated further than the actual sample audited.
Performance against National Priorities
Table 6: Performance against National priorities 2013/14
National Priority
Target
Performance 2013/14
C-Diff
0 cases per year - locally agreed
threshold
1 case or less per year - locally
agreed threshold
Pre 48 hours
Post 48 hours - 10% reduction
Surgery (94%)
Anti cancer drug treatments (98%)
Target met –no cases
MRSA
MSSA
All cancers; 31 day
wait for second or
subsequent
treatments
Target met – no cases
Monitoring only (but reduced)
Target not met *1
Target met -100%
Target met – 100%
55
All cancers: 62 day
wait for first
treatment
Radiotherapy (94%)
N/A
From GP referral to treatment (85%)
N/A -66% (this target requires
>5 patients to be applicable).
In 2013/14 BCH had only 2
patients on this pathway and 1
patient was a shared breach.
Of the 1.5 patients applicable
for this target 1 patient met
the target.
N/A
From consultant screening service
referral (90%)
All cancers: 31 day
wait from diagnosis
to first treatment
(96%)
All cancers: two
week wait from
referral to date first
seen (93%)
Total time in A&E
Target met -98.5%
Target met -96.7%
95% of patients time taken from
arrival to discharge/admission < 4
hours.
90% admitted patients at the end of
each month
95% non admitted patients at the
end of each month
Target met -97.2%
Single Sex
Accommodation
Breaches
0 breaches
Target Met
Emergency
Readmissions
Emergency readmissions within 28
days of discharge from hospital as a
% of all relevant admissions.
Monitoring only:
Age 0-15: 9.7%
Age 16 or over: 11.3%
Operations
<=0.8% each quarter across the year
cancelled on the day
by the hospital
Target not met*2-1.1%
18 weeks
Target met -90.6%
Target met-97.3%
56
Cancelled
operations and
those not admitted
within 28 days
Certification against
compliance with
requirements
regarding access to
healthcare for
people with a
learning disability
*1
Readmit >95% of those patients we
cancel within 28 days
Target not met*2- 91%
Fully compliant
-Details for our performance relating to MSSA and what we are doing to improve can be found on
pages 35 to 36
*2
-Details of our performance relating to cancelled operations and what we are doing to improve can
be found on pages 12 to 15
Core National Indicators
Due to the time it takes central bodies to collate and publish some of the data, sometimes
comparative figures are not available at all (N/A). It should also be appreciated that some of the
‘Highest’ and ‘Lowest’ performing Trusts on some of the data may not be directly comparable to
Birmingham Children’s Hospital.
There are several core national indicators that are not applicable to Birmingham Children’s Hospital,
because they relate to adult patients/services only, or due to the specialist nature of many of our
services.
Hospital Readmissions: The percentage of patients readmitted to Birmingham Children’s Hospital
within 28 days of being discharged in 2013/14
Highest
Trust
AGE
0-15
16 or
over
2011/12
2012/13
2012/13
2013/14
10.0%
9.97%
9.97%
9.7%
11.0%
7.7%
7.7%
11.3%
Lowest
Trust
N/A
Birmingham Children’s Hospital NHS Foundation Trust considers that these percentages are as
described for the following reasons:
Between 2010/11 and 2012/13 we undertook a monthly audit including a detailed review of every
emergency readmission and reported this to our commissioners. There were no concerns with the
discharge decision in any of the cases. The audit was funded by our host local PCT and has now
ended.
The audit was funded by our host local PCT and has now ended. Readmissions continue to
monitored on a specialty by specialty basis.
Birmingham Children’s Hospital NHS Foundation Trust intends to take the following actions to
improve these percentages, and so the quality of its services, by:
57
We will continue to regularly monitor emergency readmissions to identify any concerns.
Staff Survey: Percentage of staff who would recommend the Trust to family or friends
BCH 2012
BCH 2013
2013 Acute Trust
Average
2013 Acute
Trust Lowest
2013 Acute
Trust Highest
83%
84%
88%
39.5%
93.9%
Birmingham Children’s Hospital NHS Foundation Trust considers that this percentage is as described
for the following reasons:
We acknowledge that the result is slightly below the national average and that this has remained
consistent over the last few years.
Birmingham Children’s Hospital NHS Foundation Trust intends to take the following actions to
improve this percentage, and so the quality of its services, by:
Our plans to improve this percentage our outlined at page 18 to 20.
C.difficile: rate per 100,000 bed days of cases of C.difficile infection reported within the Trust
amongst patients aged 2 or over
2012/13*
2012/13 National
Average*
2012/13 highest
Trust*
2012/13 Lowest
Trust*
1.2
17.3
30.8
0.0
*Latest available comparative data from the HSCIC Information portal
Birmingham Children’s Hospital NHS Foundation Trust considers that this rate is as described for the
following reasons:
There was one case of C.difficile in 2012/13
The information above is based on the latest available data from the HSCIC information portal in
2013/14 we had no cases of C.difficile.
Birmingham Children’s Hospital NHS Foundation Trust intends to take/has taken the following
actions to improve this rate, and so the quality of its services, by:
Actions we are taking to minimise the risk of C.Difficile are described at page 33.
Patient Safety Incidents: the number and rate of patient safety incidents reported, and the
number and percentage of such patient safety incidents that resulted in severe harm or death
As there is not a nationally established and regulated approach to reporting and categorising patient
safety incidents, different trusts may choose to apply different approaches and guidance to
reporting, categorisation and validation of patient safety incidents. The approach taken to
determine the classification of each incident, such as those ‘resulting in severe harm or death’, will
often rely on clinical judgement. This judgement may, acceptably, differ between professionals. In
addition, the classification of the impact of an incident may be subject to a potentially lengthy
investigation which may result in the classification being changed. This change may not be reported
58
externally and the data held by a trust may not be the same as that held by the NRLS. Therefore, it
may be difficult to explain the differences between the data reported by the Trusts as this may not
be comparable.
Oct 2012-March
2013
BCH
Number of patient
safety incidents (acute
specialist)
Rate of patient safety
incidents per 100
patient admissions
(acute specialist)
Percentage of such
patient safety
incidents that resulted
in severe harm or
death (acute specialist)
1,203
6.5
0.1%
March 2013- Sept
2013*
BCH
March 2013- Sept
2013* Acute
Specialist Lowest
1,324
March 2013Sept 2013*
Acute
Specialist
Highest
91
2,038
3.69
27.88
0.0%
1.3%
6.74
0.3%
*Latest available comparative data from the HSCIC Information portal
Birmingham Children’s Hospital NHS Foundation Trust considers that this number and/or rate is as
described for the following reasons:
We are pleased to note the high number of reported incidents and the low percentage of these that
resulted in severe harm or death compared with the national average, as this indicates an open
safety culture.
Birmingham Children’s Hospital NHS Foundation Trust intends to take/has taken the following
actions to improve this number and/or rate, and so the quality of its services, by:
Actions we are taking to monitor and improve our safety culture are described on pages 61
to 64
We investigate and learn from every incident;
We take actions to address safety issues identified through safety monitoring and analysis;
A more detailed breakdown of our 2013/14 patient safety incidents is outlined on page 62
and 63
59
Other information
Overview of Quality of Care
Complaints
We take all complaints about our services very seriously and ensure that the way we respond is
tailored to the individual and that we answer all of their concerns. Our Chief Executive is involved in
every response and writes personally to each individual. Responding to a complaint can include
meetings with clinical staff and senior managers, including the Chief Executive.
Formal complaints often originate in a concern raised with PALS (Patient Advice and Liaison Service)
which supports families in obtaining the response they need in the best way for them. We
encourage people to use our Formal Complaints service and PALS as, if something has gone wrong
we want to know about it so we can try to put it right, learn from it and improve. This information,
when combined with other quality information about our services, can also help us identify when
there are other problems.
Fortunately, compared to the numbers of patients we see every day, we receive very few formal
complaints. Each one is considered in detail and incorporated into our Safety Dashboard and our
Quality Report.
Figure 27: Numbers of formal complaints per month/per 1,000 admissions (This data is governed by local
definitions)
20
Complaints
15
Complaints per 1000 Admissions
10
5
0
In order to see whether there are any themes amongst the complaints we receive, we group the
issues raised in each complaint into categories. The pattern of complaints received about the 5 main
categories is set out below.
Figure 28: Pattern of complaints per top 5 categories, (This data is governed by local definitions)
50
Waiting, delays &
cancellations
40
Staff Attitude
30
20
Quality of Treatment
10
Communication
0
Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
1011 1112 1112 1112 1112 1213 1213 1213 1213 1314 1314 1314 1314
Other
60
As part of the formal complaints investigation process, we identify any areas in which the quality of
the services could be improved, and make appropriate recommendations. These range from
reminders to staff about proper practices and behaviour, to fundamental changes in practice and
documentation. We regularly follow up on these recommendations to make sure action has been
taken.
As a result of these recommendations a number of changes have been made, including:
Various: In multiple areas staff were required to attend advanced
communication training;
Cardiac: New process to be implemented to ensure that all patients who
require a cardiac MRI receive appointments in a timely fashion;
CAMHS: We have reviewed the guidance for assessing the risks of patients
taking ward leave;
Histopathology: We have reviewed the process for managing newly diagnosed
tumours;
Complex Care: Daily planners for all patients are visible at the patient's
bedside, so that all staff are aware of their routine, including feeding plans. A
Nurse in Charge Checklist has been introduced that ensures that all patients
have received their feeds, medications, observations and gives the nurse in
charge responsibility for checking that all cares have been provided.
Emergency Department: We have increased the number of staff in the ED who
are trained in breastfeeding;
Ward 11: We have developed an escalation process and plan for home leavers
returning out of hours;
Outpatients: We have purchased a hoist and wheelchair weighing scale;
Maxillofacial: A new referral process has been implemented for referral to the
Multi-Disciplinary Team.
Incidents
We have robust systems for managing incidents. In 2012 we carried out a ‘Lean’ process on our
investigation management system to ensure it is as efficient as it can be. This means that
investigations can now be concluded more quickly, which is better for the patients and families
involved and allows us to start implementing learning from the incident earlier than we previously
could.
In 2013 our Internal Auditors gave an opinion of ‘significant assurance’ about our incident
management processes.
We encourage all members of staff to report all incidents, errors and near misses so we can make
improvements, work out what went wrong, identify themes and drive quality improvements in
everything we do. Our Quality Report - which is published on our website includes information
about incidents, which any member of staff or the public can read.
61
Some of the major changes we have made as a result of learning from incidents and incident analysis
include:
We have redeveloped our observation and monitoring (PEWS) training so that it is clearer
for patients with very specialist conditions.
We are reviewing the Drugs and Therapeutics Committee approval process for one off drug
usage so that the process considers the risks and benefits of the proposed drug regime more
broadly (e.g. the risks and benefits of using specific devices for administration of the drug)
We are re-developing the WHO safer surgery process so that it is better aligned with and
compliments other existing checks.
We are exploring the risks and benefits of changing the concentration of IV morphine that is
stocked across the Trust.
We are developing our post-cardiac surgery handover sheet so that patient observation
parameters are clearly specified to facilitate management on PICU.
We monitor the numbers of patient safety incidents and the proportion of those which involve
harm. The high levels of incidents involving low or no harm and the very low proportion of incidents
that involve more than minor harm provide assurance that we have a good safety culture.
Figure 29: Patient Safety Incidents by harm 2011/12-2013/14
62
Patient Safety Incidents by Harm Category 2011/12-2013/14
Year
Total
PSI
2011/12
2012/13
2013/14
2789
2343
2608
No
Harm
82%
75%
79%
Minor, Non
Permanent Harm
Moderate, Semi
Permanent Harm
Severe, Severe
Permanent Harm
Catastrophic,
Death
17%
24%
19%
1%
1%
1%
0%
0%
0%
0%
0%
1%
The following will help us ensure we sustain and improve this positive position:
We carry out an annual safety culture survey of all our clinical staff
We carry out regular audits of incident reports to identify any staff groups, wards or
departments that may not be reporting all incidents.
A lower than expected number of reported incidents is one of the measures we use to
identify possible issues on wards or departments through our Safety Dashboard.
We run a Safety Hotline which trainee doctors can use to report any safety concerns and
obtain advice.
We run an advice service specifically for trainee doctors (Trainee Advice and Liaison Service
– TALS), which mirrors the processes of our Patient Advice and Liaison Service (PALS).
We have introduced a facility which allows staff to report an incident direct into our online
incident reporting system via a mobile phone.
Implementation of actions arising from reviews of incidents is robustly monitored.
Incidents are analysed to identify themes and significant safety issues.
Never Events
Never Events are very serious, largely preventable patient safety incidents that should not occur if
the relevant preventative measures have been put in place. There are 25 defined Never Events, 4 of
which are not relevant to BCH due to the services we provide. We have developed processes to
prevent these Never Events happening.
2 Never Events were reported and investigated during 2013/14. However, it should be noted that in
one of these cases, the incident occurred in March 2013.
Case 1:
A patient requiring a corrective procedure on both feet was due to have a staged operation,
operating on one foot at a time. The plan was to operate on the right limb first, however, and
incision was made on the left limb. The procedure was converted to a bilateral procedure with the
consent of the parents.
The investigation concluded that the time WHO Safer Surgery checking process had not included a
formal check of the operative site. A working group has been set up to improve the application of
the WHO Safer Surgery process. The group will lead on enhanced training and consider modifications
to the tools which support this process.
Case 2:
An Inner component was retained following insertion of a vascular access catheter required for
dialysis. The investigation concluded that there are certain types of equipment for which
departments independently manage their stock levels. This means that when equipment is
borrowed it may be of a slightly different model than the one usually used in that area. The design
63
of the device does not clearly suggest that the inner component should be removed and there was
no warning.
An evaluation of available vascular access devices has been carried out and a single device identified
for use in the organisation. A request has been made to the manufacturers and MHRA to consider
amending the labelling or packaging of the device to more clearly highlight the potential risk.
Patient Experience
We work with children and young people every day to provide the best clinical experience possible,
we know there is a clear link between patient experience and how it influences clinical effectiveness
and safety and we also know that a fantastic patient experience goes well beyond the health
outcomes of children, young people and families at Birmingham Children’s Hospital (BCH).
There have been significant developments in how we capture, listen and act upon feedback from
children, young people & families. We want to hear about all aspects of experience, both positive
and that which could be improved. Importantly, where poor experience is reported actions are taken
to ensure improvements are made.
We hear about experiences from many different sources including, including feedback cards, e mail,
ward walkabouts, verbal feedback; all collated on our in-house Patient experience Database (PED).
We also have the Friends and family Questionnaire and the Feedback App, as well as encouraging
children, young people and families, if they prefer to use the independent feedback site Patient
Opinion.
We have introduced Tea@ 3 a monthly forum where parents can share their experiences in an
informal setting over tea and biscuits.
In addition this past year has seen an increase in the use of more qualitative approaches to try and
gain a better understanding of the experiences of children, young people and families "trying to see
the experience through their eyes" through the use of patient shadowing, mystery shopper, quality
walkabouts and patient stories.
Of all the feedback we receive, approximately 78% is positive and the positive comments continue to
reflect great satisfaction with nursing care, the overall experience of children, young people and
families, care by Allied health Professionals and overall quality of care.
Our Patient Feedback App has gone from strength to strength. The first of its type in the NHS, the
app allows patients and families to send anonymous feedback directly to the manager in charge of a
particular area of department so it can be addressed in real time with no delays. The messages are
also published openly on our hospital website for patients and families to view too.
Since it was launched in 2013 we have received over 1,200 messages for 55 different areas from
children, young people and parents. The vast majority have been positive, with many leading to
changes and improvements. It has also been recognised nationally with a Guardian Public Service
Award for Digital Excellence, a PR Week Public Sector communications award and Birmingham
Chamber of Commerce Excellence in Innovation award.
64
We engage in conversation with our patients, families and supporters through social media too. We
have a strong presence on Facebook with 26,000 followers, one of the largest social media profiles
of all children's hospitals.
Each method brings its strengths and weaknesses and therefore utilising all methods enables the
Trust to better understand the patient’s experience and helps prioritise where to focus efforts on
action planning. The app and social media provide an opportunity for parents, children and young
people to let us know about their experience, both positive and not so good, in real time and for
staff to respond directly in real time too. They also support our ambition to be open and transparent
and encourage frank conversations as well as a great opportunity to interact directly with children,
young people and parents.
To ensure responsiveness
All feedback information is reviewed monthly for analysis and action.
It is scrutinized as part of an overall quality report by the Trust Board monthly.
This past year has seen the successful development of a new more accessible database to
provide improved data analysis.
Our KIDS transport team are a good example of a team who have acted on parent/carer feedback.
They have introduced the following improvements based on listening to parents and carers who
have had the extremely stressful experiences of having a critically ill child:
As a direct result of parent feedback, mobile phone chargers (with multiple adapters) and a
snack and a drink are provided to all the parents who travel in the ambulance. After only a
couple of weeks the team were getting positive parent feedback which has continued;
Some parents had asked about getting to destination hospitals, especially when it was more
remote centres like Leicester or Liverpool. Often whilst the one parent went in the
ambulance the other parent would travel in their car. Therefore, the team have purchased 4
Sat Navs and have programmed every UK PICU into them. They will offer to loan them to
the family and will give them a jiffy envelope with the KIDS address stamps on it so they can
post it back to the team.
65
Examples of Patient and Carer Feedback:
‘My son has only
seen a play
specialist twice in
the last 10 months.
I’m concerned he
will fall behind as he
has special needs’
‘It is very
difficult for us
to get parking
spaces’
‘To all the kind
Nurses on Ward 5,
thank you for
looking after me
and helping me
and making me
happy’
‘Today it was over 20
minutes after our
appointment slot when
we were seen, and this
was 9am in the morning.
Please try to be
more timely’
‘Took us over an hour in
the cubicle to see a
Doctor, in that time no
one came and advised
us of the delay, I thought
they had forgotten about
us'
‘Give us an idea as
to how long the
operation will take,
what order the
operations are done
and whereabouts in
the waiting list the
patient is’
‘I felt listened too
and the team were
good at explaining
and reassuring’.
‘A lovely housekeeper
made us feel so at ease
and offered us drinks on
arrival and also a
sandwich. She was so
lovely and calm and
made us feel happy’.
‘Staff are very friendly and
care and attention in the
anaesthetic room was
excellent. Also very caring
staff who monitored our
son post operation’
.
‘Two visits in one
week and can’t
thank staff
enough for
fantastic level of
care’
The Doctors were not
very friendly and didn’t
put myself or my
scared son at ease.
Their bedside manner
requires attention’
‘The Kids Team told
us what was going
on, we knew when
KIDS were involved it
all seemed to get
more organised’.
‘You are doing well,
everywhere is nice
and clean and tidy’.
‘Reception needs
improving and staff need
to be aware of the needs
of deaf parents and book
an interpreter if requested.
Deaf parents need an
interpreter to understand
the information and what
is going on’ .
‘I liked choosing
my smell for my
sleepy gas’.
66
Implementation of the national friends and family test for children and young people
We have continued to ask parents/carers and children and young people how likely they would be to
recommend our hospital to friends and family should they require similar care or treatment.
This year has seen the additional asking of children, young people and families who are seen and
discharged without admission from our Emergency Department (ED).
We have seen an improved response rate and overall score from last year.
In 2013/14 we asked 21% (13% in 12/13) of parents and 19% of children and young people, over the
age of 8 years whether they would recommend our hospital.
Our overall net promoter score was an impressive and improved 82% (73% 12/13).
Out of 2930 parents, 2895 were either likely or extremely likely to recommend Birmingham
Children’s Hospital to Friends and family.
Play and activities will remain high on the agenda for 2014/15 and we have recently recruited a new
Play Project Manager for play for a 6 month secondment that is reviewing both specialised and
normalising play provision in the trust. Hopefully to give a fuller service that will cover more out of
hours activities for children and young people. Also to help raise the profile of play, raise awareness
of what facilities are available and define roles within the team.
Strengthening the voice of children and young people will be a key priority for 2014/15 and we will
be building on the excellent work of our young people’s advisory group (YPAG) from last year.
Young Person Advisory Group
The Young Persons’ Advisory Group (YPAG) at Birmingham Children’s Hospital hosted a unique
event which brought together local youngsters and healthcare professionals from all over the UK, to
discuss important health topics.
The Big Discussion welcomed health professionals from hospitals and councils across the country.
Representatives from the Care Quality Commission, NHS England, The Department of Health and the
National Institute for Health and Care Excellence were in attendance to hear about the important
areas faced by young people in the NHS.
The four key topics of the day were transition from paediatric to adult care, mental health, health
education/health promotion and communication between healthcare professionals and young
people.
We asked Iona Clayton the Chair of YPAG to work with her fellow YPAG members to produce a
statement on their work to strengthen the voice of children and young people in shaping the future
of care both at BCH and across the country in 2013/14. This is outlined below:
67
‘Over the past year, YPAG has continued to establish itself as a group who want change and
improvement in healthcare for young people, not only at Birmingham Children’s Hospital, but across
the NHS. Much of the work that YPAG did throughout 2013 was based upon the findings of The
Francis Report and involved members of YPAG conducting research at BCH. The content of these
research projects was developed during a residential trip which took place in June, during which,
members of YPAG undertook training as to how to conduct research effectively. As a group, we
decided that we wanted to look at two aspects of care in particular, asking; how can excellent care
be achieved and how is compassion shown? The research was carried out over the summer and
involved speaking to patients and their families as well as members of staff. After analysing and
evaluating the data, members of YPAG then gave presentations to some of the hospital’s executive
team, outlining the findings of the research. As a group, we felt this was particularly valuable, as it
proved that young people offer a fresh perspective and this enables healthcare professionals to have
a more informed approach when making decisions.
Another highlight has been YPAG’s involvement in the planning and organising of ‘The Big
Discussion’ which was an event held in April with the aim of bringing together young people and
health care professionals to discuss four issues. These were; mental health, communication, health
education and transition from paediatric to adult services. YPAG collaborated with two other groups,
the RCPCH Youth Advisory Panel and the National Children’s Bureau to coordinate the event. With
key-note speakers such as Kath Evans, Head of Patient Experience for NHS England and Maggie
Atkinson, the Children’s Commissioner, there was a great sense that the conversations taking place
during the day could instigate real change. YPAG’s involvement in this project has not only helped
raise awareness of the work we do as a group but has demonstrated our capacity to work on a
national level. Both of which, I feel are huge achievements.
Alongside these projects, throughout the year, YPAG has continued to make valued contributions to
BCH. From offering advice on how the KIDS Ambulance Services could be improved, to forming
interview panels for several jobs within the hospital, YPAG has sustained a strong voice at BCH. After
such a successful year for YPAG in 2013, I am looking forward to the work that we will do in the
coming year. After our quarterly meeting in January, we decided as a group that one of the aims for
this year would be to increase patient representation within YPAG. I believe this will be achieved by
conducting more ward walkabouts to engage with patients. As well as this, we discussed the
possibility of starting a ‘buddy scheme’ in which young people from YPAG would pair up with
patients; this would also increase patient voice within the group.
Overall, YPAG has achieved a great deal in the past year and I am certain that we will continue to go
from strength to strength in order to overcome any challenges and show ourselves to be a key part
of BCH’
The Healing Environment
It is well evidenced that a positive environment helps people to heal. Basic needs are a quiet space, a
good diet and light which reduce the psychological effects of being ill. When we design new areas for
patient care we consider the operational requirements and also increasingly plan to provide a
Healing Environment.
We do this by,
Reducing environmental stressors such as noise or a lack of privacy.
68
Recognising the need for social interactions especially play and activities for children and
young people but also social support for parents.
Providing activities which are emotionally and spiritually uplifting such as our Giggle Doctors,
Singing Medicine and our Chaplaincy services’ pastoral participatory work.
We also design to soften the environment by using sympathetic designs, colour and music.
STATEMENTS FROM STAKEHOLDERS
Commissioners
Birmingham South Central Clinical Commissioning Group (BSC CCG), as coordinating commissioner
for Birmingham Children’s Hospital NHS Foundation Trust (BCH), welcomes the opportunity to
provide this statement for their 2013/14 Quality Account.
A draft copy of the Quality Account was received by BSC CCG on the 25th April 2014 and the
statement has been developed from the information presented to date. Feedback on the draft
account has also been received from Birmingham CrossCity CCG and NHS England Area Team,
including specialised commissioning.
We have reviewed the content of the Quality Account and confirm that it complies with the
prescribed information, format and content as set out by Monitor and NHS England. The information
provided within this account is, to the best of our knowledge, accurate and fairly interpreted.
The account captures progress made by the Trust in 2013/14, identifies where further improvement
is required and details the actions needed to achieve these goals. We support the priorities set for
this year and recognise the areas identified by the Trust where more focus is required.
The number of cancelled operations and waiting times for MRI scans remain key priorities for
improvement and we are working closely with BCH and NHS England Area Team to monitor the
effectiveness of initiatives currently being implemented. In particular, there is focus on the impact of
these waits on patient safety and patient experience.
The report clearly reflects that the Trust is a learning organisation that is continually striving to
improve the quality of care across its services, with an open and transparent culture in place. This is
particularly evident through the innovative methods of capturing real time feedback from children,
young people and families, with examples of how this experience continues to drive improvement.
We welcome the continued focus on improving patient safety and recognise the positive steps that
are being taken, such as further expansion of the Hospital Handover Project, initiatives in place that
focus on reducing medication incidents and further development of both the safety dashboard and
paediatric safety thermometer.
During 2013/14, we have supported the Trust in raising awareness of the need to develop paediatric
mortality measures nationally in order for them to be used effectively to improve the quality of
services and we are keen to see progression of this work in the coming months.
Over the past year the Trust has reported two serious incidents classified as “Never Events”. The
CCG attended the root cause analysis meetings for these incidents and received assurance that
69
learning has been identified and robust actions put in place in order to prevent recurrence of these
types of incident. Updates on progress against the action plan and dissemination of learning have
been received at the CCG / BCH Clinical Quality Review Group (CQRG) meetings.
The Quality Account reflects a number of the performance quality indicators which are monitored
monthly, along with areas for improvement at the CCG / Trust CQRG. In addition to this we will
continue to discuss actions developed in response to recommendations from the Mid Staffordshire
NHS Foundation Trust Public Inquiry and subsequent recommendations from the Berwick, Keogh
and Clwyd reports.
We also continue to be invited to the Trust’s Clinical Risk and Quality Assurance Committee and to
all Root Cause Analysis meetings following serious incidents, reflecting the open and transparent
relationship the CCG has with the Trust.
We have made some specific comments to the Trust directly in relation to the quality account which
we hope will be considered as part of the final document. These include; addition of supporting
narrative related to clinical audits, surveys and other quality data and inclusion of further
information on CQUIN outcomes.
Through this quality account and the ongoing quality assurance process, BCH have demonstrated
their commitment to continually improve the quality of services provided to children, young people
and families. As coordinating commissioner, we look forward to continuing to work in partnership
with the Trust and supporting them to deliver these quality priorities.
Dr Raj Ramachandram
Chair – Birmingham South Central Clinical Commissioning Group Quality and Safety Committee
14th May 2014
Healthwatch Birmingham
Healthwatch Birmingham recognise that Quality Reports are a useful contribution to ensuring NHS
providers are accountable to patients and the wider public about the quality of the services they
provide. We welcome the opportunity to comment on the Quality Report for Birmingham Children’s
Hospital NHS Foundation Trust.
The presentation of the report and the way in which the information has been presented is
welcomed. It is an accessible report, the language used is clear and along with the simple design the
overall feel is that the report has been written for the wider public and it encourages readers to
continue reading.
We welcome the range of initiatives to improve the experience of patients, carers and visitors that
were implemented during the year such as the Friends and Family App, and we see as a real positive,
the work done with the Young Person’s Advisory Group supporting them to have greater autonomy
to hold the Trust to account.
There have been a lot of improvements in care and outcomes and where targets for improvement
haven’t been met, the report is transparent and honest and clearly shows how plans are in place to
work hard to continue to improve outcomes for Children, Young people and their relatives and care
givers.
70
The Trust’s commitment to reducing infection rates is commended especially for Clostridium Difficile
and MSSA. In addition, for the 3rd year in a row there have been no MRSA blood stream infections
which demonstrates the multi-disciplinary team work of staff and clinicians is achieving safer
outcomes for patients.
The report documents the number of cancelled appointments and the reasons why the cancellations
occur as well as taking on board the distress caused for patients and families when these occur,
especially when operations are cancelled on multiple occasions.
The largest reason for the cancellation of an operation is the absence of PICU beds (accounting for
24% of cancellations). It is encouraging that the Trust clearly outlines steps in addressing this figure,
in particular in terms of securing higher levels of specialist staff needed to resource the PICU beds
and by looking at ways to make discharges speedier, especially over the pressured winter months.
Healthwatch Birmingham is pleased to see that the improving standards of overall care is taken
seriously across the entire Trust team, demonstrated in the Trust meeting all required standards in
an announced visit by the Care Quality Commission.
Healthwatch Birmingham looks forward to seeing the results of the Trust’s continued focus on
improving patient experience in the year ahead.
Healthwatch Birmingham – 22nd of May 2014
Birmingham Health Overview and Scrutiny Committee
In April 2014 Birmingham Health Overview and Scrutiny Committee notified us that they would not
be providing a statement relating to the 2013/14 Quality Account
Council of Governors
The Council of Governors are pleased to review and comment on Birmingham Children’s Hospital
NHS Foundation Trust’s Quality Account 2013/14.
The Account provides a thorough and well balanced view of safety, patient experience and clinical
effectiveness. We consider it accurately reflects the experience of the Governors throughout the
year. The Governors would like to praise the continued open and transparent culture at the Trust.
Last year, we encouraged the Trust to incorporate more of the patient’s voice in the Account this
year and we are pleased that this suggestion has been taken on board. The Trust is very good at
seeking feedback from patient and families and is proactive about the feedback it receives – using it
to inform service improvement. Our Patient Feedback App has gone from strength to strength this
year and, since its launch in 2013, we have received over 1,200 comments from children, young
people and parents through the App.
We are impressed by the achievements outlined in the report. The Governors are pleased to see the
continued improvement in managing infection control rates. There have been no cases of
Clostridium difficile (C-Diff) over the past year and no cases of MRSA for the third year in a row.
The Governors would like to recognise the day in day out commitment and value of our Hospital
Operations Centre (HOC). The HOC team work under continuous pressure to oversee the day to day
use of our capacity, which has helped to improve outcomes. We recognise the hard work that goes
71
in to making sure that the demand for our beds is managed appropriately to ensure our children and
young people are in the right beds in the right clinical timeframe.
The Governors are pleased to see that the Trust remains at the forefront of innovation. During the
past two years, the National Safety Thermometer has been used to measure harm in our hospital.
However, the Trust identified that the tool was not sufficiently sensitive to the harms in children and
young people so has collaborated with other providers to design and test a new tool (SCAN - Safer
Children Audit No Harm). In 2013, the pilot was endorsed by NHS England who have now
commissioned the development of SCAN as a national paediatric safety thermometer.
Importantly, however, the report also makes it clear where the Trust has not met its objectives, such
as in relation to play and activities. The Governors note that there has been a swing from a majority
of positive comments in 2012/13 to a majority of ‘need to improve’ comments in 2013/14. The
improvement strategy is comprehensive and the Governors will be interested to see the impact this
will have on patient feedback in the next Account.
The Trust has invested a considerable amount of time in a wide variety of listening, engagement and
learning activities post Francis which has included the involvement of external experts, such as
Professor Michael West. Professor West has provided the Trust with expertise around the factors
that determine the effectiveness and innovativeness of individuals and teams at work. He has also
helped to provide focus on improving the well being of those who work within our Trust. This links
well to the clear aim of the Trust to improve our staff satisfaction score in the National NHS Staff
Survey.
During the year we have welcomed the CQC. They made an unannounced visit to the Trust in
November 2013 and concluded we were meeting all core standards. This is an incredible
achievement and a very positive endorsement by our Inspectors of the quality, service and care
provided by the Trust.
These are challenging times for the Trust and the NHS as a whole. Demand for our services continues
to grow and we have important decisions to make in respect of our future estate. The Governors are
confident that the Trust has the strong leadership and financial control necessary to be in a good
position to plan for the future without affecting safety, patient experience and clinical effectiveness.
Governors’ Scrutiny Committee on behalf of the Council of Governors of Birmingham Children’s
Hospital NHS Foundation Trust
15 May 2014
72
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 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 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 2013-14;
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 2013 to June 2014;
o Papers relating to quality reported to the Board over the period April 2013 to June
2014;
o Feedback from the commissioners dated 13th May 2014
o Feedback from governors dated 15th May 2014
o Feedback from local Healthwatch dated 22nd May 2014
o The Trust’s complaints report published under regulation 18 of the Local Authority
Social Services and NHS Complaints Regulations 2009, dated 15th May 2014
o The national staff survey 2013;
o The Head of Internal Audit’s annual opinion over the trust’s control environment
dated (due to be received at audit committee 23rd May 2014)
The Quality Report presents a balanced picture of the NHS Foundation Trust’s performance
over the period covered;
the performance information reported in the Quality Report is reliable and accurate;
there are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Report, and these controls are subject to review to
confirm that they are working effectively in practice;
the data underpinning the measures of performance reported in the Quality Report is robust
and reliable, conforms to specified data quality standards and prescribed definitions, is
subject to appropriate scrutiny and review; and the Quality Report has been prepared in
accordance with Monitor’s annual reporting guidance (which incorporates the Quality
Accounts regulations) (published at www.monitor-nhsft.gov.uk/annualreportingmanual) as
well as the standards to support data quality for the preparation of the Quality Report
(available at www.monitor-nhsft.gov.uk/annualreportingmanual)).
73
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
Keith Lester - Interim Chairman
Sarah Jane Marsh -Chief Executive
How we have engaged people in setting priorities for improving quality
Foundation Trust Governors
At quarterly meetings governors are provided with our Quality Report, Resources Report and
information on Trust developments.
Governors take part in scheduled Quality Walkabouts.
At meetings of the Council of Governors, governors take part in Quality Walkabouts and visit new
developments to better understand the Trust’s services and the issues that are important to
patients, families and staff.
Twice a year we hold a joint meeting between the Council of Governors and the Board of
Directors to consider the future strategy of the Trust and developments within the Trust and the
NHS which are relevant to the Trust’s strategy.
Governors are engaged in our governance structure, with governors as members of committees
and groups.
A Public Governor chairs our Organ Donation Committee.
The Governors Scrutiny Committee is an active sub-committee of the Council of Governors which
provides a forum for more detailed debate and challenge on quality and resources issues and
strategic developments.
The Governors selected one of the quality indicators for review by the External Auditor and also
asked for another indicator to be audited additional to Monitor’s requirements.
Our Staff
Our Board and Governor Quality Walkabouts involve engagement with staff as well as patients
and families.
Surveys, including the national annual Staff Survey and our own Staff Safety Survey.
Regular staff polls.
Staff attendance at public Board meetings.
Chief Executive Briefings
Our New ‘in-Tent 2 listen’ staff events
Our patients and families
Quality Walkabouts.
PLACE assessments
Direct patient feedback through feedback cards, feedback app and other means.
Patient stories which accompany reports to the Board to help bring issues to life.
Focus groups on particular issues.
Mystery Shoppers.
74
Taking account of concerns raised through formal complaints and the PAL Service
Surveys Consultation on potential new developments
Parent representatives on the Learning Disabilities Steering Group
Feedback from CAMHS parents and young people by way of an exit interview (Chi Esq)
How to provide feedback on the Quality Report
Despite the improvements in the quality of services we have seen over the last year, we know we’re
always learning about how things can be done even better.
At the heart of everything we do are our patients, their families and the communities that we serve.
That’s why we’re always interested in hearing from you – whether you have a suggestion on how we
can provide care more innovatively, or whether you had an experience you think we could improve
on.
We actively encourage people to get in touch and stay in touch with us, so if you have any ideas
about how we could make this Quality Account even better we’d like to hear from you.
To tell us about what you think, please contact our Communications Department on:
 0121 333 8538
 communications.department@bch.nhs.uk
75
Board of Directors
In Public
29th May 2014
Item 14.79
Report Title
Sponsoring Directors
Contributors
Previously considered by
Enc 05
Quality Report
Dr Vin Diwakar, Chief Medical Officer & Michelle McLoughlin,
Chief Nursing Officer
Governance Services, Corporate Nursing, Education, Infection
Prevention and Control, PICU & Cardiac Services
Clinical Risk & Quality Assurance Committee, SLT
Situation
The enclosed report provides an update on key clinical safety and quality topics.
Background
The report is collated from a number of information sources and provides assurance that key
risks are being escalated and monitored until sufficient action has been taken to address the
concerns.
The report includes information on key risks, serious incidents, mortality data, cardiac arrest,
respiratory arrest, other acute life threatening events, infection control data, Safety
Thermometer data, Net Promoter Question results, and data from the PED database.
Information on Never Events and other safety information is included by exception.
The report now aligns information against Trust priorities and measures.
Assessment
Please see the enclosed report for a discussion of the key risks.
Recommendations
Review the enclosed report
Key Risks
Risk Description
Failure to correctly identify the
greatest risks to the quality of care
and safety of our patients.
Controls
Directorate Governance
systems
Board Assurance
Framework
Risk Register
Safety Strategy
Safety Dashboard
Assurances
Monthly Board Safety Report
Mortality Review
Monitoring of incident trends
Monitoring of complaints
trends
Key Impacts
Strategic Objective
Strategic Priorities
CQC Registration
NHS Constitution
Other Compliance
Equality, diversity & human
rights
Every child and young person cared for by Birmingham Children’s
Hospital will be provided with safe, high quality care, and a
fantastic patient and family experience
3. Further develop our approaches to gaining feedback from staff,
children, young people and families to ensure that their voice is
heard at every level of the organisation.
4. Further innovate our systems to promote and enhance patient
safety and reduce avoidable harm.
Standard 16 - Assessing & monitoring the quality of service
provision could be affected by a failure to manage risks
highlighted by the report. Risks to compliance with other
standards may be highlighted by the reports.
Patient Rights
• Quality of Care and Environment
•
Treatments, Drugs
•
Respect
•
Consent and Confidentiality
•
Informed Choices
•
Complaint and Redress
The report supports compliance with NHSLA and Monitor
requirements
Right to life
Quality Report:
Safety & Patient Experience
May 2014
Vin Diwakar, Chief Medical Officer
Michelle McLoughlin, Chief Nurse
Item 14.79, Enc 05
1
The BCH Vision of Quality
Strategic Objectives which reflect our commitment to Quality, Safety and a fantastic patient Experience.
Every child and
young person
requiring access to
care at Birmingham
Children’s Hospital
will be admitted in a
timely way, with no
unnecessary waiting
along their pathway
Every child and
young person cared
for by Birmingham
Children’s Hospital
will be provided
with safe, high
quality care, and a
fantastic patient and
family experience
Every member
of staff working
at Birmingham
Children’s
Hospital will be
looking for, and
delivering better
ways of
providing care,
at better value
Clinical Quality is our organising principle. It has always
been our mission to provide outstanding care and
treatment to all children and young people who choose
and need to use our services, and to share and spread new
knowledge and practice, so we are always at the forefront
of what is possible. Our vision is to be the leading provider
of healthcare for children and young people, giving them
care and support – whatever treatment they need – in a
hospital without walls
The physical capacity of the estate is the biggest challenge
to this vision. Thus, our clinical quality strategy is founded
on capital investment in our estate, modernisation of care
pathways, equipping our staff with the skills to use our
existing resources more safely, effectively and efficiently,
and partnership working to deliver healthcare for children
and young people closer to their home wherever possible.
Birmingham Children’s
Hospital’s leaders will
work hard to strengthen
its position as a provider
of Specialised and Highly
Specialised Services, so
that it becomes the
national provider of
Children’s Healthcare
Services in the UK
Birmingham
Children’s
Hospital will
continue to
develop as ‘a
hospital without
walls’, working in
close partnership
with other
organisations
Birmingham
Children’s
Hospital will be
a champion for
children and
young people.
We have built in a relentless focus on the experiences of our children,
young people and families at every level.
We want to be a place where safety is everyone’s top priority and have
set the following 3 year objectives to reflect this:
• Continue development of tools to prevent predictable and
preventable cardiac and respiratory arrests, reduce extravasation
injuries and medication incidents, improve time from decision to
administration of antibiotics, and prevent Grade 2 pressure sores
• Reduce risks in the handover of patients between services and
caregivers during their inpatient stay
• Develop a Trust wide quality outcomes dashboard
• Introduce new methods of collecting and responding to the
experience of our patients and families in real time using all
appropriate means
• Ensure that Patient Experience feedback is used to inform the strategy
for ensuring that we continue to demonstrate our Core Values.
2
The May Report at a glance
New Events & Concerns
Past harm
•New SIRIs
•New Complaints
•New PED Need to Improve Comments
4
4
4
Highlights
•Zero new Never Events for 13 months
•Over 80% of Patient Experience Feedback is positive
•Our overall net promoter score was 82% (73% 12/13)
•73 out of 74 social media comments were positive
Learning from Experience
Integration & Learning
•Closed SIRIs
•Closed Complaints
5
5
Themed Analysis
Lowlights
•2 new SIRIs
•11 new complaints
•146 new Need to Improve comments
Sensitivity to Operations
•Q4 Incident Analysis
•Patient Experience Database
6-9
10
Monitoring & Review
Reliability & Sensitivity to Operations
•Friends & family test
•Feedback App
•Focus on Breastfeeding
•YPAG Activity
•Eye Department Walkabout
•Safety & Workforce Dashboard
•Infection Control
•Arrests, ALTEs and Unplanned Admissions to PICU
•Safeguarding
•Safety Thermometer & SCAN
•Learning from Excellence Pilot
11
12
13-14
15
16
17-18
29
20
21
22
23
We continue to align existing data to the 5 domains of patient
safety identified by the Health Foundation.
We also continue to align data to the Trust priorities wherever
possible.
Mortality
Past harm
•Absolute number & deaths /1000 admissions
•SMR Run chart
•SMR Funnel Plot & Bar Chart
•PICU Cusum
•Cardiac Cusum & VLAD
•Liver Cusum
24
25
26
27
28
29
3
New Events & Concerns
Past Harm
There have been no new Never Events (None since 15/4/13)
Complaints Overview 2013/14
There have been 2 new SIRIs
14/15:01 - Handover sheet containing some patient identifiable details was found on the site of another organisation.
Another incident (13/14:83 – reported previously) involved a very similar circumstances – that report is currently being
finalised.
14/05:02 - Delays processing referrals from other organisations have resulted in delays in outpatient appointments. One of
the patients involved had symptoms which indicated a brain tumour. That patient was reviewed urgently and does not
have a brain tumour. None of the patients involved have suffered from harm, however, this case has increased concern
about our internal referral processing systems.
Other similar incidents:
Since October 2013 we have had 78 recorded incidents where there have been difficulties with organising outpatient
appointments, these involve administrative processes as well as delays in clinical decision making. Of these cases only one
patient has been confirmed as suffering from harm as a consequence and this case was investigated as SIRI (13/14:80).
15
96
58
67
105
Waiting, delays, cancellations and access to services
Staff Attitude
Quality of Treatment
Communication
Other
Need to Improve
Comments April 2014
There have been 11 new Formal Complaints
Concerns raised about consistent rude and inappropriate behaviour of taxi drivers.
Mother raised concerns that her daughter's urine infection was not treated on first attendance at
BCH. Mum felt staff did not listen to her and believes the wrong diagnosis was provided. Child has
since been seen at Heartlands, where blood tests and urine tests showed e-coli, and septicaemia.
Concerns raised by a father in relation to significant delays in organising an MRI scan. The MRI showed abnormalities,
and the father believes these should have been picked up and treated earlier. The father has also complained that
he had to chase every result, and an explanation about diagnoses, test results and management plans.
Concerns that there was a delay in
investigating and diagnosing a cyst
Mother complained that a planned gastronomy was not performed
Concerns raised about the comments a nurse made about
on the knee caused by a
during surgery as the Consultant had become ‘distracted’ when a
the weight of a child at an Oncology Clinic appointment and deteriorating hip condition/end
hiatus hernia was discovered during the procedure.
did not listen to concerns about the link to eating and autism. stage arthritis of the hip. Parents
Mother concerned that she was subjected to an
believe that a total hip replacement
Mother raised concerns that that there was inconsistency of care and that
interrogation before treatment was given as to
could have been avoided if the
she felt belittled, undermined and ignored during an attendance at ED.
why they attended the hospital and not the GP.
delays had not occurred.
Concerns about an incorrectly fitted gastronomy and the subsequent
She is also concerned that inappropriate
management of pain in the community
comments were made in front of her daughter.
Concerns about delays due to a misplaced referral.
Parents are unhappy with the delays and treatment received at the fracture clinic.
Parents believe they received mixed communication and a delay diagnosis of MRSA.
Learning from Experience
Integration & Learning
There were zero closed SIRIs in April
Summary
There were 4 Closed Complaints in April
Key Actions
•New process agreed and implemented in relation to delays in going to theatre
Mother states that her daughter was
•Implementation of a new process - all trauma patients will now be admitted to Ward 1 where they will
without fluid for several hours due to
remain until reviewed by the Consultant and a decision made on whether they require surgery.
mis-communication. There were also
•The consultant will review all cases and liaise with the anaesthetist to prioritise patients on a clinical need
delays in going to Theatre with staff
basis in order to organise the list. The order of the list will be decided on clinical priority and then
saying that the patient was not on list.
Mother believes that the Registrar was communicated to the Ward.
•A standard operating procedure is being developed to provide clear guidelines for fasting and fluid
rude towards her. Mother states she
restrictions prior to theatre
was told that stitches were needed to
minimise scarring and would be in for 2 •An apology was provided for the experience together with passing on the apology of the Junior Doctor in
- 4 weeks, but they dropped out within relation to his attitude.
15 hours .
Concerns raised in relation to General •Assistance provided with obtaining an appointment for further assessment.
Paediatric Consultant and their referral •All future patients presenting with similar feeding problems will be referred directly to the BCH feeding clinic.
•The concerns have been discussed with the consultant and colleagues and this will form part of the appraisal
to Community Paeds and the lack of
understanding of what Community
and re-validation process.
•Planned engagement with Birmingham South Central Clinical Commissioning Group to increase the provision of
Paeds can offer.
care from BCH for feeding issues, to ensure our families are supported as much as possible.
Concerns about blood tests to rule out •Whilst the full range of blood tests had been done, not all of these were communicated to the GP. Reassurance
and a full explanation was given to the family with an apology for the failure to send all result to the GP.
a metabolic disorder. Anxiety
centred around the impact on the
mothers pregnancy.
Parents are concerned that their son
is not receiving sufficient home care
from the Complex Care team.
• Apology provided to the family for occasions when complex care shifts could not be covered.
5
Incident analysis
1400
Level of Harm
Severe
Moderate
Low
Very low
1200
1000
800
600
400
200
The chart represents the actual impact suffered
by the person involved, apparent at the time of
the incident and recorded by the reporter.
There are three incidents subject to investigation where the patient
has died and this may have been a result of a care management failure
rather than as result of the patient’s underlying condition.
• SIRI 13/14:77 – a patient with an underlying neurology condition was
being cared for on PAU and suffered from an unexpected arrest.
• SIRI 13/14:87 – a patient known to the dermatology team was
transferred to ward 1 from a DGH and unexpectedly suffered from
an arrest.
• A patient admitted to PICU for non-invasive ventilation suffered from
a respiratory arrest leading to a cardiac arrest. The initial review has
indentified some predictable factors, but no preventable factors.
There was one incident report which noted a major adverse outcome for
the patient. This was an extravasation injury noted on a patient admitted
to PICU, via KIDS, from another hospital.
That incident remains subject to local investigation.
0
Clinical Incident categories
Medication incidents
One of the challenges that we currently face when understanding medication incident data is that
we do not currently have a validated denominator to allow us to compare data. We do not know
how many doses of which drugs are given in each area.
The Medication Safety
Committee is planning a
piece of work to allow us
to understand this. This
will allow us to identify the
relative risk of each drug
as well as better assess
the relevance of each
areas medication reporting
rate.
Top 10 Reporters after PICU
The most frequently reported sub-categories of
incident
1.02 Medication
Administration - Unintentionally Omitted
Administration - Wrong Rate
Administration - Repeat Dose
Prescribing - Incomplete/ Unclear
Prescribing - Unintentionally Omitted Or Late
Medication Storage Error - Other
Prescribing - Overdose Prescribed
Medicines Management - Documentation (CDs)
Administration - Wrong Dose
Dispensing - Drug Availability
224
41
16
14
14
13
11
10
9
8
8
Control Measures in place:
•High Risk Medicines information now
1-click from intranet homepage
•Induction session for all new starters
on medicines management
•Prescribing assessment for all new
trainee doctors
•Newly qualified nurse course – drug
calculations – clinical decision exercise
•IV study day – drug calculation test
•Morphine monograph written
•Reviewing available concentrations of
morphine
•Poster campaign
Hospital Incurred trauma
Overview of Hospital Incurred trauma incidents
Hospital Incurred Trauma
Total 70
Extravasation
38
Other Hospital Incurred Trauma
22
Pressure Ulcer
10
Where they happen
Hospital Incurred
Trauma
PICU
Paediatric Assessment
Unit
Ward 10
Ward 8
Ward 2
Burns Ward
Ward 5
Ward 7
Emergency Department
Medical High
Dependency Unit
What are we doing?
There is a programme of work to improve our processes for
identification, assessment and mitigation of those risks of
wounds developing.
Recent extravasation injuries have raised similar concerns
about the checking of infusion sites with conclusions of
local investigations pending.
Sub-categories of incident and their
locations
Total 70
29
6
4
4
3
3
2
2
2
2
Other Hospital Incurred Trauma
PICU
Ward 8
Ward 2
Burns Ward
Extravasation
PICU
Paediatric Assessment Unit
Ward 10
Pressure Ulcer
PICU
Outpatients - Plaster Room
Ward 7
Ward 10
Total 22
10
2
2
2
Total 38
12
6
3
Total 10
7
1
1
1
4. Why they happen
During the quarter we concluded a
SIRI investigation into the
occurrence of a pressure ulcer.
That concluded that a lack of
checking led to a failure to identify
the wound site.
Equipment incidents
Overview of Clinical Equipment issues incidents
1.04 Clinical Equipment
Total 101
Lack/ Unavailability Of Device/ Equipment
46
Failure Of Device/ Equipment
27
Equipment - Other
15
User Error
11
Sub-categories of incident and their locations
Lack/ Unavailability Of Device/ Equipment
PICU
Theatres - Equipment Stores
Theatre 1
Kids Intensive Care And Decision Support
46
14
9
3
3
Failure Of Device/ Equipment
Radiology
PICU
Ward 7
27
8
7
2
User Error
PICU
Ward 5
Ward 9
Ward 1
11
8
1
1
1
Where they happen
Clinical Equipment
PICU
Theatres - Equipment Stores
Radiology
Kids Intensive Care And Decision Support
Emergency Department
Theatre 1
Ward 7
Theatre - Hybrid
ENT
Ward 12
Theatre - Angio
Paediatric Assessment Unit
Theatre 5
Haemodialysis Unit
Total 101
35
10
8
6
3
3
3
3
2
2
2
2
2
2
Why they happen
Those issues of equipment unavailability cluster in PICU and describe local
issues of temporary absence of equipment due to stocking or failure. None
are associated with patient harm.
Theatres issues report absence of items noted upon return from sterilisation.
The device failure reports in Radiology focus in part on failures in ED
Radiology. Equipment risks in Radiology are known, on the risk register and
with management plans in place.
Those device failure reports from PICU represent staff monitoring equipment
and responding to instances where they have concerns, in order to mitigate
patient harm.
Themed Analysis
Sensitivity to Operations
Patient Experience Database
Apr-14
Directorate
Total
Total Positive
Need to Improve
CAMHS
130
72
58
%+ve
55.38
Clincial Support Services
47
39
8
82.98
Clinical Support Services
53
49
4
92.45
Medical
24
14
10
58.33
Other
5
5
0
100
Specialised Services
328
282
46
85.98
Surgery
157
137
20
87.26
Trust
744
598
146
80.38
Adult
437
76
85.19
Young Person
161
70
69.7
The top 5 positive comments
continue to reflect satisfaction
with nursing care, the overall
experience of children, young
people and families, care by
Allied health Professionals and
overall quality of care. This is
consistent with the feedback
from the Friends & Family
questionnaire and the patient
experience APP
You said….
No welcome packs available offering
services i.e. parking play centre,
restaurant
We did…..
Parent / carer information folders have
been developed for every ward
Friends and family
•In 2013/14 we asked 21% (13% in 12/13) of parents and 19% of children and young people, over the age of 8 years whether they
would recommend our hospital.
•Our overall net promoter score was an impressive and improved 82% (73% 12/13).
•Out of 2930 parents, 2895 were either likely or extremely likely to recommend Birmingham Children’s Hospital to Friends and family.
Parent/Carer
Apr-14
Young people
Apr-14
Total number of Trust Discharges
854
Total number of Trust Discharges
270
Total number of responses in
period
211
Total number of responses in
period
32
Number of promoters
189
Number of promoters
27
Number of passives
21
Number of passives
3
Number of detractors
1
Number of detractors
2
Neither likely or unlikely
0
I Disagree a bit
0
Extremely Unlikely
0
I Disagree a lot
0
Unlikely
1
I’m Undecided
2
Net Promoter Score
89
Net Promoter Score
78
Response Score (20% Target)
25
Response Score (15% Target)
12
Target (15%)
Total
16
41
35
6
85.37
Adult
16
41
34
5
82.93
Young Person
3
2
1
1
2.44
Emergency Department
Responses
Total Need to %+ve
Positive Improve
We did……..
All detractor comments are discussed
with the relevant individual ward
managers for response and action.
Overall the number of passive
responses have remained very similar
and the number of detractors remains
extremely small. The 1 detractor this
month was related to ED waiting times.
See patients on time
You said.….
ED waiting area a bit on the small side as
busy so nowhere to sit and maybe a few
toys for the younger children
Activity and colouring books now
introduced to ED
Young people response rates were below expectation, significantly in ED and we are working with the lead nurses to
improve on this. In order to increase children and young people responses we are looking at alternative more childfriendly forms and will explore alternative methods to paper questionnaire.
11
Monitoring & Review
Reliability & Sensitivity to Operations
Feedback App & Social Media
Finalist
During April we received 44 app comments, slightly less than last
month. The ratio of approx 70/30 positive/need to improve has been
maintained and is comparable with PED and F&F ratios.
Hi my daughter had her appointment cancelled by your department and referred to ENT and Dr
Panagamuwa had referred her back to your department and after a phone call from me to see
how long her appointment will be, I was told she isn't on your list yet, ENT have confirmed
referral was sent, I have been passed from pillar to post since February and still I haven’t
received a phone call from your department as promised to see Dr Kenia and none the wiser as
to why my 5 year old daughter stops breathing in her sleep! Please Help from a worried Mommy
The parent was contacted and an appointment was offered the following week.
The past year has seen an increase of the use of social media by staff. Social media and the app can
support our ambition to be open and transparent and encourage frank conversations as well as a great
opportunity to interact directly with children, young people and parents. The app and social media
provide an opportunity for parents, children and young people to let us know about their experience,
both positive and not so good, in real time and for staff to respond directly in real time too.
Facebook and Twitter:
In April 2014 we received 74 comments via the BCH facebook page and twitter account @Bham_Childrens - 73 were positive 
The one negative comment was: Feeling v disheartened atm by the
lack of help and support my son was due for operation today that
we have waited 3 mo the for to be told as we were getting on the
train it was cancelled and no new date... My son has aspergers and
has been getting worked up about this op for weeks.
??? Anyone suggest anything
Mum was contacted through
facebook and asked to phone
us. A further appointment
was given and the contact
details of the LD specialist
nurse were made available
for additional support .
12
Things we could do better…..
…..Focus on Breast feeding
Recently, we have heard and seen feedback from parents that suggests we could improve on our support for breast feeding mothers.
It is widely acknowledged that breastfeeding protects babies and mothers against many
There was no-one to support me in breast
illnesses. Therefore more women are choosing to breastfeed their babies.
feeding my baby, the nurses either didn’t
The support that these women require in order to enable them to
know how to or didn’t have the time
continue/sustain breastfeeding for as long as they want to seem to be a significant issue.
Parent, Ward 2
Mothers have an expectation that Staff within BCH would be adequately trained to provide breastfeeding support, this therefore results in
dissatisfaction and thus increase amount of negative patient feedback.
Limited resources and lack of available written information for
The following issues have been highlighted by BCH
breastfeeding parents.
In terms of expressing breast milk - lack of facility and milk
Staff inclusive of clinical support workers, nurses,
expressing pumps.
Staff lack of knowledge regarding
Speech and Language Therapist,
Lack of skills and time to support with breastfeeding
external services that are available to
dieticians and doctors:
issues such as positioning and attaching to the breast.
support mothers such as
Particularly in cases whereby baby may have been feed
Members of staff that have completed breastfeeding
Breastfeeding Peer Support and
via NG Tube for a significant period of time and therefore
and expressing training in the past, reported lack of
national helplines.
may reject or struggle to attach to the breast.
confidence and competency to provide
Parents are not given accurate information to support their choice or decision in the feeding method for
breastfeeding/expressing support and advice to
their baby. Attitude and culture appears to be negative towards encouraging breastfeeding.
mothers.
Lack of continual professional development, education and training has negatively impacted on the management of breastfeeding practice within
BCH. Paediatric nurse training does not incorporate breastfeeding training. Staffs feel a breastfeeding lead role would be beneficial within the
trust to advocate for the best interest of breastfeeding mothers and also improve quality of support provided.
“Despite complaining several times about the mismanagement of expressed breast milk at this
hospital….. today I found out that your freezer has broken and all EBM has been defrosted, much of it
wasted. I am so disappointed that this hospital just cannot get this right. Do you really have no backup
for your freezer? I know this has happened more than once. I am fed up of pathetic responses to all my
attempts to complain, I feel I'm wasting energy I don't have with a baby in hospital.” - Sent
anonymously through the feedback app.
“I couldn’t stay at the hospital and my baby was
given formula milk…I was not happy”
Parent, Ward 9
“There was nowhere private to
express” - Parent, PICU
Breastfeeding Actions
There have been an
impressive amount of
staff from various
wards and department
keen to undertake
breastfeeding training.
Cheryl Curson (BLISS Family
centred Care Coordinator
Southern West Midlands New
born Network ) has recently
started within BCH funded by
BLISS, Heartlands and
Women’s hospital to support
the quality care provided to
parents of preterm babies,
this includes elements
breastfeeding.
Small group of staff members
will be meeting to discuss short
term plans for the way forward
such as staff education and
training needs analysis,
ordering resources and
developing a database of staff
already trained and competent
to deliver breastfeeding and
expressing support.
National Institute for Health and Clinical Excellence
(NICE) guidance mandates multifaceted programmes of
support peer support integrated with health
professionals. Birmingham Women’s Hospital,
Heartlands Hospital and City Hospital currently have
breastfeeding peer support workers within their service
delivery of breast feeding support. Birmingham
Women’s Hospital has implemented the method of
having a peer support worker that floats to various
wards/ departments as needed, alongside the
community referral route -follow up and support to
breastfeeding mothers within the community,
continuity of care from hospital through to community.
This service has been sustainable for a significant
amount of years, health visitors and community
midwifes also signpost and refer mothers that require
additional support. Discussions have been held with
the Chief Nurse regarding the possibilities of this
service being implemented within BCH.
The Big Discussion
The Young Persons’ Advisory Group (YPAG) hosted a unique event which brought together local youngsters and healthcare
professionals from all over the UK, to discuss important health topics. The Big Discussion was supported by the Royal College of
Paediatrics and Child Health, the National Children’s Bureau and Healthwatch Birmingham.
The Big Discussion welcomed health professionals from hospitals and councils across the country. Representatives from the Care
Quality Commission, NHS England, The Department of Health and the National Institute for Health and Care Excellence were in
attendance to hear about the important areas faced by young people in the NHS.
Hosted by BBC Radio 1's Aled Haydn-Jones, there were also keynote speeches from Children’s Commissioner of England Maggie
Atkinson and NHS England Head of Patient Experience Kath Evans.
The four key topics of the day were transition from paediatric to adult care, mental health, health education/health promotion and
communication between healthcare professionals and young people.
Other participatory activity
YPAG undertook a confidentiality walkabout – A Questionnaire and observation were used to look at how personal
information was handled and if confidentiality was discussed with parents and patients.
•Patient boards have been raised with the Lead Nurses as it was noted some wards only had first names whereas
others had full names
The questionnaire looked to find out what parents, children and young people would like to see displayed in wards
and departments about what others had said about the ward or department and how this information should be
displayed.
•Parents and young people generally would like to see positive comments that other families had made about the
ward. They thought it was a good idea to present this verbatim and also wanted to see figures and graphs
depicting performance.
•Children and young people thought it would be nice to see images that other children and young people had
drawn
•The overall ambition is to present this information digitally and we will explore this as an option.
Eye Department Safety Walkabout
Actions
Update
Lack of available resuscitation equipment and no piped
oxygen or suction within the Department.
Immediate contact with the Resuscitation Officer, member of staff now responsible
for equipment and checking. Equipment placed in an accessible area.
Safe management of the 40 inpatients who attend the
Department.
Process produced to manage in patient referrals. Currently being reviewed by the
medical team. Process will mitigate for the lack of piped oxygen and suction in the
department.
Review of administration process to include patient clinic
bookings.
Clinic processes being reviewed with support from Newton.
There was poor storage and organisation of inpatient
notes.
All notes within the Department are now tracked on Lorenzo.
Orientation of staff new to the reception area
Receptionist posts are being recruited.
Current practice is to use two seta of additional notes
those being ophthalmic and RB notes.
Eye Department notes remain separate to the main notes.
Consider a review this practice.
Confusion over outcome forms following clinic.
New outcome form is production currently being reviewed by Health Records and
Ophthalmology team.
Poor positioning of PC AT Reception desk – did not
maintain confidentiality.
PC has been adjusted.
Error within letters and severe delay in letters being sent
out to patients.
Perceived increase in capacity.
Service Manage and Clinical Lead to review
First Impressions – there is no obvious queuing system
and insufficient seating
SBAR Re environmental redesign has been submitted to DMT which includes review
of Departmental redesign
Electronic Information grid and TV in the reception had
broken, poor environment
New TV had been installed, twice daily visits from a refreshment trolley.
Safety & Workforce Dashboard
What is the Safety Dashboard?
We produce a quarterly Safety Dashboard for
each Clinical Directorate, which incorporates
an overview of incident reports, including
Serious Incidents Requiring Investigation
(SIRIs), complaints and Nursing Care Quality
Indicators
(NCQI)
performance
per
ward/department to highlight potential issues
or concerns about safety or quality of services.
The dashboard allows an aggregated review
and comparison of these metrics against each
individual ward and department and
incorporates a series of defined ‘triggers’
which, in combination, may indicate problems
with safety or quality in a specific area. Such
areas are allocated a
symbol and the
Directorates are asked to review the area and
provide an update/assurance to the Clinical
Risk & Quality Assurance Committee.
Staff Engagement figures now included as a metric
Some of the metrics
What is the benefit?
At Birmingham Children’s Hospital we have relatively low numbers of complaints and incidents and meaningful trend analysis is difficult. The
dashboard approach allows us to really focus on the areas where potential for harm is the highest.
How do we use the Dashboard?
The Dashboard is used by the Directorate Management Teams as a safety management tool. Whenever the dashboard identifies potential concerns a
more detailed in depth analysis is provided for the area in question. This analysis will include details of levels of harm reported, complaint and
incident types for that area. The Dashboard is an early warning system - not a Performance Management tool.
Developing the workforce metrics
The list of workforce metrics on the dashboard have been expanded to include: Sickness Absence; Turnover; Appraisals; Consultant Appraisals; Bank
Usage; Formal Sickness Cases; Disciplinary Cases; Grievances; Dignity at work cases; Organisational Change cases; Mandatory Training Overall
Score. The Workforce Directorate will provided a quarterly analysis of this data via this report.
An analysis of theQ4 data is included overleaf, together with a list of departments that have triggered the safety metrics and have been identified for
review by the Directorate Management Teams.
(These reviews are reported via Clinical Risk & Quality Assurance Committee)
Safety & Workforce Review Areas
Safety – Review Areas
It should be noted that the threshold
for review is set deliberately low. The
areas are identified for review may
give no cause for concern.
The Dashboard allows the
Directorates to focus on those areas
identified.
•Surgical Day Care
•Haem/Onc (inc W15)
•General Paediatrics
•Emergency Department
•Ward 7
•PAU
•Clinical IMD
•Neurology
•PICU
•Ward 8
•Cardiac Services
•Anaesthetics
•Ward 9
•Ward 5
•Eye Department
•Plastics
•Neurosurgery
•Paediatric Surgery
•ENT
•Urology
•T&O
Workforce – Review areas which also feature on the Safety Dashboard
PIastics
Haematology/
Oncology:
Ward 7
Opthamology
Admin Team
PAU
Clinical IMD
Sickness is 8.97% with the majority related to medical staff. There are restricted clinical
duties (on-call) for a number of staff due to Occupational Health referrals. Sickness is being
closely monitored. A Consultant Plastic Surgeon is being recruited as a replacement for a
pending retirement. A trauma co-ordinator has been employed to support the trauma list. 2
Registrars appointed to support on-call rota and stabilise handover
Sickness rate 6.57% - Turnover 14.18% - 2 ER Cases. A business case was presented .
International recruitment; Review recruitment tools re resillience; Review of NQN
Programme; Recruitment to permanent ward managers for both ODC and W15;
Monthly confirm and challenge meetings for sickness absence.
Sickness 5.76% - Turnover 24% - PDR 81% - 1 ER Case. Staffing to be reviewed linked to
additional beds.
Recruitment of Band 5 Co-ordinator/Team Leader to support administration team.
Review current working practices and processes. Team work development session to
support staff, improve moral and motivation and enhance stronger team working.
Sickness 7.2% - 1 ER Case. Recruitment to experienced staff nurse vacancies, including
some 50:50 posts with Emergency Department/Hospital @ Home.
Sickness 10.2%. Consultant due to leave service in next 3 months. Service will be
covered by 2 Consultants doing a 1 in 2 on-call. Business case being generated for 2
further consultant posts. Specialty doctor post advertised.
Monitoring Infection control
April 2014
Infection
No.
MRSA Bloodstream Infections (BSI)
0
MSSA BSI (pre 48 hour)
1
MSSA BSI (post 48 hour)
2
E. Coli bacteraemia (pre 48 hour)
2
E. Coli bacteraemia (post 48 hour)
1
Glycopeptide-resistant enterococci
0
C. Difficile
0
5
MSSA pre 48 Hours 2011/12
MSSA pre 48 Hours 2013/14
MSSA pre 48 Hours 2012/13
MSSA pre 48 Hours 2014/15
4
3
2
1
0
MSSA post 48 hours 2011/12
MSSA post 48 hours 2013/14
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
April May June
3.5
3
2.5
2
1.5
1
0.5
0
E-Coli - pre 48 hours 2011/12
E-Coli - pre 48 hours 2013/14
E-Coli - pre 48 hours 2012/13
E-Coli - pre 48 hours 2014/15
July
Aug
Sept
E-Coli - post 48 hours 2011/12
E-Coli - post 48 hours 2013/14
MSSA post 48 hours 2012/13
MSSA post 48 hours 2014/15
Oct
Nov
Dec
Jan
Feb March
E-Coli - post 48 hours 2012/13
E-Coli - post 48 hours 2014/15
5
4
3
2
1
0
19
Monitoring & Review
Reliability & Sensitivity to Operations
Respiratory Arrests, ALTEs and Unplanned Admissions to PICU
Explanation of Data
Unplanned admissions to PICU are a
measure of how well we are
monitoring patients on the wards.
Good monitoring on the wards means
that we will pick up deteriorating
patients more quickly, allowing us to
admit them to PICU when required. A
combination of high levels of
unplanned admissions and low levels
of cardiac arrests, respiratory arrests
and acute life threatening events
(ALTEs) means that we are monitoring
and escalating clinical deterioration in
a timely manner.
Details of Cardiac Arrests
In April there was 2 cardiac
arrests outside PICU (1 Out of
hospital ED). There were 4
cardiac arrests on PICU.
None have been classified as
predictable or preventable.
Number of Emergency Events
19
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
No of Cardiac Arrests (ex PIC)
No of Cardiac Arrests (PICU)
No of Respiratory Arrests
No of ALTEs
Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14
20
Monitoring & Review
Reliability & Sensitivity to Operations
Safeguarding
Key Figures
Child Protection Training
Level 1
98.9%
Level 2
73.0%
Level 3
89.0%
There has been 0 Safeguarding SIRIs
There has been 0 new Safeguarding Complaints
There has been 0 “Position of Trust’ cases
There have been no new recommendations from Serious Case Reviews
100% of BSCB Meetings attended by BCH Executive lead or representative
90% of cases which require peer review /clinical supervision have had this
There has been 0 child deaths related to suspected physical abuse/neglect
Safeguarding Children and Young people:
Roles and competences for health care staff:
Intercollegiate document 2014
The recent publication of the above guidance introduces some
significant changes to the training delivered for different staff
groups. We will review the content and levels of Trust Child
Protection Training. One of the main changes is the
introduction of specific training to be targeted towards
Executive Team/Board Members.
Audit : Children Act 2004
Section 11
We have undertaken an annual self assessment
of our compliance with Section 11 of the Children
Act 2004:
We were fully compliant against the majority of
the standards, however, there were some areas
where we self assessed as partially compliant
And this allowed us to identify some areas for
improvement, including:
•Increase the number of level 2 training sessions
and provide an online option
•Update the Position of Trust and Supervision
Policies to reflect current requirements
•Signpost Child Protection information for
parents and children on the website
•Work in collaboration with BSCB in formulating
agreed referral thresholds for CAF
•Monitor and improve participation at multi
agency meetings
•Finalise Restraint Policy
Monitoring & Review
Reliability & Sensitivity to Operations
Safety Thermometer & SCAN
We continue to work with Haelo and NHS England to further test the safety
measures that were designed for SCAN. The intention is to develop the process
measure into outcome measures. We have participated in weekly testing of one
definition per week during April and will contribute to the WebEx at which the
results will be discussed at the end of May.
At this point there is no data available to present.
We are no longer required to survey using the
Classic Adult Safety Thermometer.
Learning from Excellence Pilot
Traditionally we have looked to adverse incident reporting as a way to learn from the errors
that we manage during our working lives.
We are now running a pilot looking for those positive experiences, the moments of excellent care and service, where the hospital
can learn from the moments where everything goes right.
The pilot is being run
in PICU, KIDS, NSW
and Physiotherapy.
An online form has
been set up to
capture these reports.
The intention is to share best
practice and analyse the data to
identify those common factors
that contribute to success.
A selection of the reports received
so far is included.
The following core questions are asked:
•Who achieved excellence?
•What did they do that was excellent?
•What went well?
•What did we learn?
•What are we going to do differently?
Who achieved excellence?
PICU Team
What did they do that was excellent?
Responded to ALTE in a timely manner
What went well?
Allocated roles and calm atmosphere.
Excellent team work and clear
communication.
What did we learn?
On PICU we have an amazing team
Is there anything that we will do differently
or change as a result of this?
No
What did they do that was excellent?
Took on a role of communication facilitator in a difficult situation, with a family/patient
that he was not looking after, but did so appropriately.
What went well?
He was able to engage a parent who was struggling with the complexities of PICU and
his daughters care, and so becoming increasingly angry. Facilitated a discussion
between professionals and parent.
What did we learn?
That it is beneficial to seek help in difficult circumstances and he has very good at
diffusing a difficult situation.
Is there anything that we will do differently or change as a result of this?
Realise the importance of approaching parents that are struggling to connect
with staff, and ineffective communication is not acceptable.
What did they do that was excellent?
Passed a new nasogastric tube on her patient. When she obtained no aspirate, she requested for a chest
X-ray to check the position. This showed that the tube had gone into the right main bronchus. The tube
was removed and potential aspiration of feed was avoided.
What went well? Charlotte showed good adherence to clinical guidelines for
nasogastric tube placement, good situational awareness and clinical judgement.
What did we learn?
It is important to follow guidelines, maintain situational awareness and use clinical judgement
Is there anything that we will do differently or change as a result of this?
No, keep up the good work
Who achieved excellence?
Theatre 1 team
What did they do that was excellent?
They took a teenage girl to theatre for neurosurgery. She returned beautifully presented after having some hair
removed for surgery, the rest had been washed, conditioned and neatly styled into plaits. They didn’t have to do
this but it was a nice touch and helpful to family that she looked nice when they saw her after surgery and that
she had been taken such good care of.
What went well? see above. Positive reaction from family
Updates will be
What did we learn? provided in future
Is there anything that we will do differently or change as a result of this?
Hope they keep up to good work, and that other theatre teams might follow suit.
reports
23
Mortality
Past Harm
Mortality data is presented in a number of ways, and
an overall picture can only be gained by using a
number of indicators. These are:
•Absolute number of deaths per time period.
•Number of deaths per time period per 1000
admissions.
•Standardised mortality ratio (See next slide)
•Cumulative sum (CUSUM) charts.
•Review of individual deaths.
Inpatient deaths per 1000 admissions
This is a simple calculation to overcome any
variations in admission numbers over time (e.g.
the hospital may have more admissions in the
winter months) or between hospitals of different
sizes.
Data can be compared between
organisations by this method as it allows for
different admission numbers but it is limited as a
tool for comparison as there is no modification
for case mix. The graph on the right shows the
number of inpatient deaths per 1000 inpatient
admissions at BCH since June 2012. Please note
that the data does not include deaths which
occurred in the Emergency Department.
Absolute Number of Deaths
The simplest way to represent mortality is as an
absolute number of deaths in a particular time period;
however it does not take into consideration either the
number of admissions to the hospital or the case mix of
patients. It is useful only as a sense guide to other data
as it has not been modified in any way. Data cannot be
compared between organisations in this format.
16
Deaths
Deaths per 1000 Admissions
14
12
10
8
6
4
2
0
24
Standardised Mortality Ratio (SMR)
In order to account for differences in case mix for different organisations the idea of standardised
mortality ratios has been developed. This attempts to account for differences in patients, such as
diagnosis, age and pre-existing medical problems, and allows for comparisons between hospitals.
A standardised mortality ratio (SMR) is the ratio of the actual number of deaths in a hospital within a
given time period, to the number that might be expected if the hospital had the same death rates as a
larger reference population (e.g. all English Hospitals). The SMR scores can be presented in a number of
ways.
Run Chart
This shows how the standardised
mortality rate of a hospital changes
over time. If there are a small
number of deaths in each time
period then the month to month
variation can be quite wide (as is the
case with BCH where there are on
average 4-12 deaths a month).
25
Bar chart presenting data comparing a number
of hospitals:
This shows the position of an individual hospital in comparison
with its peer group. It is easy to understand but does not give
much information about whether our outcomes are unusual. The
graph presented below shows 6 months’ worth of data rather
than 12 as previously presented.
Our SMR has risen from 163.48 to 164.31
This shows the standardised mortality ratio on the Y axis, and the
number of expected deaths on the X axis. Control limits can be
applied, so that it is possible to see how likely that the variation
from a score of 100 is by chance only. In the example below an
amber dot occurs if there is between a 0.3% (1 in 330) and 5% (1 in
20) likelihood that the score is different from 100 by chance and a
red dot if there is less than a 0.3% likelihood that the score is
different from 100 by chance. Such warnings should be investigated
as to cause. The funnel plot below is presented using 6 months’
worth of data.
We are in the red section of the funnel plot.
New
Movement in last month
Funnel plot
26
Deaths in the Paediatric Intensive Care Unit
(PICU)
CUSUM Charts
Another way of representing outcome
data is by cumulative sum charts.
These can be used where there is a
score available to give a risk of
mortality for each individual patient.
Currently this method is in use at BCH
for intensive care.
The charts use data from all patients,
not just deaths, so are more powerful
than SMR in detecting problems.
For BCH, the PICU CUSUM is a good
reflection of overall hospital mortality
as over 70% of deaths at the hospital
occur on PICU. There is no evidence of
systemic care failures which could have
contributed to deaths on PICU.
27
Deaths in Cardiac Services
CUSUM Chart
One of the Trust’s highest risk specialties is Cardiac Services. The nature of the activity means that proportionally
more of our mortality is related to that specialty than others. The team carefully monitors clinical outcomes to
ensure that that we are providing high quality care.
The CUSUM chart is a graphical representation of the outcome data
for the specific procedures which are nationally monitored (70-80% of
our patients fall into this group).
In addition, the team also monitors overall mortality for all surgical
patients. In 2000-2005, the overall mortality rates (30 days postoperatively) was 4.8%. In the period October 2010 – September 2012
this had dropped to 3.3%.
An upward movement in
the chart means that the
outcome for a specific
patient was better than
expected. A large increase
means that the outcome
was significantly better
A downward movement
means that the outcome for a
specific patient was worse
than expected, again the size
of the decrease is a measure
of how much worse the
outcome was than expected
Overall our outcomes are better than
expected. However, please note that
the baseline will be reset on a regular
basis, so we do not expect to move
further and further from the x-axis
28
Deaths in Liver Transplant
CUSUM Chart 6 month lag time
Another of the Trust’s higher risk activities is Liver transplantation.
Although we do not carry out a large number of these, the team monitors the outcome rates posttransplant. The graphs below show that our outcome rates are comfortably within acceptable limits.
Interpretation of the charts
The O-E chart is a useful tool for
observing performance over time.
A downward trend indicates a
lower than expected rate of
mortality compared with the
baseline period, whereas an
upward trend points to an
observed mortality rate that is
higher than expected.
To identify statistically significant
changes the tabular CUSUM chart is
used to complement the O-E chart.
A significant shift in the underlying
mortality rate is evident when the
chart crosses the limit and
generates a signal. The tabular
CUSUM chart can be used to
forewarn of possible future signals
as the chart approaches the limit.
Such ‘signals’ may be due to one of
a number of different reasons. A
signal may be due to
transplantation of patients of
higher risk than previously, a short
run of adverse events, or it may
occur just by chance with no
underlying cause (i.e. a false
positive result).
29
Board of Directors
In Public
29th May 2014
Item 14.80.
Enc 06
Strategic Objective/ Enabler
Every child and young person requiring access to
care at BCH will be admitted in a timely way, with no
unnecessary waiting along their pathway
Report Title
Performance – April 2014 Performance Report
Sponsoring Director
Deputy Chief Executive
Author(s)
Deputy Chief Officer Contracting and Performance
Previously considered by
n/a
Situation
This report provides the April update on this month’s Trust Performance supporting
improving our patient experience. The report highlights where performance is not being met
and any concerns or improvements.
The attachments provide:
Further details on our current and comparative performance
Background
Performance in April was variable against a backdrop of bed pressures which impacted on
flow through the hospital. ED performance remained strong and the numbers of children
that were unable to access a bed in PIC was low. Tertiary referrals remained high but there
were a low number of children who were not able to be admitted. However the levels of
cancelled operations increased significantly due to there not being enough beds.
Cancelled operations
In April there were 66 patients or 3.23% of all operations were cancelled on the day due to
hospital reasons. This is an increase on previous months and significantly higher than April
2013 and April 2012. In addition there were a further 123 patients that had their operation
cancelled by the hospital before the day of the operation. The total number is above the
upper confidence level and any previous months.
Over the last two months it has been reported that there was a shift in the reasons for
cancellation as well as the specialties impacted and this has continued. Of the total number
of cancellations 64 (34%) were due to no ward bed being available and only 7(4%) were due
to no PICU bed. This compares to 24% of all cancellations being due to no PICU beds for
2013/14 and 14% being due to ward beds. In terms of the specialties impacted, 130 (69%)
of the total cancellations were in surgical specialties with only 16 in cardiac/cardiology (8%).
There are a significant number of cancellations that have been categorised under cancelled
by the clinician/hospital which is due to reasons such as no longer needing the operation or
not being fit for the operation. This category has increased significantly and so further
validation and review is to be carried out. There continues to be cancellations due to
administration error (12) and equipment failure (4).
Sixteen patients had their operation cancelled more than once by the hospital, all being
cancelled twice.
There were two breaches of the 28 day standard in April. The target is zero except that it is
recognised that there may be breaches due to no PICU capacity. These were all due to no
ward beds reflecting the challenge of meeting this standard after several months of high
cancellations.
Further work is being completed by the Directorate team and Informatics to understand the
drivers for the cancellations and bed capacity issues. This includes looking at levels of
emergency admissions, length of stay and tertiary referrals.
Diagnostic waits
There were 123 patients who at the end of April who had been waiting over 6-weeks for a
MRI diagnostic test. This is 10.9% of all diagnostic waits and above the 1% NHS standard.
The overall MRI waiting list size has decreased as anticipated due to the mobile scanner
being on site at the end of April.
The trajectory for zero breaches by the end of June is now at risk with latest forecasts being
25 breaches which is around 2%. This is due to high levels of diagnostic referrals in early
May and a scanner failure. This continues to be monitored on a weekly basis and the team
are trying to identify if this can be reduced. This assumes a mobile scanner on site in May
and June. The team are continuing to review and identify any other opportunities. There
remains limited flexibility in the service and so a shift in the number and types of referral still
has the potential to affect this.
Recruitment for additional radiographers has been successful and interviews for additional
radiologists resulted in an appointment.
The independent review commissioned with a specialist from the Royal College of
Radiologists transformation team has now commenced with Commissioner input. This will
consider how the team works and what actions can be taken to improve the performance.
Emergency Department
The Trust continues to perform well against the 4 hour standard and met the target in April.
The 95th percentile performance was 3.93 hours. This was despite significant increases in
activity in month.
There was one Emergency Department (ED) standard that was not met:
The local ED triage objective (all within 15 minutes), the 95 percentile performance
being 34 minutes (previous month was 36).
Generally performance in April was consistent with previous years.
18 weeks waiting time.
The 18-week standard was met in April with performance for admitted patients at 91.3%
against the 90% standard. 90 admitted patients and 4 non-admitted patients were not
treated within 18 weeks due to insufficient capacity.
There was a small decrease in the standard for incomplete pathways achieving 92.2%
against 92% standard. As shown on the chart on page 8 the drop in the numbers of those
waiting over 14 weeks without a TCI and over 18 weeks without a TCI seen in January has
been reversed and has begun to increase in April.
Looking forward, based on current assumptions and forecasts the standard will be met in
May but there is greater risk than in previous months.
The number of patients waiting over 30 weeks is 140 an increase from March.
There was one patient reported to be waiting over 52 weeks, this is due to patient choice
and once seen will be validated out. Of note, as part of the national contract, hospitals will
be charged £5000 for all patients waiting over 52 weeks if it is due to hospital reasons.
The overall waiting list size showed a small increase which was as expected due to the high
levels of cancellations in April.
CAMHS achieved 99.4% for 18 weeks with the average wait being less than 4 weeks.
There is increased focus on 18 weeks from Monitor and Commissioners with requests for
further detail on specialty performance and the breakdown of waiting times for those on the
list. It is expected that there will be significant scrutiny during the year.
Tertiary referrals
There were two West Midlands patients who couldn’t get a bed in April and no out of region
patient. When reviewing the long term trend it can be seen that there has been a significant
drop in refusals since December 2010 with the numbers fluctuating between 0 and 6 each
month.
Forty four patients, of which thirty six were West Midlands patients that were admitted had to
wait over 24 hours before a BCH bed was provided. This is consistent with last month. This
is against a higher level of urgent referrals. When a referral is received the specialty
consultant is asked to identify the time period in which the child should be admitted. This is
under 12 hours, 12 – 24 hours or 48 hours. When comparing actual time to admission
against recommended time for admission it can be seen that 83% of requests were met of
this 85% of patients who were assessed as needing a bed within 12 hours were admitted
within the timeframe.
PICU (Paediatric Intensive Care Unit) referrals
The West Midlands (WM) PICU service is provided by BCH, University Hospitals of North
Staffordshire NHS (UHNS) Trust and the KIDS (Kids Intensive care Decision Support)
service run by BCH.
Three West Midlands (WM) patients and seven non WM patients could not be supported due
to hospital reasons.
Overall the KIDS team continue to be successful in supporting local hospitals, 19% of
children did not need to be moved because of the support provided.
CAMHS referrals
The CAMHS Tier-4 (Child & Adolescent Mental Health Service) West Midlands service is
provided by BCH and other providers (some private) with BCH providing the assessment of
all requests. Fourteen patients could not be supported by BCH CAMHS in April which was
higher than last month due to no capacity and urgency. There continues to be significant
capacity pressures across the West Midlands and nationally for Tier 4 beds. We are still
awaiting the results of the national review but early indications are that it will not make
significant changes. A procurement exercise is likely to be carried out which we will need to
respond to.
Internally the ERA service has now extended to 7 days a week and this has had a positive
impact providing a more rapid response where needed and ensuring young people receive
support whilst waiting.
The service is continuing to experience difficulties in discharging patients and at the end of
April there were 5 that were unable to be discharged due to reasons out of the Trust’s
control.
Delayed discharges
There were 9 children and young people at the end of April who were fit for discharge but
waiting for other reasons. One has waited for over a year. The reasons are for housing and
social care reasons. The total number of bed days relating to these delays is 1018 days.
Assessment
A reduction in capacity due to staffing and a spike in demand has led to an increase in the
waiting times for MRI and pressures around ward beds and PICU beds has led to continued
high levels of cancellations.
Plans to reduce delays include:
PICU Capacity:
We expect a delay to increase beds from 28 to 31 beds. This is predominantly due to
staffing issues. Therefore there will continue to be an impact on performance.
A review is being carried out by NHS England to consider paediatric critical care capacity
across the region, the Trust are supporting this.
Theatre Capacity:
Weekend working is now taking place as well as additional capacity at the Birmingham
Treatment Centre.
A Theatre Working Group is in place with a focus on improving staffing levels to maintain
and increase theatre capacity.
A Cancellations Working Group is in place which is running a series of pilots to reduce
total cancellations. A project is underway to look at how we ensure all elective patients
undergo pre-admission which will help to reduce the risk of cancellation.
Additional anaesthetists now in place.
Business case for extending capacity through use of the Plaster room approved.
Further business case under development for development of Interventional Radiology
capacity.
Newton have been appointed to support the Trust in terms of flow management through
theatres.
Diagnostic waits - MRI capacity:
A medium term capacity plan for Imaging is being produced which includes new ways of
working.
New consultants are now in place with further interviews in May.
Additional lists for GA were agreed both in week and on Saturdays for January and April,
with discussion over this continuing in future months.
Mobile scanner planned for end of April, May and June.
Extended working hours agreed with radiographer workforce.
New roster agreed with radiologists.
Overall bed capacity:
Analysis being completed to understand the drivers behind the current pressures.
The Medium Term Clinical Estates Strategy is being developed to identify future demand
and solutions to meet demand.
Recommendations
The Board is asked to note the performance and plans for further improvement.
Key Risks
Risk Description
Controls
Insufficient capacity in place Appropriate
to meet service demands
systems in place
Assurances
escalation Daily, weekly and monthly
reporting in place.
Capacity
plans
being Revised capacity plans being
renewed and developed. produced.
This
includes
modelling
capacity/demand
between
now and 2020 (new hospital)
Winter plan implemented
providing
additional bed
capacity & flexibility
Key Impacts
Strategic Objectives
CQC Registration
outcome)
NHS Constitution
This reports covers progress against meeting the strategic
objectives linked to supporting improving our patient
experience.
(state 4: Care and welfare
Yes – treatment within 18-weeks is a requirement within the
NHS Constitution.
Other Compliance (e.g. Many of the indicators are local or national standards
NHSLA,
Information monitored by the Department of Health, Monitor and our
Commissioners.
Governance, Monitor)
Equality, diversity & human The report considers any particular impact on patients with
learning disabilities, and on different ethnic groups.
rights
Trust contracts
Non-delivery of NHS standards can result in financial
penalties
Other
Meeting the strategic objectives raises the profile of Trust
locally, regionally and nationally
Performance Report
Month 1 2014/15
Performance for April 2014
Georgina Dean
Deputy Chief Officer for Contracting and Performance
Item 14.80
Enc 06
1
Performance Indicators
Cancelled operations – national
definitions
ED – Left without being seen
MRI waits over 6 weeks
Cancelled operations – all hospital
cancellations
ED – Unplanned readmissions
In region Tertiary referrals sent elsewhere
Cancelled operations - patients
cancelled more than twice
18 weeks performance (admitted)
Tertiary patients waiting over 24 hours for
a BCH bed
Cancelled operations - equipment
failures or admin errors
18 weeks performance (non admitted)
PICU – WM patients not supported
Cancelled operations – breaches of
28 day standard
18 weeks performance (incomplete)
PICU – non WM patients not supported
ED - time in ED
18 weeks performance - CAMHS
PICU – non WM patients supported
ED – time to seen
Long waiters - patients not treated within
18 weeks due to insufficient capacity
CAMHS Patients that requested a T4 bed
and were not admitted
ED – Time to triage (all)
Long waiters - patients not treated within
30 weeks
Patients with delays after being declared fit
for discharge
ED – time to triage (ambulance)
Long Waiters - patients waiting over 52
weeks
Indicates strategic objective measure
2
Cancelled operations trends
Cancelled operations overall position: the number of cancelled operations flagged as nationally reportable in April 2014 is
very high (66). Total hospital cancellations at 189 are at a record high and we remain above our strategic goal of a reduction on 12/13
levels. There were two breaches of the 28 day standard in April.
There were 66 nationally reportable* cancelled operations in April 14, the
second highest since Apr-12, and almost double the average for the same
period of 36.
Cancelled Operations On The Day - National
Definition
* Cancelled by hospital for non medical reasons on the day of admission or after admission
66
All Hospital Cancelled Operations
60
Total
Hospital
Cancelled
Operations
are well
above the
upper
confidence
interval in
Apr 14 (189
cancelled)
200
50
40
150
30
100
20
50
47
Total
66
Apr-14
Jan-14
Oct-13
Jul-13
Apr-13
Jan-13
Oct-12
Jul-12
Apr-12
5
0
Apr-14
No Ward bed
10
Jan-14
4
15
Dec-13
No ITU bed
There were 2 breaches of
the 28 day standard in
April 2014, patients
rescheduled operations
were cancelled because
of lack of capacity eg
urgent operations taking
the slot
Nov-13
7
20
Oct-13
Emergency/Trauma
Breaches of 28 Day Cancelled Operations
Standard
Sep-13
4
lci 2stdev
Aug-13
Equipment failure
uci 2stdev
Jul-13
4
mean
Jun-13
Lack of Theatre Time
Data
May-13
Total
Avge
Apr-13
Nationally Reportable
Cancellations by Reason
2014/15
Jan-12
2013/14
Oct-11
2012/13
0
Apr-11
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Jul-11
10
Mar-14
70
Feb-14
80
3
All Hospital cancelled operations for April 2014 by
Reason
All Hospital cancelled operations for April 2014 by
Specialty
Admin error,
12
Other, 4
Cardiology, 3
Other Dir 4, 21
Cancelled by
clinician/
hospital, 55
Cardiac, 13
More urgent
patient, 26
Other Dir 3, 10
ENT, 26
No ITU bed, 7
Other Dir 2, 17
Staff shortage,
5
Operation
Equipment
would
have/did unavailable, 4
overrun, 12
Paed Surg, 26
No Ward bed,
64
Urology, 24
T&O, 9
Plastics, 24
Radiology, 16
The hospital cancelled 189 operations in April 14. Lack of ward beds account for 34%. This reason has been increasing in recent months and is
much higher than average in April 14. The next highest area is cancelled by clinician/hospital, covering reasons such as unsuitable or unfit
patients where the hospital cancelled the operation, further analysis of this area is required as this is higher than previous months.
Analysis by specialty shows that Surgical specialties have experienced the most cancellations in April 14, amounting to 130 of the 189. This is a
change from previous months when Cardiac and Cardiology tended to be the largest area
4
Multiple cancellations
Cancelled Operations Associated With Patients cancelled more
than once in same specialty
Patients cancelled more than once in same Specialty
18
40
16
35
14
30
12
10
25
8
20
6
15
4
2
10
0
5
0
Twice
3 times
4 times
5 times
6 times
7 times
In April 2014 sixteen patients had an operation cancelled who
had previously had an operation cancelled at least once in the
same specialty in the previous 12 months. These 16 patients
had 32 cancellations between them in total in the previous 12
months in the relevant specialty.
Strategic objective: Year to date hospital cancelled
operations are running 249% higher than the equivalent
year to date figure for 2013/14. (Target 10% reduction)
Twice
3 times
4 times
5 times
6 times
7 times
Strategic Objective – patients cancelled more than twice
(Hospital Cancellations Only)
No patients had an operation cancelled in April 2014 for the
third or more time (NB cancellations have to be in the same
specialty and in the previous 12 months to be counted)
Strategic objective: In April 2014, twelve patients or operation
slots were cancelled due to admin error, and four patients due
to equipment failure (Target is zero)
5
Emergency Department
95th % time
in A&E:
3.93hrs
95th % time to
triage (all):
34 minutes
95th % time to triage
(ambulance):
13 minutes
ED re-attenders for
related condition
2.33%
Left without being
seen:
2.35%
Median time
to be seen:
60 minutes
ED overall position: In April all but one of the targets in the ED department has been met.
This target of all patients having an initial
assessment within 15 minutes has not been met for the last three years. The total number of attendances has reduced to 4500 from last
months record high of nearly 5000.
% Patients Who Left ED Without Being Seen
Standard < 5%
Total Time Spent in A&E Standard ≤ 4 hours
(95th Percentile)
Time to be Seen
Standard ≤60 minutes (Median)
4.70
7.0
90
80
6.0
4.50
70
5.0
60
4.30
50
4.0
40
4.10
3.0
30
3.90
2.0
20
10
1.0
3.70
0
A M J
0.0
A M
J
J
A
2012-13
2014-15
S
O N D
J
F M
2013-14
Target
J
A
S O N D
J
F M
3.50
A M
J
J
A
S
O N
D
2012-13
2013-14
2014-15
Target
J
F M
2012-13
2013-14
2014-15
Target
6
18 week waits
Admitted
Non admitted
• 91.3%
• 98.5%
Incomplete
• 92.2%
18 weeks overall position: all targets were met in April 2014. The admitted performance showed a good improvement from
March 14. Incomplete pathways remain only just above target. Numbers waiting over 30 weeks and also the number of patients
receiving TCIs late in their pathway remain relatively high, so the pressure on waiting times is likely to continue going forward
94 patients were not treated within 18 weeks due to
insufficient capacity
18 weeks admitted performance
94.0%
Patients not treated within 18 weeks due to insufficient
capacity
93.0%
14
92.0%
14
10
11
90.0%
12
8
4
7
1 patient was waiting over 52 weeks
(once patient related pauses is applied the wait
reduces to 257 days)
Admitted
90
Non admitted
Mar-14
Target
Feb-14
M
Jan-14
F
Dec-13
J
2014/15
112
75
Nov-13
D
118
97
Oct-13
N
118
73
Sep-13
O
Jul-13
S
2013/14
128
105
61 56 62
54
1
2
0
Jun-13
A
25 29
41
May-13
J
8
Apr-13
J
2012/13
4
8
83
Mar-13
M
Nov-12
A
Oct-12
86.0%
Sep-12
38 44 42
3
Feb-13
87.0%
Jan-13
2
2
4 14
Dec-12
88.0%
3
Aug-13
89.0%
Apr-14
91.0%
1 patients was waiting over 52 weeks. This patient has pauses in their pathways that
cannot be applied to their wait until they are admitted. Applying the pauses would
reduce their waiting time to 257 days.
7
18 week waits
Fig 1 - % still waiting for clock stop (incomplete) under
18 weeks
100.0%
600
98.0%
500
96.0%
400
94.0%
300
92.0%
200
90.0%
100
88.0%
0
A
M
2012/13
J
J
A
2013/14
S
O
N
2014/15
D
J
F
Target
M
07.04.13
21.04.13
05.05.13
19.05.13
02.06.13
16.06.13
30.06.13
14.07.13
28.07.13
25.08.13
08.09.13
22.09.13
06.10.13
20.10.13
03.11.13
17.11.13
01.12.13
15.12.13
05.01.14
19.01.14
02.02.14
16.02.14
01.03.14
16.03.14
30.03.14
13.04.14
27.04.14
Fig 2 - 18 Weeks:Current Problem, Future Problem
Performance for patients still waiting for their initial treatment (either admitted or non admitted pathway) has decreased slightly since last month
to 92.2% (Fig 1.)
Regarding patients waiting for an admission (Fig. 2), the green line, (which is the total of the red and blue lines) illustrates the overall potential
problems we have in managing our 18 weeks admitted demand; this showed a large increase in December 13 and has steadily decreased until
March, when it is starting to increase again during March and April.
The blue line illustrates patients with a date to come in who are already over 18 weeks or whose TCI date is over 18 weeks – this has increased
slightly in April . The red line illustrates patients who are waiting 14 plus weeks and do not have a TCI date yet, again this is increasing.
Overall there was an increase in the number of long waiters with TCIs over 18 weeks or patients who get TCIs late in their pathway during Autumn
2013, peaking in Dec 13. The levels have been slowly reducing since then but since March have started to increase.
8
Whole Inpatient waiting list and long waits
140 RTT patients either still waiting or
whose clock stopped after 30 weeks
Inpatient Waiting List Size
4,250
3,750
All Patients Still Waiting or Whose Clock
Stopped Over 30 Weeks
160
Specialty break down of the 125
patients still waiting over 30 weeks
140
3,250
Paediatric Plastic
Surgery
120
100
80
140
60
40
73
109 99 107
Mar-14
Feb-14
Dec-13
Nov-13
Oct-13
Sep-13
Aug-13
Jul-13
0
Jun-13
Inpatients
20
54 49 54 57 61
39
May-13
01/04/2013
15/04/2013
29/04/2013
13/05/2013
27/05/2013
10/06/2013
24/06/2013
08/07/2013
22/07/2013
05/08/2013
19/08/2013
02/09/2013
16/09/2013
30/09/2013
14/10/2013
28/10/2013
11/11/2013
25/11/2013
09/12/2013
23/12/2013
06/01/2014
20/01/2014
03/02/2014
17/02/2014
03/03/2014
17/03/2014
31/03/2014
14/04/2014
28/04/2014
1,750
94
Jan-14
2,250
Surgical & Cardiac
The overall waiting list for surgical and
cardiac stood at 2170 at end of April ,
with the total list standing at 3807. The
Cardiac/Surgical list has been reducing
since the new calendar year but has
increased slightly in April.
At end of April, there are 140 patients
waiting over 30 weeks (either still waiting or
who had their clock stopped in the month)
This is the highest value since Nov 12.
Of the 140 patients 15 had their clock
stopped over 30 weeks and 125 are still
waiting.
Apr-14
2,750
35
Paediatric Surgery
Paediatric Trauma
and Orthopaedics
17
Paediatric Cardiology
Paediatric Ear Nose
and Throat
15
Paediatric Urology
Paediatric
Ophthalmology
10
16
14
3
Craniofacial Surgery
Paediatric
Neurosurgery
3
Radiology
2
Paediatric Burns Care
Paediatric
Dermatology
Paediatric
Gastroenterology
2
Paediatrics
1
Paediatric Dentistry
1
2
2
2
9
CAMHS 18 Weeks
CAMHS 18 Weeks Performance
105
18 weeks
performance
100
95
• 99.4%
90
85
80
75
Apr
May
Jun
2012/13
Jul
Aug
Sep
Oct
2013/14
Nov
2014/15
Dec
Jan
Feb
Mar
CAMHS continue to achieve against their 18
week wait target with 99.4% of their
patients being seen within target in April.
Target
CAMHS Time to Assessment
CAMHS are now successfully assessing more of their
patients within four weeks.
The overall level of
assessments has reduced over time following the
introduction of improved protocols for the management
and assessment of referrals.
Average Wait for
Assessment
(weeks)
2010/2011
2011/2012
2012/2013
2013/2014
2014/2015
Total Assessments
6.8
7.8
7.9
3.9
4.0
2010/2011
3491
2011/2012
3427
2012/2013
2754
2013/2014
2333
2014/2015
163
10
CAMHS Referrals
All Long Stay Patients
CAMHS Patients that requested a T4 bed and were not
admitted (month trend)
16
14
12
April 14 joint highest in last
2 years
The Blue line shows the trend in patients who are in hospital for seven days or
more at any particular day in time. This has been increasing significantly in the
final quarter of 2013/14 but has started to show some reduction in April. The
over 30 day curve has also shown a slight reduction this month
140
10
8
120
6
4
100
2
0
Apr May Jun
Jul
2012/13
Aug Sep Oct Nov Dec Jan
2013/14
Feb Mar
2014/15
80
60
CAMHS Tier 4 Gateway Referrals
Total No Referrals
40
GA Completed
Referred to SCT
40
20
35
25
20
15
0
08/05/2013
25/05/2013
11/06/2013
28/06/2013
15/07/2013
01/08/2013
18/08/2013
04/09/2013
21/09/2013
08/10/2013
25/10/2013
11/11/2013
28/11/2013
15/12/2013
01/01/2014
18/01/2014
04/02/2014
21/02/2014
10/03/2014
27/03/2014
13/04/2014
30/04/2014
30
10
5
0
Sum of GT7
Sum of GT30
Sum of GT90
Linear (Sum of GT7)
Linear (Sum of GT30)
Linear (Sum of GT90)
11
Fit For Discharge Days
CAMHS - Long Stay Patients at end of April - Fit for
Discharge Days
Long Stay patients at end of April - days fit for discharge
Patient 9
Patient 5
Patient 8
Patient 7
Patient 4
Patient 6
Patient 5
Patient 3
Patient 4
Patient 3
Patient 2
Patient 2
Patient 1
Patient 1
0
0
100
200
300
400
100
200
400
500
500
Before fit for discharge
Before fit for discharge
300
After fit for discharge
After fit for discharge
5 CAMHS patients were fit for discharge. 2 were waiting for adult
placement place (since 2013), 1 was waiting for suitable available
bed (since March) and 2 were waiting social services to complete
assessments (since Feb). In total these five cases have been fit for
discharge for 442 days.
9 patients were waiting for discharge in April. Three patients were waiting for
housing (one has waited 443 days), four patients are waiting social
care/package and one was waiting on parental training and one due to social
issues. In total these 9 patients have been fit for discharge for 1018 days.
Assuming an average length of stay (excluding day cases) of 4 days, another
254 patients could have been seen at the hospital if these patients had been
discharged, as they became fit .
12
Diagnostic waiting lists
The charts below illustrate that demand for diagnostic test continues to be high and
the waiting list is showing no real sign of decreasing in size. There is a switch in the
make up of the list towards non GA recently
Diagnostic waits overall position: we continue to fail to
meet our key target for MRI and are a significant outlier
nationally in this area . Demand continues to be high.
MRI Waiting list
Total WL
GA WL
NON GA WL
139
133
115
97
1000
500
0
123
107
101 106
110
88
71
Total waiting list additions by week
51
Total external referrals
Total Additions by week
Linear (Total Additions by week)
200
25
0
Patient numbers
45
2012-…
2012-…
2012-…
2012-…
2012-…
2012-…
2012-…
2012-…
2012-…
2012-…
2012-…
2013-…
2013-…
2013-…
2013-…
2013-…
2013-…
2013-…
2013-…
2013-…
2013-…
2013-…
2013-…
2013-…
2014-…
2014-…
2014-…
2014-…
12/05/…
Number of patients waiting over 6 weeks for MRI (actual and
forecast)
Patients
1500
150
100
50
0
The MRI service continues to be under significant pressure
with 128 patients breaching the 6 week target in April 2014
(123 for MRI and 5 for CT scan.) It is now forecasted that a nil
breach position will be reached by July (not June as predicted
last month). This is due to increased demand in early May and
also scanner failure on 12th May.
The Directorate continues to put a range of additional actions
to address this issue. A mobile scanner was hired in January,
and for 5 days at end of April thus increasing activity. A scanner
is be hired for 5 days at end of May and June to try and ensure
that a nil breach position is achieved by July.
GA additions per week
80
60
40
20
0
13
Urgent Tertiary and Home Referrals
209 referrals for
specialist beds,
177 admitted
3 in region
patients unable to
get a bed
3 out of region
patients unable to
get a bed
26 patients no
longer required a
BCH bed
26 in region patients
waited over 24 hours
to get a BCH bed
5 out of region waited over
24 hours to get a BCH bed
Overall position: Tertiary and home urgent referrals in April at 209 remain very high. Three in region patients did not get a bed and 31
patients waited over 24 hours . However 83% of requests were still met within the required clinical timescale.
Urgent Tertiary and Home Referrals
Activity levels
250
200
197
188 191
186 199 175
177 188 181 173 163 169
175
172 182
170
164
225
209
150
Levels of urgent referrals remain
high; although they have reduced
from the March peak demand in
April 14 is still the second highest
since in October 2012
100
50
0
Home
Tertiary
Total
Performance vs clinical tgt time for patients provided a bed
- home and urgent tertiary referrals - April 14
Waiting time vs. clinical target time
The previous slide includes a chart that illustrates performance
regarding the admission of tertiary and home urgent referrals
within 24 hours. However clinicians can request the patient to be
admitted in up to 48 hours, dependent on their assessment. The
graph below shows the timescales requested for admittance and
what was achieved for April. Overall 83% of requests were met
in April.
100
84%
80
83%
60
40
81%
20
0
within 12 hours
12-24 hours
85%
84%
83%
82%
81%
80%
79%
78%
Up to 48 hours
Target Time
Met
Not met
% patients meeting tgt time
14
Urgent Tertiary and Home Referrals
Referrals Sent Elsewhere
Referrals Waiting over 24 Hours
Six referrals were sent elsewhere in April 14, this is 16.6% of the
entire 13/14 financial year total, indicating that April was a
challenging month for the management of urgent referrals.
The number of children waiting over 24 hours for a bed
after a tertiary referral is closer to average than the very
high figure in March. Referrals continue to be high. 83% of
referrals were managed within the clinical target time.
Tertiary and Home Urgent Referrals Sent Elsewhere
Paediatrics
T&O
Trend - Tertiary and Home Referrals Waiting Over 24
Hours for a Bed
Surgery
Resp Med
50
45
40
35
30
25
20
15
10
5
0
Neurology
Nephrology
Medical Oncology
ENT
Clin Haem
Cardiology
Apr-14
Mar-14
Feb-14
Jan-14
lower ci
Dec-13
Nov-13
Oct-13
Sep-13
Jul-13
Avge
Aug-13
Jun-13
May-13
Mar-13
Over 24 Hr Waits
Apr-13
20
Feb-13
Tot 13/14
15
Jan-13
YTD 14/15
10
Dec-12
5
Nov-12
0
Oct-12
Hepatology
upper ci
15
PICU Demand and KIDS Service
3 West Midlands patients
could not be supported
7 non West Midlands patients
could not be supported
PICU demand overall: Referrals
9 additional non West Midlands
patients were supported
were lower than the previous month. 10 patients could not be supported within the local network
and had to be taken out of region.
Year on Year Comparison of Total Referrals to KIDS
300
There were 110 referrals to KIDS in April 2014. 19% of referrals
were avoided , 45% were admitted to BCH, 26% were referred to
other WM hospitals and 9% went out of the region
200
100
0
Referrals to KIDS Service Taken Out of Region
Apr
May
Jun
Jul
2012/13
Aug
Sep
Oct
2013/14
Nov
Dec
Jan
Feb
2014/15
Outcome of Referrals to KIDS Apr 13 to Apr 2014 - Trend
70%
Mar
(Leics or Other Non WM Provider)
Total
30
Avge
25
20
60%
15
50%
10
40%
5
30%
0
Apr-14
Mar-…
Feb-14
Jan-14
Dec-13
Nov-…
Oct-13
Sep-13
Aug-…
Jul-13
Jun-13
May-…
Apr-13
Mar-…
Feb-13
Jan-13
Dec-12
Nov-…
Oct-12
Sep-12
Aug-…
20%
10%
0%
Avoided Admission
UHNS and Other WM
BCH
Out of Region
The red line shows that
BCH took fewer referrals
in the first part of Winter
2013, but is now able to
return to a more normal
level.
For the winter periods patients
are more likely to be taken out of
Region.
16
Board of Directors
Public Meeting
Thursday 29 May 2014
Item 14.81
Enc 07
Strategic Objective/ Enabler
Every child and young person requiring access to
care at BCH will be admitted in a timely way, with no
unnecessary waiting along their pathway
Report Title
Resources report period 1st April 2014 – 30th April 2014
Sponsoring Director
Chief Finance Officer
Author(s)
Director of Finance and Procurement, Chief Officer for
Workforce, Deputy Chief Officer for Performance and
Contracting and Interim Deputy Chief Finance Officer
Previously considered by
N/a
Situation
This report is to communicate the various aspects of Trust performance in the financial
year to date, period ending 30 April 2014, and to identify any key risks that are evident
within the organisation.
The Trust is also required to report its predicted status for Governance and Mandatory
Services.
Background
The Trust is required to comply with the finance related legal issues contained within our
Terms of Authorisation as well as other key financial targets. This includes:
Not breaching the Private Patient Cap (a legal requirement);
Performing at plan for Monitor’s Continuity of Service Risk Rating leading to an overall
CoSRR of 4;
Minimising triggering the additional financial indicators; and the
Risk Assessment Framework, which may result in formal discussions with Monitor.
Delivery against these targets is driven by:
The volume and mix of demand experienced by the Trust; and
How the Trust uses its most valuable resource, its staff, in responding to that
demand.
The report explores each of these areas in turn and the impact on the financial position
and performance.
Assessment
Monitor Declarations
The key ongoing governance issue for the Trust is the performance against the 18 week
target for admitted patients. Performance in month was 91.3% ie just above the 90%
threshold. This and the continuing level of performance of the other metrics enable the
Trust to forecast a Green Governance rating.
From a financial perspective the ratings will be a 4 under the Continuity of Service Risk
Rating.
Under the old Compliance Framework a FRR of 4 would also have been reported. These
remain strong performances.
Activity
Plan figures are in the process of being agreed with Commissioners and internally within
the Trust. This will include agreeing the phasing of the plans. Given this, activity reporting
in Month 1 is based on actuals and comparison against the equivalent period in 2013.
Compared to April 2013, ED, Planned Care and Follow-Up Outpatients all performed
above last year’s level. Emergency activity and New Outpatients performed below last
year’s level.
From a financial perspective income has underperformed by £0.5m in the month. The
level of cancelled operations reported in the Performance Report is instrumental in this.
Workforce
Demand remains high and this has brought into sharp focus the short to medium term
capacity issues faced by the Trust. Sickness levels increased in remained at 3.8% in the
month. The cumulative rate has also remained static with both measures well above the
Trust’s 3% target.
The combined substantive and bank staff level decreased in April. Bank use dropped by
38wte whilst reduced by 16.5wte although this was a result of the transfer of the WM
CRN transferring to Royal Wolverhampton NHS Trust. Compared to April 2013
substantive wte have increased by 4% whilst Bank Staff have increased by 1%.
Engaging with staff, especially during periods of pressure, is important and appraisals are
one indication of how well this is working in the Trust. The reported appraisal rate has
dropped below 81% in the last month and remains short of the 90% target.
Finance
The first financial report of the new year sees the Trust performing below plan. An inmonth surplus of £0.5m sounds strong. However, it falls short of the plan submitted to
Monitor and is also below the actual levels reported in each of the last 5 months of
2013/14.
Typically the Trust reports an abridged Month 1 position. This is the first year that this
level of detail has been produced and it is acknowledged that as we transition from one
financial to the next there are certain phasing/timing issues that need addressing which
have influenced this position. Any such issues will be resolved by Month 2.
Controlling the costs of care that we provide remains central to our financial success as
downward pressure continues on the tariffs we are paid. Our savings levels are slightly
below target in April although we have started the year more strongly than in 2013/14.
We have to secure the level of savings that we anticipate this financial year to ensure
affordability of the Next Generation project and having plans exceeding 100% of our
target is a positive move to achieving this. The key issue financially in April was the
impact of cancelled operations on clinical income, which is £0.5m under target. This is
unsustainable.
Our cash balances remain strong albeit below plan. Receipt of cash during April can
sometimes be variable and whilst we received the expected cash off our key
commissioners receipt from other sources was not as timely as anticipated. This will
improve during May. The Capital Programme is due to be ratified by the Finance and
Resource Committee in June after which capital expenditure will start to increase. It is
pleasing to report that the Trust has finally successfully concluded the legacy debt issue
with former PCTs.
Recommendations
The Board review, discuss and approve the Resources Report.
Key Impacts
Strategic Objectives
Staff and finance are key enablers to meeting the Trust’s strategic
objectives.
CQC Registration (state
outcome)
N/A
NHS Constitution
NHS Constitution has a pledge regarding 18-week waits.
Other Compliance (e.g.
NHSLA, Information
Governance, Monitor)
Monitor metrics are considered in the report.
Equality, diversity & human
rights
N/A
Trust contracts
N/A
Other
N/A
Resources Report
May 2014
Phil Foster
Theresa Nelson
Georgina Dean
Director of Finance and Procurement
Chief Officer for Workforce
Deputy Chief Officer for Contracting and Performance
Item 14.81
Enc 07
1
Reporting on resources use
1. Summary
2. Monitor Assessments and Declarations
3. Volume and mix of activity
4. The impact on our workforce
5. Productivity
6. Financial Performance Summary
2
Summary.
May 2014
The first financial report of the new year sees the Trust performing below plan. An in-month surplus of £0.5m
sounds strong. However, it falls short of the plan submitted to Monitor and is also below the actual levels
reported in each of the last 5 months of 2013/14. Typically the Trust reports an abridged Month 1 position. This
is the first year that this level of detail has been produced and it is acknowledged that as we transition from
one financial to the next there are certain phasing/timing issues that need addressing which have influenced
this position. Any such issues will be resolved by Month 2.
Controlling the costs of care that we provide remains central to our financial success as downward pressure
continues on the tariffs we are paid. Our savings levels are slightly below target in April although we have
started the year more strongly than in 2013/14. We have to secure the level of savings that we anticipate this
financial year to ensure affordability of the Next Generation project and having plans exceeding 100% of our
target is a positive move to achieving this. The key issue financially in April was the impact of cancelled
operations on clinical income, which is £0.5m under target. This is unsustainable.
Bank usage in April was 1% higher than the equivalent period last year although whilst substantive staffing
levels are 4.0% higher. Appraisal rates have reduced further and are now just over 80%. In-month sickness
remained static at 3.8% and is well above the 3% target.
Our cash balances remain strong albeit below plan. Receipt of cash during April can sometimes be variable and
whilst we received the expected cash off our key commissioners receipt from other sources was not as timely
as anticipated. This will improve during May. The Capital Programme has been provisionally agreed by the
Investment Committee and awaits formal ratification by the Finance and Resource Committee after which
capital expenditure will start to increase. The Trust has finally successfully concluded the legacy debt issue with
former PCTs.
3
2. Monitor Assessments and Declarations
4
Our month 1 regulatory position has started strongly.
Month 1
Monitor Quarter 4 2013/14 (Predicted)
Finance risk rating - Continuity of Service Risk Rating
Based on this performance the predicted
measureable Month 1 performance is Green.
The Continuity of Service Risk Rating for April
is a 4 (the highest level).
Governance risk rating
Finance risk rating - Compliance Framework
G
G(4)
Monitor Quarter 1 2014/15 (Predicted)
Finance risk rating - Continuity of Service Risk Rating
Governance risk rating
For information under the old Compliance
Framework regime a FRR of 4 would have
been reported in Month 1.
G (4)
Finance risk rating - Compliance Framework
G (4)
G
G(4)
The above will result in the Trust achieving its
planned Risk Ratings for 2014/15.
5
3. Volume and Mix of Activity
6
Emergency and ED activity performance
ED attendances
5000
4000
3000
2000
1000
0
A
M
2011/12
J
J
A
2012/13
S
O
Emergency /Non Elective FCEs
2000
1800
1600
1400
1200
1000
800
600
400
200
0
6000
N
D
2013/14
J
F
M
A
M
J
J
A
S
O
N
D
J
F M
2014/15
2011/12
2012/13
2013/14
2014/15
Only activity against actuals for last year is reported this month as the planned activity levels are to be confirmed.
Emergency Department (ED) attendances have increased by 6.7% YTD compared with last year (for month of April).
Emergency FCE activity in month has decreased by 14.6% compared with April 2013. This relates to activity for patients
being admitted through the Observations ward associated with the Accident and Emergency Specialty and consultants (not
the children admitted under the Paediatrics specialty). There has been a drop of 200 FCEs (40%) since April 2013 for these
patients.
7
Planned Care and Outpatient activity performance
New OP attendance
All Elective FCEs
3000
4000
2500
3500
2000
3000
Follow up OP attendance
12000
10000
8000
2500
1500
1000
2000
6000
1500
4000
500
1000
0
500
A M J
J A
S O N D J
2011/12
2012/13
2013/14
2014/15
F M
2000
0
0
A M
2011/12
J
J
A
2012/13
S
O N D
2013/14
J
A M J
F M
2014/15
2011/12
J A
S O N D
2012/13
2013/14
J
F M
2014/15
Only activity against actuals for last year is reported this month as the planned activity levels are to be confirmed.
Elective activity in April was 4.2% higher than in April 2013. The high volume specialties recording the most notable increases in year on year
activity are:
Clinical Haematology +17.9%, Medical Oncology +33.6%, Nephrology +13%, Paediatric Surgery +17.3%, Paediatric Urology +34.8%
April 2014 saw a 3.9% decrease for new attendances and 5.7% increase for follow up patients when compared with April 2013.
The specialties recording the most notable changes in year on year activity are:
1. New patients - Paediatrics -21.5%, Urology +25%, T&O +12.5%;
2. Follow up patients – Clinical Haematology + 19%, Plastics +23%, Paediatric Surgery +21%, Urology +32%.
8
4. Workforce
9
Workforce Report Summary April 2014
The workforce numbers at 3156 WTE is lower than last month by 16.48 WTE but still above last year. However 2 nd Induction starters have
not yet been added to ESR, so this WTE is expected to increase. The 3 slides relating to nursing levels will be further developed as guidance
becomes clearer for paediatric nursing.
Sickness Summary – In month sickness has remained constant at 3.80% and is higher than this time last year. The 2013/14 year ended at
3.47%. Long term sickness has increased slightly to 2.40%, these staff are being supported through our processes. Short term sickness has
decreased slightly to 1.40% during March 2014.
The top 3 reasons for sickness during March are Anxiety/Stress (791.22 WTE days lost), Musculoskeletal (515.91 WTE days lost) and
Gastrointestinal (349.12 WTE days lost).
Bank/Agency Usage – There has been a decrease during April 2014 to 166.03 WTE, an decrease of 37.97 WTE compared to March 2014,
Admin usage has decreased by 2.74 WTE continues to be high in the Medical Secretary profession (16.93 WTE)and also in Health Records
(11.85 WTE). Top 3 Clinical departments using bank are PICU (21.76 WTE), Theatres (14.57 WTE) and Ward 7 (8.85 WTE). The latest month
is an indicative figure and about 95% accurate.
PDR Summary - PDR % continues to show a decrease month by month however we still remain above 80%. All staff groups have shown a
decrease in their %. CAMHS Directorate is the only directorate to see an increase in their % and none of the directorates have achieved 90%
compliance in April 2014.
Turnover Summary -12 month Turnover % for the Trust has again increased for the 12 month period ending April 2014 and remains above
the Trust KPI (9%) at 12.77%. All Directorates have a 12 month turnover % above the Trust 9% KPI target. The Trust has lost 373.44 WTE in
the last 12 months of which 12.07 WTE was due to dismissal, 23.33 WTE due to retirement, 37.40 WTE due to promotion and 53.65 WTE
due to relocation. MCRN (17.24 WTE) has been TUPE transferred to Wolverhampton NHS Trust at end of April 2014 which would have an
impact on our turnover %.
10
Workforce Dashboard
Trust
Target
CSS
Medical
Specialised
Surgical
CAMHS
Corporate
Trust (Previous
Month)
Trust (Current
Month)
Trend
<3.00%
3.34%
4.37%
3.68%
2.93%
3.32%
2.68%
3.46%
3.47%
▲
<3.00%
3.50%
4.88%
4.37%
3.20%
1.86%
3.56%
3.80%
3.80%
▬
80
132
142
71
34
84
546
543
▼
LT Sickness %
2.31%
3.20%
2.86%
1.96%
0.66%
2.23%
2.35%
2.40%
▲
ST Sickness %
1.19%
1.68%
1.51%
1.24%
1.20%
1.33%
1.45%
1.40%
▼
£44,695.12
£69,348.40
£74,510.24
£30,188.27
£20,501.62
£35,100.28
£254,915.24
£274,343.93
▲
£476,566.58
£824,055.05
£717,551.35
£276,733.47
£311,910.94
£347,677.14
£2,921,001.78
£2,954,494.53
▲
528.03
981.55
1019.92
438.81
175.73
567.33
3356.25
3711.37
▲
86.25%
79.25%
79.07%
88.01%
85.94%
71.30%
83.10%
80.75%
▼
Starters FTE
0.80
4.20
5.00
10.00
0.00
13.00
88.40
33.00
▼
Leavers FTE
2.47
7.87
8.00
13.55
4.00
23.91
76.05
59.79
▼
10.02%
11.46%
13.53%
11.22%
12.75%
16.90%
12.02%
12.77%
▲
0.50%
0.94%
0.95%
2.01%
1.33%
4.23%
1.14%
1.63%
▲
555
489.61
695
636.21
822
753.45
471
434.42
332
299.21
588
543.38
3481
3172.76
3463
3156.28
n/a
n/a
Indicator
Sickness % (YTD)
Sickness %
(Month)
Episodes
Cost of sickness
Cost of sickness
YTD
FTE days lost
sickness
PDR's %
Rolling Turnover %
In Month Turnover
%
Headcount
WTE in post
90%
<9%
12
16
4
6
2
12
97
52
▼
4.61
37.97
44.51
25.97
8.45
44.53
204.00
166.03
▼
3.58%
3.96%
3.57%
4.17%
4.74%
1.67%
3.46%
3.52%
▲
7
13
15
7
1
6
48
49
▲
0
0
1
0
0
1
3
Org Change
Please note that sickness is still one month behind so we are currently reporting on Marchs data
Current months WTE may be slightly lower due to new starters from the 2nd induction still being inputted onto ESR.
Employee Relations - On going or started during reporting month
Turnover now excludes apprentices on a 12 months fixed term contract
2
n/a
Active Recruitment
Bank Usage
Maternity Leave %
Staff in Difficulty
11
Workforce Plans
Demand
Baseline
Plan
Forecast
As at 31st
Mar-14
As at 31st
Mar-15
As at 31st
Mar-16
As at 31st
Mar-17
As at 31st
Mar-18
As at 31st
Mar-19
3,177.9
3,267.4
3,281.4
3,281.4
3,281.4
3,281.4
423.8
446.2
448.3
448.3
448.3
448.3
1,181.8
1,223.9
1,235.8
1,235.8
1,235.8
1,235.8
Qualified Scientific, Therapeutic & Technical Staff
448.6
448.6
448.6
448.6
448.6
448.6
Support to Clinical staff
453.5
479.8
479.8
479.8
479.8
479.8
NHS Infrastructure Support
670.2
668.8
668.8
668.8
668.8
668.8
Medical and Dental Staff
Registered Nursing, Midwifery & Health visiting staff
The Trust is currently preparing a workforce plan using information collected though the current business planning process. Above is an initial overview
of the annual workforce return Trust figures including the overall headcount predictions broken down into staff groups over the next 5 years. Further
changes are required prior to submission to the Commissioning Support Unit by the end of May 2014. Following this the Clinical Commissioning Group’s
(CCG) will assure the first two years and the LETC will utilise plans to inform the commissioning intentions for 2015 and 5 years beyond.
At BCH the development of the workforce plan is built around a structured business planning process including: • Review of Strategic Plans and work functions (taking account of the Annual Plan, declared commissioning intentions and contractual position).
• Forecasting and anticipating demand, business developments and potential cost pressures.
• Assurance and projections for workforce supply (staff in post, establishment and forecast).
It is apparent that for many developments we are not yet able to understand the workforce implications, however certain predictions have been made
within the plan. It is recognised the pace of growth coupled with our ability to recruit, retain and develop the right numbers of skilled staff to meet our
future demands will be a challenge. To address this new ways of working are crucial as workforce supply will not necessarily be available in future and
developing managers competency to undertake good workforce planning will be a key component for our Next Generation project.
12
BCH Nursing Staffing:
•
•
•
•
•
First national stock take completed: with BCH compliant with the requirements and on
target to achieve future expectations
Summary and detail nursing data presented in April and May
Draft Establishment report presented to Trust Board in April, a review is planned in the
summer.
The nurse staffing levels have been at expected numbers and skill mix levels and
therefore no concerns highlighted with this months results
The following two slides describe the specific ward by ward detail which forms part of
the national reporting requirements from June 2014.
Nursing Workforce Summary
Monthly
Ave:
Mar-14
Apr-14
Act vs.
Plan
Acuity
98.1%
TBC
79.2%
103.6%
TBC
81.5%
Annual
Mat Leave Sickness
Leave
Bank
7.5%
16.6%
4.8%
8.1%
3.3%
6.0%
12.4%
5.8%
4.6%
2.3%
Skill Mix Vacancy
Nursing Workforce April 2014
Nursing
Nursing Staffing
Workforce
Actual vs Planned
Dashboard: Ward
Apr-14
Patient Acuity Level
Planned Resources
Unplanned: Actual & Response
No of Green
shifts
No of Amber
shifts
No of Red
shifts
Registerd
Skill Mix%
Unfilled
Roster%
Vacancy
WTE
Leave%
Mat Leave %
Sickness
98%
101%
98%
114%
98%
105%
101%
106%
95%
142%
113%
84%
85%
101%
101%
90%
87%
99%
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
78
83
85
75
82
81
80
84
89
85
100
88
81
87
88
90
91
84
14.8
5.2
9.1
11.3
9.4
2.3
8
8.8
9
2.8
8.7
13.7
31.7
14.3
11.1
13.8
22.2
17.8
0.8
0.1
0.8
-0.4
-0.2
0.6
10.6
0.6
1.4
2.6
-3
6.9
1.4
3.2
-0.3
0.8
37.5
-1.2
12.5
12.2
12.2
7.9
14.6
13.8
9.4
13.8
14.6
12
14.8
7.9
13.3
18.8
13.2
9.9
10.4
9.6
2.7
5.3
6
4.1
5
10.2
9.1
6.2
7.3
7.3
3.6
7.1
6.1
7.5
2.8
8.3
5.3
5.1
3.7
3.3
4.6
3.2
7.4
2.1
4.8
5.3
8.2
5
1.8
4.7
11.8
2.3
6.6
8.3
2.3
6.4
38
88
47
56
28
17
77
67
56
78
N/A
53
50
41
58
59
51
N/A
0.3
1.7
2.2
0.5
1.5
0.3
6.3
2.7
5.5
15.3
0
1.9
0.8
2.6
1.4
1.2
2.6
0
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
180%
TBC
TBC
TBC
81
36.5
-3.9
12.2
6.2
1.6
88
2.5
TBC
90%
86%
106%
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
TBC
67
54
59
22.2
21.6
8.4
-0.6
-3.7
-0.1
13.9
12
11.3
6.1
0
7
4.1
2.50
1.9
75
N/A
86
3.1
0
0.2
TBC
TBC
TBC
81.5
13.8
2.5
12.3
5.8
4.6
58.6
2.4
Bank Fill % Bank Used
No of Times
Raised to HoN
Monthly Average
Burns
Neonatal Surgical
Ward 1
Ward 5
Ward 9
Ward 10
ED
PAU
Ward 2
Ward 7
MHDU
Ward 15
ODC
Ward 8
Ward 11
Ward 12
PICU
MDC
SDC
Ashfield
Heathlands
Iriwn
Trust Average:
104%
Planned vs Actual Draft Establishment
Exception Report
ursing Workforce
Dashboard: Ward
Planned est
Acuity
Planned Skill
level HDU
Mix
+
Beds
n-14
Action
Current Status
Planned
Activity levels Q4
Bed days
Nursing
Workforce to
Patient Ratio
Current
Nursing
Establishment
Staff in post
ESR Apr
Current
Vacanicies
Nursing Skill Acutiy
Mix
level In line
Beds
Admissions
Activity levels Q4
Bed days
Nurse to
Patient ratio
23.5
83%
23%
7
312
350
1 to 3.4
27
26.2
0.8
81%
7
480
481
1 to 3.7
Neonatal Surgical
35
79%
27%
15
1168
154
1 to 2.3
34.89
34.8
0.09
86%
15
1334
140
1 to 2.3
Ward 1
20.8
81%
3%
12
828
601
1 to 1.7
21.2
20.4
0.8
82%
12
891
350
1 to 1.7
Ward 5
28.7
78%
18%
18-12
1103
573
1 to 1.8
35
35.4
-0.4
79%
15
1278
701
1 to 2.4
Ward 9
30.8
80%
5%
19-15
1493
370
1 to 1.8
33.5
33.7
-0.2
82%
18
1327
532
1 to 1.9
Ward 10
33.4
83%
15%
19
2048
233
1 to 1.8
33.5
32.9
0.6
83%
18
1388
312
1 to 1.8
55.7
45.1
10.6
83%
N/A
N/A
N/A
N/A
Yes
Yes
Yes
Yes
Yes
Yes
Yes
N/A
PAU
27
81%
3%
14
756
257
1 to 1.9
32.7
32.1
0.6
84%
19
1432
766
1 to 1.7
Ward 2
32.8
845
17%
18
1096
135
1 to 1.8
36.8
35.4
1.4
86%
20
1707
192
1 to 1.8
Ward 7
21.5
86%
7%
12
867
178
1 to 1.8
21.6
19
2.6
86%
13
905
137
1 to 1.5
MHDU
18.5
100%
80%
6
298
132
1 to 3.1
18
21
-3
100%
6
459
147
1 to 3.5
Ward 15
62.2
86%
35%
24
1589
300
1 to 2.6
69.5
62.6
6.9
87%
28
2399
370
1 to 2.2
872
N/A
14.08
12.7
1.38
80%
N/A
1000
N/A
ODC
15%
Ward 8
38
85%
26%
15
1062
164
1 to 2.5
38
34.8
3.2
86%
15%
18
882
198
1 to 1.9
Ward 11
34.8
91%
25%
17
1233
208
1 to 2
35.2
35.5
-0.3
85%
29%
18
1173
283
1 to 2
Ward 12
33.8
84%
10%
17
1349
334
1 to 2
32
31.2
0.8
88%
2%
16
1224
254
1 to 2
24
1550
325
1 to 0
254.8
217.3
37.51
92%
28
2123
361
1 to 7.8
PICU
ReCal
planned
Admissions
Burns
ED
DMT Signed
MDC
11.1
74%
1%
10
991
N/A
11.5
12.7
-1.2
84%
14
N/A
1341
1 to 0.9
SDC
15.6
78%
0%
18
1776
N/A
16.5
20.4
-3.9
79%
18
N/A
2216
1 to 1.1
Ashfield
N/A
N/A
28.5
29.1
-0.6
68%
8
417
4
1 to 3.6
Heathlands
N/A
N/A
23.8
27.5
-3.7
61%
14
1818
17
1 to 2
Iriwn
N/A
N/A
26.5
26.6
-0.1
67%
12
6
726
1 to 2.2
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Sickness Absence
BCH Monthly Sickness %
Long and Short Term Sickness %
4.00%
3.50%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
3.00%
2.50%
2.00%
1.50%
1.00%
0.50%
0.66%
2.40%
2.31%
3.20%
2.86%
1.96%
1.40%
1.19%
1.68%
1.51%
1.24%
BCH Trust
Sickness
284 Dir 1
Clinical
Support
Services
1.20%
0.00%
12/13
13/14
2.23%
284 Dir 2
Medical
Directorate
284 Dir 3
Specialised
Services
Short Term Sickness
Trust Target
284 Dir 4
Surgical
Directorate
1.33%
284 Dir 5
CAMHS
Services
284 Dir 6
Corporate
Long Term Sickness
BCH Sickness Comparison
12/13
April
May
June
July
August
September
October
November
December
January
February
March
2.62%
3.20%
3.35%
3.05%
2.79%
2.95%
3.46%
3.45%
3.29%
3.61%
3.29%
3.07%
3.13%
3.39%
3.58%
3.22%
3.36%
3.74%
3.65%
3.43%
3.75%
3.80%
3.80%
13/14
2.85%
BCH Sickness Absence –
March 2014
BCH Total
Clinical Support Services
Medical Directorate
Specialised Services
Surgical Directorate
CAMHS Services
Corporate
Number of
Episodes
Monthly
Sickness %
Cumulative 12 Month
Sickness %
543
3.80%
3.47%
80
3.50%
3.34%
132
4.88%
4.37%
142
4.37%
3.68%
71
3.20%
2.93%
34
1.86%
3.32%
84
3.56%
2.68%
There has been a high level of sickness absence in the medical secretary areas following the
admin review. As a result an intent to listen event recently took place and the directorate is
also reviewing the impact of the admin review. There has also been a number of stress
related illnesses due to employee relations issues. Confirm and challenge meetings are
now taking place in all areas.
Ward areas are high due to number of cases relating to long term health conditions
resulting in a combination of LT and ST sickness. Confirm and challenge meetings are now
in place.
A sickness/stress audit has been carried out in PICU and actions are in place and the
department are already seeing a reduction in sickness absence.
Theatres has a high level of LTS (5.06%) due to a mixture of reasons. All of these are being
actively managed by the sickness absence policy.
16
Sickness Absence Annual Analysis (April 13 to March 14)
Directorate Sickness %
Directorate
Absence Occurrences by
number of days
%
Clinical Support Services
3.34
Medical
Specialised
Surgical
CAMHS
Corporate
BCH Total
4.37
3.68
2.93
3.32
2.68
3.47
Top 5 Sickness Reasons
WTE Days
Lost
%
Anxiety/stress/depression/other psychiatric illnesses
9,127.57
23.2
Other musculoskeletal problems
4,658.33
11.9
Gastrointestinal problems
4,045.64
10.3
Genitourinary & gynaecological disorders
2,409.10
6.1
Cold, Cough, Flu - Influenza
2,325.51
5.9
Absence Reason
Absence Occurrences by start day
Sickness % by Staff Group
Going forward the
directorates are
focussed on
identifying trends
and have requested
further information
based on this data.
Alongside tighter
management
controls this will
enable them to do a
deep dive as
appropriate and
support them to
reduce sickness
absence in their
areas.
17
Bank Usage
Nov 13
Dec 13
Jan 14
Feb 14
Mar 14
Apr 14
CSS
7.11
5.68
8.29
8.20
8.88
4.61
Medical
48.97
40.16
41.03
39.80
57.04
37.97
Directorate Bank Usage Comparison March & April 2014
57.12
57.04
60.00
Surgical
CAMHS
60.59
27.88
7.66
45.98
18.52
9.19
47.33
17.62
9.27
48.30
57.12
19.60
44.51
27.99
7.80
25.97
9.01
8.45
Corporate
42.57
36.08
40.46
35.54
43.91
44.53
Total
194.78
155.62
163.99
159.24
204.00
166.03
* The latest month is an indicative figure and about 95% accurate. The previous month figure will be updated
each month
43.97 44.53
44.51
50.00
37.97
40.00
WTE
Specialised
27.99 25.97
30.00
20.00
8.88
10.00
9.01 8.45
4.61
Mar-14
Apr-14
0.00
D1 Clinical
Support
Services
D2 Medical
Directorate
D3
Specialised
Services
D4 Surgical
Directorate
D5 CAMHS
Services
D6 Corporate
Directorates
Top 3 reasons for bank usage
1. Vacancy – 121.24 WTE
2. Sickness – 17.41 WTE
3. Increased Patient Dependency – 9.30 WTE
Priority
7
Top 3 reasons for Admin usage are Vacancy, Backlog and Sickness
Medical Locum/Agency Usage Cost (£)
The below table shows the cost of medical locum and
agency usage for April 2014.
Locum
9,271.95
9,722.00
Medical
8,908.41
11,148.91
20,269.72
38,929.00
Surgical
9,197.81
8,657.44
CAMHS
6,581.66
74,242.25
54,229.55
142,699.60
Specialised
Total
Directorate Admin bank and agency is as follows:
% Bank/Agency Usage
April 14
Agency
CSS
Admin bank and agency usage = 78.94 WTE. This is a decrease of 2.74 WTE (March’s
usage was 81.68 WTE).
14.05
CSS - 0.86 WTE
D Med - 7.19 WTE
Specialised - 5.16 WTE
Surgical - 20.24 WTE
CAMHS – 6.16WTE
Corporate – 39.34 WTE
Medical Bank and Agency Project
47.55
A project has recently started to support the role out of a centralised
medical bank as well as focussing on tackling medical agency spend and
reviewing the procurement of external medical locum agency.
38.40
A&C
Reg
Non Reg
The project is on track to deliver projected savings of £107,546.00 in
2014/15. Updates will be provided in future reports.
18
PDR - AFC Staff
Staff Group - Table 1
Add Prof Scientific &
Technical
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14 Apr-14
84.97%
87.82%
86.43%
83.50%
87.24%
86.67%
Nov
Table 2
Dec
Jan
Feb
Mar
Apr
BCH
85.35%
84.03% 85.23% 84.29% 83.10% 80.75%
Clinical Support Services
85.51%
85.68% 87.23% 87.71% 88.68% 86.25%
Medical Directorate
89.72%
86.15% 87.34% 87.18% 84.78% 79.25%
Specialised Services
81.72%
81.16% 81.79% 80.40% 80.80% 79.07%
Surgical Directorate
87.21%
85.54% 91.09% 89.47% 90.54% 88.01%
Additional Clinical
Services
87.46%
85.05%
88.89%
89.49%
87.17%
83.39%
Admin & Clerical
80.37%
76.77%
77.96%
77.22%
76.60%
75.18%
AHP's
86.67%
85.05%
87.76%
87.96%
89.09%
88.39%
Estates & Anciliary
87.40%
88.28%
89.92%
90.40%
88.28%
85.61%
Healthcare Scientists
84.96%
83.64%
83.78%
83.04%
73.60%
73.17%
CAMHS Services
92.12%
92.34% 92.86% 90.59% 85.43% 85.94%
Nursing
87.09%
86.33%
87.50%
85.76%
84.48%
81.30%
Corporate
79.71%
78.52% 76.80% 75.29% 74.19% 71.30%
Table 1 shows via staff group the Appraisal compliance. Compared to last
months report all staff groups PDR’s have decreased slightly.
Directorate Plans to target PDR %
Medical - Directorate management have been alerted and they are going to
be writing to each department manager to find out when PDR’s are planned.
Specialised - At DMT all Managers have discussed their action plans to
increase the PDR rates within their ward/area. All new Line Managers are
going through PDR training to ensure they understand the importance of
PDR compliance, and the focus on the quality of the conversation.
CAMHS - A PDR strategy was discussed at the last quarterly performance
review and they have agreed to target areas with less than 75%.
Corporate - Departments are being alerted advising them of their PDR rates
and requesting future PDRs dates are scheduled and inputted onto ESR once
completed.
This table shows the PDR %. Each months totals is for PDR’s that have taken place and
recorded on ESR during the last 12 months, so for March the PDR period is May 13 to
April 14.
The data in table 2 shows overall the Trust PDR rate continues to decrease
and has done so since January, however it still remains above 80%.
All directorates have seen a decrease in their PDR % during April 14 with
the exception of CAMHS. All directorates are now below the 90% target.
Further work will be done to improve the %.
Alongside the information
shown above future
reports will include
feedback from employees
showing the quality of the
PDR that took place. This
will enable the Trust to
support managers to
undertake more
meaningful PDR’s.
19
Prevent Awareness Workshops
Prevent Awareness 1 hour workshops were launched in Nov 2013 and have been well received. To date we
have trained 969 staff in total and 150 in April.
Workshops are delivered at Induction and Mandatory Training and there is also the option for managers to
request workshop delivery as part of team meetings, away days etc. This is a popular route and the area
where we are seeing lower engagement is in the stand alone workshops.
Referrals
BCH has completed 1 referral to the West Midlands Counter Terrorism Unit to date. This referral is closed
with no action following communications from the Security Partnerships Officer.
Priorities
CAMHS
ED
Burns
6 Prevent workshops organised between now and June 2014.
Undertaking training through mandatory updates/independent scheduled workshops however
the Prevent Team are working with ED to see if there are other opportunities to deliver
workshops more quickly.
Planning in progress.
Future Developments
• Regional Steering Group report revised WRAP3 programme with new case studies due later in year.
Possibility of eLearning module development.
• Prevent Dashboard tool used to share performance data with commissioners and at Safeguarding
Forums.
• Prevent Lead working with BCH Comms to improve engagement at the stand alone workshops and also
to support dissemination of key information to staff e.g. the latest Syria item in the Daily Bulletin.
Contact
Prevent Lead:
Jan Furniss
prevent@bch.nhs.uk
0121 333 8358
20
Mandatory Training Update
Mandatory training compliance is currently 81.56%. This represents a 3.05% increase compared to the average for mandatory training taken at the end of Dec 2013
which in terms of the Trust KPI is 13.4% below the target of 95% . The table below identifies the compliance statistics for all mandatory topics between Dec 2013 and
May 2014 (source Vesper 6/5/14).
Reporting suggests that there has been pockets of low staff engagement in the last 3 months (72% attendance at the last 4 mandatory training sessions) . Three
mandatory training sessions were also cancelled due to very low numbers. Non attendances (DNA’s) are a feature however the planned introduction of DNA
reporting and a booking reminder system should support improvement.
Education and Learning offer face to face sessions and 66% of topics are available via Moodle online training however to support the challenges around release of
staff, Education and Learning are looking at utilising “Training Boards” in areas as another option for staff to access training. This has proved successful in other
Trusts and is in the early stages of review.
Issues and Risks
• Staff engagement – low
numbers
• DNA rates result in underutilised
training places – DNA reporting
and escalation planned
Exclusions not set correctly for
some topics – Training leads to
validate exclusion list
• Top 3 staff groups with low
compliance – Nursing, Medical
and Additional Clinical Services
Completed Actions:
• Blood exclusion rules amended and implemented (28/4/14)
• Exclusions review requested with CP Team (CP L2 and CP L3).
• Ongoing development of Ed Reporting systems – 21 day Education Reporting response working well.
• Review training plans and course content with Trainers – M&H and CP currently planning changes
using Moodle.
• “Hot Topics” page in development to post late availability training places to managers/staff
• “Email Checker” – developed to correct email anomalies and gaps to ensure reminders reach staff
Future Plans:
•
•
•
•
•
•
Continue exclusion rule amends across all topics
Booking reminder service pilot
Ongoing development of reporting e.g. DNA’s
Moodle update (15th May) to make courses/resources
available on mobile devices
Implementation of “Hot Topics”
Implementation of “Email Checker”
21
5. Financial Performance
22
Financial Performance Summary
FINANCIAL PERFORMANCE REPORT
Monitor Risk Assessment Framework
Criteria
Financial Performance
Plan
Actual
Capital Service Capacity
4
4
Liquidity
4
4
Status
Direction
Issue
of Travel
Income and Expenditure


ramew ork seeks assurance regarding w hether the Trust is a going concern.
Plan
£'000
Actual
£'000
Variance
£'000
758
527
-231
46,419
44,027
-2,391
Capital Programme
337
700
363
CIP
512
473
-40
Cash Balance
Status
Direction of
Travel




Incom e and Expenditure
(M o nito r assesses financial risk o n a scale fro m 1(high risk) to 4 (no evident co ncerns)
The Trust is reporting a below plan position in Month 1. The key cause of this is a shortfall in clinical
Foundation Trust Requirements
Issue
Measure
Plan
Actual
Private Patient Cap
Not to exceed 49%
0.4%
0.1%
Status
Direction
of Travel

income. Bed pressures and subsequent cancelled operations plus the impact of Easter are the primary
causes of this.
Cash Balance
At the end of April cash balance w as 5% below plan.
Capital Program m e
The Trust performing ahead of plan in Month 1 due to greater levels of expenditure being incurred on
schemes carried forw ard from the previous financial year.
CIP
Performance in April w as 8% below plan.
23
Update on 2013/14
Annual Accounts Update
Deloitte has been on site for 3 weeks. The Closure meeting took place on May 19 with Audit Committee due to
ratify the Accounts on May 23. The Board will then sign off the Accounts on May 29 with submission to Monitor by
May 30.
Overall the audit has been positive with outcomes much improved on previous years.
As per previous years an area of key focus has been the analysis and assessment of all provisions and a detailed
review of deferred income.
The likelihood is that the reported Group surplus will remain at £8.1m.
This final point is important as this ensures that no costs previously charged against 2013/14 will need to be
charged against 2014/15.
24
Income and Expenditure against Plan
The Trust has commenced the year reporting a £0.2m
deficit against plan.
EBITDA
2013/14 I&E to April 2014
Headlines are:
• The Trust is reporting a deficit against Clinical
Income;
• The key issue is the financial impact of cancelled
operations, long stay patients and the associated
causes of these;
• Shortfalls in other parts of the plan are being
reviewed although a recurring theme of these is one
of timing and phasing. This is expected at this stage
of the year;
• As Directorates’ budgets and their phasing are being
finalised no reporting by Directorate has been
included this month. This will commence in Month 2;
• At this stage of the year the Trust remains confident
that the planned surplus of £4.377m will be
achieved.
Income from activities
Other Income
Operating Expenses
EBITDA
Interest Receivable
Depreciation
Profit/(Loss) on Asset Disposal
Impairment
PDC Dividend
Interest Paid
Net Surplus/(Deficit)
Annual
Revised
YTD Plan
Plan per Annual Plan per LTFM
LTFM
£'000
£'000
£'000
215,914
215,915
18,508
21,747
21,747
1,690
-225,841
-225,841
-18,820
11,820
11,821
1,378
243
243
20
-4,624
-4,624
-385
0
0
0
0
0
0
-2,762
-2,762
-230
-300
-300
-25
4,377
4,378
758
Revised
YTD Plan
£'000
18,508
1,690
-18,820
1,378
20
-385
0
0
-230
-25
758
YTD Actual
£'000
18,028
1,669
-18,549
1,148
-10
-377
0
0
-210
-23
527
Variance
£'000
-481
-21
271
-230
-30
8
0
0
20
2
-231
Productivity metrics will be included within the
Resources Report from Month 2.
25
Profitability against Target
The EBITDA (Earnings Before Interest, Taxation, Depreciation
and Amortisation) Margin has started the year
below target (5.8% compared with 6.8%). In
monetary terms EBITDA was also above the
Monitor Plan, which is the measure of
efficiency used in the Financial Risk Rating
calculation.
EBITDA Margin
8.0%
7.5%
7.0%
6.5%
6.0%
Actual
5.8%
5.5%
Plan for
Year
5.0%
4.5%
4.0%
Apr May Jun
The I&E Surplus Margin has also commenced
ended the year below plan (2.7% compared
with 3.8%) which is reflecting the EBITDA
margin.
Jul
Aug Sep Oct Nov Dec
Jan
Feb Mar
I&E Surplus Margin
5.0%
4.5%
4.0%
3.5%
3.0%
2.5%
2.0%
1.5%
1.0%
0.5%
0.0%
2.7%
Actual
Plan for
Year
Apr May Jun
Jul
Aug Sep
Oct Nov Dec
Jan
Feb Mar
26
CIP
This is the first CIP report for the new year. The overall target reflects the following:
• Directorate targets;
• Trust-wide scheme targets; and
• Residual balance of the underlying legacy position from 2013/14.
Headlines from Month 1 are as follows:
• Overall schemes identified exceed the annual target – this is an improved position compared to 2013/14;
• The majority of schemes have been risk assessed within the Directorate;
• Quality Impact Assessment review process has commenced;
• Corporate is the area which is furthest from target for overall schemes;
• The April performance although under plan is potentially a prudent position as work continues on the
evidencing of savings in some key areas. Where this remains incomplete, no savings have been declared;
• Delivery against schemes in April for Clinical Directorates is on target;
• Phasing throughout the year is back-ended. This will be reviewed prior to Month 2 being reported.
Directorate
CAMHS
Corporate
CSS
Medicine
SSD
Surgery
Trustwide
Totals
Annual Target In Year Identified
£
£
£
£
£
£
£
£
389,526
723,251
666,136
1,324,237
1,390,984
725,583
4,240,000
9,459,716
£
£
£
£
£
£
£
£
388,640
474,724
662,967
1,649,825
1,420,330
740,282
4,241,400
9,578,168
April Plan
£
£
£
£
£
£
£
£
15,799 £
20,478 £
34,372 £
127,631 £
108,858 £
36,191 £
169,167 £
512,496 £
April Actual
15,799
20,121
39,244
105,572
93,618
78,326
120,000
472,680
% Plan To Date
% Annual Target
100%
98%
114%
83%
86%
216%
71%
92%
4%
3%
6%
8%
7%
11%
3%
5%
27
Cash and Capital
The Capital performance in April was ahead of plan.
With the core 2014/15 Capital Programme now due
to be agreed at June’s Finance and Resource
Committee, expenditure to date relates to schemes
carried forward from 2013/14. The impact of these
is higher than anticipated although over the course
of the year this will have a neutral impact upon
cashflow.
2014/15 Cash Position and Rolling Forecast
2014/15 Plan
Mar-16
Jan-16
Feb-16
Dec-15
Oct-15
Nov-15
Sep-15
Jul-15
Aug-15
Jun-15
Apr-15
May-15
Mar-15
Jan-15
Feb-15
Dec-14
Oct-14
Actual
Nov-14
Sep-14
Jul-14
Aug-14
Jun-14
Apr-14
May-14
55,000
50,000
45,000
40,000
35,000
30,000
£k 25,000
20,000
15,000
10,000
5,000
0
Mar-14
Cash is 5% below plan at Month 1. The key reasons
for this is that whilst creditors have been paid as
normal during the month there are certain strands
of income where receipt of April monies has been
delayed. This includes:
• Non-Clinical Income SLAs;
• Health Education England;
• R&D allocations; and
• Smaller Clinical Income categories.
Additionally, capital expenditure was higher than
expected in April.
Although cash is below target the Trust’s Liquidity
remains significantly above the Continuity of
Service threshold of 4.
Rolling Forecast
2014/15 Cumulative Capital Expenditure against Plan and Monitor
Margins
16,000
14,000
12,000
10,000
£k
8,000
6,000
4,000
2,000
Apr
May
14/15 Actual
Jun
Jul
Aug
14/15 85%
Sep
Oct
14/15 115%
Nov
Dec
Jan
Feb
Mar
14/15 Plan - Original
28
Debtors and Creditors
Debtors over 90 days have increased in April in
both percentage and actual terms. The overall level
of debt is such that the top 5 debts reported below
account for 10% of our overall debt.
However, in early May the largest debt was paid,
which with the previous payment of the other key
2012/13 legacy debts has closed this as an issue.
The dialogue with NHSE and the DH has enabled a
positive resolution to this issue.
As a result of the payment of the South Birmingham
and Solihull PCT debts, other issues will be at the
forefront of our overall debt recovery processes.
Discussions on these have will continued as part of
the Annual Accounts Agreement of Balance
exercise.
The Creditors position over 90 days has remained
static in the month.
% Debtors and Creditors over 90 days
18%
16%
14%
12%
10%
8%
6%
4%
2%
0%
Apr May
Jun
Jul
Aug
Debtors>90 days %
Top 5 Debts Over 90 Days Old
Customer
Sep
Oct
Nov
Dec
Creditors>90 days %
30th April 2014
Jan
Feb
Mar
Target
31st March 2014
Age
(Days)
397
Value
(£k)
464
Age
(Days)
367
Value
(£k)
464
Private Patient - MK
1002
139
972
139
Slater & Gordon (UK) LLP
204
136
174
136
367
132
Birmingham Women's Hospital
198
107
168
107
Birmingham Community Healthcare
120
Solihull PCT
South Birmingham PCT
77
923
978
29
Financial summary.
April 2014
The Monitor Financial Risk rating is 4 per plan, with liquidity remaining strong. This 4 is per the Compliance
Framework and the Continuity of Service Risk Rating (CoSRR).
The I&E position is below the Monitor plan and the revised plan at £0.527m.
The EBITDA and Income Surplus margins are 1.0% and 1.1% below plan, respectively.
Clinical Income performance in April was below the Monitor plan and this was the key cause of the shortfall
against the I&E plan.
CIP has started the year more strongly than previous years. This will remain the primary focus throughout
the year. To date the schemes identified exceed the Trust’s total requirement. In April 92% of the YTD plan
was achieved.
Cash balances are below plan in April. The causes of the shortfall are known and being acted upon. Capital in
month 1 performed ahead of plan.
The Forecast position for the Trust remains to achieve the planned surplus of £4.377m, excluding any further
benefit of donated asset income.
30
Board of Directors
Public Meeting
29 May 2014
Item 14.82
Report Title
Author(s)
Enc 08
Report on the Use of the Trust Seal
Simon Crooks, Executive Office Manager
Situation
The Trust’s Standing Orders require that the use of the seal is authorised by the Board of Directors and
entered in the Register of Sealings. The seal is used to execute deeds (e.g. conveyances of land) or where it may
be required by law.
The Company Secretary is Custodian of the Trust Seal.
Background
The seal was used on the following document:
Lease of Premises at Selly Oak Hospital, Raddlebarn Road, Selly Oak, Birmingham for use by the CAMHS
Directorate.
Recommendations
The Board is asked to endorse the use of the Trust seal.