Quality Account 2012/13
GHNHSFT Quality Account 2012/13
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What is a quality account? A Quality Account is an annual report about the quality of services provided by an NHS healthcare organisation. Quality Accounts aim to increase public accountability and drive quality improvements in the NHS. Our Quality Account looks back on how well we have done in the past year at achieving our goals. It also looks forward to the year ahead and defines what our priorities for quality improvements will be and how we expect to achieve and monitor them.
Table of contents Introduction
4
Our Priorities
8
Safety
14
Clinical Effectiveness
24
Patient Experience
36
Statements of assurance
46
Review of Quality Performance
66
Statements from stakeholder organisations
72
Glossary of abbreviations and terms
86
Glossary Symbol This symbol đ&#x;“š indicates a term's inclusion in the glossary on page 84
 01 Introduction We are committed to providing excellent care of the highest quality for all our patients
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GHNHSFT Quality Account 2012/13
GHNHSFT Quality Account 2012/13
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1 INTRODUCTION
Statement from Chief Executive I am pleased to introduce the Gloucestershire Hospitals NHS Foundation Trust Quality Account for 2012/13. This is our fifth Quality Account and I hope that once again, this report will demonstrate our strong commitment to delivering care of the highest quality. The delivery of high quality services has always been at the heart of our organisation and we want people to have complete confidence that our hospitals will provide the best care for all patients. Our vision as an organisation is to provide safe, effective and personalised care, every patient, every time. This vision is underpinned by four strategic objectives:
ÆÆ Safety ÆÆ Clinical effectiveness
ÆÆ Our patients: to improve year on year
the experience of our patients ÆÆ Our business: to ensure our
organisation is stable and viable with resources to deliver its vision ÆÆ Our staff: to further develop a highly
skilled, motivated and engaged workforce which continually strives to improve patient care and the Trust’s performance ÆÆ Our services: to improve year on
year the safety of our organisation for patients, visitors and staff and the outcomes for our patients Our quality framework is based on the three dimensions of quality as described by Lord Darzi’s NHS Next Stage Review (2008):
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ÆÆ Patient experience
2012/13 has been another busy and challenging year for us. Thanks to the determination and focus of our staff, we made significant and essential improvements to our emergency care pathway, employing new staff, improving facilities and by working with partners to reduce the pressure on our staff and services. While we are pleased with our performance in this area, we are not complacent and we know that in order to maintain high quality, safe and effective emergency care we will need to consider our approach to the provision of this service in the coming year. Another key quality improvement in 2012/13 has been in our care for stroke patients. The percentage of patients spending 90% of
1 INTRODUCTION
their inpatient stay on a specialist stroke ward has increased and we are now achieving this target. This is the result of a move of our stroke services onto one site and demonstrates how the careful reorganisation of services can deliver real benefits for patients. I am pleased to report that we have exceeded our targets for several quality improvement priorities in the last 12 months. Our excellent performance in safety programmes to standardise and improve care for patients with sepsis and venous thromboembolism, as well as reduce the incidence of these potentially fatal conditions are making a real and positive difference to clinical outcomes for patients. There are also interesting and challenging times ahead. Like all NHS organisations we face increasing demands on our services; a growing population with an extending lifespan, access to new medicines and rapid advances in technology. We respond to these demands by exploring new and better ways of working, using the creativity of our staff to help us transform the way we deliver services. Innovation is essential for the NHS and there are many examples of our success in this area. During the year ahead we will be progressing one of our most ambitious innovations to date – a digital patient records system called SmartCare which will revolutionise communication in our hospitals. The Francis Report, published in February this year, contains many recommendations which have quality of care at its heart. The best way for us to improve our organisational culture is to ensure patients are at the
centre of everything we do. We will learn from our mistakes and encourage greater involvement of patients and carers in the review of our services, giving us a valuable insight into how well care is delivered. Throughout this report we have shared some positive feedback and comments from patients. However, we know that on occasion we do not get it right and patients’ expectations or our own high standards are not met. When this happens we must learn from what went wrong and understand how we can integrate this learning into on-going and continuous improvement. As a result of the Health and Social Care Act 2012 which came into force on April 1, 2013, the commissioning landscape has also shifted significantly and we look forward to working with our new partner organisations in 2013/14. Maintaining our excellent quality standards will be essential if we are to compete effectively with other qualified providers and our real commitment to success in this area will equip us to deal with any challenges which lie ahead. The pursuit of quality is a constant journey and this account cannot cover everything we have achieved in the past year or hope to achieve in the coming months. I hope however, that this report provides some insight into the work being carried out in our hospitals every day to make sure quality remains our central focus. I can confirm that to the best of my knowledge the information contained in this Quality Account is accurate.
Dr Frank Harsent
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 02 Our Priorities We can improve the quality of our services by working together to reach our goals
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GHNHSFT Quality Account 2012/13
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2  OUR PRIORITIES
Each year our Quality Committee agrees a set of core priorities which help us improve the quality of the care we provide to patients. Some of these priorities are identified because they are important to our regulators đ&#x;“š and/ or commissioners đ&#x;“š. However most are decided following discussions with our Council of Governors, the Gloucestershire Health, Community and Care Overview and Scrutiny Committee (HCCOSC) and Gloucestershire Local Involvement Network (LINk) đ&#x;“š, collectively known as our stakeholders. The following section is divided into three parts, each looking at one of the dimensions of quality: ÆÆ Safety ÆÆ Clinical effectiveness ÆÆ Patient experience
In each of these parts we will examine how well we have performed against the quality priorities and goals we set ourselves for 2012/13. If we have not achieved what we set out to do we explain why and outline how we intend to address these areas for improvement. We also look ahead to the coming year, setting out the priorities and goals for 2013/14, and explain why they were identified as priorities, how we intend to meet them and how we will track our progress.
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This year our priorities include 'pre-qualification criteria' for CQUINs (Commissioning for Quality Innovation payment framework) and we will outline how we aim to achieve each of these within the relevant priority area. The Quality Committee is responsible for monitoring the progress of the organisation against our quality improvement priorities. The committee meets eight times a year and views a series of measures which give us a picture of how well we are doing. This year, for the first time, we have included all the measures viewed by the Quality Committee (see p70–71) in this report to enable greater insight into how quality is assessed. The Quality Committee is a subcommittee of the Board and has clinical and managerial representation from across the Trust. It includes non-executive directors, executive directors, governors, representation from NHS Gloucestershire and during 2013/14 was chaired by Helen Munro, Non-Executive Director. On p12–13 are two tables which clearly list all of our priorities for improving quality in 2012/13 and 2013/14.
2  OUR PRIORITIES
"All staff take great care of patients and nursing care is excellent. All work very hard and everybody moves quickly and purposefully. The excellent team work is indicative of good management. I was very impressed." Patient at Cheltenham General Hospital, January 2013, NHS Choices
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2 OUR PRIORITIES
Priorities for improving quality in 2012 / 13 Priorities
Incomplete from last year
National priority for 2012/13
Issue for
commissioners
/ CQUIN
Issue for HCCOSC
Issue for LINk
Issue for Governors
Poor performance
1. Safety Emergency care pathway
Management of sepsis
ÆÆCatheter induced UTI
ÆÆVTE
ÆÆFalls
NHS Safety Thermometer including; ÆÆPressure sores
2. Clinical Effectiveness Implement all NICE Quality standards
Readmission rates
Dementia Avoidable renal failure
Cardiac output monitoring during surgical procedures
3. Patient Experience Discharge experience
Responsiveness with emphasis on:
ÆÆCommunication about treatment options
Patient experience escalator
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ÆÆPeople with visual and hearing impairment ÆÆHydration and nutrition
GHNHSFT Quality Account 2012/13
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Priorities for improving quality in 2013 / 14 Priorities
Incomplete from last year
National priority for 2013/14
Issue for
commissioners
/ CQUIN
Issue for HCCOSC
Issue for LINk
Issue identified internally
1. Safety Emergency care pathway
NHS Safety Thermometer
VTE assessment
Sepsis six
Medicines management
2. Clinical Effectiveness Readmission rates
Dementia
Cardiac Output Monitoring during surgical procedures (HII)
(PQ)
Acute Kidney Injury
COPD admissions bundle
3 Million Lives (telehealth)
Digital First
Exploitation of IP
Supporting clinical programmes
(PQ)
(PQ)
(PQ)
3. Patient Experience Family and Friends test
Information for carers of people with dementia
Personal care
ÆÆPrivacy and dignity
ÆÆInvolvement in decisions
(PQ)
Improving the discharge process Patient experience escalator
PQ = pre-qualification requirement for CQUINs GHNHSFT Quality Account 2012/13
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Our Priorities: Safety
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How well have we done this year? Improving the management of sepsis
delivered by doctors or nurses within one hour of diagnosis. The targets in 2012/13 were to ensure that 75% of patients with severe sepsis should receive all six elements of the Sepsis Six within one hour of diagnosis in the Emergency Department and in inpatient areas, 50%.
Worldwide, sepsis kills more than 1,400 people every single day. In the UK alone, it is estimated that more than 37,000 people die every year. This means that more people die each year from sepsis than from lung cancer, and from breast and bowel cancer combined.
We are pleased to report that we have performed extremely well (see Fig. 1), making a significant improvement to the quality of care we provide for sepsis patients. The commitment of our clinicians to exceeding our goals has been vital in our continuing success in this area. We have introduced a range of system improvements throughout the year and held a number of education sessions, study days and café-style events to promote and communicate new procedures, reviewed and amended the format of patient documents, and implemented a wide-ranging communications campaign including Sepsis Six screensavers.
Sepsis is a life-threatening condition that arises when the body’s response to an infection injures its own tissues and organs. Sepsis can lead to shock, multiple organ failure and death, especially if not recognised early and treated quickly. Each month our hospitals’ Emergency Department treats between 40 and 50 patients with severe sepsis. During the past two years we have had increasing success in implementing the ‘Sepsis Six’ – a simple set of six tasks which should be
Figure 1: Achievement of Sepsis 6 in Emergency Departments 100 90 80
60 50 40 30 20 10
Data
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
0
Apr-12
% OF TARGET ACHIEVED
70
Target
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Implement the NHS Safety Thermometer
Improve the emergency care pathway
The NHS Safety Thermometer was developed as a survey instrument that allows hospitals to measure the proportion of patients that are ‘harm free’ during their stay. It is based around four key nationallyrecognised indicators of harm to patients:
In May 2012, Monitor, the independent regulator of NHS foundation trusts, announced that it was using its powers of intervention to require us to improve our A&E waiting times. All Emergency Departments must see, treat and admit or discharge 95% of patients within four hours of their arrival. This year, improving the emergency care pathway has been one of our top priorities. The Emergency Care Programme, headed up by Nursing Director Maggie Arnold, aimed to improve the flow of patients from the Emergency Departments through to discharge.
ÆÆ pressure sores ÆÆ falls ÆÆ venous thromboembolism (VTE) đ&#x;“š ÆÆ urinary tract infections in
patients with a catheter These conditions affect more than 200,000 people each year in England alone, leading to avoidable suffering and additional treatment for patients. The ‘harm free’ care programme aims to eliminate these four avoidable conditions through one plan. Our target during 2012/13 was to audit 95% of all inpatients on one day for three consecutive months – approximately 880 patients per day – for these four indicators of harm.
Actions taken by the Emergency Care Programme included: ÆÆ building new consultation and treatment
cubicles in the Emergency Departments (EDs) at Gloucestershire Royal and Cheltenham General Hospitals ÆÆ recruiting more Emergency Nurse
Practitioners who can see, treat, discharge or admit certain groups of patients where appropriate, without the patient seeing a doctor ÆÆ changing the way people are
Thanks to the commitment of our nursing staff, we exceeded our target and we audited 100% of inpatients on the chosen survey days (see Fig. 2). This collection of data has now given us a baseline from which we can set targets to improve and demonstrate the level of ‘harm free’ care we are providing to our patients (see Fig. 3).
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discharged from hospital including earlier and more ward rounds ÆÆ developing a live web page which
shows how long people are currently waiting to be seen at the EDs and Minor Injury Units. This helps people choose where they should go for treatment
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Figure 2: Safety Thermometer audit 100 90 80
% OF COMPLIANCE
70 60 50 40 30 20 10
Mar-13
Dec-12 Dec-12
Mar-13
Nov-12 Nov-12
Feb-13
Oct-12 Oct-12
Feb-13
Sep-12 Sep-12
Jan-13
Aug-12 Aug-12
Jan-13
Jul-12 Jul-12
Jun-12
May-12
Apr-12
0
Full data collection started in July 2012. June 2012 was only CGH.
Figure 3: Harm free care 98 97
% OF HARM FREE CARE
96 95 94 93 92 91 90 89
Jun-12
May-12
Apr-12
88
Full data collection started in July 2012. June 2012 was only CGH.
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ÆÆ reducing unnecessarily long stays in hospital
for patients who are ready to leave hospital ÆÆ further development of Surgical
Assessment Units to assist with patients who are referred to hospital by their GP. This successful programme of work has contributed to good performance against the four hour target and in December 2012 Monitor announced that the Trust was no longer in significant breach of its terms of authorisation. We were able to provide significant evidence that the Trust had addressed Monitor’s concerns. Maintaining this performance has been challenging for us in the last quarter of the year, partly due to an unprecedented number of attendances at our Emergency Departments (see Fig. 4).
Figure 4: Emergency Department 4 hour target 100%
% OF TARGET ACHIEVED
95%
90%
85%
80%
Grand total
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CGH
GRH
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
75%
Target
2  OUR PRIORITIES: SAFETY
"Thank you @gloshospitals Ward 6b for your care & support during my stay, am very grateful for all the hard work you invest in your patients" Twitter, January 2013
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Priorities for the year ahead Improve the emergency care pathway
Improve the management of sepsis
As outlined in the previous chapter, we have made progress this year in achieving the national target to see, treat, admit or discharge 95% of patients within four hours of their arrival at the Emergency Department. This remains a priority for us and in 2013/2014 our focus will move to sustaining this good performance, examining the flow of patients throughout the hospital and looking at how we can reduce the amount of time patients stay in hospital once they are clinically fit to leave. Following a public consultation in the early part of 2013, we expect to be making changes to the provision of emergency care to ensure that the sickest patients are seen by skilled specialist staff.
We hope to build on our success in the past year by continuing to work closely with doctors, nurses and other healthcare professionals to review the way patients with sepsis are managed and increase the percentage of patients who receive the Sepsis Six. We will hold regular sessions with clinicians to discuss new ways of encouraging staff to ‘think sepsis’ using the ‘Plan, Do, Study, Act’ (PDSA) methodology đ&#x;“š.
“ We hope to build on our success in the past year by continuing to work closely with doctors, nurses and other healthcare professionals�
One of the ideas arising from a PDSA session, which we aim to trial this year, is the use of a ‘Sepsis Box’ in wards and emergency departments. This would contain appropriate antibiotics and other items required to help make sure the patient can be treated as quickly as possible after diagnosis.
Implement the NHS Safety Thermometer In 2012/13 we successfully set up a data collection process to enable us to audit inpatients, using the thermometer as a ‘temperature check’ for the proportion of harm free care provided for patients. After evaluating the data gathered, it has been agreed the Trust’s safety team will work with nursing staff to focus on reducing the incidence of pressure sores in 2013/14.
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Pressure sores, also known as pressure ulcers, are a type of injury that affects the skin and underlying tissue, caused when the affected area is placed under too much pressure. A hospital patient may be at risk of developing a pressure sore as without intervention, they may lie in the same position for prolonged periods of time. Nationally, around one in 20 people who are admitted to hospital with an acute (sudden) illness will develop a pressure ulcer.
such as PE. This is when a piece of blood clot breaks off into the bloodstream and blocks one of the blood vessels in the lungs.
Pressure sores can be unpleasant and upsetting for patients and are challenging to treat. To help prevent this avoidable harm to our patients, staff use a range of techniques. These include:
During 2012/13 our target was to risk assess 90% of all patients for VTE – every patient, every time. By the end of March 2013 we had exceeded this target and had completed VTE assessments for 95% of all patients.
ÆÆ regularly changing a person’s position
Our target for 2013/14 is to build on this year’s successful performance – ensuring that we stay at or exceed the 95% assessment rate.
ÆÆ using equipment, such as a specially
Each year more than 25,000 people in England die from VTE contracted in hospitals. This is more than the combined total of deaths from breast cancer, AIDS and traffic accidents and more than 25 times the number who die from MRSA.
designed mattress and cushions to protect vulnerable parts of the body. Improve the management of medicines In order to reduce the incidence of pressure sores, we will be working with nursing teams to identify ways to standardise the care across all our wards.
Increase the number of those assessed for venous thromboembolism (VTE) Venous thromboembolism is the collective term for Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE). DVT is a blood clot in one of the deep veins in the body. It can cause pain and swelling and may lead to complications
Medicines management is the term used to describe a system of processes and behaviours that determines how medicines are used by patients and the NHS. Good medicines management means that patients receive better, safer and more convenient care. It leads to better use of time and enables practitioners to use their skills where they are needed the most. Nationally the NHS spends billions on medicines every year so effective management of the use of medicines also means these funds can be spent on providing the most appropriate treatments.
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Our hospital pharmacists, as experts in medicine, provide advice and support to ensure the safe, evidence-based use of medicines. Working alongside senior clinicians they have produced guidance to aid the correct choice and dose of medication – known as a formulary. To improve the ability of clinicians to access and implement its recommendations, the formulary is now web-based, demonstrating compliance with NICE technology appraisals đ&#x;“š. More importantly, access to the formulary ensures doctors can quickly and simply locate and prescribe clinically and cost-effective technologies and medicines for their patients. In 2012, as part of our ongoing drive to reduce the incidence of healthcare-associated infections and minimise antimicrobial resistance đ&#x;“š, an Antimicrobial Stewardship Programme has been created. Developments have included a smartphone application, called Doctor’s Pocket, to allow doctors fast access to evidence-based antibiotic guidelines at the patient’s bedside.
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"Thank you to @gloshospitals for the care & attention shown to my mother in law #acutecareward Excellent communication to date" Twitter, December 2012
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02
Our Priorities: Clinical Effectiveness
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How well have we done this year? Implement all NICE quality standards NICE quality standards are a concise set of statements designed to drive and measure quality improvements within a particular area of care. The standards are derived from the best available clinical evidence, such as NICE guidance. According to the NHS National Institute for Health and Clinical Excellence, the quality standards should enable:
This year we identified a clinical lead for each of the standards and have put in place a process to assess our ability to measure each of the 24 quality standards. We have made good progress and report regularly to the Quality Committee. 14 of the 24 Standards have been reviewed and assessed, 6 have been partially assessed, 3 required further assessment and one was not applicable to the Trust.
Reduce the incidence of avoidable renal failure (or Acute Kidney Injury)
ÆÆ health and social care professionals
and public health professionals to make decisions about care based on the latest evidence and best practice ÆÆ people receiving health and social care
services, their families and carers and the public to find information about the quality of services and care they should expect from their health and social care provider ÆÆ service providers to quickly and easily
examine the performance of their organisation and assess improvement in standards of care they provide
Acute Kidney Injury (AKI) is a sudden loss of kidney function and is strongly associated with mortality and increased lengths of stay. In a hospital environment there are a number of reasons why a patient may develop an AKI, for example through infection or as a result of dehydration. A number of innovative ideas have helped us significantly reduce the number of patients affected by AKI in our hospitals this year. In particular, a plan to ‘flag’ adverse results from a key blood test indicating a high risk of AKI on the pathology results computer system has been implemented, with excellent results.
ÆÆ commissioners to be confident that
the services they are purchasing are high quality and cost effective and focussed on driving up quality.
By September 2012, we had a target to treat 30% of all patients ‘flagged’ on the pathology system as being at risk of AKI with a ‘care bundle’ đ&#x;“š within 24
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hours. This care bundle prescribes: ÆÆ a review by a senior clinician ÆÆ a fluid balance assessment for the patient
accords with the national guidance estimate of between 20-25% readmissions being avoidable. A number of service developments were identified for targeting funding for post discharge support which could help to prevent future readmissions. See p30 for more details.
ÆÆ a review of medication to ensure drugs
prescribed do not adversely affect kidneys ÆÆ a repeat creatinine test (a blood test
Increase the use of cardiac output monitoring
which measures kidney function) By December 2012 this target increased to 45% and by the end of March 2013 it increased to 60%. By identifying and treating a potential AKI at an early stage we have been able to significantly reduce the incidence of this serious condition and improve the quality of care for these patients (see Fig. 5).
During operations anaesthetists use a variety of equipment to monitor patients to ensure that they are stable and comfortable. Cardiac output monitoring is one of the tools that can be used; it gives information on the blood volume circulating each time the heart beats and allows anaesthetists to give fluids accurately throughout surgery. Having the right level of fluids can help speed up recovery and reduce post-operative complications.
Reduce readmission rates Reducing unnecessary readmissions to hospital is better for patients and better for the NHS. In June 2012 a clinical review was carried out to understand which readmissions are truly avoidable and identify any actions in our hospitals or in the community which could have prevented readmission. The review found that 21% of readmissions within 30 days were avoidable by actions that could have taken place in our trust, primary care or community services within the existing systems and services (see Fig. 6). This value
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In 2012/13 we had a locally agreed target to increase the use of cardiac output monitoring. In order to achieve this, we targeted complex and long procedures that can be higher risk and patients who have risk factors that make them less stable. Our target was to achieve 20% usage of cardiac output monitoring in this defined group of patients by the end of March 2013. Figure 7 on p29 shows that we have made good progress and have exceeded the target.
2 OUR PRIORITIES: CLINICAL EFFECTIVENESS
Figure 5: Compliance with the AKI bundle 90 80
RATIO PER 1000 BEDDAYS
70 60 50 40 30 20 10
Data
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
Apr-12
May-12
0
Target
Figure 6: Total Readmission Activity 7%
4,500
3,500 3,000 4%
2,500
3%
2,000 1,500
2% 1,000 1%
500
0%
Occupied Bed Days
% Re-Admissions
March
February
January
December
November
October
September
August
July
June
May
0 April
RE-ADMISSION RATE %
5%
OCCUPIED BED DAYS (RE-ADMISSIONS)
4,000
6%
Average 2012/13
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Improve diagnosis of dementia
continued priority for us during 2013.
In England today there are an estimated 670,000 people living with dementia. This is expected to double in the next 30 years. In our hospitals, one in four patients may experience cognitive impairment (problems with memory and processing thoughts) and around 180 patients with a diagnosis of dementia are discharged each month. Building on the 2009 publication of a National Dementia Strategy, in March 2012 the Prime Minister’s Dementia Challenge was launched, with the aim of driving improvement in three core areas:
There have been a number of highlights this year. We have:
ÆÆ awareness ÆÆ quality care ÆÆ research
Early diagnosis is vitally important for dementia patients and their carers, as it enables them to understand the condition, access the right treatment to help relieve symptoms and give them time to plan for the future.
ÆÆ trained more than 5,000 members of
staff in dementia care level one and 1,640 members of clinical staff at level 2 ÆÆ held eight dementia champion events,
attended by 100 dementia champions ÆÆ held training sessions for volunteers to
help them support dementia patients ÆÆ further developed an intranet page with
information for staff about dementia and links to relevant patient/carer documents ÆÆ continued to work in partnership
with key organisations, particularly the Gloucestershire Alzheimer’s Society who are members of our internal Dementia Steering Group ÆÆ held a seminar on dementia for
our foundation trust members Improving the diagnosis of dementia in hospital is a core objective for us. During 2012 our dementia strategy focussed on delivering actions to support the assessment of patients who may have dementia, the launch of our best practice clinical pathway and increased awareness of the needs of patients with dementia in hospital. In April we set up a Dementia CQUIN Steering Group to develop and oversee the implementation of actions to help identify patients with symptoms of memory loss, forgetfulness or confusion on admission. This is a
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ÆÆ established a ‘confusion pro forma’
used to assess all patients admitted as an emergency and over the age of 75, for dementia. This is part of the clinical care pathway also launched in 2012 ÆÆ developed and launched a patient/
carer document called 'Tell us about you' to support those who would like to share information with us about their specific health needs.
2 OUR PRIORITIES: CLINICAL EFFECTIVENESS
Figure 7: Rate of Cardiac output monitoring
25%
20%
15%
10%
5%
% receiving cardiac output monitoring
Q4
Q3
Q2
0% Q1
% OF PATIENTS RECEIVING CARDIAC OUTPUT MONITORING
30%
Year end target
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Priorities for the year ahead Reduce readmission rates We are leading on two initiatives to help reduce readmission rates this year. Firstly, we are developing cross-organisational management plans for patients who frequently attend and are readmitted to our hospitals. We have also started a pilot to establish the benefits of making phone calls to a defined group of patients after they have been discharged from our Acute Care Units or specialty wards following admission with respiratory conditions or chest pain. A nurse will ask the patients how they are, following their discharge from hospital, and can advise on medication or any follow-up treatment they may need. We continue to work closely with our commissioners to improve the integration of acute and community care. We will also continue to monitor readmission rates to measure and evaluate the success of these projects.
Improve diagnosis and care for patients with dementia In early 2013 we submitted a joint bid for funding with our community healthcare partners, as part of the NHS Dementia Friendly Care Environment scheme. The scheme is aimed at improving healthcare environments for patients with dementia.
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As a result of feedback from patients, carers and staff including our dementia champions we have proposed several improvements to our hospital ward areas including: ÆÆ establishing an environment which
encourages dementia patients to socialise, away from clinical areas ÆÆ providing an area of quiet, calming space
to support the care and management of patients with delirium, patients who may be experiencing behaviours that challenge and to enhance end of life care ÆÆ providing concise signage, themed bays
and pictograms to help dementia patients find their way around the wards ÆÆ provide artwork for the ward areas to help
dementia patients orientate themselves and stimulate conversation with others. This year we will continue to work with our key partners, including the Gloucestershire Alzheimer’s Society, to identify new ways to support patients and carers. We are committed to listening to and learning from the experience of carers. We are developing a leaflet for carers of people with dementia and will introduce a method of capturing carers' feedback on their experiences. This feedback will then be used to further develop our dementia services and help inform the
2 OUR PRIORITIES: CLINICAL EFFECTIVENESS
content of our staff training programme. Throughout 2012 our dementia training and champion development programmes have reflected what we've learned to date from listening to patient and carer experience and we will build on this during 2013.
" Our dementia training and champion development programmes have reflected what we've learned to date from listening to patient and carer experience."
Increase the use of cardiac output monitoring during surgical procedures The use of this technology will continue to be a priority in 2013/14 and will appear within national guidelines. We plan to expand the use of cardiac output monitoring to a wider group of procedures and patients than the group identified in 2012/13 (see p29). We have already increased our training in the use of cardiac output monitoring technology and will increase the number and variety of machines we have available for use.
Reduce the incidence of avoidable renal failure (Acute Kidney Injury) Our ambition this year is to increase further the percentage of at risk patients receiving the AKI ‘care bundle’ (see p25–26 for more details). In particular the safety team will be working with clinical staff to improve consistency across all wards in fluid management. Fluid management is important because it allows healthcare staff to monitor the hydration of a patient and ensure they do not become dehydrated. Improve care for patients with Chronic Obstructive Pulmonary Disease (COPD) Chronic Obstructive Pulmonary Disease (COPD) is the name for a collection of lung diseases including chronic bronchitis, emphysema and chronic obstructive airways disease. People with COPD have difficulties breathing, primarily due to the narrowing of their airways. COPD is one of the most common respiratory diseases in the UK, affecting more than 3 million people nationwide. Patients with COPD often attend hospital regularly, so it is acknowledged that standardising and improving the way that they are treated will benefit both the patient’s experience and reduce pressure on services. The British Thoracic Society, in partnership with NHS Improvement, have used the ‘care bundle’ approach to propose a new method of treating and caring for patients with COPD. When implemented they expect
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2 OUR PRIORITIES: CLINICAL EFFECTIVENESS
the following benefits to be realised: ÆÆ creation of a multidisciplinary
team confident in quality improvement methodologies
from April 1, 2013 all trusts must comply with a number of ‘high impact interventions’ in order to qualify for CQUIN payments (see p57 to find out more about CQUINs). In the category of Clinical Effectiveness, these criteria are:
ÆÆ an improved experience of care for
patients admitted with COPD and community acquired pneumonia (CAP)
Cardiac output monitoring See pages 26 and 29.
ÆÆ a shorter length of stay, reduced mortality
and reduced re-admission rates for patients admitted with COPD and CAP. Care bundles are a simple way of focusing improvement efforts on a set of actions which help achieve a specific aim. In the coming year we will be implementing this care bundle.
Supporting clinical programmes Our commissioners for 2013/14, the Gloucestershire Clinical Commissioning Group, intend to adopt the clinical programme approach to commissioning which enables them to consider service development related to clinical pathways of care. This CQUIN relates to clinicians within the hospitals trust playing a full part in these clinical programme groups.
3 Million Lives The Department of Health (DH) believes that, nationally, at least three million people with long term conditions and/or social care needs could benefit from the use of what is known as ‘telehealth’ and ‘telecare’ services. In Gloucestershire we are currently running schemes in both these areas: ÆÆ Telecare: This provides equipment,
such as smoke, fire and falls alarms, to enable vulnerable people to remain living independently. Jointly run by Gloucestershire Care Services and Gloucestershire County Council, the service currently supports around 1800 people in the county. ÆÆ Telehealth: Building on the success of
Pre-qualification criteria In its ‘Innovation Health and Wealth, Accelerating Adoption and Diffusion in the NHS’ report, the NHS nationally set out that
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a local ‘specialist’ telehealth service started in 2008 for around 180 patients, Gloucestershire's Clinical Commissioning Group is now working in partnership with Tunstall’s Health to deliver telehealth on a
2 OUR PRIORITIES: CLINICAL EFFECTIVENESS
‘large scale’ for up to 2000 patients with long term conditions. Patients at home take regular readings of their vital signs (eg. blood pressure, temperature) which are then monitored remotely by their healthcare team, usually in the GP practice.
Implement Digital First initiatives Digital First is a term for a Department of Health initiative which aims to reduce unnecessary face-to-face contact between patients and healthcare professionals by incorporating technology, for example phone or email, into these interactions. We have already implemented many of the suggested changes: ÆÆ appointment reminders ÆÆ electronic discharge summaries
teams who might benefit from using telehealth. We plan to pilot its use for children with respiratory illnesses, and adults receiving peritoneal dialysis at home. Another project helping us improve quality through the use of digital technology is SmartCare. This is an exciting project that will enable us to develop and improve the use of clinical information across our hospitals. The SmartCare project will be a major investment in the infrastructure upon which we, and the wider NHS, relies in order to support the provision of safe, consistent and effective care for patients as well as providing real-time information through an Electronic Patient Record for both clinical and business information. SmartCare is a collaborative project for an integrated clinical system with:
ÆÆ remote communication of test results ÆÆ Gloucestershire Hospitals ÆÆ remote secondary care follow-up (in
NHS Foundation Trust
some services eg. pain management) ÆÆ North Devon Healthcare NHS Trust
We know we could do more to improve electronic communications with GPs – both when providing advice and guidance, and sending letters following outpatient appointments. We can also further reduce hospital visits when patients would prefer a ‘virtual’ visit or phone call. Although these schemes are mainly led by partner organisations, there are small groups of patients under the care of our specialist
ÆÆ Yeovil District Hospital NHS
Foundation Trust We are currently in the process of procuring a system and plan to identify a preferred supplier shortly to enable deployment of SmartCare by early 2014. The deployment is expected to take up to two years for full go-live status.
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2  OUR PRIORITIES: CLINICAL EFFECTIVENESS
Establish clear process to enable the exploitation of Intellectual Property (IP) Innovation is about converting knowledge and ideas into a benefit - delivering value by implementing new ideas and doing things differently. Innovation can transform patient outcomes, improve quality and productivity as well as contribute to the wider economic growth of the country. It may relate to services, processes or products. We encourage our staff to bring forward ideas for new products. Each idea is assessed carefully to identify any potentially valuable intellectual property (IP) and opportunities for commercial exploitation. Projects with potential are supported by our innovation leads and specialist advisors. Our Innovation Panel oversees the management of our IP portfolio. The panel is chaired by Non-Executive Director, Clive Lewis. The Intellectual Property Policy offers staff the opportunity to share the benefits of any revenue from commercialisation. In 2013/14 we will continue to contribute to the implementation of the government’s strategy “Innovation, Health and Wealthâ€?, through: raising awareness of the part innovation can play in meeting the challenges of the NHS and the benefits to patients, the NHS, the Trust and its staff ÆÆ drawing attention to the potential IP
value of novel ideas and the importance of protecting the Trust’s IP assets
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ÆÆ encouraging staff to bring their projects
forward for assessment, with the opportunity to have a share in any revenue generated from commercialisation ÆÆ supporting projects, working with
specialist advisors to take forward key projects - in collaboration, where appropriate, with commercial partners ÆÆ working with partners from across
the NHS, academia and industry as members of the emerging Academic Health Science Network đ&#x;“š.
Case Study
Brian and June Hennell Brian has been diagnosed with frontal temporal dementia and aggressive prostate cancer. A dual diagnosis can be challenging, particularly when one of those is dementia, and for Brian and his wife June, difficult decisions have had to be made. Moving to Gloucestershire from London to be near children and grandchildren meant that they had to learn what services were available locally. June says that the radiotherapy team at Cheltenham General Hospital gave Brian 35 daily sessions of radical radiotherapy and involved her and Brian in the decision making throughout the process. She said: “They called us ‘June and Brian Hennell’ instead of just ‘Brian Hennell’ and kept me within easy consultation distance of Brian’s treatment room. My experience within all areas of the NHS has been co-operation and common sense. My attitude
as a carer has always been ‘I can save you time, money, frustration and energy if you involve me and also prevent misinterpretation leading to wrong treatment’. What busy cash-strapped organisation wouldn’t respond to such logic? Gloucestershire Hospitals NHS Foundation Trust has responded. “ June added that in general information regarding the dual elements of Brian’s diagnosis could have been communicated better to her in her key role as carer. However, she said: “Dementia has brought new friends, challenge, stimulation and support and close contact with special grand-children. We focus on what Brian can do, not what he cannot. Brian enjoys socialising with friends, walking his beloved dog Jack and sharing our ‘dementia adventure.’ Brian dictates that dementia and cancer must take their place, not take over his life.”
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2 OUR PRIORITIES: PATIENT EXPERIENCE
02
Our Priorities: Patient Experience
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2  OUR PRIORITIES: PATIENT EXPERIENCE
We place great value in knowing and understanding the experiences of our patients and their carers and relatives. It is those experiences that continue to help us plan and deliver high quality healthcare. To ensure we provide a consistently excellent service we have Patient Experience Groups that drive and support clinical teams to improve. The groups are chaired by the Trust’s Director of Nursing and have a diverse membership including patient/carer representation and Governors. These groups have responsibility for identifying key areas for improvement arising from all patient and carer feedback, assisting with the development of improvement plans and monitoring their implementation.
Key facts: ÆÆ 700-800 complaints are received and
responded to each year. In 2012/13 we received a total of 743 complaints - 0.7% of all Trust activity. The main themes for these complaints were concerning information and communication, medication, test results and discharge, and delayed appointments and cancellations ÆÆ up to 4,000 patients, carers and
staff access the Patient Advice and Liaison Service (PALS) each year ÆÆ up to four National Patient Experience
Surveys are coordinated each year ÆÆ up to 30 locally-developed patient
Both groups report to the Quality Committee, ensuring that issues and developments relating to the experience of our patients remains at the forefront of the committee’s agenda. Those of our members đ&#x;“š and governors đ&#x;“š who are 'service users’ continue to play a vital role in improving the experience of patients and carers. The Foundation Trust Members Involvement Forum contributes significantly, making sure that the views and experiences of patients and carers influence our work. The role played by Gloucestershire LINk during 2012/13 in providing us with further insight into the experiences of patients has been invaluable. We look forward to working with their successor Healthwatch in 2013/14.
experience surveys are supported each year ÆÆ more than 2,271 patients have
been included within our realtime inpatient ward surveys ÆÆ 800 patient and carer information leaflets
are available, 117 have been reviewed and 41 have been created this year ÆÆ more than 300 volunteers work
in our hospitals undertaking a variety of ward, meet and greet and other roles to support staff
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2 OUR PRIORITIES: PATIENT EXPERIENCE
How well have we done this year? Over the past year we have made good progress against many of the priorities set during 2012/13. To help us judge the quality of care provided, we have set out our performance in relation to each individual priority for the past year:
Improving the discharge experience of patients and carers Improving the flow of patients through our hospitals is vital if we are to meet our targets for seeing, treating and admitting or discharging patients within four hours of their arrival at the ‘front door.’ Our business intelligence information system, known as Analyzer, has this year enabled us to track our discharges, including the time of day patients are discharged from our hospitals. Our Length of Stay Steering Group reviews all aspects of the discharge process and how it can be improved. We have launched a 'discharge tool kit' which helps staff plan and communicate a patient's discharge from hospital, and continue to monitor the experience of our patients. A recent unannounced visit by the Care Quality Commission in February 2013 reviewed our discharge processes and we were found to be compliant with their standard.
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Improving communication about treatment options A project took place this year to improve communication between colleagues, between staff and patients and between staff and a patient's family or carer. We know from our own surveys that if patients feel involved in the decisions made about their care and treatment, their experience of our services is often greatly improved.
" We know from our own surveys that if patients feel involved in the decisions made about their care and treatment, their experience of our services is often greatly improved." Over a period of four weeks, key methods of improving communication were trialled on four wards. These methods included nurses introducing themselves to their patients at the beginning of their shift, checking patients have understood the information given to them, having patient information leaflets available on the most common procedures or conditions. In addition, the
2 OUR PRIORITIES: PATIENT EXPERIENCE
project also trialled the use of a protected period of time set aside for staff to update family members or carers on their patient’s condition or arrangements for discharge.
Improving the experience of those with visual and hearing impairment We have continued to work with patients and improved our collaboration with Gloucester Deaf Association (GDA) and the Gloucestershire County Association for the Blind (GCAB). We have set up a project group with a remit of enhancing communication and accessibility for people with hearing or visual impairment - from the beginning of an outpatient's journey in reception, to the waiting room and consultation. As a result, reception staff now ask if a patient has a visual or hearing impairment at the point of arrival. Stickers which indicate the impairment are then put onto the patient’s documentation, allowing staff to adjust their methods of communicating when calling a patient for an appointment or during consultation. We have also developed and put up posters in all outpatient reception areas which provide information about sensory impairment and how we can help. As a result of feedback from patients a project to re-design and develop new signage to aid navigation around our hospitals is underway. Developed in accordance with the relevant guidelines, the signs are then presented to GCAB for feedback and
any amendments or suggestions acted upon. The project is being led by patient representatives and as a result, the new signage has been developed by looking at the hospital site through the eyes of a patient.
Improving the hydration and nutrition of patients Getting the basics right, making sure our patients are well nourished and adequately hydrated while in our hospitals, is vitally important if we are to provide good quality healthcare. The consequences of poor nutrition and hydration are well documented and include an increased risk of infection, delayed wound healing, decreased muscle strength, constipation, depression and in extreme cases, premature death. Certain groups of patients are more vulnerable to dehydration and malnutrition as they may be unable to or have difficulty in feeding or drinking without assistance. To help encourage patients with dementia to recognise food and drink close to them and therefore eat and drink more, this year we have been testing the use of specialist coloured crockery and glasses. The results of this project are now being evaluated and a plan for implementation developed. Specific improvement projects involving the recognition and treatment of patients with acute kidney disease, which is closely associated with dehydration, have been
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2 OUR PRIORITIES: PATIENT EXPERIENCE
successfully implemented this year (see p25). Patients who may be at risk of kidney injury are diagnosed at an early stage so staff can make sure they are well hydrated and their care is promptly reviewed by a senior clinician. We are also trialling the use of a hands-free drinks system, known as the ‘Hydrant’ on our wards. The Hydrant is a bottle attached to the patient’s bed designed to give patients access to fluids at all times without have to reach for or hold a drink. Its design also enables staff to accurately measure how much fluid the patient has consumed. This national study will be completed next year. Visit www. hydrateforhealth.co.uk for more information.
positive feedback as well as comments or concerns about their personal experiences.
The patient experience escalator
In order to improve methods of providing feedback from our younger patients and their carers, we designed and developed a ‘Your experience counts’ comment card which can be found in the children’s outpatients departments and on the wards.
Responding to patient and carer feedback Our priority in 2012/13 was to focus on creating opportunities for our patients and carers to share their views. Without feedback we cannot know what people think about the services they have received or expect to receive. During the year we have developed an online feedback form through our website. All feedback is used to either praise staff for the excellent care or service they have provided, or used to make improvements where needed. Our online feedback page ‘how are we doing?’ has been developed and given a prominent position on the home page. This is used by patients and carers to share
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We have also developed a new web page which demonstrates how we have responded to the feedback and ideas received – called ‘What you said and what we did.’ This page is also linked to the websites of our partner organisations such as Carers Gloucestershire. In partnership with these carer and patient support organisations, we worked to increase awareness of how to raise a concern or make a complaint. We have also linked our feedback form to partner organisations’ websites.
Promoting shared decision making Working in partnership with the Patients Association and with the support of volunteers we have established an “Observation of Care” tool which is used to identify the experiences of patients who do not have a voice due to their illness. This may be as a result of dementia or another cognitive impairment. An ‘observation’ is sitting and watching what happens on a ward, waiting area or an admission unit.
2 OUR PRIORITIES: PATIENT EXPERIENCE
The observational tool provides staff with an opportunity to take dedicated time out to stop, look and listen to what happens to a patient; to understand how day-to-day routines and behaviours may be detrimental to a patient’s well-being. Observers use their senses to see what happens focusing upon the human interactions between staff and patients and then recording how they felt about what they saw and heard. It is a qualitative tool to provide a measure of the quality of interaction between staff, patients and visitors and is designed to develop sensitive communication within a ward or department.
Attitudes of staff and improving leadership
This year we have continued to embed these standards into all of our internal processes, appraisals and training programmes. We already know that the majority of our staff behave in a professional manner but members of staff whose kind and considerate behaviour exemplifies the standard have been recognised and nominated for a Kindness and Respect Award which are made on a monthly basis. There is now a full range of training and development tools for staff and managers who need help to take action to make improvements. New training sessions have been developed which range from ‘Having Difficult Conversations’ to ‘Making a Difference on the Telephone’.
In 2012 we launched the Kindness and Respect Behaviour Standards which clearly define the quality of behaviour and communication our patients, visitors and colleagues should expect from all staff. The standards were put together for staff, by staff with the involvement of patient representatives so that: ÆÆ everyone is clear about what is
acceptable behaviour at work ÆÆ we recognise and reward
positive role models ÆÆ we expect poor behaviour to be addressed
and we all know that action will be taken
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2  OUR PRIORITIES: PATIENT EXPERIENCE
Priorities for the year ahead The Friends and Family test This year, in line with national guidance, we will be carrying out the Friends and Family test. This is a simple question that patients will be asked about the care they have received as an inpatient or in an A&E department. This question is: How likely are you to recommend our ward/A&E to friends and family if they needed similar care or treatment? Patients are encouraged to explain why they gave a particular score, so we can use this insight to improve services in the future. The test aims to encourage patient feedback, show patients that their views and experiences matter to us, improve patient care and let people know where they can get the best care. The results of the test will allow patients and the public to compare healthcare services and clearly identify the best performers as well as those which need to improve. We started to roll out this project in the two Emergency Departments (A&Es) and 39 inpatient wards in April 2013.
the clinical teams, listening to patients, carers and staff to ensure that privacy and dignity is central to the care delivered. We will do this by identifying areas of excellent practice and embedding the practice in all areas. For example we will closely monitor patient and staff communication, making sure patients understand decisions made about their care.
Improve the discharge process We are committed to involving patients and their carers in the process of discharge planning. Patient and carer feedback gathered through our patient experience surveys, and also monitored through the complaints process, has highlighted this as an area in which we need to focus improvements. We will ensure that we fully involve the patient, their carer and family members in the discharge process, we are committed to providing information on who to contact and advice on the purpose of medications and side effects. We will be undertaking a review of our processes and this will involve a countywide engagement event for our Foundation Trust members, governors and partner organisations.
Personal care: Privacy and dignity, involvement in decisions Patient experience escalator Our focus this year will be to further develop the work started on the privacy and dignity agenda. We will do this by working closely with
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Building upon the good foundations achieved from last year's Patient Experience Escalator
2 OUR PRIORITIES: PATIENT EXPERIENCE
CQUIN, we will continue to focus on the five domains. Whilst responding to patient and carer experience we will have greater transparency with results being available on the Trust website. We aim to increase Trust membership among working age men and women, who are a hard-to-reach group. Our Foundation Trust members events will have a focus this year on issues such as Organ Donation and Disability Equality. The attitudes of our staff will continue to be celebrated through our Kindness and Respect awards. Within leadership, our Executive Team will undertake visits at night to wards and departments to engage with staff and patients.
they need in one place. We will learn more about the experiences of carers of patients with dementia, and aim to use their feedback to help inform our training programmes into the future so that staff can truly understand what it is like to care for a patient with dementia.
Pre-qualification criteria In its ‘Innovation Health and Wealth, Accelerating Adoption and Diffusion in the NHS’ report, the NHS nationally set out that from April 1, 2013 all trusts must comply with a number of ‘high impact interventions’ in order to qualify for CQUIN payments (see p57 to find out more about CQUINs). In the category of Patient Experience, this is:
Information for carers of people with dementia Building on our established partnership with the Gloucestershire Alzheimer’s Society we are currently reviewing our written information for dementia patients and their carers, with the aim of providing carers with the information
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Case Studies
A carer's story S-J has a profound multiple learning disability, cerebral palsy, epilepsy and no formal communication. She is an essential wheel chair user and has a PEG, a tube that is placed into a patient’s stomach to feed them. She needs help with all activities of living and is dependent on carers. She needs to have carers with her who are familiar to her for her to feel safe. S-J had been under the care of paediatricians for years, and coming up to age 18 it was decided she should start using adult services. However the transition did not go well and S-J and her carer had a very poor experience the first time they used adult services which resulted in the carer making a complaint. In order to make improvements, the learning disability liaison nurses arranged a meeting with the carer, her social worker, S-J’s mother, staff from children’s services and from adult services (ACUA), the ward sister from the ward she had attended and the learning disability liaison nurse. There was learning on all sides and negotiation and compromise was necessary to reach a workable solution to ensure S-J’s needs and the needs of her carer could be met. In S-J’s case the outcome was that S-J would have a support plan that outlined all her health needs and how they would need to be met in adult care. This included equipment needs and where the equipment would be 44
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found as unlike in child services where the equipment was all on the unit; in adults it wasn’t all on one ward but located on different wards or in the equipment library. There was some equipment that had been available in child services but wasn’t in adult services so equipment was bought in by the Trust. This would not only benefit S-J but would be useful for other patients. In paediatric services S-J had direct access to the children’s in-patient unit, this meant that she did not have to be admitted via the Emergency Department. It was agreed that due to her specific equipment needs, if S-J needed to be admitted then her carer or GP could contact the ACUA ward at Gloucestershire Royal Hospital, prior to admission. Staff at ACUA would refer to the support plan, make sure they had all the equipment that S-J required and then contact S-J’s carer who could then bring S-J straight to ACUA. The only time they would need to go to the ED đ&#x;“š was if it was an emergency and she couldn’t wait at home or if she had a surgical need. So far this system has worked well. S-J’s experience underlined the need for a better transition process and underpinned the Trust’s plan for a transition policy for young people with learning disabilities moving from child to adult services. S-J’s carer agreed to help us produce the policy and reviewed the policy drafts. Her input was invaluable and changes were made at her recommendations.
Involving patients
Learning from feedback
“In October 2010 I had a stroke. I was a relatively fit 51 year-old and to say it came out of the blue would be an understatement. I had to learn to walk and talk again. Throughout my stay in hospital I was involved in my care decisions as were my family.
Our Patient Advice and Liaison Service (known as PALS) received some comments from parents of children who were inpatients in the Children’s Centre at Gloucestershire Royal Hospital regarding their children being moved at short notice.
This took the form of discussions in the ward round by my consultant, and care planning meetings with all disciplines involved in my care – nursing, occupational therapy and physiotherapy.
The parents were concerned and did not understand why their children were moved between beds while on the ward. One of the parents suggested to PALS that if they had been made aware from their child’s admission that there was a chance they may be moved from a single room onto the main ward, then they would have felt prepared should the need arise.
In the early days when my cognitive abilities were compromised my family were kept fully informed of my progress and were able to encourage me to meet the targets. I was not a model patient by any means – frustration got the better of me at times and I went 'missing' a couple of times because being cooped up in the ward was horrible for me. Despite this the staff maintained an entirely professional approach and when I go back as a volunteer everyone says hello and enquires after my progress.” – Tony Goss, stroke patient at GRH.
Our PALS team fed back this suggestion to staff on the ward and as a result, a parent information sheet was developed which is now handed to each parent and child for information. The sheet covers a range of useful information from overnight stay arrangements for parents, to visiting hours and mealtimes. It also explains why children may be moved from a side room to the ward and offers reassurance that providing safe and effective care for the children is always the number one priority.
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 03 Statements of assurance We share information about our services so you can make an informed judgement about the quality of care we provide
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3 STATEMENTS OF ASSURANCE
The following section includes responses to a nationally defined set of statements which will be common across all Quality Accounts. The statements serve to offer assurance that our organisation is: ÆÆ performing to essential standards,
such as securing Care Quality Commission registration ÆÆ measuring our clinical processes and
performance, for example through participation in national audits ÆÆ involved in national projects and
initiatives aimed at improving quality such as recruitment to clinical trials.
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3  STATEMENTS OF ASSURANCE
Information on the Review of Services The purpose of this statement is to ensure we have considered quality of care across all our services. The information reviewed by our Quality Committee is from across all clinical areas. Information at individual service level is considered within our divisional structure and any issues emerging escalated to the Quality Committee.
The Trust has reviewed the data available to us on the quality of care in all of these NHS services. The income generated by the NHS services reviewed in 2012/13 represents 100% of the total income generated from the provision of NHS services by Gloucestershire Hospitals NHS Foundation Trust for 2012/13.
During 2012/13 Gloucestershire Hospitals NHS Foundation Trust provided and/ or subcontracted 42 NHS services. Please see Table 1 for more detail. Table 1: Provided and/or subcontracted services for 2012/13 Acute Care
Neonatal Care
Ambulatory Care
Neurology
Anaesthetic Services
Nuclear Medicine
Audiology (Hearing Services)
Occupational Therapy
Breast Screening
Oncology
Breast Surgery
Ophthalmology
Breast Radiology
Optometry
Cardiology
Oral and Maxillo-facial Surgery
Chemotherapy
Orthoptics
Clinical Haematology
Pathology
Critical Care
Paediatrics
Colorectal Surgery
Palliative Care
Dermatology
Physiotherapy
Diabetes
Radiology
Ear, Nose and Throat
Radiotherapy
Emergency Department
Renal
Endoscopy
Respiratory Medicine
Fertility Services
Rheumatology
Gastroenterology
Stroke
General Old Age Medicine (GOAM)
Trauma & Orthopaedics (T&O)
Gynaecology
Upper Gastro-intestinal Surgery
Gynae-oncology
Urology
Maternity
Vascular Surgery
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3 STATEMENTS OF ASSURANCE
Information on participation in Clinical Audit The purpose of this statement is to demonstrate that we monitor quality in an ongoing, systematic manner. From 1 April 2012 to 31 March 2013, 34 national clinical audits and four national confidential enquiries covered the NHS services that Gloucestershire Hospitals NHS Foundation Trust provides. During that period Gloucestershire Hospitals NHS Foundation Trust participated in 31 (91%) of national clinical audits and four (100%) national confidential enquiries of the national clinical audits and national confidential enquiries in which it was eligible to participate. Of the three audits where the Trust did not participate there were justifiable reasons for non- participation in 1 (please see table on p52–53). The national clinical audits and national confidential enquiries that Gloucestershire Hospitals NHS Foundation Trust was eligible to participate in from 1 April 2011 to 31 March 2012 are listed in the table on p52–53. The national clinical audits and national confidential enquires in which Gloucestershire Hospitals NHS Foundation Trust participated, and for which data collection was completed during 1 April 2012 – 31 March 2013 are listed in the table on p52–53, alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases
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required by the terms of that audit or enquiry or a straight percentage of cases submitted The reports of 21 (100%) national clinical audits/confidential enquiries participated in were reviewed by the provider in 2012 – 2013. Ten reports are still awaited. The actions Gloucestershire Hospitals NHS Foundation Trust intends to take to improve the quality of healthcare provided are summarised in the table on p52–53. The reports of more than 2,000 local clinical audits were reviewed in 2012 2013 and Gloucestershire Hospitals NHS Foundation Trust either has or intends to take the following actions to improve the quality of healthcare provided: ÆÆ the completion of consent forms
has considerably improved since the introduction of the consent audit rolling programme ÆÆ a gynaecology post-operative pain
re-audit indicated considerable improvement. This arose from changes in peri-operative and post-operative administration of various drugs that had been recommended by the previous audit ÆÆ an Oral Maxillo Facial Surgery (OMFS)
audit identified the need to improve the use and reporting of radiographs in OMFS. This is to be implemented
3 STATEMENTS OF ASSURANCE
ÆÆ for vaginal birth after caesarean section
new documentation was developed to ensure the management plan was fully documented Clinical Audit has been an integral part in the Trust’s CQUIN programme for the years 2012/2013, providing evidence information for a number of priority measures such as venous thromboembolism, sepsis, acute kidney injury and the NHS Safety Thermometer. Additionally, clinical audit has also provided information for other national projects eg. the Saving Lives campaign. This high level of participation demonstrates that quality is taken seriously by our organisation and that participation is a requirement for clinical teams and individual clinicians as a means of monitoring and improving their practice.
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Yes
Yes
National Diabetes Audit (NDA) paediatric
Epilepsy 12 (Childhood epilepsy)
Yes
Yes
Yes
Yes
National Cardiac Arrest Audit
Fractured neck of femur (College of Emergency Medicine)
Renal Colic
Adult Critical Care (ICNARC)
Acute Care
Yes
Yes
Did the Trust Participate?
Fever in Children (College of Emergency Medicine)
Children
Neonatal Intensive and Special Care Audit Programme (NNAP)
Peri and Neonatal
Audit title
Between 700-800 admissions annually 100% submitted
30/30 – 100% submitted
30/30 – 100% submitted
60/60 – 100% submitted
63/63 100% submitted
279/279 patients (3210 records) 100% submitted
40/40 100% submitted
487 patients entered between 01/04/12 and 31/12/12. 100% submitted
Number of case submitted / number required
Participation in National Audits
Yes – Quarterly business and mortality meetings
Actions taken as a result of previous BAEM audits include: Development of a local pain policy
2012 report not yet available. Previous BAEM reports reviewed at ED Clinical Governance
The reports provide information on mortality rates, length of stay, etc and provide the Trust with an indication of our performance in relation to other ICUs. The current SMR is around 0.8, meaning that fewer patients die than would be expected according to the model used. Where trends are identified then these allow us to make recommendations about changes to practice. Data is also collected on hospital-acquired infection rates (C.diff, central venous catheter infections, MRSA, ventilator-associated pneumonia) as part of our involvement in the SW IHI program. There has not been a central venous catheter infection since data collection began in 2010. Standards are reviewed against those proposed as quality indicators by the Intensive Care Society (but yet to be published). To date the Trust is compliant with all these.
Actions taken as a result of previous BAEM audits include: Increased use of pain score and appropriate analgesia
Results showed good compliance. As a result of audit there was a review of the ‘Deteriorating Patient’ documentation and the ceiling of treatment was adjusted to minimise inappropriate interventions eg. CPR
2012 report not yet available Previous BAEM reports reviewed at ED Clinical Governance
Yes – Resuscitation committee
Actions taken as a result of the audit include: Appointment of paediatric epilepsy nurse, assessment of emotional and behavioural problems included in junior doctors' training, first seizure care pathway being developed.
Hba1c is slightly better than previous years but still needs improvement. Documenting the care processes has been improved (mainly done by the nurses). The audit has highlighted a need for a dedicated diabetes administrator to input the data and chase up all the appointments and other annual screening processes.
Await 2012 report. 2011 report reviewed at Paediatric Governance Yes – Paediatric clinical governance
Actions taken as a result of previous paediatric BAEM audits include: Advice sheet for patient/carers for feverish children being investigated NICE guidance for feverish children now included in junior doctors induction and in folder in department
The Trust participates via the ‘Badger’ system. This is the database used to record all the NICU activity. The data is used internally for benchmarking against similar units
Actions taken as a result of audit / use of the database
2012 report not yet available Previous British Association of Emergency Medicine (BAEM) reports reviewed at ED Clinical Governance
Yes – Paediatric Governance
Was the report reviewed?
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Yes
Yes
Yes
Adult asthma
National Audit of Dementia
Yes
Ulcerative Colitis and Crohn’s disease (UK IBD audit)
Parkinson Diseased Audit
Yes
No, but
National Pain Audit
Heavy Menstrual Bleeding (HMB)
National Diabetes Audit (NDA) ADULT
Yes
No
BTS (suite) audit
Long term conditions
Yes
NHS Blood and Transplant: potential donor audit
120/120 - 100% submission
Data collection in progress
30/30 – 100% submission
The Trust submitted 20 Crohn’s and 7 cases of UC. This exceeded the minimum requirement. Note; Data collection for IBD 4 has just started and the trust is participating which focuses on the care for the acute colitis patient
73 patients submitted within audit guidelines
This was discussed at Gynaecology governance and the Trust decided not to participate as it has already undertaken two significant audits (involving patient participation) in HMB. This audit would be repeating work already undertaken
All in patients on the snapshot day submitted – 100% submitted
N/A
381/381 – 100% of all auditable deaths
Not applicable The national audit identified a lack of care pathway, lack of recognition of delirium, difficulty in accessing intermediate care. Actions on these have been incorporated into the Trust action plan on dementia.
2012 report not yet available. 2011 report reviewed by Trust, Dementia Programme Managers Board, dementia project group
Review of documentation and changes to existing documentation to ensure more complete review of patients and more consistent information collected
Development of an ‘Acute Colitis Pack’ detailing the agreed pathway for a patient admitted with acute colitis. Action plan developed following the IBD QIP assessment
89% of patients remembered receiving advice on pain management
National Requirements Trust achieved 75% Overall satisfaction rate 83% 30% Amenorrhoea rates 54% 75% Reduction in Menstrual blood flow 81% Less than 2% immediate complication rates 0% In all instances the Trust exceeded the national standard requirements, therefore comparison with the national standards demonstrated that no changes were needed.
The results obtained were as follows:
The following changes were made as a result of the audit: ÆÆIntroduction of hypo boxes onto the wards with regular audits of their use ÆÆIncreased education and training to staff ÆÆDaily (Monday through Friday) ward rounds by diabetes team to key areas at CGH and GRH ÆÆE referral service set up – patients continue to be seen within 12 working hours of referral ÆÆImprovement in the foot service ÆÆLooking at insulin self-administration for inpatients
The trust is now actively participating in the: ÆÆCOPD Admission care bundle ÆÆCOPD Discharge care bundle, ÆÆCommunity Acquired Pneumonia care bundle
None yet published as still in first year of audit
Yes – Regular Parkinson Disease meeting
Yes – Gloucestershire Gastroenterology Group and IBD Quality Improvement Programme
Yes – Pain Team
N/A
2011 report reviewed by Countywide Diabetes Group Await report for 2012/2013
N/A
Yes – Trust Board
In Gloucestershire (as of November 2012) since 1st April 2012 ÆÆ27 individuals had received an organ ÆÆ21 patients had the gift of sight through corneal transplant ÆÆ38% of the population are on the organ donor register ÆÆ4 patients had died on the waiting list ÆÆ83 patients are awaiting a transplant
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Yes
Adult cardiac interventions coronary angioplasty
No
Yes
Acute Stroke SINAP
National sentinel stroke audit
Yes
Yes
National Lung Cancer Audit (NLCA)
National Bowel Cancer Audit Programme (NBOCAP)
Cancer
Renal registry: Renal replacement therapy
Yes
Yes
Heart Failure Audit
Renal Disease
Yes
Myocardial Infarction National Audit Project (MINAP)
Cardiovascular Disease
Yes
Did the Trust Participate?
National Joint Register (NJR) Hip and knee replacements
Elective Procedures
Audit title
2012 Annual report 2011 Annual report in ( ) 389 (225) cases submitted
2012 Annual Report 323 (132%) of patients submitted
100% of renal dialysis and transplant patients registered
Yes by 3CCN
Yes by 3CCN
Yes – Renal Team latest report is 14th annual report
Yes
Yes – At relevant cardiology meetings
A minimum of 20 patient per month; trust compliant with audit requirements
60/60 – 100%
Yes – Shared with regional, network and local colleagues
Yes – Cardiology audit cycle on an annual basis. Monthly Mortality and Morbidity meetings
Yes. Annual report is reviewed at Governance meetings
Was the report reviewed?
100% for patients with ST elevation MI
608/650 – 94% eligible patients
Yes – Trust continues to submit. 100% submission
Number of case submitted / number required
Participation in National Audits
81% (51.5%) case ascertainment 94% (50.8%) data completeness for patients who had major surgery
96% discussed at MDT. Audit work is currently being undertaken relating to small, cell lung
Trust is generally compliant and no changes to practice are required
In the past the audit has led to a review of time spent in a stroke unit and of the availability of therapy resources and a stroke coordinator. It has been a considerable driver for change within the Trust
The Trust does not contribute to SINAP but has contributed to SSNAP (the organisational audit) and will participate in the online SSNAP (which replaces SINAP) data collection in due course.
Ongoing
Emphasis on improving timings of response. Analysis of patients with timings outside set standard. Greater liaison with GWAS
Data on unit and operator specific mortality is generated from data returns to NICOR. From June this year, the NHS Medical Director, Sir Bruce Keogh, requires data to be provided to allow publication of operator specific outcomes (ie. tagged to GMC number and Unit). As in previous years, the clerical and IT support for this work is minimal. It is likely that this will be a factor in any data quality/publications.
Data is entered retrospectively. Action is taken as necessary eg. metal on metal hip replacement
Actions taken as a result of audit / use of the database
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Yes
National Oesophagogastric cancer
Yes
Yes
TARN: Severe Trauma
National falls and bone health
Yes
2011/2012 National Comparative Audit of Use Blood in Adult Medical Patients
Yes
Yes
Yes
Yes
Risk factors – NHS Health Promotion in Hospital
Child Health CHR–UK
NCEPOD
National Elective Surgery PROMS: Hip replacement, Knee replacement, Hernia, Varicose veins
Miscellaneous
Yes
National comparative audit of blood transfusions: Suite of changing topics
Blood transfusion
Yes
National Hip Fracture Database (NHFD)
Trauma
Yes
DAHNO: Head and Neck cancer
Average participation ÆÆGroin hernia 69% ÆÆHip replacement 80% ÆÆKnee replacement 68% ÆÆVaricose vein 39%
Ongoing data collection
Data collection in progress for less than 6 months
100/100 – 100% Submission
100% submission
100% submission
60/60 – 100% submission
Yes – First full year of participating
GRH –100% submissions (727 since April 2011) CGH – 100% submissions (303 patients in 2012)
2012 annual report 534 Cases submitted by 3CCN
2011 annual report 105 cases submitted
Yes By surgical lead to the Division
Await report
Reports Available January 2013. To be reviewed by Hospital Transfusion Committee and Hospital Transfusion team
Yes – Team Divisional and medicine board
N/A
Yes at Clinical governance meeting and NOF strategic meetings
Yes by 3CCN
2012 annual report not yet published. Yes by 3CCC
Actions taken with the division: ÆÆ Monthly monitoring of patient participation and forms returns from wards. ÆÆ Weekly volunteer who visits wards to collect forms. ÆÆ Regular reports by Consultant lead to surgical division
Of the eight standards the trust met five. Non-compliance was assessment of smoking, alcohol and physical activity
Changes will be made as necessary after presentation to HTT and HTC
Changes will be made as necessary after presentation to HTT and HTC
This has resulted in improvement in numbers being assessed for postural BP, vision and in written information being given out. A countywide patient satisfaction questionnaire for the falls clinics is currently being undertaken. All the work on the falls CQUIN will have also had an impact on the care on in-patients.
Not applicable
Trust has participated since 2008. NICE recommends cemented arthroplasties and the data was used from the Hip Fracture data base to support a change in practice at GHNHSFT. GOAM input is needed within 72 hours of admission. Theatre lists were reordered to try to ensure smaller cases are first on the list so there is time for the GOAM team to review. Future work will revolve around length of stay.
As a result the following was agreed ÆÆTo continue to improve data collection ÆÆTo review use of one stop clinics and ways of improving bookings
As a result of the 2011 report: ÆÆ90% had both T and N recorded ÆÆ95.7% of new cases discussed at MDT
3  STATEMENTS OF ASSURANCE
Participation in Clinical Research The inclusion of this statement demonstrates the link between our participation in research and our drive to continuously improve the quality of services.
by the National Institute for Health research, but close to the target of 1200 set by the Western Comprehensive Local Research Network, taking into account variations in the available study portfolio.
The number of patients receiving NHS services provided or subcontracted by Gloucestershire Hospitals NHS Foundation Trust in 2012/13, which were recruited during that period to participate in research approved by an NHS research ethics committee, and included on the National Institute for Health Research (NIHR) Portfolio is currently 667. This figure includes recruitment recorded on the NIHR Internet Portal up to December 2012.
As the Gloucestershire R&D Consortium Delivery Budget is dictated by activity, the reduction in recruited participants is likely to result in a lower allocation of Delivery Funding in 2013/14. This could have consequences for supporting the research delivery infrastructure, so careful local portfolio management will be important in ensuring maximum recruitment opportunities.
This figure is likely to increase over the following months as participants recruited to research studies in the second half of the financial year continue to be reported. If recruitment continues at a similar rate, we can expect a final total for 2012/13 at around 1000 participants. This would be slightly higher than 2011/12 but lower than the final total for 2010/11. This is mainly due to the loss of a number of high recruiting studies in the last couple of years. Three of these studies recruited 1133 participants between them, accounting for 53% of the total recruitment in 2010/11. Without those studies, the recruitment for 2012/12 will inevitably be lower than the expected year on year increases expected
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During 2012/13, Gloucestershire Hospitals NHS Foundation acted as host to 72 new studies approved from 1st April 2012. Of these studies 44 were adopted to the NIHR Portfolio. In total the trust was contributing/recruiting to around 180 Portfolio Studies over the 12 month period. This is an increase over the 139 Portfolio studies contributed/recruited to in 2011/12. There was a wide range of clinical staff participating in research approved by an NHS Research Ethics Committee during 2012/13. These staff participated in research covering the majority of medical specialties across all four Divisions in Gloucestershire Hospitals NHS Foundation Trust.
3 STATEMENTS OF ASSURANCE
Information on the use of the Commissioning for Quality & Innovation (CQUIN) framework The CQUIN payment framework aims to support the cultural shift towards making quality the organising principle of NHS services by embedding quality at the heart of commissioner-provider discussions. The level of the Trust’s income in 2012/13 which was conditional upon achieving locally agreed quality and innovation goals was £8,395,920 out of a total planned income from our host, associate and specialist commissioners of £384.396m. In line with national rules this represented about 2.5% of income. The CQUIN schemes agreed with NHS Gloucestershire, the rationale behind them and the associated payments for 2012/13 can be seen in Table 1. These include four nationally mandated, five local schemes and three schemes from specialised commissioning. Current indications are that we will be successful in securing the majority of this sum. The main areas of risk are patient experience measures and breast feeding for neonates. It is anticipated that there will be a shortfall of between £500k and £1m. The final figure will not be known until end of year audits have been completed for some schemes.
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3  STATEMENTS OF ASSURANCE
Table 1: 2012/13 CQUIN goals Goal No.
Measure
Weighting as % of contract value
Description
Potential value of goal ÂŁ
Quality domain
National CQUIN goals (including specialised element) 1
VTE
Continuation of nationally mandated goal. Weighting set: Risk assessment 90%. Prophylaxis 90%
0.125
401,250.00
Safety
2
Patient Experience - personal needs
National CQUIN based on the annual inpatient survey
0.125
401,250.00
Patient Experience
3
Dementia
Screening, risk assessment and referral to a specialist for all admissions over the age of 75
0.125
401,250.00
Safety
4
Safety Thermometer
Data collection for all patients in four harm areas: VTE, pressure ulcers, falls, and UTI in patients with catheters
0.125
401,250.00
Safety
Clinical Effectiveness
Local CQUIN goals 5
Cardiac output monitoring
Monitoring technology recommended for patients undergoing major or high risk surgery
0.125
401,250.00
6
Patient experience escalator
Multi - level goal on organisational responsiveness to patient experience
0.375
1,203,750.00
7
Sepsis management
Implementation of the Sepsis 6 care bundle
0.250
802,500.00
Safety
8
Acute kidney injury
Avoidance, detection and management of AKI
0.250
802,500.00
Safety
9
Supporting clinical change programme
Promotion of clinical engagement and system change to deliver the QIPP programme
1.000
3,210,000.00
Contract performance
Patient Experience
Specialised CQUIN goals 10
Quality dashboards
Completion and return of data to support national registries of clinical information
0.250
46,365.00
Clinical Effectiveness
11
Neonatal
Improvement in monitoring of screening for retinopathy of prematurity, catheter infections and fed on breast milk at discharge
1.000
194,733.00
Safety
Renal
To increase the proportion of patients receiving Home dialysis, to encourage the use of Renal Patient View during nephrology outpatient attendance and to actively offer choice of patients with CKD to access RPV
0.750
129,822.00
Safety
2.500
8,395,920.00
12
Summary
The proposed quality incentive goals for 2013/14 are summarised in Table 2. There is a high level of overlap between these goals and the priorities in our Quality Account for 2013/14. This demonstrates the high level of active engagement with our commissioners in quality improvement. It has been confirmed from national guidance that the value of CQUIN schemes in 2013/14 has again been set 58
GHNHSFT Quality Account 2012/13
at 2.5% of total patient care income value. A major change for 2013/14 is the introduction of pre- qualification goals, which have to be achieved in order to qualify for CQUIN payments. These were first promoted in Innovation, Health and Wealth. These schemes are also shown in Table 2.
3 STATEMENTS OF ASSURANCE
Table 2: 2013/14 CQUIN goals Goal No.
Weighting as % of contract value
Potential value of goal £
Quality domain
Measure
Description
–
Compliance with 3 Million Lives
The national programme to roll out telehealth and telecare.
Gateway
Access to CQUIN monies
Clinical Effectiveness
–
Intellectual property and commercialisation
Clear processes in place to exploit commercial intellectual property
Gateway
Access to CQUIN monies
Business development
–
Dementia
Signposting of carers with dementia to relevant services
Gateway
Access to CQUIN monies
Safety
National CQUIN goals (including specialised element) 1
VTE
1. Risk assessment 95% 2. RCA on hospital acquired thrombosis
0.125
tba
Safety
2
Friends and family test
Adult inpatient services and ED from Apr 13. Maternity from Oct 13. Improvement in staff recommendation
0.125
tba
Patient Experience
0.125
tba
Safety
Monthly surveying of all patients to collect data on 3 outcomes:1. Pressure Ulcers 2. Falls 3. UTI in patients with catheters. Indicators for GHT will be:1. Data collection plus 2. Reduction targets
0.125
tba
Safety
All patients aged >75 admitted as emergency: 3
4
Dementia
Safety Thermometer
ÆÆ1. Case finding, assessment & specialist ÆÆ2. Dementia clinical leadership plus staff training (new for 13/14) ÆÆ3. Supporting Carers (new for 13/14)
Local CQUIN goals 5
COPD Admission Care Bundle
Care bundle approach using BTS best practice guidelines for admission COPD patients
0.200
tba
Clinical Effectiveness
6
Patient experience escalator
Multi - level goal on organisational responsiveness to patient experience
0.200
tba
Patient Experience
7
Sepsis management
Implementation of the Sepsis 6 care bundle
0.200
tba
Safety
8
Acute kidney injury
Avoidance, detection and management of AKI
0.200
tba
Safety
9
Medicines Management
Related to antimicrobial stewardship and joint formulary
0.200
tba
Clinical Effectiveness
10
Supporting Clinical Change Programmes
Promotion of clinical engagement and system change to deliver the QIPP programme
1.000
tba
Clinical Effectiveness
Continue from 12/13. Completion and return of data to support national registries of clinical information
0.25%
tba
Clinical Effectiveness
Specialised CQUIN goals 11
Quality dashboards
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3  STATEMENTS OF ASSURANCE
Table 2: 2013/14 CQUIN goals (cont.) Goal No.
Measure
Description
12
Neonatal
Continue from 12/13 Retinopathy of prematurity (ROP) screening.
13
Neonatal
Timely administration of total parenteral nutrition (TPN) in preterm infants.
14
Radiotherapy
15 16
60
Weighting as % of contract value
Quality domain
tba
Safety
0.375%
tba
Clinical Effectiveness/ Patient Satisfaction
Improving the proportion of IMRT with Level 2 imaging IGRT
0.375%
tba
Safety/Clinical effectiveness/ Patient Experience
Renal
Avoidance, detection and management of AKI
0.375%
tba
Safety
Specialised Cancer
Access to and impact of clinical nurse specialist
0.375%
tba
Patient Experience
GHNHSFT Quality Account 2012/13
0.25%
Potential value of goal ÂŁ
3  STATEMENTS OF ASSURANCE
The Care Quality Commission The Care Quality Commission (CQC) is the independent regulator of health and adult social care services in England. From April 2010, all NHS Trusts have been legally obligated to register with the CQC. Registration is the licence to operate and to be registered, providers must, by law, demonstrate compliance with the regulatory requirements of the CQC (Registration) Regulations 2009. Gloucestershire Hospitals NHS Foundation Trust (GHNHSFT) is registered with the CQC without conditions. This means that the Trust has continued to demonstrate compliance with the regulations. The Care Quality Commission has reviewed the Trust twice in the past year. The first review was a responsive review of Cheltenham General Hospital on 12 July 2012 and involved the assessment of seven core standards. The CQC concluded that the Trust met six of the standards fully and had a minor concern involving record keeping. More details on this can be found below and an action plan to address this concern has now been developed. The full report is available on the CQC website www.cqc.org.uk
In summary the CQC at Cheltenham Hospital findings were as follows: Outcome 01: People should be treated with respect, involved in discussions about their care and treatment and able to influence how the service is run. Patient's views and experiences were taken into account in the way the service was provided and delivered in relation to their care. Their privacy, dignity and independence were respected. Outcome 04: People should get safe and appropriate care that meets their needs and supports their rights. Patients’ needs were assessed and care and treatment was planned and delivered in line with their individual care plans in most cases. The provider was meeting this standard Outcome 07: People should be protected from abuse and staff should respect their human rights. Patients who use the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. The provider was meeting this standard. Outcome 09: People should be given the medicines they need when they need them, and in a safe way. Patients were protected against the risks
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3  STATEMENTS OF ASSURANCE
associated with medicines because the provider has appropriate arrangements in place to manage medicines. The provider was meeting this standard. Outcome 13: There should be enough members of staff to keep people safe and meet their health and welfare needs. There was enough qualified, skilled and experienced staff to meet patients’ needs. The provider was meeting this standard. Outcome 16: The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care. The provider had an effective system to regularly assess and monitor the quality of the service that patients receive. The provider was meeting this standard. Outcome 21: People's personal records, including medical records, should be accurate and kept safe and confidential. Patients were not fully protected against the risk of unsafe or inappropriate care and treatment because accurate records were not always kept of the administration of medicines. Staffing level records were incomplete and some care records were inaccurate and had omissions. The provider was not meeting this standard. We judged that this had a minor impact on people using the service and action was needed for this essential standard. The CQC re-visited Cheltenham Hospital on the 18th February 2013 and found the Trust to be fully compliant to this standard.
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In summary the CQC findings at Gloucestershire Royal Hospital on the 5th February 2013 were as follows: Outcome 01: People should be treated with respect, involved in discussions about their care and treatment and able to influence how the service is run. People's privacy, dignity and independence were respected. People's views and experiences were taken into account in the way the service was provided and delivered in relation to their care. Outcome 6: People should get safe and coordinated care when they move between different services. People's health, safety and welfare was protected when more than one provider was involved in their care and treatment, or when they moved between different services. This was because the provider worked in cooperation with others. The Trust continues to receive monthly Quality Risk Profiles from the CQC. The CQC Quality and Risk Profile currently declares no significant risks to compliance with any of the 16 essential standards for quality and safety.
3 STATEMENTS OF ASSURANCE
Quality of Data Good quality data underpins the effective delivery of patient care and is essential if improvements in quality of care are to be made. The patient NHS number is the key identifier for patient records. Accurate recording of the patient’s General Medical Practice Code is essential to enable the transfer of clinical information about a patient from a trust to the patient’s GP.
" Good quality data underpins the effective delivery of patient care"
we have insufficient data to raise a bill (leading to missing income), the NHS number is missing and where we do not hold an ethnic category for a patient. This information is used in national and local data sets to measure equity of access to and take up of our services. Gloucestershire Hospitals NHS Foundation Trust submitted records during 2012/13 to the Secondary Users Service (SUS) for inclusion in the Hospital Episode Statistics which are included in the latest published data. In data published for the period April 2012 to February 2013, the percentage of records which included a valid patient NHS number was: ÆÆ 99.8% for admitted patient care
(national average: 99.0%) ÆÆ 99.8% for outpatient care
(national average: 99.3%) ÆÆ 98.2% for accident and emergency
Gloucestershire Hospitals NHS Foundation Trust will be taking the following action to improve data quality: ÆÆ review existing reports structure
care (national average: 94.9%) The percentage of published data which included the patient’s valid GP practice code was*:
and access methods ÆÆ 99.9% for admitted patient care ÆÆ review usage within the organisation ÆÆ improve existing monitoring reports
which identify areas of concern eg where
(national average: 99.9%) ÆÆ 99.9% for outpatient care
(national average: 99.9%)
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3 STATEMENTS OF ASSURANCE
ÆÆ 100% for accident and emergency
care (national average: 99.7%) A comprehensive suite of data quality reports covering the Trust’s main operational system (PAS) is available and acted upon. These are run on a daily, weekly and monthly basis and most are now available through the Trust’s Business Intelligence system, Analyzer. These include areas such as:-
the intranet setting out responsibilities for data quality. All Trust systems have an identified system manager with data quality as a specified duty for this role. System managers are required under the Clinical and Non- Clinical Systems Management Policy to identify data quality issues, produce data quality reports, escalate data quality issues and monitor that data quality reports are acted upon.
ÆÆ outpatients including attendances,
outcomes, invalid procedures ÆÆ inpatients including missing data such
Information Governance
as NHS numbers, theatre episodes ÆÆ critical care including missing data,
invalid Healthcare Resource Groups. These are derived by a complex algorithm from diagnosis and procedure codes assigned to a patient's stay in hospital plus some simple demographic data (age, sex) to produce a large set of codes which group together treatments with similar resource consumption ÆÆ A&E including missing NHS
numbers, invalid GPs
The Trust’s Information Governance Assessment Report score for 2012/13 remains 77% and is graded green. The Information Governance Toolkit is available on the Connecting for Health website www. igt.connectingforhealth.nhs.uk. The information quality and records management attainment levels assessed within the Information Governance Toolkit provide an overall measure of the quality of data systems, standards and processes within an organisation.
ÆÆ waiting list including duplicate
entries, same day admission On a weekly basis this missing/incorrect data is chased and input/rectified. The Trust Data Quality Policy is published on
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GHNHSFT Quality Account 2012/13
The effectiveness and capacity of these systems is routinely monitored by the Trust's Information Governance Committee and a performance summary is presented to the Trust Board annually in March.
3 STATEMENTS OF ASSURANCE
Clinical Coding Error Rate Clinical coding translates the medical terminology written by clinicians to describe a patient’s diagnosis and treatment into standard, recognised codes. The accuracy of this coding is a fundamental indicator of the accuracy of the patient records. The Trust was subject to an audit of clinical coding accuracy during the reporting period by the Audit Commission under its Payment by Results Data Assurance Framework.
ÆÆ provide further training and re-emphasise
guidance to coders on the need to record mandated co-morbidities, in particular current smoker status. ÆÆ ensure that all procedures, including
scans and secondary procedures such as biopsies, are coded. ÆÆ introduce a process for ensuring
coders check the radiology system to ensure scan codes are not omitted. ÆÆ ensure that the code 251.8 is
The error rates for diagnosis and treatment coding for 2012/13 were: ÆÆ primary diagnosis incorrect 6.0% ÆÆ secondary diagnosis incorrect 14.2%
consistently assigned to denote the Liverpool Care Pathway. ÆÆ keep staffing levels under review to ensure
workload is manageable and consistent with delivering high quality coding.
ÆÆ primary procedures incorrect 2.0% ÆÆ secondary procedures incorrect 9.0%
These error rates have increased in the past 12 months. The net impact of these errors was that we over-charged commissioners by £2,900 on a total bill of more than £100million. The results should not be extrapolated further than the actual sample audited, which in 2012/13 was general abdominal and lobar pneumonia in admitted patient care. We will be taking the following actions to improve data quality:
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 04 Review of Quality Performance Understanding how well we are doing helps us improve for the future
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4 REVIEW OF QUALITY PERFORMANCE
The following section presents information relating to the quality of the services that we provide. The information will outline our performance against National Priorities and Core Standards as well as the measures agreed locally as part of our Quality Account last year.
Overview of Performance against the 2012/13 National Priorities and Core Standards 2009-10
2010-11
2011-12
2012-13
National Target for 2012-13
126
116
92
67
73
6
2
3
2
1
18 week maximum wait from point of referral to treatment (admitted patients)
91.0%
88.9%
89.4%
92.4%
90%
18 week maximum wait from point of referral to treatment (non-admitted patients)
96.3%
97.2%
98.4%
97.8%
95%
Maximum waiting time of four hours in A&E from arrival to admission, transfer or discharge (GHNHSFT only)1
96.2%
94.97%
92.8%
94.7%
95%
99%
99.7%
99.4%
99.7%
96%
Maximum waiting time of 31 days from decision to treat to subsequent treatment: surgery
99.4%
99.8%
100%
99.8%
94%
Maximum waiting time of 31 days from decision to treat to subsequent treatment: drugs
99.7%
100%
100%
100%
98%
N/A
100%
100%
99.9%
94%
Maximum waiting time of 62 days from urgent GP referral to first treatment for all cancers (including rare cancers)
84.1%
85.4%
85%
85.2%
85%
Maximum waiting time of 62 days from urgent referral from national screening programme to first treatment
99.4%
98%
95.5%
94.8%
90%
Maximum waiting time of 62 days from urgent referral from consultant upgrade suspected cancer referrals
91.7%
92.7%
88.6%
98.3%
90%
Maximum waiting time of two weeks from urgent GP referral to first outpatient appointment for all urgent suspected cancer referrals
93.3%
93.6%
92.2%
92%
93%
Maximum waiting time of two weeks from urgent GP referral to first outpatient appointment for patients referred with non cancer breast symptoms
91.9%
90.6%
89%
96.2%
93%
National Priority Clostridium difficile year on year reduction ÆÆPost 48 hrs MRSA bacteraemia at less than half the 2003/4 level ÆÆPost 48hrs
Maximum waiting time of 31 days from decision to treat to first treatment for all cancers
Maximum waiting time of 31 days from decision to treat to subsequent treatment: radiotherapy
1. From 2010/11 this measure changed from countywide to GHNHSFT only.
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4  REVIEW OF QUALITY PERFORMANCE
Performance against selected metrics The following tables show the Trust’s performance for 2012/13 and the last three financial years for a selection of indicators relating to safety, clinical effectiveness and patient experience. We have chosen to include the same indicators as in past years to enable patients and the public to understand performance over time. In addition, we have also chosen this year to present the full range of measures reviewed on a quarterly basis by the Quality Committee. These measures have been chosen because we believe the data from which they are sourced is reliable and they represent the key indicators of safety, clinical effectiveness and patient experience within our organisation.
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4 REVIEW OF QUALITY PERFORMANCE
Performance against selected metrics 2009-10
2010-11
2011-12
2012-13
National Target 2012-13
National average 2012-13
Adverse event rate
61
34.19
17.61
15.58*
-
N/A
Never events
2
2
4
2
0
N/A
Reduce harm from falls (per 1000 bed days)
N/A
1.62
1.59
1.6 †
-
N/A
Reduce errors in medication (per 100 bed days, ward areas only)
N/A
2.26
1.94
2†
-
N/A
Reduce pressure sores
N/A
101
99
76§
-
N/A
Number of patients discharged with Deep Vein Thrombosis (DVT) or Pulmonary Embolus (PE) per 1000 discharges
12.6
14.6
9.0
N/A
-
N/A
Percentage of patients risk assessed for VTE
-
-
94.20%
93.7%
90%
-
Rate of patient safety incidents based on internal database
-
-
10238
10718
-
-
Percentage resulting in severe harm or death (which equates to Serious Untowards Incidents reported with harm or death)
-
-
0.30%
0.26%
-
N/A
Rate of C.diff (per 10,000 bed days cases >2 years)
-
-
3.38
2.25
-
-
Summary Hospital-level Mortality Indicator (SHMI)
-
-
97.4
97.3‡
<100
-
Hand washing compliance
-
-
-
98% #
100%
-
VTE prophylaxsis prescribed (clinical audit)
-
-
-
100%
100%
-
Rate of inpatient falls per 1000 bed days
-
-
-
1.3
-
-
Number of RIDDOR
-
-
-
3.2†
-
-
Rate of staff falls per 1000 head count
-
-
-
1.2†
-
-
Rate of incidents arising from clinical SHARPS per 1000 staff
-
-
-
1.7†
-
-
Rate of incidents of Physical Violence
-
-
-
2.3†
-
-
Central Alert System (CAS) alerts closed within timescale (trust wide)
-
-
-
2†
-
-
Percentage of women seen by midwife by 12 weeks
-
-
-
89.3%
90.0%
-
Measure
Safety Measures
* Rate as of end of January–December 2012 † Data from April–December 2012 ‡ Data from October 2011–September 2012. Tends to be reported nationally as 0.97 now. § Data from July 2012–March 2013 # Data from April 2012–February 2013
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Performance against selected metrics (cont.) 2009-10
2010-11
2011-12
2012-13
National Target 2012-13
National average 2012-13
102.4
95.3
98.8
97.3†
100
-
Number of patients on a stroke ward for 90% of their stay
N/A
N/A
78.5%
80%
-
Emergency readmission rates within 28 days
N/A
N/A
9.89%¥
8.98%‡
7.9%
-
Crude mortality rates
-
-
-
1.4%
<2%
-
Number of ambulance handovers delayed over 20 minutes
-
-
-
4209§
2094
-
Emergency spells year to date within 2.5% of plan
-
-
-
43,291#
44,586
-
Percentage of complaint responses sent within 25 days
91%
97%
98%
95%**
N/A
-
Percentage rating standard of care as excellent or very good
78%
75%
74%
78%
78%
-
Percentage with medicines to take home who had side effects explained to them*
25%
26%
33%
28%
38%
-
ÆÆGroin hernia surgery
N/A
N/A
47.8%
68% ◊
-
-
ÆÆVaricose vein surgery
N/A
N/A
47.4%
51% ◊
-
-
ÆÆHip replacement surgery
N/A
N/A
86.8%
74% ◊
-
-
ÆÆKnee replacement surgery
N/A
N/A
50.2%
74% ◊
-
-
Percentage of staff who would be happy to recommend the standard of treatment provided by the Trust to friends or family needing care
N/A
N/A
51%
54%
-
-
Responsiveness to inpatients' personal needs
N/A
N/A
N/A
68%***
-
-
Research accruals
1897
2154
869
938
-
-
Comparison of median time to complete local governance checks
N/A
N/A
N/A
4.5 days
-
-
Measure
Clinical Effectiveness Measures Hospital Standardised Mortality Ratio
Q3
66.7%
Patient Experience Measures
Patient Reported Outcome Scores for:
* We now work with a new company who prepare a mean rated score. A mean rated score was not used in previous years. The answer ‘yes completely’ therefore should only be used. ** As of the end of March 2013, 597 of 743 complaints have been dealt with in a time frame agreed with the complainant, not necessarily 25 days. *** Percentage that answered positively five questions in the inpatient survey † Source: Dr Foster Health website (overall 1 year HSMR as published on 25 April 2013) ‡ Emergency readmission after an emergency spell § Target 50% reduction on 2011/12 (which was 4187) # Emergency spells actual vs plan April 2012–March 2013 from M12 devolved income report ◊ Indicative participation rates for PROMS for period April 2012–March 2013 ¥ Data for 2011/12 is for readmission rates within 30 days
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â&#x20AC;&#x160;05 Statements from stakeholder organisations Good working relationships with our partners are central to our plans to improve quality
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5 STATEMENTS FROM STAKEHOLDER ORGANISATIONS
Gloucestershire Local Involvement Network (LINk) comments on the Quality Account 2012/13 Gloucestershire LINk welcomes the opportunity to comment on Gloucestershire Hospitals NHS Foundation Trust’s 2013 Quality Account. The following comments have been compiled by a group of LINk members.
General Comments While we appreciate the need for our comments to be on an early draft, the incomplete tables make it impossible for us to comment on the whole document. The presentation of this year’s report is user friendly, and the intention to have the document primarily web based is a good one. The inclusion of pictures of real patients helps bring the document to life. Although there are a number of references to carers as well as patients in the document we think it could be improved by a having a separate section relating to work done by the Trust with carers.
Specific Comments Our Priorities: Priorities for Improving Quality We were particularly pleased to have the opportunity to give you views on the priorities for 2013/14 in January. Taking into consideration the views that we collected from the public, we do not wish to change or add to these priorities. We were pleased to see that there was a clear improvement in the quality of care provided for sepsis patients during the year. This is clearly illustrated in the graphs.
Our Priorities: Priorities for the Year Ahead ÆÆ Improve the Emergency Care Pathway We are aware of the considerable efforts made by a large number of Trust staff to improve the Emergency Care Pathway but we remain concerned that the A&E waiting times are still too high. ÆÆ Implement the NHS Safety Thermometer It would be better if the actual incidence of pressure sores within the Trust, compared with the national incidence was mentioned here.
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5 STATEMENTS FROM STAKEHOLDER ORGANISATIONS
Our Priorities: Clinical Effectiveness
Our Priorities: Patient Experience
ÆÆ Reduce the incidence of avoidable renal failure for Acute Kidney Injury We recognise that the Trust has made considerable progress in identifying potential Acute Kidney Injuries
ÆÆ Improving the discharge experience of patients and carers In spite of considerable efforts by the hospital staff, the discharge experience for both patients and carers is an area which still needs considerable improvement. A number of the problems are not within the control of the trust.
ÆÆ Improve Diagnosis of Dementia Gloucestershire LINk has evidence that the emphasis by the hospital in improving the diagnosis of dementia and the care of patients with dementia is being actually achieved. Improving services for dementia is one of the priorities identified by LINk from the comments they have received as well as from members’ personal experience. An explanation of the use of dementia champions would be helpful.
The Patient Experience Escalator ÆÆ Responding to patient and carer feedback This is an essential priority for the Trust but the details in this Quality Account seem to emphasise improving the ability to make comments for the computer literate and a proportion of the population are not able to make comments in this way.
ÆÆ Reduce readmission rates The integration of acute and community care into a seamless service for patients are one of LINk highest priorities. We will be very interested in the results of this pilot.
Barbara Marshall Chair of Gloucestershire LINk 28 March 2013
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5 STATEMENTS FROM STAKEHOLDER ORGANISATIONS
Health, Community and Care Overview and Scrutiny Committee Comments on the GHNHSFT Quality Account 2012/13 The Health, Community and Care Overview and Scrutiny Committee (HCCOSC) welcome the opportunity to comment on the Gloucestershire Hospitals NHS Foundation Trust’s Quality Account 2012/13. The committee was pleased to note that Monitor has removed the Trust from significant breach relating to its A&E performance, and the associated improvements to the emergency care pathway. However despite this A&E remains a significant challenge for the Trust. The Trust has put forward proposals on changes to the delivery of urgent and emergency care in Gloucestershire which are currently out for consultation. The committee has debated these proposals and given initial feedback to the Trust. It will, however, be up to the new Health and Care Overview and Scrutiny Committee in the new council to receive and debate the outcome report from this consultation and the final change proposals. Managing public expectations is important. The committee was therefore pleased to welcome the Trust’s decision to create a resource on its website which demonstrates waiting times for the emergency departments and minor injury units across the county. Members are pleased to note that this
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page has been shortlisted for the Public Sector Communications Awards 2012. Other challenges for the Trust include how it can rebuild the trust of the general public following the adverse publicity and public reaction relating to the whistle-blower interview with BBC Radio Gloucestershire in January 2013; the result of the latest staff survey undertaken by the Trust also indicates that staff morale is low. The publication of the Francis Report on the care provided by Mid Staffordshire NHS Foundation Trust has also had cause to focus people’s minds on the delivery of care across all Trusts. The committee has been assured by the Chair of the Hospitals Trust that the Board takes these matters seriously and has commissioned activity to address these issues. The committee welcomes this work, and in particular that the Trust will be ensuring that staff are engaged with and help drive this work forward. The committee is clear that the design and delivery of services must be patient focused so it is good to see that this is reflected within this Quality Account. It was also good to hear this message reiterated by the Chair of the Trust at a recent meeting of the committee. The decision, by the Trust, to ensure that
5â&#x20AC;&#x192; STATEMENTS FROM STAKEHOLDER ORGANISATIONS
clinicians lead on service change proposals has made a real difference in helping members of the committee understand the reasons behind the service change proposals. This approach has enabled a clear and robust dialogue between the Trust and the committee. The committee has developed a good professional relationship with the Trust and I hope that this will continue into the new council and the new Health and Care Overview and Scrutiny Committee. I would like to thank Professor Clair Chilvers, Dr Frank Harsent, and Dr Sally Pearson for attending committee meetings and responding to members many questions in a positive and helpful manner. I would also like to thank Dr Sally Pearson for attending the committeeâ&#x20AC;&#x2122;s work planning sessions. Her thoughtful and timely contributions have been of great benefit to the committee.
Cllr Stephen McMillan Chairman HCCOSC
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5 STATEMENTS FROM STAKEHOLDER ORGANISATIONS
Clinical Commissioning Group comments on the GHNHSFT Quality Account 2012/13 Gloucestershire Clinical Commissioning Group (CCG), on behalf of its predecessor NHS Gloucestershire, has taken the opportunity to review the Quality Account prepared by Gloucestershire Hospitals NHS Foundation Trust (GHNHSFT) for 2012/13. We are very pleased that GHNHSFT has been working closely alongside NHS Gloucestershire and the shadow CCG during 2012/13 to maintain and further improve the quality of commissioned services. GHNHSFT has also been co-operative in building new clinical and managerial relationships in preparation for the CCG to take over commissioning responsibility from 1st April 2013. GHNHSFT has been open and transparent regarding challenges and concerns, whilst being supportive of and engaged with the development of initiatives such as the Joint Formulary, Map of Medicine and Your Health, Your Care strategy – our shared vision for the future. They have demonstrated further improvement of the safety, effectiveness and patient experience of services across a wide range of specialties, with particular progress made in the assessment and care of patients with acute kidney injury (AKI) or sepsis. The CCG very much welcome GHNHSFT’s strong focus on patient experience and quality of care, which demonstrates a joint commitment to delivering high quality
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compassionate care. We look forward to developing a whole health and social care community clinical programme approach towards commissioning and delivering services, with a strong emphasis on clinical leadership and engagement. Integrated care will be delivered according to agreed pathways and standards, with strong user and carer involvement being evident from prevention to end of life. There are robust arrangements in place with GHNHSFT to agree, monitor and review the quality of services. The Clinical Quality Review Group continues to meet bi-monthly and brings together GPs, senior clinicians and managers from both GHNHSFT and Gloucestershire CCG. We have received assurance throughout the year from GHNHSFT in relation to key quality issues, both where quality and safety has improved and where it occasionally fell below expectations with remedial plans put in place and learning shared wherever possible. The priorities for 2013/14 have been developed in partnership and Gloucestershire CCG endorse the proposals set out in the Quality Account. Gloucestershire CCG is very pleased with the approach taken by GHNHSFT, which is reflected in the Quality Account, to persist with and reinforce the values of honesty, transparency and effective engagement with stakeholders. Upholding these values ensures that the population of Gloucestershire will
5â&#x20AC;&#x192; STATEMENTS FROM STAKEHOLDER ORGANISATIONS
maintain trust and confidence in these core NHS services. GHNHSFT are in a strong position to manage both present and future challenges, and to work with Gloucestershire CCG to deliver best value effective care for the people of Gloucestershire. Gloucestershire CCG can confirm that we consider that the Quality Account contains accurate information in relation to the quality of services that Gloucestershire Hospitals NHS Foundation Trust provides to the residents of Gloucestershire and beyond.
Dr Charles Buckley
Marion Andrews-Evans
Clinical Commissioning Lead for Quality Gloucestershire Clinical Commissioning Group
Executive Nurse and Quality Lead Gloucestershire Clinical Commissioning Group
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5 STATEMENTS FROM STAKEHOLDER ORGANISATIONS
Independent Auditor’s Report to the Board of Governors on the GHNHSFT Quality Account 2012/13 We have been engaged by the Council of Governors of Gloucestershire Hospitals NHS Foundation Trust to perform an independent assurance engagement in respect of Gloucestershire Hospitals NHS Foundation Trust’s Quality Report for the year ended 31 March 2013 (the “Quality Report”) and certain performance indicators contained therein.
Scope and subject matter The indicators for the year ended 31 March 2013 subject to limited assurance consist of the national priority indicators as mandated by Monitor:
out in the NHS Foundation Trust Annual Reporting Manual issued by Monitor. Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything has come to our attention that causes us to believe that: ÆÆ the Quality Report is not prepared in
all material respects in line with the criteria set out in the NHS Foundation Trust Annual Reporting Manual; ÆÆ the Quality Report is not consistent in
all material respects with the sources specified in paragraph 2.1(2) of Monitor's 2012/13 Detailed Guidance for External Assurance on Quality Reports; and
ÆÆ C. difficile ÆÆ the indicators in the Quality Report ÆÆ Maximum waiting time of 62
days from urgent GP referral to first treatment for all cancers We refer to these national priority indicators collectively as the “indicators”.
Respective responsibilities of the Directors and auditors The Directors are responsible for the content and the preparation of the Quality Report in accordance with the criteria set
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identified as having been the subject of limited assurance in the Quality Report are not reasonably stated in all material respects in accordance with the NHS Foundation Trust Annual Reporting Manual and the six dimensions of data quality set out in the Detailed Guidance for External Assurance on Quality Reports. We read the Quality Report and consider whether it addresses the content requirements of the NHS Foundation Trust Annual Reporting Manual, and consider the implications for our report if we become
5 STATEMENTS FROM STAKEHOLDER ORGANISATIONS
aware of any material omissions. We read the other information contained in the Quality Report and consider whether it is materially inconsistent with:
30/09/2012, 31/10/2012, 30/11/2012, 31/01/2013, 28/02/2013; and ÆÆ The Head of Internal Audit’s annual
opinion over the Trust’s control environment dated May 2013.
ÆÆ Board minutes for the period
April 2012 to May 2013; ÆÆ Papers relating to quality reported
to the Board over the period April 2012 to May 2013;
We consider the implications for our report if we become aware of any apparent misstatements or material inconsistencies with those documents (collectively, the “documents”). Our responsibilities do not extend to any other information.
ÆÆ Feedback from the Commissioners
dated 26/03/2013; ÆÆ Feedback from local Health-watch
organisations dated 28/03/2013; ÆÆ Feedback from Governors
We are in compliance with the applicable independence and competency requirements of the Institute of Chartered Accountants in England and Wales (ICAEW) Code of Ethics. Our team comprised assurance practitioners and relevant subject matter experts.
dated 11/03/2013; ÆÆ The Trust’s complaints report published
under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated 16/04/2012; ÆÆ The 2012 national patient survey
published by the Care Quality Commission in April 2013; ÆÆ The 2012 national staff survey
dated 1/03/2012; ÆÆ Care Quality Commission quality
and risk profiles dated 2/04/2012, 31/05/2012. 30/06/2012, 31/07/2012,
This report, including the conclusion, has been prepared solely for the Council of Governors of Gloucestershire Hospitals NHS Foundation Trust as a body, to assist the Council of Governors in reporting Gloucestershire Hospitals NHS Foundation Trust’s quality agenda, performance and activities. We permit the disclosure of this report within the Annual Report for the year ended 31 March 2013, to enable the Council of Governors to demonstrate they have discharged their governance responsibilities by commissioning an independent assurance report in connection with the indicators.
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5 STATEMENTS FROM STAKEHOLDER ORGANISATIONS
To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the Council of Governors as a body and Gloucestershire Hospitals NHS Foundation Trust for our work or this report save where terms are expressly agreed and with our prior consent in writing.
Assurance work performed We conducted this limited assurance engagement in accordance with International Standard on Assurance Engagements 3000 (Revised) – ‘Assurance Engagements other than Audits or Reviews of Historical Financial Information’ issued by the International Auditing and Assurance Standards Board (‘ISAE 3000’). Our limited assurance procedures included: ÆÆ Evaluating the design and implementation
of the key processes and controls for managing and reporting the indicators. ÆÆ Making enquiries of management.
Reporting Manual to the categories reported in the Quality Report. ÆÆ Reading the documents
A limited assurance engagement is smaller in scope than a reasonable assurance engagement. The nature, timing and extent of procedures for gathering sufficient appropriate evidence are deliberately limited relative to a reasonable assurance engagement.
Limitations Non-financial performance information is subject to more inherent limitations than financial information, given the characteristics of the subject matter and the methods used for determining such information. The absence of a significant body of established practice on which to draw allows for the selection of different but acceptable measurement techniques which can result in materially different measurements and can impact comparability.
ÆÆ Testing key management controls. ÆÆ Analytical procedures ÆÆ Limited testing, on a selective basis, of
the data used to calculate the indicator back to supporting documentation. ÆÆ Comparing the content requirements
of the NHS Foundation Trust Annual
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The precision of different measurement techniques may also vary. Furthermore, the nature and methods used to determine such information, as well as the measurement criteria and the precision thereof, may change over time. It is important to read the Quality Report in the context of the criteria set out in the NHS Foundation Trust Annual Reporting Manual.
5 STATEMENTS FROM STAKEHOLDER ORGANISATIONS
The scope of our assurance work has not included governance over quality or nonmandated indicators which have been determined locally by Gloucestershire Hospitals NHS Foundation Trust.
Conclusion Based on the results of our procedures, nothing has come to our attention that causes us to believe that, for the year ended 31 March 2013: ÆÆ the Quality Report is not prepared in
all material respects in line with the criteria set out in the NHS Foundation Trust Annual Reporting Manual; ÆÆ the Quality Report is not consistent in
all material respects with the sources specified in Monitor's 2012/13 Detailed Guidance for External Assurance on Quality Reports paragraph 2.1(2); and ÆÆ the indicators in the Quality Report
subject to limited assurance have not been reasonably stated in all material respects in accordance with the NHS Foundation Trust Annual Reporting Manual. [Draft copy – audit not complete] Grant Thornton UK LLP Chartered Accountants Hartwell House, 55-61 Victoria Street, Bristol, BS1 6FT Date:
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5 STATEMENTS FROM STAKEHOLDER ORGANISATIONS
Statement of Directors’ Responsibilities in respect of the Quality Account 2012/13 The directors are required under the Health Act 2009, National Health Service (Quality Accounts) Regulations 2010 and National Health Service (Quality Account) Amendment Regulation 2011 to prepare Quality Accounts for each financial year. The Department of Health has issued guidance on the form and content of annual Quality Accounts (which incorporate the above legal requirements). In preparing the Quality Account, directors are required to take steps to satisfy themselves that:
dated 11/03/13 ÆÆ feedback from LINk dated 28/03/2013 ÆÆ the Trust’s complaints report published
under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated 16/04/2012 ÆÆ the 2012 National Patient Survey
published by the Care Quality Commission in April 2013 ÆÆ the 2012 National Staff Survey
dated 01/03/2013 ÆÆ the content of the Quality Account meets
the requirements set out in the NHS Foundation Trust Annual Reporting Manual;
ÆÆ the Head of Internal Audit’s annual
opinion over the Trust’s control environment dated May 2013
ÆÆ the content of the Quality Account is not
inconsistent with internal and external sources of information including; ÆÆ board minutes and papers for the
ÆÆ Care Quality Commission quality and
risk profiles dated 02/04/12, 31/05/12, 30/06/12, 31/07/2012, 30/09/12, 31/10/12, 30/11/2012, 31/01/13, 28/02/13;
period March 2013 to May 2013; ÆÆ the Quality Accounts presents a ÆÆ papers relating to Quality reported
to the Board over the period April 2012 to May 2013;
balanced picture of the Trust’s performance over the period covered; ÆÆ the performance information reported in
ÆÆ feedback from the commissioners
the Quality Account is reliable and accurate;
dated 26/03/2013 ÆÆ there are proper internal controls over ÆÆ feedback from the Governors
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the collection and reporting of the
5 STATEMENTS FROM STAKEHOLDER ORGANISATIONS
measures of performance included in the Quality Account, and these controls are subject to review to confirm that they are working effectively in practice; ÆÆ the data underpinning the measures
of performance reported in the Quality Account is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review; and ÆÆ the Quality Account 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 Account.
The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the Quality Account. By order of the Board
Dr Frank Harsent
Prof Clair Chilvers
Chief Executive Gloucestershire Hospitals NHS Foundation Trust May 2013
Chair Gloucestershire Hospitals NHS Foundation Trust May 2013
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â&#x20AC;&#x160;06
Glossary of abbreviations and terms
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6 GLOSSARY
Academic Health Science Networks
Academic Health Science Networks are new partnerships responsible for driving improvements in patient care by sharing innovations across the NHS. Their creation was announced in December 2011 in the Government’s ‘Innovation, Health and Wealth’ report as a way to align education, clinical research, informatics, innovation, training, education and healthcare delivery at a local level.
Care bundle
A care bundle is a set of clinical interventions that, when used together, significantly improve patient care.
Commissioners
From April 1, 2013, our commissioners will be the Gloucestershire Clinical Commissioning Group. Commissioning is the process of assessing the needs of a local population and putting in place services to meet those needs. Commissioners are those who do this and who agree service level agreements with service providers for a range of services.
Emergency Department
Otherwise known as A&E
Gloucestershire LINk
Gloucestershire’s Local Involvement Network (LINk) is an independent voluntary body made up of individuals, community groups and organisations across the county, who work together to influence, improve or change the way local health and social care services are planned and delivered. This organisation will cease to exist on April 1, 2013 and will be replaced by Healthwatch.
Governors
Members can become more involved by standing for election as a governor and representing their fellow members’ views on the Council of Governors. Governors play an important role in the governance of the Trust. They represent the views of patients, carers and patients.
Members
As an NHS Foundation Trust we are accountable to our local community. This means we give greater say in how we’re run to local people, staff and all those who use our services including patients, their families and carers. Each foundation trust must recruit ‘members’ to reflect these groups and help us ensure that we are providing the best service we can.
NICE technology appraisals
These are recommendations by the National Institute for Clinical Excellence (NICE) on the use of new and existing medicines and treatments within the NHS in England and Wales. Examples include medicines, medical devices, diagnostic techniques, surgical procedures and health promotion activities.
Plan, Do, Study, Act
A method of implementing change by trialling and testing new methodology or working practice on a small scale, before evaluating and deciding whether to progress further.
Regulators
The Care Quality Commission (CQC) regulates all health and adult social care services in England, including those provided by the NHS, local authorities, private companies or voluntary organisations. It also represents the interests of people detained under the Mental Health Act. Monitor is also another regulatory body, responsible for safeguarding choice, protecting and promoting the interests of patients.
Venous thromboembolism (VTE)
This is a disease that includes Deep Vein Thrombosis (DVT) and pulmonary embolism (PE)
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6窶エLOSSARY
GHNHSFT Quality Account 2012/13
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6窶エLOSSARY
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6 GLOSSARY
“My son spent 26 days in the critical care unit and this was the most amazing hospital unit I have ever known. The staff from top to bottom were exceptional and the most caring, professional people I have ever had the fortune to meet. My son has a serious disability and this was so well catered for and did not have any bearing on the way he was treated by all the staff. Some would say that it was a shame we were in [hospital] all through the Olympics, but I would say team GB cannot hold a candle to the team spirit and personal application that I witnessed. I can proudly say I witnessed first-hand team GRH and every one of them deserves a gold medal.” Relative of patient at Gloucestershire Royal Hospital, August 2012, NHS Choices GHNHSFT Quality Account 2012/13
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Our Quality Account forms part of a larger range of Trust documents for 2012/13. To read any of these documents visit www.gloshospitals.nhs.uk
Equality Report 2012/13
Annual Report 2012/13
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