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Our Vision
To provide every patient
with the care we want
for those we love the most
Norfolk and Norwich University Hospitals
NHS Foundation Trust
Quality Report
2014/15
Table of Contents
Part 1 - Chief Executive’s Statement on Quality ............................................................. 5
Information about this Quality Report ........................................................................ 7
Part 2a - Introduction and priorities for improvement ..................................................... 8
Patient Safety Priority 1 – Continuing reduction of medication errors ...................... 10
Patient Safety Priority 2 – 100% appropriate response to an elevated Early Warning
Score (EWS) in all areas of the hospital, including paediatrics ................................ 12
Patient Safety Priority 3: No hospital-acquired, avoidable, grade two, three or four
pressure ulcers ................................................................................................... 14
Patient Safety Priority 4: Review of all emergency patients by senior clinician within
12 hours of admission ......................................................................................... 17
Patient Safety Priority 5: 100% compliance with the sepsis bundle......................... 18
Patient Experience Priority 1 – To improve our score in relation to the Friends and
Family Net Promoter Test question. ..................................................................... 19
Patient Experience Priority 2 – Improving discharge processes ............................... 21
Patient Experience Priority 3 – Extension of inpatient self-administration of medicines
(SAM)................................................................................................................. 24
Clinical Effectiveness Priority 1 - Improving infection prevention, focussing on C. Diff
and surgical site infection (SSI)............................................................................ 25
Clinical Effectiveness Priority 2 - Identifying the critical path for patients with complex
discharge needs .................................................................................................. 29
Clinical Effectiveness Priority 3 - CT scan within 60 minutes of arrival in hospital for
patients with suspected stroke ............................................................................. 30
Looking Forwards - Our 2015/16 priorities for improvement ......................................... 31
Patient Safety Priority 1 – Ongoing reduction in medication errors ......................... 33
Patient Safety Priority 2 – Review of all emergency patients by senior clinician within
12 hours of admission ......................................................................................... 33
Patient Safety Priority 3 – 100% compliance with the sepsis bundle ....................... 34
Patient Safety Priority 4 – Reduce avoidable pressure ulcers .................................. 34
Patient Safety Priority 5 – Reduce numbers of outliers........................................... 35
Patient Experience Priority 1 – Treat patients with dignity and respect ................... 36
Patient Experience Priority 2 – Improve discharge processes ................................. 36
Patient Experience Priority 3 – Improve patient repatriation services for patients
transferred here from other Trusts ....................................................................... 37
Clinical Effectiveness Priority 1 - Improve infection prevention, focussing on C. Diff
and surgical site infection .................................................................................... 38
Clinical Effectiveness Priority 2 – CT scan within 60 minutes of arrival in hospital for
patients with suspected stroke. ............................................................................ 38
Clinical Effectiveness Priority 3 – Ensure urgent radiological investigations requested
on inpatients are performed within 24 hours or earlier if clinical need dictates ........ 39
Part 2b...................................................................................................................... 40
Board Assurance Statements ...................................................................................... 40
Review of services .............................................................................................. 40
Information on participation in national clinical audits and confidential enquiries ..... 41
Participation in research and development ............................................................ 44
Commissioning for Quality and Innovation (CQUIN) .............................................. 46
Care Quality Commission (CQC) reviews ............................................................... 46
Data Quality ....................................................................................................... 47
Information Governance Toolkit Attainment Levels................................................ 47
Clinical Coding error rate ..................................................................................... 48
Performance against the national quality indicators .................................................. 49
a) Summary hospital-level mortality indicator (SHMI) ............................................ 49
b) Coding of palliative care deaths ....................................................................... 49
Hospital Standardised Mortality Ratio (HSMR) ....................................................... 50
Patient reported outcome measure (PROM) scores ................................................ 52
Readmission rates within 28 days ........................................................................ 53
Responsiveness to the personal needs of our patients ........................................... 54
Staff net promoter scores (Staff Friends and Family Test)...................................... 55
Patient Friends and Family Test ........................................................................... 56
Venous thromboembolism (VTE) risk assessments ................................................ 57
Incidence of C. Difficile ........................................................................................ 58
Patient safety incidents ....................................................................................... 59
Part 3 ....................................................................................................................... 61
Other Information...................................................................................................... 61
Performance of Trust against Selected Metrics ......................................................... 61
Patient Safety – Serious Incidents (SIs) ................................................................ 61
Patient Safety – Never events .............................................................................. 62
Patient Safety – Reducing Falls in the Hospital ...................................................... 64
Clinical Effectiveness – Achieving cancer referral and treatment times .................... 66
Clinical Effectiveness – Achieving 18 week waiting times ....................................... 68
Clinical Effectiveness - Performance against Monitor’s Compliance Framework ........ 70
Patient Experience - National Cancer Patient Experience Survey 2014 .................... 71
Patient Experience - CQC Inspection and Intelligent Monitoring ............................. 72
Patient Experience – Meeting Nutritional Needs .................................................... 72
Patient Experience – Dementia Strategy ............................................................... 74
Patient Experience – Patient-Led Assessments of the Care Environment (PLACE) .... 75
Patient Experience – Complaints Handling ............................................................ 75
Staff and Patient Experience - Meeting Equality and Diversity Standards ................ 77
Building a more supportive work environment ...................................................... 79
Innovation in practice.......................................................................................... 80
Awards and Commendations................................................................................ 83
Appendix A - National Clinical Audit – Actions to improve quality .................................. 85
Appendix B - Local Clinical Audit – Actions to improve quality ....................................... 89
Annex 1 - Statements from Clinical Commissioning Boards, Local Healthwatch
organisations and Overview and Scrutinty Committees............................................... 103
Statement from NHS North Norfolk CCG ............................................................. 103
Statement from Norfolk Health Overview and Scrutiny Committee ....................... 105
Statement from Healthwatch Suffolk .................................................................. 105
Statement from Healthwatch Norfolk .................................................................. 105
Statements from Governors ............................................................................... 107
Annex 2 - Statement of Directors’ responsibilities in respect of the Quality Report ....... 110
Annex 3 - Independent Auditor Report ...................................................................... 112
Annex 4 - Mandatory performance indicator definitions .............................................. 118
Glossary of terms .................................................................................................... 124
Part 1 - Chief Executive’s Statement on
Quality
This is our sixth annual Quality
Report and its purpose is to
provide an overview of the
quality of the services we
provided to our patients during
2014/15, and to outline our
priorities and plans for the
forthcoming year.
The NHS has had a difficult
year, and high-profile failures
to meet key performance
targets in the face of
unprecedented levels of
emergency demand have
made national headlines and
given rise to new levels of
scrutiny and oversight. We
have not been immune either
to those pressures or to that
scrutiny but, whilst it is
important to acknowledge the
failures, we must also
remember that there is a great
deal to celebrate and
commend.
In this report we have many successes to celebrate. It is now over 36 months since a
patient last developed MRSA whilst in our care, and the results of our patient and family
test show that, despite unprecedented levels of emergency demand, over 80% of our
inpatients and those attending our Accident & Emergency department would recommend
us as a provider of care. We have achieved significant improvements in our
administration of timely antibiotics to patients with suspected sepsis, and made
considerable progress in ensuring that patients admitted for emergency treatment receive
the prompt care that is essential in identifying and addressing factors that could cause
further clinical deterioration and poor outcomes. These achievements are a huge
testament to the commitment, care and skill of all our staff.
Many other examples of progress, improvement and innovation are included within this
report, and our staff should feel proud of their effort and achievements. Sometimes we
NNUHFT Quality Report 2014/15 – Aiming to EXCEL
Page 5
have fallen short of the ambitious goals that we set for ourselves, and these areas too are
included within the report, alongside our plans to refocus our efforts in 2015/16.
Looking forward to the year ahead, the report sets out what we aspire to achieve in
respect of the priorities identified by our patients, staff and other stakeholders. Our aim
as always is to continue to focus on the essentials of care in order to continue to improve
clinical outcomes and to ensure that our patients have a positive care experience.
We remain, as always, grateful for the ongoing commitment and contribution of patients,
staff, governors and members in supporting our quality improvement activities and
providing the oversight, scrutiny and constructive challenge that are essential to
improving the quality of our services.
The content of this report has been subject to internal review and, where appropriate, to
external verification. I confirm, therefore, that to the best of my knowledge the
information contained within this report reflects a true, accurate and balanced picture of
our performance.
Anna Dugdale, Chief Executive
Information about this
Quality Report
We would like to thank everyone who
contributed to our Quality Report.
To help readers to understand the
report a glossary of abbreviations or
specialised terms is included at the
end of the document. All words in
orange italics are included within the
glossary.
We welcome comments and feedback
on the report; these can be emailed
to communications@nnuh.nhs.uk or
sent in writing to the Communications
Department, Norfolk and Norwich
University Hospitals NHS Foundation
Trust, Norfolk and Norwich Hospital,
Colney Lane, Norwich NR4 7UY.
Further copies of the report are
also available on request from the
addresses above.
The quotes from service users
included within this report are
either taken from the Patient
Opinion website or are extracts
from letters sent to the Chief
Executive. Copies of those letters
are viewable on request from the
Chief Executive’s office.
If the report is required in
braille or alternative
languages, please contact
us and we will do our best
to help.
To request a large print copy, please contact
us by email via the email address
communications@nnuh.nhs.uk or in writing
at the following postal address:
Communications Department,
Norfolk and Norwich University Hospitals
NHS Foundation Trust,
Norfolk and Norwich Hospital,
Colney Lane, Norwich NR4 7UY.
7
Part 2a - Introduction and priorities for
improvement
Part Two of our report begins with a review of our performance during the past twelve
months compared to the key quality targets that we set for ourselves in last year’s quality
report. Where possible, we have included comparative performance data from previous
reporting periods, to enable readers to assess whether our performance is improving or
deteriorating.
The focus then shifts to the forthcoming twelve months, and the report outlines the
priorities that we have set for 2015/16, and the process that we went through to select
this set of priorities.
This is followed by the mandated section of Part 2, which includes Board assurance
statements and supporting information covering areas such as clinical audit, research and
development, Commissioning for Quality and Innovation (CQUIN) and data quality.
Part 2 concludes with a review of our performance against a set of nationally mandated
quality indicators.
“
8
A big thanks to
the doctor and
his team for
taking such
considerate and
professional
care of me
during a recent
day procedure
at the NNUH.
From start to
finish I was so
impressed by
the way the
whole team
dealt with me.
Not wishing to
pay a return
visit but if I had
to I would have
total confidence
in my
treatment.”
Anon July 2014
Progress against our 2014/15 priorities
Detailed action plans and measures were developed for
each of our quality priorities and, throughout the year,
performance has been monitored by the appropriate
Executive Sub-Board and governance committees.
Learning points for issues such as medication
administration, pressure ulcer prevention, and falls
avoidance have been disseminated through our
innovative Organisation Wide Learning (OWL) bulletins,
and examples of these OWLs are included throughout
this report.
In reviewing our progress against our targets, we will
highlight not only those areas where we have done
particularly well, but also those areas where further
improvement is still required.
9
Patien
nt Safety Priority
P
1 – Contin
nuing redu
uction of medicatio
on errors
did we aim
m to do?
What d
To conttinue to imp
prove the sa
afety of med
dicines presscribing and
d administraation.
Improv
vements made
m
in 20
014/15
Over the
e course off a year, ourr staff admiinister almo
ost 5.5 millio
on doses off medication
n.
Whilst tthe number of overall medication
m
eerrors has not
n fallen, only
o
a very ssmall propo
ortion
of these
e error (circca 2%) have
e resulted in
n moderate or serious harm to pattients (28 in
n
2014/15
5 which is comparable
c
with the 24
4 in 2013/14
4 and the 28
2 in 2012/113). This is
against a backdrop
p of rising ad
dmissions ((193,758 in 2012/13 rissing to 210,,428 in 2014/15
- an 8.6
6% increase
e).
MediccationErrors
1500
1000
500
0
2
2012/13
2013/14
20144/15
Med
dicationerrorss
Med
dicationerrorssresultinginppotentialoractualharm(IH
HIcategories EI)
Source: N
NNUH Data, naational definiti
tions applied
To ensu
ure that we learn from every incid ent, we hav
ve a very ro
obust audit programme
e,
which in
ncludes:
x
x
x
Using the audit
a
data on the clinicaal interventions made by
b pharmaccists to high
hlight
prescribing issues for discussion
d
w
within directtorate gove
ernance meeetings
IIdentifying and implem
menting the mes and initiatives through the M
Medicines
Managemen
nt Group
Undertaking
g prescribin
ng audits to give assura
ance on the
e standard oof prescribin
ng.
The su
uccessful bid
d to the NHS
S Technology Fund witth James Paaget Univerrsity
Ho
ospitals NHS
S Foundatio
on Trust (JPUH), combined with innvestment frrom
bo
oth trusts, has
h enabled
d us to jointly purchase
e software tthat will allo
ow
th
he electronicc prescribing
g of medicines, replace
e the writteen drug chart as
a record of medication
m
aadministratio
on, and make the proccess of writiing
E
Discharge
D
Leetter much quicker.
q
an Electronic
E-prescribing provides a legiblle and comp
plete mediccation order, easily shaared by multtiple
ns, allowing reliable acccess to med
dicines inforrmation with
hout havingg to locate a
clinician
single p
paper record
d. The syste
em also provvides vital support
s
to clinical
c
decission-makerss,
providin
ng them witth information on data such as a patient’s
p
kno
own allergiees or potential
drug-drug interactiions, which can help to
o avoid pote
entially harm
mful adversse drug even
nts. A
c
on two NN
NUH wards (Brundall
(
annd Elsing) in
n
successsful three month pilot commenced
Octoberr 2014, and the roll-out will be com
mpleted by the end of July 2015.
10
Our Head of Pharmacy has been the project lead for
the development of a unified acute drug chart,
which will be used in all the hospitals in the region.
Elements of the chart will be used, as appropriate,
in acute, mental health and community settings.
The development of the chart was sponsored
through a grant from the Eastern Academic Health
Science Network (EAHSN), following a joint bid
between four Trusts. We have involved over 15
Trusts throughout EAHSN catchment area and over
1000 staff have contributed to its design.
We have piloted the new chart on two wards at
NNUH and across six other Trusts, and the feedback
from that pilot is being incorporated in the revised
chart that will be rolled-out across all Trusts in the
East of England. The aim of the chart is to improve
safety in the prescribing and administration of
medicines, through improving the continuity and
familiarity that clinicians have with the drug chart
when moving between Trusts.
The Pharmacy Department produces a monthly
Medication Organisation Wide Learning (OWL)
which is sent to staff and made available on our
intranet. Each OWL highlights issues arising from
RCA of the previous month’s medication incidents,
and then the second half focuses in depth on a
specific area of medicines prescribing. They are
therefore an invaluable tool for quickly
disseminating information to staff about key
medication issues.
What we aim to do next
We will continue to encourage a transparent
approach to the reporting of drug errors, and will
continue to share the lessons learned throughout
the entire organisation. We will complete the
implementation of e-prescribing, and we will finalise
the roll out of the unified drug chart across all
Trusts in the East of England.
11
Patient Safety Priority 2 – 100% appropriate response to an elevated
Early Warning Score (EWS) in all areas of the hospital, including
paediatrics
What did we aim to do?
To achieve a 100% appropriate response to an elevated Early Warning Score (EWS) in all
areas of the hospital, including in paediatric services. The score is derived from the
nursing observations of factors such as the patient’s temperature, systolic blood pressure,
pulse and urine output. Any deterioration in one or more of these factors can alert staff to
the patient’s worsening condition, and prompt a review by a senior clinician.
Improvements made in 2014/15
A week long audit was carried out on all adult emergency admissions that took place
between midnight on 27th February 2015 and midnight on 6th March 2015. This showed
that 100% of patients were given an early warning assessment within the first twelve
hours of their admission (often within the first hour as part of admission clerking), and
that this EWS was repeated regularly if there was evidence of a high or deteriorating
EWS.
The following charts show that, whilst we have made progress in improving our
compliance with some elements of the EWS, there has been a marked deterioration of
performance in respect of the repeating of observations in response to an elevated EWS
of 4. Further improvement is therefore required.
Monthly Early Warning Score Trigger Audit Results from
across all ward areas
100%
95%
90%
85%
80%
75%
70%
65%
Jan-15
Dec-14
Nov-14
Oct-14
Sep-14
Aug-14
Jul-14
Jun-14
May-14
Apr-14
Mar-14
Feb-14
Jan-14
Dec-13
Nov-13
Oct-13
Sep-13
Aug-13
Jul-13
Jun-13
May-13
Apr-13
60%
Were observations repeated in response to EWS>=4 (within 1 hour)?
Was there documented intervention /review by RN or request for Dr review for
triggering episode?
Where the RN documented evidence of request for Dr review, is there docume
evidence Dr attended?
Source: NNUH data, national definition used
12
d
to
t all clinicaal
These results are distributed
ear on Nursing Ward
staff and also appe
ards, so performance is
i discussed
d
Dashboa
with sen
nior nursing
g staff and the
t Directorr
of Nursiing. Areas not
n performing well aree
visited b
by the Direcctor of Nurssing and thee
Critical C
Care Outrea
ach Team Lead,
L
to
discuss how improvvements can be made..
Actions undertaken
n
e observatio
on chart hass been
• The
revised and the new call out
o cascadee
hass been imple
emented.
• Info
ormation ha
as been dissseminated
regarding chan
nges throug
gh EWS
Linkks
• Eacch ward hass an EWS re
esults
posster delivere
ed on a mon
nthly basis
sho
owing perce
entage comp
pliance with
h
botth EWS trigg
ger responsse and the
qua
arterly obse
ervation com
mpleteness
and
d accuracy.
• Info
ormation avvailable on the
t intranett
hass been upda
ated and giv
ven higher
visibility with a link via an
n EWS logo.
e
easy access to
This will also enable
all E
Early Warniing Score au
udit results..
• Aq
quarterly audit program
mme
con
ntinues of all adult ward areas;
those falling below seet targets are
a
required to
t put indiviidual ward
action plans in place..
hat we aim
m to do nex
xt
Wh
We
e will continue to audit EWS
com
mpliance across all areaas and act
swiiftly to supp
port improveement or if we
dettect any detterioration i n performance.
Clinical Safe
Rep
porting will be via the C
ety
Sub
b-Board.
All wards will continue
c
to undertake their
own weekly se
elf-audits off observatio
on
mpleteness and plot thhe results on
na
com
lam
minated run chart to dissplay the re
esults
clea
arly for all staff
s
to see..
13
Patien
nt Safety Priority
P
3:
3 No hosp
pital-acqu
uired, avo
oidable, g rade two,
three o
or four prressure ulcers
What d
did we aim
m to do?
To have
e no avoidab
ble, hospita
al-acquired, grade two,, three or fo
our pressure
re ulcers (PU
Us)
Improv
vements made
m
in 20
014/15
We knew
w from the outset thatt this would
d be a very challenging target, andd we have not
n
fully me
et it, althoug
gh we have
e continued to maintain
n the level of
o improvem
ment that we
w
achieved in 2013/1
14, despite rising activi ty levels (an 8.6% incrrease in adm
missions
n 2012/13 and
a 2014/15).
between
2
2012/13
2013/14
2014/1
15
1
193,758
203,748
210,42
28
Total n
no. of avoid
dable grad
de
2 hospital acquirred PUs
206
106
112
Total n
no. of avoid
dable grad
de
3/4 ho
ospital acquired PUs
36
24
2
34
Total a
admissions
s
Source: N
NNUH data, naational definitiions used
Older pa
atients are at greater risk
r of deveeloping PUs, and here in Norfolk w
we have a high
proportiion of olderr patients when
w
compa red againstt the national average.
Our patients arre particularrly susceptible when thhey have lim
mited
bility, illnessses which affect their blood
b
circulaation, or wh
hen
mob
they
y are too po
oorly to eat properly, which
w
impaccts on the body’s
b
abiliity to heal aand repair ittself. Even with
w the higghest standards
of clinical care,, it is not alw
ways possib
ble to preveent PUs,
partticularly am ongst the most
m
vulnera
able group of patients.. Our
goal therefore is to mitigate the risk as
a much as possible by
y
minating as m
many of the
e avoidable factors as w
we can, and
d
elim
carrrying out thee appropria
ate preventa
ative care w
where patien
nts
are iden
ntified as be
eing at risk of developi ng a PU.
The follo
owing are not
n photogrraphs of ourr own patients, but the
ey illustrate some of the
grades o
of PUs that our healthccare professsionals enco
ounter amo
ong vulnerabble adults.
We conttinue to see
e a rise in PUs
P on our ppatients’ he
eels, and the
e tissue viabbility (TV)
Nurses have contin
nued to worrk closely w
with the ward
d TV link nu
urses regardding the
importance of regu
ular repositio
oning and tthe use of pressure-rel
p
ief aids to pprotect patie
ents’
heels.
14
We have developed a PU OWL which publicises the outcomes of RCAs to all staff and
focuses on one particular area of PU prevention in each issue. The importance of heel
awareness was the subject of the inaugural issue. All wards have their own dedicated
supply of Repose heel protectors, gel pads and heel troughs for patients, and an
education campaign continues to raise awareness across all staff groups of the
importance of checking patients’ heels.
On admission, all patients are now assessed for their risk of developing PUs using the
national Waterlow risk assessment tool, focussing on each patient’s individual risk factors
and needs. We highlight the importance of factors such a regular repositioning, the use of
a special pressure-relieving mattress or cushions, nutritional advice and dietary
supplements. Large plastic clocks are positioned at patients’ beds to remind staff, patients
and carers when the patient is due to be repositioned, and we have worked closely with
patients and carers to co-design information leaflets to inform patients and their families
of the risks of pressure damage, and ways of preventing ulcers from occurring.
Learning points from recent RCAs are shown on the following table:
Issue
Inaccuracy of
Assessments of
Waterlow score
Reporting incidence of
PUs
Non – compliance
with care
Recommendation
x To ensure accurate assessment of patient’s risk a
Waterlow assessment is undertaken and all
comorbidities are assessed
x Ensure correct actions are implemented following
assessment and using clinical judgement.
x Ensure staff are reporting PU incidence in a timely way
x Remind staff to report any concern concerning PU to
ward co-ordinator so this can be handed over to senior
band 6/7 at earliest opportunity.
x Ensure all noncompliance issues are recorded
accurately in the patient’s record along with a
15
Condition of skin
during stay & on
discharge, possible
presence of PU
Lack of awareness
concerning prevention
of heel ulcers.
x
x
x
x
x
x
Informing ward of
RCA outcomes
x
x
x
Appropriate use of
pressure care aids
x
x
Lack of pressure
prevention equipment
at ward level
x
description of any risks associated with noncompliance
that were discussed with the patient.
Provide all patients with PU information leaflet.
Ward staff to undertake a full skin inspection on
discharge and to document findings.
When undertaking care, all areas of skin to be
inspected e.g. all skin folds
Highlight ‘Think Heels’ campaign and poster to staff.
Encourage staff to use current heel care poster issued
November 2014.
Encourage staff to use mirrors (all wards supplied with
these in November 2014) when assessing patients’
heels.
Outcome of RCA to be discussed with ward staff at
monthly ward meeting and included in ward news
letter
Discuss relevant issues from the RCA with nursing staff
that were directly responsible for the patient’s care.
Share outcomes with other ward areas within the
directorate as a learning tool.
In conjunction with physiotherapists, consider use of
Kerrapro heel protectors in foot splints
Wards to purchase more foot protectors / PU aids to
help prevent PU s.
Ward to ensure Kerrapro pressure aids for heels,
sacrum etc., are available on the ward at all times
What we aim to do next
We will continue to
develop action
plans to implement
the learning from
RCAs of hospital
acquired
preventable PUs,
and to share the
learning point with
all staff. We will
also continue to
work with
community and
social care
colleagues to promote better PU prevention and risk awareness among staff and relatives
caring for patients in their homes, in care homes and in community hospitals.
Learning from the individual case reviews will continue to be published in our monthly
Clinical Safety Sub-Board report and on the internet following our Board meetings.
16
“We all dread going
into hospital, and
having to be an
emergency admission
on Friday 13th at 02.00
in the morning doesn't
get a lot worse! I feel
incredibly lucky that I
was taken into
your hospital.
The care, concern,
thought and effort put
in from the very first
moment that the
Paramedics arrived
was all anyone could
hope for, then the
transfer to the hospital
again with so much
care.
What can I say about
your Hospital,
everyone from the
cleaning staff up to the
consultant couldn't
have put anymore
thought in the only
person they focused on
was me (I guess with
several hundred
others!!)”
SD June 2014
Patient Safety Priority 4: Review of all
emergency patients by senior clinician
within 12 hours of admission
What did we aim to do?
For 100% of emergency patients admitted to the Acute
Medical Unit (AMU) and the Emergency Assessment
Unit – Surgical (EAUS) to be reviewed by a senior
clinician within 12 hours of admission. A ‘senior
clinician’ is a doctor of specialist registrar level 4 or
above, meaning a doctor with at least four years’ postgraduation experience, of which at least two years are
within their chosen specialty.
Improvements made in 2014/15
During the final quarter of the reporting period, a
week-long audit reviewed the care records of all 836
adults who were admitted as emergency inpatients
during the week of the audit.
The audit showed that, despite the hospital being on
the highest levels of operational alert throughout the
week of the audit, more than nine out of every ten
patients admitted as emergencies were reviewed by a
senior decision-making doctor within 12 hours of
admission, regardless of where the admission took
place in the hospital, and regardless of the specialty to
which the patient was triaged.
Of the 236 patients that were admitted over the
weekend (from 19:00 hours on Friday until 07:00 on
Monday), only 7 were not assessed within 12 hours.
The audit provided a high level of assurance that,
despite activity pressures, we are appropriately
monitoring and assessing patients admitted as
emergencies, irrespective of day, time and location of
admission and the triaged specialty.
What we aim to do next
Timely senior review remains one of our quality
priorities for 2015/16, and we will continue to
appropriately monitor compliance and to address
learning outcomes or performance shortfalls with the
appropriate staff groups. Our performance will be
reported on fully in the 2015/16 Quality Report.
17
Patient Safety Priority 5: 100% compliance with the sepsis bundle
What did we aim to do?
We aimed to achieve 100% compliance with all elements of the ‘sepsis 6’ bundle, which is
a standardised care bundle protocol which reduces variation in clinical care and ensures
that clinical processes are optimised. Executed within one hour of the onset of symptoms,
the sepsis bundle ensures that patients:
•
are started on high flow oxygen which delivers oxygen to shocked tissues
•
receive fluid therapy, which improves cardiac output by increasing venous
return to the heart;
•
have blood cultures taken and have IV access in place
•
have their lactate levels checked, since this is predictor of critical care need
•
are started promptly on antibiotics prescribed from the Sepsis Bundle
antibiotic policy
•
have their urine output measured accurately, to detect whether the kidneys
are functioning effectively.
Improvements made in 2014/15
An audit within the A&E department shows improvement in compliance (%) with the
sepsis bundle.
Blood cultures taken
Serum lactate measured < 1 hour
Antibiotics given within 1 hour
December 2014
68%
94%
72%
July 2014
44%
70%
40%
Source: NNUH data, national definitions applied
These results have been discussed with staff in the A&E department and work continues
to ensure that the improvement trajectory is maintained.
In addition, a rolling daily audit has been ongoing since the beginning of January 2015 to
assess the percentage of patients attending A&E who receive intravenous antibiotics
within one hour of being given a provisional diagnosis of sepsis. The baseline in July 2014
was 40%, and this has increased to over 80% since the beginning of January.
What we aim to do next
Timely implementation of the Sepsis 6
bundle remains one of our quality priorities
for 2015/16, and we will continue to
appropriately monitor compliance and to
address learning outcomes or performance
shortfalls with the appropriate staff
groups. Our performance will be reported
on fully in the 2015/16 Quality Report.
18
Patient Experience Priority 1 – To improve
our score in relation to the Friends and
Family Net Promoter Test question.
“This is the NHS
at its best –
world-class
medicine with
nursing and
caring to match. I
have spent time
in the most
expensive private
hospitals in the
UK and elsewhere
- would rather be
here.”
What did we aim to do?
To improve our score in relation to the Friends and
Family Net Promoter Test question ‘How likely is it that
you would recommend this service to friends and
family on a scale of 0 to 10?’, and to continue to
investigate the reasons underpinning poor scores and
to translate these findings into actions where
appropriate.
Improvements made in 2014/15
Since the test was introduced in April 2012, we have
steadily improved our score across all inpatient areas.
The test was expanded into A&E areas in June 2013,
into Maternity Services in October 2013, and into
outpatient areas from April 2014 onwards.
When the test was introduced, our overall inpatient
score was 67%; at the time of writing this report it is
in excess of 85%
Anon
November 2014
19
Friends and Family Test Score for Inpatient Wards
90%
85%
80%
75%
70%
65%
60%
Apr
May
Jun
Jul
Aug
2012/13
Sep
Oct
2013/14
Nov
Dec
Jan
Feb
Mar
Jan
Feb
Mar
2014/15
Source: NNUH Friends and Family test data, national definitions used
Friends and Family Test Score for Maternity
95%
90%
85%
80%
75%
70%
65%
Apr
May
Jun
Jul
Aug
Sep
Oct
2013/14
Nov
Dec
2014/15
Source: NNUH Friends and Family test data, national definitions used
Op cancelled
3 times
otherwise
treatment ok
Improve
night staff,
lot of bank
staff. Day
staff brilliant
Staff are
absolutely
marvellous
The staff are
under
pressure and
I was
overlooked
I was treated
like a king.
Friendly and
efficient and
kept me
informed at
all times
Good
Attention.
Very helpful
Clean
hospital.
20
Friends and Family Test Score for A&E
90%
80%
70%
60%
50%
40%
30%
Apr
May
Jun
Jul
Aug
Sep
Oct
2013/14
Nov
Dec
Jan
Feb
Mar
2014/15
Source: NNUH Friends and Family test data, national definitions used
A staff Friends and Family test has also been introduced, through which staff are asked
whether they would recommend our hospitals to friends and family as a place to receive
treatment. The results are included within the National Staff Survey, and they show that
our score has deteriorated when compared against our 2013 score, and is now slightly
below the national average for Acute Trusts.
Staff recommendation of the trust as a
place to work or receive treatment
NNUH
2014
3.62 (out
of 5)
Median
Acute
3.67 (out
of 5)
NNUH
2013
3.77 (out
of 5)
NNUH
2012
3.71 (out
of 5)
Source: National staff survey data, national definitions used
What we aim to do next
The results show how it has felt to work under the intense and sustained operational
pressure of the recent months, and confirm that we need to find ways to support our staff
better, and together make the NNUH the best possible place to work.
To put the survey results into perspective, despite February 2015 being our busiest ever
month, it was also the month in which we achieved our highest ever score from patients
in our patient surveys, which attests to the commitment, compassion and skill of our staff.
The Friends and Family Test results will continue to be included within the monthly
Nursing Quality Dashboard, where they will be reviewed with the Director of Nursing and
the Matrons within the context of other quantitative measures such as vacancy rates,
sickness, complaints, hospital acquired PUs, falls and incidents. They are also included in
the monthly Caring and Patient Experience report to the Board.
Patient Experience Priority 2 – Improving discharge processes
What did we aim to do?
To eliminate avoidable delays in the discharge process, and reduce the number of delayed
transfers of care.
21
Improv
vements made
m
in 20
014/15
The follo
owing graph shows tha
at the numb
ber of patie
ents that experience a ddelayed transfer
of care (DTOC) desspite being medically fiit for discha
arge, remain
ns unaccepttably high, and
suggestts that furth
her improvement is stilll possible. Since
S
DTOC patients haave complex
discharg
ge needs, our
o ability to
o reduce theeir numberss is reliant on
o our comm
munity parttners
increasing the availability of post-acute ccommunity and
a social care.
c
Until tthat additional
nity capacitty is in place
e, it is unlikkely that we
e will be able
e to significcantly reducce the
commun
numberr of DTOCs.
Delay
yed Discha
arges
70
60
50
40
30
20
10
Delayed disccharges - acttual
Mar-15
Feb 15
Feb-15
Jan-15
Dec-14
Nov 14
Nov-14
Oct-14
Sep-14
Aug-14
A 14
Jul-14
Jun-14
May-14
Apr-14
Mar-14
Feb-14
Jan-14
Dec-13
Nov-13
Oct-13
Sep-13
Aug-13
Jul-13
Jul 13
Jun-13
May-13
Apr-13
Apr 13
0
Delayed disscharges - taarget
Source: N
NNUH data, naational definitiions used
Some off the initiatiives that we
e have intro
oduced to trry to addresss the probllem of delay
yed
discharg
ges are outllined below.
22
Volunteer Settle-In
Service
We have developed an
initiative whereby
volunteers accompany
patients home on discharge
and carry out small but vital
tasks, e.g. checking utilities,
unpacking and shopping for
basic groceries. Volunteers
will be trained to complete
the falls environment risk
assessment. Training will be
completed by the end of
March and the service will
commence in April 2015.
Home Based Therapy
Occupational therapists and
physiotherapists facilitate
earlier discharges, working
with Norfolk First Support
care provider and Age UK,
and complete a reablement
programme. The service
commenced in October
2014 and at the time of
writing the team has
discharged 247 patients, of
which 60% have been
discharged on the day of
referral to the team
Henderson Ward
Opened Jan 2015 and now
has 24 beds, providing a
‘stepping stone’ service for
people who are medically fit
to leave hospital but need
further support to enable
them to return home safely.
At the time of writing, the
unit has already discharged
137 patients, of whom 118
were discharged home.
Age UK Benefits Service
This service, which was
introduced in 2013/14, is
still working well. The team
runs clinics 3 days per
week, providing advice,
guidance and benefits to
patients, carers and staff.
Additional funding to
continue the service in
2015/16 is being sourced by
Age UK.
Placement without
Prejudice
The continuing care team
has been strengthened,
allowing patients to be
transferred to nursing
homes for their continuing
care assessment. Only the
assessments for the
minority of patients with
very complex needs now
take place in hospital.
Weekend working
We have increased the
number of therapists
working at weekends and
also introduced a 7 day
social services presence at
the hospital.
What we aim to do next
We aim to continue with the above initiatives and work with our Commissioners, our
community partners and voluntary organisations to improve the discharge experience for
patients with complex needs. We will seek to procure additional capacity for post-acute
phase, whilst working with our system partners to develop a system-wide strategic
capacity plan, and we will explore the potential to access additional step-down or
intermediate care beds close to the main hospital site in partnership with an external
partner.
23
Patient Experience Priority 3 – Extension of inpatient self-administration
of medicines (SAM)
What did we aim to do?
To increase the number of inpatients who, where appropriate, are offered the opportunity
to self-administer their medications during their hospital stay if they wish to do so
Improvements made in 2014/15
We completed our project to provide the opportunity on all appropriate wards for patients
to self-administer their medications during their inpatient spell, and whilst uptake has
been a little slow, we are continuing to encourage patients to take advantage of this
opportunity if they would like to do so. In order to increase the numbers of patients who
take responsibility for administering their usual medicines, we are working through an
action plan which includes:
•
x
•
•
•
Exploring the possibility of starting SAM assessment in admissions areas (AMU, EAUS)
Exploring the possibility of adding a twice weekly assessment for SAM suitability to
the patient care record so that it is considered regularly
Publicising SAM to patients, through posters developed by the Patient Experience
Working Group
Continuing to audit at least bi-annually to determine uptake and compliance with the
SAM policy
Pharmacists helping to promote and facilitate the use of SAM for appropriate patients.
What we aim to do next
We will continue to work through the action plan, and report the outcomes via the Caring
and Patient Experience Executive Sub-Board.
24
Clinical Effectiveness Priority 1 - Improving infection prevention,
focussing on C. Diff and surgical site infection (SSI)
What did we aim to do?
No inpatient to develop a preventable infection whilst under our care.
Improvements made in 2014/15
At the time of writing this report, it
is now more than 36 months since
we have had a case of hospitalacquired MRSA bacteraemia, and
we are hugely proud of this
achievement.
Every patient that we admit is
swabbed for MRSA, which results
in the microbiology team
processing approximately 10,000 samples every month. In addition to this, extra processes
are in place to monitor and care for patients who are assessed as being at higher risk of
carrying MRSA.
However, MRSA is not the only infection that is of concern to our patients. The following
series of graphs illustrates our performance in respect of other areas of infection prevention
and control.
Hospital Attributable C. Difficile
12
10
8
6
4
2
Apr
May
Jun
Jul
Aug
2012/13
Sep
Oct
2013/14
Nov
Dec
Jan
Feb
Mar
2014/15
Source: NNUH data, national definition used
Following successful appeal, our final figure in
respect of hospital attributable C-Difficile was 41
for this reporting period.
25
We acknowledge that the number of clearly hospital-attributable cases has been
disappointing, and we are working hard to identify what, if anything, we can do differently
to reduce the incidence in the future.
Hospital Attributable MSSA
5
4
4
3
3
2
2
1
1
Apr
May
Jun
Jul
Aug
2012/13
Sep
Oct
2013/14
Nov
Dec
Jan
Feb
Mar
Jan
Feb
Mar
2014/15
Source: NNUH data, national definition used
Hospital acquired E Coli.
5
4
4
3
3
2
2
1
1
Apr
May
Jun
Jul
Aug
2012/13
Sep
Oct
2013/14
Nov
Dec
2014/15
Source: NNUH data, national definition used
In respect of surgical site infections (SSIs), the graphic on the following page illustrates our
current performance.
26
SSI HII audit results
Colorectal surgery
30/12/14
Screening & decolonisation
Preoperative showering
Hair removal
Orthopaedic Surgery
100%
0%
33%
80%
10/12/14
Preoperative
100%
100%
100%
100%
Orthopaedic Surgery
0%
100%
20%
60%
100%
100%
N/A
Post operative
Colorectal surgery
Orthopaedic Surgery
10/12/14
Colorectal surgery
0%
100%
0%
67%
100%
100%
100%
30/12/14
Intra-operative
Skin preparation
Prophylactic antibiotics
Normothermia
Incise drapes
Supplemented Oxygen
Glucose control
Hand hygiene
Full compliance
100%
Action required
71%-99%
Urgent action
required
Organisational
priority
50% - 70%
0% - 49%
100%
100%
100%
10/12/14
30/12/14
Surgical dressing
100%
100%
100%
As a result of this surveillance SSI bundle
practice audits have been introduced, an
information leaflet including information for
patients around recognising SSI and what to do
in this instance is awaiting approval and
antibiotic prophylaxis has been changed.
Source: NNUH data, national definition used
Orthopaedic SSI data is subject to mandatory national surveillance, and therefore
comparative benchmarking is possible. The data has not yet been published for 2014/15,
but 2013/14 data is available from the following website:
https://www.gov.uk/government/publications/surgical-site-infections-ssi-surveillance-nhshospitals-in-england
27
What we aim to do next
Infection control remains one of our key priorities for 2015/16 and a full report of our
2015/16 performance will be included in next year’s Quality Report. Our Department of
Infection Control will continue to work closely with clinical teams to ensure that the focus
on infection prevention and control is maintained, and results will be monitored by the
Clinical Safety Executive Sub-Board.
As a result of this surveillance, SSI bundle practice audits have been introduced, an
information leaflet has been produced which includes information for patients around
recognising and acting upon SSI, and antibiotic prophylaxis has been changed.
28
Clinical Effectiveness Priority 2 - Identifying the critical path for patients
with complex discharge needs
What did we aim to do?
For all emergency admissions that are identified on admission as having complex needs
following discharge to have a critical path identified within 24 hours of admission, and be
managed through this critical path.
Improvements made in 2014/15
Multidisciplinary team (MDT) meetings now take place in Older People’s Medicine (the
specialty that has the greatest number of patients with complex discharge needs) for all
patients who are identified during their spell as having complex discharge requirements. At
these meetings, the patient’s critical path is mapped and discharge planning commences,
with doctors, nurses, therapists and social services staff all contributing to the discussion.
To ensure that all necessary work is undertaken in a timely manner, a progress list is
updated daily with details of patients who are clinically fit for transfer but who are still
undergoing assessments linked to discharge. This list also records patients who are
clinically ready for transfer, have completed all multi-disciplinary team (MDT) assessments
and are ready to leave the hospital. Patients are discussed at a daily progress meeting and
information updated accordingly. We also have a Discharge Dashboard that identifies Trust
delays, capacity and demand status.
Patients whose discharges are more complex are supported by the ‘Complex Discharge
Team’ which continues to support wards with patients with more complex discharge needs.
Discharge ward coordinators are based on Knapton and Holt wards currently. A business
case has been agreed to increase the number of ward based coordinators. Link Discharge
nurses are also in place on all wards that admit patients with complex discharge needs.
Norwich Community Health and Care NHS Trust (NCH&C) have recruited four Band 6
discharge support nurses, based at NNUH, whose role is to identify, on admission, those
patients who have existing community case managers, and then to join the patient’s MDT
and use their knowledge of the patient’s previous capability to inform their discharge
planning.
At the time of writing this report, the Continuing Healthcare Care Team (CHC) has
maintained a zero wait for assessment allocation since before Christmas 2014. The
Placement without prejudice pathway (PWP) has enabled them to achieve significant
improvements in discharges, with 50% of patients discharged within 48 hours of referral to
nursing homes to enable the full continuing care assessment to take place.
What we aim to do next
We will continue to work through our action plan and report progress through the Caring
and Patient Experience Executive Sub-Board. This remains a priority for 2015/16, so a full
update on our progress in 2015/16 will be included in next year’s report.
29
Clinical Effectiveness Priority 3 - CT scan within 60 minutes of arrival in
hospital for patients with suspected stroke
What did we aim to do?
To ensure that all patients that arrive in hospital with suspected stroke are given a CT scan
within 60 minutes.
Improvements made in 2014/15
CT scan within 60 minutes for patients presenting with
suspected stroke
105%
95%
85%
75%
65%
Apr
May
Jun
Jul
Aug
2012/13
Sep
Oct
2013/14
Nov
Dec
Jan
Feb
Mar
2014/15
Source: NNUH data, national definition used
At the time of writing this report, 90% of
patients receive their CT scan within 60
minutes of presenting. This, in turn, has
enabled us to improve our thrombolysis
time, as thrombolysis cannot commence
until the initial scan has been carried out.
Breaches were due to patients not being
alerted to the stroke team in a timely
fashion, the stroke alert nurse being busy
with other stroke patients or the CT
scanner being occupied by equally urgent
cases. We now have 6 stroke consultants
who provide 7 day cover to the stroke unit,
which enables us to have consultant led
ward rounds 7 days a week. This also
enables our consultants to assess stroke
patients when they are on outlying wards.
We have also increased our middle grade
doctor numbers from 2 to 5 and, when all
the posts have been filled (we are currently
awaiting the arrival of the 5th doctor), we
will have cover from 09:00 until 21:00
hours 7 days a week. This will mean that a
doctor will also be available to cover our
rehabilitation ward at weekends, which
may help to prevent readmissions. On-call
medical cover will be provided outside
these core hours.
As a result of staff engagement and
concentrated effort on specific areas, our
performance on the Sentinel Stroke
National Audit Programme (SSNAP) clinical
audit has improved gradually over the past
year. We play a leading role in the Norfolk
and Waveney Stroke Network, and are
driving improvements across the region.
What we aim to do next
We will continue to drive improvements at NNUH and regionally via the Norfolk & Waveney
Stroke Network, reporting progress to the Clinical Safety Sub-Board. Stroke remains a
priority for 2015/16, so a full update on progress will be included in next year’s report.
30
Looking Forwards - Our 2015/16
priorities for improvement
We will pursue this strategy across the three quality domains of patient safety, patient
experience and clinical effectiveness.
Our Patient Safety Goals
¾ Ongoing reduction in medication errors
¾ Review of all emergency patients by senior clinician within 12 hours of
admission
¾ 100% compliance with the sepsis bundle
¾ Reduce avoidable pressure ulcers
¾ Reduce numbers of outliers
Our Patient Experience Goals
¾ Treat patients with dignity and respect
¾ Improve discharge processes
¾ Improve patient repatriation services for patients transferred here from
other Trusts
Our Clinical Effectiveness Goals
¾ Improve infection prevention, focussing on C Diff and surgical site
infection
¾ CT scan within 60 minutes for patients with suspected stroke on arrival in
hospital
¾ Ensure urgent radiological investigations requested on inpatients are
performed within 24 hours or earlier if clinical need dictates
31
We now have a well-established process for deciding upon our quality goals for the
forthcoming year. We analysed data from a myriad of sources, including responses to the
national annual patient and staff surveys, complaints and compliments, analysis of past
incidents and real-time feedback gathered from our Trust-wide patient experience
initiative. We also ran an online survey in February 2015 to directly seek the views of our
patients, staff and the wider public.
Once a set of draft priorities had begun to emerge we asked for feedback from our clinical
teams, from our Governors, and from representatives of Healthwatch, before making our
final decision.
32
Patient Safety Priority 1 –
Ongoing reduction in medication
errors
Executive Lead
Medical Director
Why this is important
Almost all patients receive medication of
some sort during an inpatient spell and,
although errors represent a very tiny
proportion of the overall number of
medicines that are administered, they
have the potential to cause serious harm
to patients, to lengthen inpatient stays,
and to cause readmissions to hospital.
Our action plan
We will complete the implementation of
e-prescribing, and we will finalise the roll
out of the unified drug chart across all
Trusts in the East of England. We will
continue to produce Medicines OWLS,
and disseminate learning across the
organisation.
Reporting mechanisms
Medicine errors and ‘near misses’ are
included in the monthly Clinical Safety
Sub-Board report to the Trust Board. The
Medicines Management Group, chaired
by the Clinical Director of Pharmacy
Services, will continue to review reported
medication incidents monthly, focussing
in particular on the errors that have
potentially or actually caused significant
harm to patients. All errors – even those
in less grave categories - will continue to
be reported to the National Reporting
Learning Service (NRLS).
Patient Safety Priority 2 –
Review of all emergency patients
by senior clinician within 12
hours of admission
Executive Lead
Medical Director
Why this is important
Prompt senior clinician review of patients
that have been admitted for emergency
treatment can help to identify our most
poorly patients, including those that are
in urgent need of treatment for
conditions such as sepsis, pneumonia
and acute kidney injury which, if
identified rapidly and treated effectively,
can lead to better outcomes.
Our action plan
We will continue to monitor compliance
with the time lapse between admission
and senior review, and identify and
address the causes of all breaches of the
12 hour target.
Reporting mechanisms
We will report progress against this
metric as part of the monthly Clinical
Safety Sub-Board report to the Trust
Board.
33
Patient Safety Priority 3 – 100%
compliance with the sepsis
bundle
Executive Lead
Medical Director
Why this is important
Sepsis can lead to shock, multiple organ
failure and death, especially if it is not
recognised early and treated promptly.
Following the standardised Sepsis 6 care
bundle protocol reduces variation in
clinical care and ensures that the clinical
processes are optimised. Executed within
one hour of the onset of symptoms, the
sepsis bundle ensures that patients:
x
x
x
x
x
x
are started on high flow oxygen
receive fluid therapy
have blood cultures taken
have their lactate levels checked,
are started promptly on
antibiotics
have their urine output measured
Our action plan
Use of the sepsis bundle will be triggered
via an elevated EWS, or where infection
is suspected. We will continue to raise
awareness of the importance of following
the bundle as soon as sepsis is
suspected, and will ensure that
mechanisms are in place to monitor
compliance.
Reporting mechanisms
We will monitor compliance and
outcomes through reports to the Clinical
Safety Sub-Board and the Mortality and
Morbidity Committee, and via divisional
and directorate safety dashboards to the
Trust Board.
Patient Safety Priority 4 –
Reduce avoidable pressure ulcers
Executive Lead
Director of Nursing
Why this is important
The prevalence of hospital-acquired
pressure ulcers (PUs) is a good proxy
indicator of overall quality of care. PUs
cause patients considerable pain and
distress, are potentially life threatening,
can lengthen an inpatient spell, and can
necessitate weeks or even months of
costly rehabilitative treatment.
Our action plan
We will continue with our PU Special
Measures Review process, which involves
the Director of Nursing and a Tissue
Viability (TV) specialist nurse visiting
wards with high incidence of patients
acquiring PUs whilst in their care, to
assess whether supportive measures
need to be put in place, and to ensure
that action plans are agreed. The
Director of Nursing will also continue to
visit the wards that have reported grade
3 or 4 PUs and carry out a full RCA with
the ward staff, to ensure that learning is
shared across the whole team.
Reporting mechanisms
Data on hospital acquired PUs will
continue to be reported monthly to the
Trust Board as part of the Clinical Safety
Sub-Board Report, and we will continue
to report grade 3 and 4 ulcers as serious
incidents. Full RCA - led by the Director
of Nursing – will continue to be carried
out with the ward teams on any hospital
acquired grade 3 and 4 ulcers.
34
Patient Safety Priority 5 – Reduce numbers of outliers
Executive Lead
Medical Director
Why this is important
Patients are regarded as outliers if they are under the care of a consultant of one medical
specialty but are placed in a bed that is classified under a different medical specialty. This
results in consultants having patients on several medical wards, which is not only
inefficient and inconvenient for hospital staff, but may also adversely affect the quality of
care provided and the patient’s experience of being in hospital. Outlier patients are at
greater risk as they may have therapeutic and monitoring needs that are only available on
their ‘home’ ward, where nursing, therapy and pharmacy staff are familiar with their
condition and equipment suitable to their care is easily accessible.
Our action plan
We will draw up an action plan to address the issues that lead to patients being displaced
from their ‘home’ ward and monitor progress via both the Clinical Safety and the Caring
and Patient Experience Executive Sub-Boards.
Reporting mechanisms
Outlier data and progress against the action plan will be monitored via the Divisional
Boards. Reports from those Boards will be discussed at the Clinical Safety and the Caring
and Patient Experience Executive Sub-Boards and reported monthly to the Trust Board.
35
Patient Experience Priority 1 –
Treat patients with dignity and
respect
Executive Lead
Director of Nursing
Why this is important.
In the public survey that we conducted
in February 2015, this was rated the
most important priority by patients and
the wider public, reflecting the fact that
the desire for respect and dignity is
among the most important of human
needs. That desire doesn’t diminish when
a person is hospitalised with an illness or
injury; indeed, it may increase because
being in hospital can make patients feel
disempowered and vulnerable, and
therefore we, as care providers, must do
everything possible to promote it through
our actions and behaviours.
Our action plan
x To continue to work through the
actions on the ‘Privacy and
Dignity Action Plan’ and report
progress via the Caring and
Patient Experience Executive SubBoard
x To ensure that staff are fully
aware that promoting dignity and
treating patients with respect are
essential behaviours that we
expect all our staff to exhibit.
x To ensure that each ward has a
nominated Dignity Champion.
x To arrange and publicise another
Dignity Action Day.
Reporting mechanisms
Progress against the action plan will be
monitored via the Patient Experience
Working Group, the Caring and Patient
Experience Executive Sub-Board and
reported to the Trust Board.
Patient Experience Priority 2 –
Improve discharge processes
Executive Lead
Director Medicine and Emergency
Services
Why this is important
A delayed discharge is associated with an
increased risk of permanent loss of
independence, decreased mobility and
developing a secondary infection; these
factors can undermine recovery and
delay discharge further.
Our action plan
To continue to work with key
stakeholders, including families and
carers, to progress the actions on the
Discharge Action Plan.
Reporting mechanisms
Data relating to discharge performance,
including average length of stay (ALoS),
and delayed transfers of care (DToCs),
will continue to be reported monthly to
the Trust Board as part of the monthly
performance dashboard, and will be
shared with the Central Norfolk Acute
Commissioning Board and the Unplanned
Care Clinical Network. It will also be used
to populate the Discharge Dashboard.
36
Patient Experience Priority 3 – Improve patient repatriation services for
patients transferred here from other Trusts
Executive Lead
Medical Director
Why this is important
Patients are understandably anxious to be returned as quickly as possible to their ‘home’
hospital, where it is easier for friends and family to visit, and where healthcare staff are
more familiar with their medical history. In a time of unprecedented demand on our
inpatient beds, it is also beneficial for us as a care provider to be able to transfer patients
back to their home trust with a minimum of disruption or delay.
Our action plan
To ensure that all ‘out of area’ patients, and those admitted as tertiary referrals, are
identified on admission and that, after the milestones on their critical path have been
identified, they are progressed as smoothly and quickly as possible along that path to a
timely and safe discharge.
Reporting mechanisms
Progress reports will be submitted to the Clinical Safety and Caring and Patient Experience
executive Sub-Boards.
37
Clinical Effectiveness Priority 1 Improve infection prevention,
focussing on C. Diff and surgical
site infection
Executive Lead
Medical Director
Why this is important
Controlling the risk of infection, and
preventing infections from spreading
amongst a vulnerable patient population,
is of paramount importance.
Our action plan
We will continue to produce a monthly
Infection Prevention and Control report
for staff, which will highlight
performance, key messages and learning
points, and we will continue to carry out
regular audits across the hospital on
metrics including the high impact
interventions, catheter hygiene,
environmental decontamination,
commode cleanliness, antibiotic
prescribing and hand hygiene.
Clinical Effectiveness Priority 2 –
CT scan within 60 minutes of
arrival in hospital for patients
with suspected stroke.
Executive Lead
Medical Director
Why this is important
Stroke is a serious medical emergency. It
is critical to assess and manage patients
as soon as they arrive at hospital, and to
commence the appropriate treatment
without delay. Patients have a CT scan to
differentiate the type of stroke before
commencing treatment, as the
thrombolysis treatment that would be
beneficial if administered quickly for a
patient undergoing an ischaemic stroke
would be catastrophic if administered to
a patient undergoing a haemorrhagic
stroke.
MSSA bacteraemia, E-coli bacteraemia
and C.Diff to the Health Protection
Agency (HPA) and share this data with
Our action plan
The regional network is reviewing the
stroke pathway across all providers, and
discussions on how to improve the stroke
service will continue with commissioners
and senior stroke network clinicians. We
will continue to actively participate in the
Norfolk and Waveney Stroke Network
and lead in promoting regional
improvements.
our commissioners. Internally, we will
continue to prominently report monthly
data on infection within the Clinical
Safety sub Board report to the Trust
Board. We will continue to submit data to
the HPA on surgical site infections for
patients undergoing hip and knee
replacement surgery, surgery for long
bone fractures and surgery to repair a
fractured neck of femur.
Reporting mechanisms
Our progress is monitored via the stroke
services dashboard and the monthly
Trust Board Responsiveness report to the
Trust Board. Stroke targets are a
contractual requirement and a key
performance indicator, so our monthly
performance will also be shared with
commissioners.
Reporting mechanisms
We will continue to capture data on all
hospital acquired infections, and submit
monthly data on MRSA bacteraemia,
38
Clinical Effectiveness Priority 3 – Ensure urgent radiological
investigations requested on inpatients are performed within 24 hours or
earlier if clinical need dictates
Executive Lead
Medical Director
Why this is important
For cancer, trauma, vascular and stroke patients, clinical radiology plays a critical role in
their diagnosis and treatment. For all these conditions, there is good evidence that early
diagnosis and treatment can improve outcomes.
Moreover, interventional radiology is increasingly important in treating a growing number
of medical and surgical conditions, sometimes avoiding the need for more invasive
procedures that involve the risks of open surgery and general anaesthesia. Examples
include angioplasty, stopping acute gastrointestinal haemorrhage by embolization of the
bleeding artery, stenting aortic aneurysms of dissections and removing kidney stones.
Our action plan
We have developed an action plan to increase capacity through changing working
patterns and increasing resources, and we will monitor progress against improving the
timeliness of treatment via the Clinical Safety Executive Sub-Board and via the Divisional
Directorate reports to the Executive Board.
Reporting mechanisms
Progress reports will be sent to the Divisional Directorate Boards and from there to the
Clinical Safety executive Sub-Board and the Trust Board.
39
Part 2b
Board Assurance Statements
All providers of NHS services are required to produce a Quality Report, and elements
within that report are mandatory. This section contains that mandatory information,
enabling readers of the report to make comparisons between other Trusts.
Review of services
During 2014/15 the Norfolk and Norwich University Hospitals NHS Foundation Trust
provided and/or sub-contracted 43 relevant health services.
The Norfolk and Norwich University Hospitals NHS Foundation Trust has reviewed all the
data available to them on the quality of care in 43 of these relevant health services
through its performance management framework and its internal assurance processes.
The income generated by the relevant health services reviewed in 2014/15 represents
85.6% of the total income generated from the provision of relevant health services by the
Norfolk and Norwich University Hospitals NHS Foundation Trust for 2014/15.
40
Information on participation in national clinical audits and confidential
enquiries
The purpose of clinical audits is to improve patient care by carrying out a review of
services and processes and making any necessary changes in light of the review’s
findings. National Confidential Enquiries are nationally conducted investigations into a
particular area of healthcare, which seek to identify and disseminate best practice.
During 2014/15
During 2014/15
41
2
national clinical audits
covered relevant health
services that the Norfolk and
Norwich University Hospitals
NHS Foundation Trust
provides
national confidential enquiries
covered relevant health
services that the Norfolk and
Norwich University Hospitals
NHS Foundation Trust
provides
During that period Norfolk and Norwich University Hospitals NHS Foundation Trust
participated in 97.6% national clinical audits (40/41) and 100% national confidential
enquires (2/2) of the national clinical audits and national confidential enquires which it
was eligible to participate in. We also participated in other national audits which fall
outside of the Quality Account recommended list.
The national clinical audits and national confidential enquiries that Norfolk and Norwich
University Hospitals NHS Foundation Trust was eligible to participate in during 2014/15
are as follows (see Figure 1). The national clinical audits and national confidential
enquiries that Norfolk and Norwich University Hospitals NHS Foundation Trust participated
in during 2014/15 are as follows (see Figure 1 on following page) alongside the number
of cases submitted to each audit or enquiry as a percentage of the number of registered
cases required by the terms of that audit or enquiry. [NB. The data collection period for
some of these audits is still in progress. Final figures are not yet available for all audits
and these participation rates may increase or decrease.]
The national clinical audits and national confidential enquiries that Norfolk and Norwich
University Hospitals NHS Foundation Trust participated in, and for which data collection
was completed during 2014/15, are listed below (see figure 1 on following page – green
highlighting) alongside the number of cases submitted to each audit or enquiry as a
percentage of the number of registered cases required by the terms of that audit or
enquiry.
Figure 1: National clinical audits and national confidential enquiries
41
National Clinical Audit
(alphabetical order)
Eligible
Took
part
Participation Rate
Cases Submitted
Acute coronary syndrome
Y
Y
BSCN and ANS Standards for UNE testing
Adult bronchiectasis
Adult cardiac surgery audit
Adult community acquired pneumonia
Adult critical care (Case Mix Programme)
National Bowel cancer audit
Cardiac arrhythmia
Chronic kidney disease in primary care
Chronic Obstructive Pulmonary Disease
Congenital heart disease
(Paediatric cardiac surgery)
Coronary angioplasty
Diabetes (Adult) ND(A)
Diabetes (Paediatric)
Elective surgery (National PROMs Programme)
Epilepsy 12 audit (Childhood Epilepsy)
Falls and Fragility Fractures Audit Programme
Familial hypercholesterolaemia (FH)
Fitting child (care in emergency departments)
Head and neck oncology
Heart failure
Inflammatory bowel disease
Lung cancer
Maternal, infant and newborn clinical outcome
review programme
Medical and Surgical programme: National
Confidential Enquiry into Patient Outcome and
Death
Y
Y
N
Y
Y
Y
Y
N
Y
N
Y
N/A
N
Y
Y
Y
Y
N
Y
N
20/20 (100%)
No 14/15 audit
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N/A
Y
Y
Y
Y
Y
Y
1227 (100%)
167/173 (96%)
307/307 (100%)
1609 (85%)
31/34 (91%)
661 (100%)
No 14/15 audit
50/50 (100%)
113 (100%)
203
15 (100%)
91/84 (108%)
38 (100%)
Y
Y
Mental health (care in emergency departments)
Mental Health programme: National Confidential
Enquiry into Suicide and Homicide for people
with Mental Illness (NCISH)
National audit of dementia audit
National audit of intermediate care
National Audit of Seizure Management (NASH)
Y
N
Gastrointestinal Bleed:3/5 clinician
questionnaires
5/5 clinical notes
Sepsis:
3/5 clinician
questionnaires
4/5 clinical notes
Y 50/50 (100%)
N/A N/A
Y
N
Y
N/A Did not run nationally
N/A N/A
N/A No 14/15 audit
1091 (100%)
Not yet available
392 validated to date
356 (100%)
876 (100% expected)
Not yet available
42
National
National
National
National
National
Cardiac Arrest Audit
comparative audit of blood transfusion
emergency laparotomy audit
Joint Registry
Vascular Registry
Y
Y
Y
Y
Y
Y
N
Y
Y
Y
Neonatal intensive and special care
Non-invasive ventilation - adults
Oesophago-gastric cancer
Older people (care in emergency departments)
Ophthalmology
Paediatric intensive care
Paediatric pneumonia
Parkinson’s disease (National Parkinson’s Audit)
Pleural procedures
Prescribing Observatory for Mental Health
Prostate cancer
Pulmonary hypertension
Renal replacement therapy (Renal Registry)
Rheumatoid and early inflammatory arthritis
Y
Y
Y
Y
Y
N
Y
Y
Y
N
Y
N
Y
Y
Y
N/A
Y
Y
N/A
N/A
N/A
N/A
Y
N/A
Y
N/A
Y
Y
Sentinel Stroke National Audit Programme
(SSNAP), includes SINAP
Severe trauma
Specialist rehab for patients with complex needs
Y
Y
Y
N
127/138 (92%)
Participation non-viable
304/304 (100%)
Anticipate 1136 (100%)
278 + 164 to be
submitted (expect
100%)
1104/1104 (100%)
No 14/15 audit
200/200 (100%)
100/100 (100%)
No 14/15 audit
N/A
No 14/15 audit
No 14/15 audit
17/8 (212%)
N/A
461/461 100%
N/A
750/750 (100%)
Clinician Baseline:
40/45 (88%)
Clinician Follow up:
47/47 (100%)
Patient Baseline:
44/44 (100%)
Patient Follow up:
11/11 (100%)
742/1024 (72%)
Y 578/822 - Expect 80%
N/A N/A
The reports of 12 national clinical audits were reviewed by the provider in 2014/15 and
Norfolk and Norwich University Hospitals NHS Foundation Trust intends to take the
following actions to improve the quality of healthcare provided (see Appendix A).
The reports of 59 local clinical audits were reviewed by the provider in 2014/15 and
Norfolk and Norwich University Hospitals NHS Foundation Trust intends to take the
following actions to improve the quality of healthcare provided (See Appendix B).
43
Participation in research and development
This is a decrease from the 8,710
patients who were recruited to
The number of patients receiving
such studies in 2013/14, but still
relevant health services provided
demonstrates our on-going
or sub-contracted by Norfolk and
commitment to the involvement
Norwich University Hospitals
of our patients in research. The
NHS Foundation Trust in
decrease is due in part to several
2014/15 that were recruited
high recruiting registry or
during that period to participate
database studies coming to a
in research approved by a
close including the Norfolk
research ethics committee was
arthritis registry (NOAR) and the
Norfolk Diabetes Prevention
Study, a study screening up to
10,000 participants over 3 years.
In addition general hospital
pressures have impacted on our ability to approve new studies and recruit to existing
studies especially in cancer research.
5,200
Participation in clinical research demonstrates our commitment to both improving the
quality of care we offer to our patients and to contributing to wider health improvement.
Involvement in research enables our clinicians to remain in the vanguard of the latest
available treatment options, and there is strong evidence that active participation in
research leads to improved patient outcomes.
We have an active programme to engage health professionals and other staff in research
through our monthly research seminar, research newsletter and e mail updates on
relevant research issues.
The Norfolk and Norwich University Hospitals NHS Foundation Trust was involved in
conducting 470 clinical research studies (388 in 2013/14) in 37 medical specialities during
2014/15 (37 in 2013/14). There were 170 clinical staff (consultants) (167 in 2013/14)
participating in research approved by our research ethics committee during 2014/15.
These consultants participated in research covering 80% of medical specialties (82% in
2013/14), and were supported by approximately 150 research nurses, research
administrators/managers and research specialists in our support departments (e.g.
Pharmacy).
Overview of research activities and achievements
In the four year period 2012-2015, about 450 journal articles have been published with a
Norfolk and Norwich staff member as a co-author as a result of our involvement in patient
care and research and development, demonstrating our commitment to transparency and
our desire to improve patient outcomes and experience across the NHS.
44
50
280
first author publications
in 2000/01
first author publications
in 2014/15
To facilitate consistent local research management, and to greatly improve performance,
we participate in the National institute of Health Research (NIHR) Research Support
services. We have a publicly available Research Operations Capability Statement and
standard operating procedures (SOPs) for research. Performance metrics on approval
times are in place, and the median approval time for studies in 2014/15 was 11 days
(2013-14 was 13 days). This figure has shown year on year improvement over the last
three years and is well within the national target of 30 days for approval of NIHR studies
and is compliant with new target of median 15 days.
We have also been assessed by NIHR on our ability to deliver the first patient with 70
days from registration of a new study and have reached 73% compliance (national
average 66%) with a steady improvement from 48% earlier in the year ranking us 22/55
Trusts providing this information to NIHR. We are also 58% compliant in the national
research metric for enrolment “to time and target” for commercially supported clinical
trials compared to the national average of 47% placing us 13 out of 59 Trusts.
Readers wishing to learn more about the participation of acute Trusts in clinical research
and development can access the library of reports on the website of the National Institute
for Health Research, at the following address: http://www.nihr.ac.uk/Pages/default.aspx
and the Trust website (full report available by April 30th 2015)
http://www.nnuh.nhs.uk/areamenu.asp?s=Research
45
Commissioning for Quality and Innovation (CQUIN)
A proportion of Norfolk and Norwich University Hospitals NHS Foundation Trust’s income
in 2014/15 was conditional on achieving quality improvement and innovation goals agreed
between the Norfolk and Norwich University Hospitals NHS Foundation Trust and any
person or body they entered into a contract, agreement or arrangement with for the
provision of relevant health services, through the Commissioning for Quality and
Innovation payment framework.
Further details of the agreed goals for 2014/15 and for the following 12 month period are
available electronically at http://www.nnuh.nhs.uk/TrustDoc.asp?ID=605&q=cquins.
The amount of Trust income in 2014/15 that was conditional upon
achieving quality improvement and innovation goals was £8.964m. The
final amount achieved is due to be agreed by September 2015. The
amount of Trust income in 2013/14 that was conditional upon achieving
quality improvement and innovation goals was £9.08m, and the Trust
received £9.08m.
We took part in all three of the national CQUINs in 2014/15, and also agreed 5 local
CQUINs with our commissioners. The local CQUINs focused on strategically important
areas, such as emergency care services, stroke services, timely treatment for patients
with sepsis and prevention of Acute Kidney Injury (AKI). At the time of writing this report,
we anticipate achieving 100% payment in respect of all national and local CQUINs.
Care Quality Commission (CQC) reviews
Norfolk and Norwich University Hospitals NHS Foundation Trust is required to register with
the Care Quality Commission and its current registration status is unconditional. The Care
Quality Commission has not taken enforcement action against Norfolk and Norwich
University Hospitals NHS Foundation Trust during 2014/15.
Norfolk and Norwich University Hospitals NHS Foundation Trust has participated in special
reviews or investigations by the Care Quality Commission relating to the following areas
during 2014/15. This took the form of an unannounced inspection in March 2015 which
was in part to re-assess ‘Respecting & Involving, Privacy & Dignity’ for which a ‘minor
concerns’, non-compliant rating remained outstanding from an inspection in December
2013 which was formally reported in March 2014. Norfolk and Norwich University
Hospitals NHS Foundation Trust intends to take the following action to address the
conclusions or requirements reported by the CQC. We will ensure that our action plan
fully addresses any outstanding requirements that the CQC bring to our attention.
Norfolk and Norwich University Hospitals NHS Foundation Trust has made the following
progress by 31st March 2015 in taking such action. An action plan in relation to the
‘minor concerns’ rating was put in place and was monitored via its Caring & Patient
Experience Sub-Board.
46
A lead matron for Privacy & Dignity was appointed and a wealth of initiatives were
implemented which included ‘Dignity Day’ celebrations supported by staff, governors and
patient group representatives, a trial of dignity shorts and enhancements to
documentation to prompt staff to update and record conversations with our patients
regarding their plans of care. The non-compliant rating was removed in the CQC report
published on 19th May 2015. Norfolk and Norwich University Hospitals NHS Foundation
Trust is drafting an action plan to address the issues raised in this report.
Data Quality
Norfolk and Norwich University Hospitals NHS Foundation Trust submitted records during
2014/15 to the Secondary Uses service for inclusion in the Hospital Episode Statistics
which are included in the latest published data.
The %age of records in the
published data:
which included the patient’s
valid NHS number was:
which included the patient’s
valid General Medical
Practice Code was:
Admitted patient care
NNUH
99.1%
99.9%
Nat Avg.
99.1%
99.3%
NNUH
100%
100%
Nat Avg.
99.9%
99.9%
99.9%
95.1%
100%
99.2%
Outpatient care
Accident & emergency care
Information Governance Toolkit Attainment Levels
Norfolk and Norwich University Hospitals NHS Foundation
Trust’s Information Governance Assessment Report overall
score for 2014/15
47
Clinical Coding error rate
Norfolk and Norwich University
Hospitals NHS Foundation Trust
was not subject to the Payment by
Results clinical coding audit during
2014/15 by the Audit Commission.
Norfolk and Norwich University
Hospitals NHS Foundation Trust
will be taking the following actions
to improve data quality:
x
x
x
x
x
x
We have streamlined processes, made the 18 week Inter-Provider Transfer
Administrative Minimum Data Set (IPTAMDS) mandatory for on-going pathways,
and the process is now electronic so we have removed the need to use the
internal postal service and improved confidentiality.
We have updated the electronic template with new, mandatory fields, to ensure
staff members provide 18 week information via a pro-forma when completing a
tertiary referral. This has been an extremely successful tool to assist with InterProvider Transfers; a recent IST audit highlighted the process as Good Practice.
We will continue to hold monthly Data Quality Governance Group meetings to
discuss data issues and problem areas, to deliver advice and coaching, and to
share best practice
We will continue to hold Referral to Treatment Operational Meetings every 2
weeks to discuss 18 week performance by Specialty, discussing any referral to
treatment issues / concerns and sharing best practice. We will also continue to
hold a monthly 18 Week Operational Performance Meeting, where operational
issues, 18 week audit actions and policy issues are discussed and plans made to
resolve issues as they arise;
The Data Quality team strive to enhance the recording / collection of accurate
data and work with multiple departments to meet objectives, improve processes,
and share best practice and to raise awareness on protocols and policy.
Data Quality have recently requested five Patient Administration System (PAS)
Enhancements that will further improve data collection / recording
All information within the Norfolk and Norwich University Hospitals NHS Foundation Trust
is derived from individual data items, collected from numerous sources, which must
comply with local and national data standards. It is essential to have measures and
processes in place to ensure data are accurate, valid, reliable, relevant, timely and
complete. We aim to have 100% accurate and timely data, compliant with NHS standards
and Trust Policies.
48
Performance against the national quality indicators
In 2012 a statutory set of core quality indicators came into effect, and all Trusts are
required to report their performance against the indicators that are relevant for their
healthcare sector in the same format, to help readers to compare performance across
similar organisations. For each of the following indicators, our current performance is
reported alongside the national average performance and the performance of the best
and worst performing acute foundation trusts. Comparative data is also shown for the
previous two reporting periods, to enable readers to assess our performance trends.
a) Summary hospital-level mortality indicator (SHMI)
b) Coding of palliative care deaths
SHMI is a hospital-level indicator which measures whether mortality associated with a
stay in hospital was in line with expectations. SHMI is the ratio of observed deaths in a
Trust over a period of time, divided by the expected number given the characteristics of
patients treated. A score above 1 indicates that a Trust has a higher than average
mortality rate, whilst a score below 1 indicates a below average mortality rate, which is
associated with good standards of care and positive outcomes.
Value of the SHMI for the Trust for the
reporting period
2012/13
2013/14
2014/15
NNUH
National average (FTs)
Best performing FT (Oct 13 to Sep 14) - UCLH
Worst performing FT (Oct 13 to Sep 14)-Medway
Banding of the SHMI for the reporting
period
NNUH
National average (FTs)
Best performing FT (Oct 13 to Sep 14) - UCLH
Worst performing FT (Oct 13 to Sep 14)-Medway
% of patient deaths with palliative care
coded at either diagnosis or specialty level
for the reporting period
NNUH
National average (FTs)
Lowest palliative care rate FT (Oct '13 to Sep '14)
- South Manchester
Highest palliative care rate FT (Oct '13 to Sep '14)
- Salford Royal
0.9916
1.0105
0.969
1.0111
2012/13
2013/14
0.9778
1.0054
0.7946
1.1982
2014/15
2
2
2
2
2012/13
2013/14
15.7
20.4
15.3
21.2
2
2
3
1
2014/15
16.9
25.8
22.9
26.3
Source: NHS Information Centre - https://indicators.ic.nhs.uk/webview/ Unique Identifier P01544
Data for 2014/15 is for the period October 2013 to September 2014, as this is the latest data
published on the NHCIC website. No data has been published on deaths associated with palliative
care coding since September 2013.
49
Crude palliative coding rate for deaths by trust (all nonspecialist acute providers) for all admissions in Oct 2013 to
Sept 2014
60
50
NorfolkandNorwich
UniversityHospitals
NHSFoundation
Trust,16.85
40
30
20
10
0
Source: Dr Foster. Palliative care data is available on Dr Foster only up to September 2014.
The Norfolk and Norwich University Hospitals NHS Foundation Trust considers that this
data is as described for the following reasons: The data sets are nationally mandated and
internal data validation processes are in place prior to submission.
The Norfolk and Norwich University Hospitals NHS Foundation Trust intends to take the
following actions to improve the indicator and percentage in (a) and (b), and so the
quality of its services.
x
x
We will continue to work with clinicians and the clinical coding team to ensure that
coding reflects the patient’s overall condition and reflects known comorbidities.
We will continue to investigate both HSMR and SHMI negative alerts to identify
whether changes in our clinical or coding practices are required. Any learning
outcomes will be shared with clinical and coding staff.
Hospital Standardised Mortality Ratio (HSMR)
The Hospital Standardised Mortality Ratio is the ratio of observed deaths (actual deaths)
to expected deaths (the number of deaths which would have been predicted from the
hospital’s case-mix) for a basket of 56 diagnosis groups which, together, represent
approximately 80% of in-hospital deaths. It represents about 35% of admitted patient
activity.
It is an indicator of healthcare quality, which measures whether the death rate at a
hospital is higher or lower than would normally be expected, taking into account
differences in the hospital’s case-mix. Case-mix is defined as the variation in the
complexity and severity of illness for the patients coming to hospital.
50
An HSMR of 100 represents the national average. So, if mortality levels in the hospital’s
patient population are higher than would be expected, the HSMR will be greater than 100.
Conversely, if the mortality levels in the hospital’s patient population are lower than would
be expected from its case-mix, the HSMR will be lower than 100. Throughout the
reporting period, our HSMR rate has been below 100.
Dr Foster Intelligence presents one-year, three-year and trend analysis data for HSMR in
English NHS acute hospitals, under the heading ‘Hospital Guide’, and is the original source
for the data re-presented in the following table.
HSMR
120
115
110
105
100
95
90
85
80
75
70
Source: Dr Foster, national definition used. (https://da.drfoster.co.uk/Morpheus/Results.aspx?ModuleID=180)
Focusing on the most recent benchmarked figures that are available on the Dr Foster
website, covering the twelve month period to November 2014, our HSMR was 100.9 and
within ‘expected’ range.
We receive monthly reports from Dr Foster, which alert us to areas of potential concern,
such as higher than expected deaths in a diagnosis group. The Medical Director and the
Head of the Mortality and Morbidity Committee are informed of the alert, and an
investigation is initiated to review the cases in question and to determine whether any
improvements in our clinical or coding processes are indicated.
For instance, we carried out case note and coding reviews in response to the alerts
regarding cancer of the rectum and anus, neurodegenerative disorders, perinatal deaths,
cancer of the bladder and cystic fibrosis. Some changes were made to clinical coding as a
result of the reviews, but none of the reviews highlighted concerns regarding clinical
practice.
51
Patient reported outcome measure (PROM) scores
PROM scores measure outcomes and the quality of care from the perspective of patients,
and reflect their expectations for how they will feel in the period following their surgical
procedure, measured in the form of a health gain. The data is collected in the form of a
questionnaire, which is completed by patients prior to surgery and then repeated some
months after their surgery has taken place. The difference between the two sets of
responses are analysed to determine the amount of health gain that the surgery has
delivered from the viewpoint of the patient. The greater the perceived health gain, the
greater the associated PROM score.
Groin Hernia Surgery
2012/13
2013/14
2014/15
NNUHFT
National average FT
Best performing FT
Worst performing FT
Varicose Vein Surgery
0.075
0.082
0.120
0.038
2012/13
0.087
0.081
0.116
0.039
2013/14
0.098
0.076
0.124
0.009
2014/15
NNUHFT
National average FT
Best performing FT
Worst performing FT
Hip Replacement Surgery
0.084
0.093
0.176
0.023
2012/13
0.111
0.091
0.138
0.025
2013/14
0.142
0.110
0.142
0.058
2014/15
NNUHFT
National average FT
Best performing FT
Worst performing FT
Knee Replacement Surgery
0.417
0.429
0.472
0.368
2012/13
0.450
0.427
0.483
0.364
2013/14
0.376
0.430
0.493
0.361
2014/15
0.273
0.314
0.369
0.234
0.308
0.316
0.382
0.215
0.272
0.336
0.383
0.272
NNUHFT
National average FT
Best performing FT
Worst performing FT
Source: NHS Information Centre - http://www.hscic.gov.uk/catalogue/PUB13415 National definitions apply.
Data for 2014/15 is for the period April 2014 to September 2014, as this is the latest data
published on the NHCIC website.
The Norfolk and Norwich University Hospitals NHS Foundation Trust considers that the
outcome scores are as described for the following reasons: The number of patients
eligible to participate in PROMs survey is monitored each month. Results are monitored
and reviewed within the surgical division.
The Norfolk and Norwich University Hospitals NHS Foundation Trust intends to take the
following actions to improve these outcome scores, and so the quality of its services: Our
primary goal over the forthcoming months is to focus on improving the patient experience
for patients that undergo primary knee replacement surgery, as that patient cohort
accounts for our worse PROM score.
52
Readmission rates within 28 days
A rapid readmission following discharge is not something that many patients would
welcome, and therefore we regularly review the factors that impact upon our readmission
rates and seek to address any issues that are within our control or influence. A low
readmission rate within 28 days of discharge is associated with good outcomes and safe,
effective discharge planning.
Percentage of patients aged 0 – 15 readmitted to a hospital
which forms part of the Trust within 28 days being discharged
from a hospital that forms part of the Trust during the
reporting period.
16.00%
14.00%
12.00%
10.00%
8.00%
6.00%
4.00%
2.00%
0.00%
2011/12
NNUHFT
2012/13
National average
2013/14
Best performing FT
2014/15
Worst performing FT
Percentage of patients aged 15 plus readmitted to a hospital
which forms part of the Trust within 28 days being discharged
from a hospital that forms part of the Trust during the
reporting period.
20.00%
18.00%
16.00%
14.00%
12.00%
10.00%
8.00%
6.00%
4.00%
2.00%
0.00%
2011/12
NNUHFT
2012/13
National average
2013/14
Best performing FT
2014/15
Worst performing FT
2011/12 data source: NHS Information Centre - https://indicators.ic.nhs.uk/webview/
53
The Norfolk and Norwich University Hospitals NHS Foundation Trust considers that these
percentages are as described for the following reasons: This is based upon clinical coding
and we are audited annually.
The Norfolk and Norwich University Hospitals NHS Foundation Trust has taken the
following actions to improve these percentages, and so the quality of its services: We
have continued to review readmission data on a monthly basis to identify emergent
trends, e.g. the rate rising in a particular specialty or for a particular procedure. In
November 2014 we participated in a Trust/GP readmissions audit to review hospital
readmissions and establish the causes of the readmissions.
Our own 28 day readmission data (not split for age of admission) shows a small rise in
readmissions since April 2011, as indicated in the following table.
28 day readmissions (internal NNUH data)
8%
7%
6%
Feb-15
Dec-14
Oct-14
Aug-14
Jun-14
Apr-14
Feb-14
Dec-13
Oct-13
Aug-13
Jun-13
Apr-13
Feb-13
Dec-12
Oct-12
Aug-12
Jun-12
Apr-12
Feb-12
Dec-11
Oct-11
Aug-11
Jun-11
Apr-11
5%
Data source: internal data, national definitions applied
Responsiveness to the personal needs of our patients
The ‘responsiveness to the personal needs of patients’ score is derived from the national
inpatient survey, and is an average weighted score from 5 specific questions (shown
below) relating to responsiveness to inpatients' personal needs.
Were you
involved as
much as you
wanted to be
in decisions
about your
care and
treatment?
Did you find
someone on
the hospital
staff to talk
to about your
worries and
fears?
Were you
given enough
privacy when
discussing
your
condition or
treatment?
Did a member
of staff tell you
about
medication side
effects to
watch for when
you went
home?
Did hospital staff
tell you who to
contact if you
were worried
about your
condition or
treatment after
you left hospital?
54
A high responsiveness rate suggests that a Trust is meeting the needs of its patients and
acting effectively on their feedback.
Trust’s responsiveness to the personal
needs of its patients during the reporting
period.
NNUHFT
National average FT
Best performing FT
Worst performing FT
2012/13
67.6
68.1
84.4
57.4
2013/14
68.4
68.7
84.2
54.4
2014/15
Source: NHS Information Centre - https://indicators.ic.nhs.uk/webview/ Data for 2014/15 not yet published
The Norfolk and Norwich University Hospitals NHS Foundation Trust considers that this
data is as described for the following reasons: The data source is produced by the Care
Quality Commission.
The Norfolk and Norwich University Hospitals NHS Foundation Trust has taken the
following actions to improve this data, and so the quality of its services: By increasing the
amount of feedback we gather from patients in real time through the Friends and Family
test and our inpatient feedback project, we are able to identify emergent issues very
quickly and to swiftly take any appropriate corrective action to address the cause of the
problem.
Staff net promoter scores (Staff Friends and Family Test)
The willingness or unwillingness to recommend our hospitals as a place to receive
treatment is an important yardstick for perceived quality of care, as measured by the
people that deliver that care.
Percentage of staff employed by, or under contract to, the
Trust during the reporting period who would recommend the
Trust as a provider of care to their family or friends.
100.0%
80.0%
60.0%
40.0%
20.0%
0.0%
2012/13
NNUHFT
National average FT
2013/14
Best performing FT
2014/15
Worst performing FT
Best performing FT in 2014/15 was the Robert Jones and Agnes Hunt Orthopaedic Hospital; worst performing
FT in 2-14/15 was Norfolk and Suffolk FT. Source: NHS Information Centre https://indicators.ic.nhs.uk/webview/
55
The Norfolk and Norwich University Hospitals NHS Foundation Trust considers that this
score is as described for the following reasons: The data have been sourced from the
Health & Social Care Information Centre and compared to published survey results.
The Norfolk and Norwich University Hospitals NHS Foundation Trust has taken the
following actions to improve this percentage, and so the quality of its services: By
analysing the feedback and the comments that were submitted by responders to the
National Staff Survey and to our internal staff survey, we have begun to understand the
factors that are causing dissatisfaction amongst the group of ‘detractor’ responders.
Patient Friends and Family Test
As with the Staff Friends and Family Test, the willingness or unwillingness of patients to
recommend our hospitals as a place to receive treatment is an important yardstick for
perceived quality of care, as measured by the people that receive that care.
IP Friends and Family Test
NNUHFT
Expressed as a score
2014/15 (Apr 2013/14
Jul)
77
85
Expressed as a
%age
2014/15 (Aug to
Jan)
96.0%
National average
74
75
94.6%
Best performing FT*
93
95
99.7%
Worst performing FT**
45
33
77.1%
*For Aug 14 to Jan 15 the best performing FT is Moorfields Eye Hospital;
** For Aug 14 to Jan 15 the worst performing FTs are Medway and The Royal Free
A&E Friends and Family
Test
NNUHFT
Expressed as a score
2014/15 (Apr 2013/14
Jul)
49
56
Expressed as a
%age
2014/15 (Aug to
Jan)
88%
National average
57
55
87%
Best performing FT***
78
89
99%
Worst performing FT****
16
5
69%
***For Aug 14 to Jan 15 the best performing FT is Wirral University Hospital;
****For Aug 14 to Jan 15 the worst performing FTs are Medway and Bradford Teaching Hospital
Source: http://www.england.nhs.uk/statistics/statistical-work-areas/friends-and-familytest/friends-and-family-test-data/
The Norfolk and Norwich University Hospitals NHS Foundation Trust considers that this
score is as described for the following reasons: The data have been sourced from the
Health & Social Care Information Centre and compared to published survey results.
The Norfolk and Norwich University Hospitals NHS Foundation Trust has taken the
following actions to improve this percentage, and so the quality of its services: By
analysing the feedback and the comments that were submitted by responders to the
National Friends and Family Test and to our internal feedback, we have begun to
understand the factors that are causing dissatisfaction amongst the group of ‘detractor’
responders and are addressing these through action work streams and plans.
56
Venous thromboembolism (VTE) risk assessments
VTEs, or blood clots, are a major cause of mortality, and timely assessment of a patient’s
risk of developing a blood clot can have a vital preventative effect. A high level of VTE risk
assessments shows that a Trust is doing all it can to identify and address the factors that
increase a patient’s risk.
Percentage of patients who were admitted to the hospital and
who were risk assessed for VTE during the reporting period.
100%
95%
90%
85%
80%
75%
2012/13
2013/14
2014/15
NNUH
National average (FTs)
Best performing FT Trust*
Worst Performing FT Trust**
Source: http://www.england.nhs.uk/statistics/statistical-work-areas/vte/
*Best performing FT in 2014/15 was The Royal Hospital for Rheumatic Diseases
**Worst performing FT in 2014/15 was Cambridge University Hospitals NHS Foundation Trust
The 2014/15 data is to the end of February 2015 only as data for March 2015 have not yet been
published.
The Norfolk and Norwich University Hospitals NHS Foundation Trust considers that this
percentage is as described for the following reason: The data have been sourced from the
Health & Social Care Information Centre and compared to internal trust data.
The Norfolk and Norwich University Hospitals NHS Foundation Trust has taken the
following actions to improve this percentage, and so the quality of its services: Monthly
reports are issued to managers detailing VTE performance by area, to enable prompt
corrective measures to be implemented if compliance appears to be deteriorating, and
monthly data is also provided to our commissioners. Overall performance is monitored
monthly by ward or department.
57
Incidence of C. Difficile
C- Difficile is a life-threatening infection, and Trusts must report all cases to Public Health
England. A low rate of C-Diff cases per 100,000 bed days is associated with robust
infection control measures and an effective safety culture
Rate per 100,000 bed days of cases of C.difficile infection
reported within the Trust amongst patients aged 2 or over
during the reporting period
40
37.1
35
30.8
30.2
30
25.5
25
20
15
14.8
12.4
10
5
0
0
2012/13
2013/14
0
2014/15
NNUH
National average (FTs)
Best performing FT Trust
Worst Performing FT Trust
Source: 2012/13 and 2013/14 data is from NHS Information Centre - https://indicators.ic.nhs.uk/webview/
No national data for 2014/15 has yet been published to facilitative comparative analysis.
The Norfolk and Norwich University Hospitals NHS Foundation Trust considers that this
rate is as described for the following reasons: The data have been sourced from the
Health & Social Care Information Centre, compared to internal Trust data and data hosted
by the Health Protection Agency
The Norfolk and Norwich University Hospitals NHS Foundation Trust has taken the
following actions to improve this rate, and so the quality of its services: Measures are in
place to isolate and cohort-nurse patients with suspected and confirmed C.Diff, in order to
contain the spread of infection, and our Infection Control team works in a targeted way to
quickly contain any emergent outbreaks. Rapid response deep cleaning processes are in
place to contain any suspected infections, and these are complemented by an established
and effective programme of preventative deep cleaning, aimed at avoiding an outbreak
entirely if at all possible.
58
Patient safety incidents
A high number of patient safety incidents can indicate that a Trust has a robust and
effective safety culture, which proactively encourages recording and reporting of harms.
Trust
2013/14
Overall
No.
Rate*
2014/15
Severe harm or
death
No.
%
Overall
Severe harm or
death
No.
%
No.
Rate
NNUH
12,853
40.6
10
0.08%
7070
41.3
5
0.07%
FT average
8,130
34.7
41
0.51%
4,291**
36.8
19
0.44%
Highest FT
(overall)
Lowest FT
(overall)
22,622
57.6
42
0.19%
12,020
60.6
22
0.18%
3,404
34.1
3
0.09%
1,574**
21.0
13
0.83%
Source: NHS Information Centre - https://indicators.ic.nhs.uk/webview/ and corrected internal data. Published
data is only available for Q1 and Q2 of 2014/15
Only Trusts that have submitted 6 months of data in each half year reporting period have been included when
determining the national FT average and the Trusts with the highest and lowest reporting rates.
*The reporting rate for 2013/14 is the revised rate published for October 2013 to March
2014. This reflects the revision of Cluster Groups in 2014/15, for which revised rates were
calculated for the period October 2013 to March 2014, to allow comparison to the
2014/15 reporting rates.
**Published 2014/15 figures submitted by Doncaster and Bassetlaw and Dorset County
Hospital have been excluded when calculating the average and determining the lowest
reporting figures, as these Trusts have submitted figures that appear to be incorrect, and
would skew the data.
In 2013/14 the FT with the highest number of recorded incidents (22,622) was Central
Manchester (of which 42 resulted in severe harm or death, equating to 0.19%).
The Trust with the highest number of incidents relating in severe harm or death (183)
was Doncaster and Bassetlaw, which was also the Trust with the highest incidents
causing severe harm or death as a proportion of overall incidents (183/6597 incidents, a
rate of 2.77%).
In 2013/14, the FT with the lowest number of recorded incidents (3,404) was Yeovil
District Hospital (of which 3 resulted in severe harm or death, equating to 0.09%).
The Trusts with the lowest number of incidents relating in severe harm or death (2) were
Chelsea and Westminster and The Rotherham NHS FT. The Trust with the lowest
incidents causing severe harm or death as a proportion of overall incidents was Chelsea
and Westminster (2/5806 incidents, a rate of 0.03%).
In April to September 2014/15, the FT with the highest number of recorded incidents
(12,020) was Central Manchester (of which 22 resulted in severe harm or death, equating
to 0.18%).
The Trust with the highest number of incidents relating in severe harm or death (97) was
Stockport, which equated to 1.85% (97/5233).
The Trust with the highest incidents causing severe harm or death as a proportion of
overall incidents was South Warwickshire (65/2820 incidents, a rate of 2.3%).
59
In April to September 2014/15, the FT with the lowest number of recorded incidents
(1,574) was Burton Hospitals (of which 13 resulted in severe harm or death, equating to
0.83%).
The Trust with the lowest number of incidents relating in severe harm or death (0) was
The Dudley Group, which was also the Trust with the lowest incidents causing severe
harm or death as a proportion of overall incidents (0/5022 incidents, a rate of 0.00%).
The Norfolk and Norwich University Hospitals NHS Foundation Trust considers that this
number and rate are as described for the following reasons: All internal data were
thoroughly re-checked and validated, in collaboration with our external auditors. This
review has given us the necessary assurance that the revised data now reflect our true
position.
The Norfolk and Norwich University Hospitals NHS Foundation Trust has taken the
following actions to improve this number and rate, and so the quality of its services:
Through the improvements we have made to our incident reporting protocols, and as a
consequence of having constantly promoted the message that each and every incident
must be reported, we are confident that we will continue to improve the quality of our
data, and increase our understanding of the factors that lead to incidents occurring.
60
Part 3
Other Information
Performance of Trust against Selected Metrics
This section of the report sets out our performance against a range of important
indicators, covering the three dimensions of quality:
• Patient safety
• Clinical effectiveness
• Patient experience
The information is presented wherever possible to allow comparison with previous
reporting periods and with the performance of other Foundation Trusts. Many indicators
were also included within previous reports, reflecting their continuing importance as
determinants and markers of the quality of patient care. Where indicators were included
in previous reports but have been excluded from the current report, readers can access
the latest performance data by reading the public Trust Board papers, which are
accessible at the following web address: http://www.nnuh.nhs.uk/publication.asp?ID=414
Patient Safety – Serious Incidents (SIs)
We regard high levels of incident reporting as a positive indicator of a culture that places
a high value on quality and candour.
The latest regional report from the NRLS, covering the period from 1st October 2013 to
31st March 2014 showed that the median reporting rate for the cluster of 29 acute
teaching hospitals was 8.69 reported incidents per 100 admissions. Our reporting rate
was 8.09 incidents per 100 admissions (6,630 incidents), and the breakdown of harm
severity is shown below. In 2013/14 our reporting rate was 6.66 incidents per 100
admissions.
Breakdownofseriousincidents,1stOct
'13to31stMar'14
1%
0%
Noharm
20%
Lowharm
Moderateharm
79%
Severeharmordeath
(Source: NRLS: http://www.nrls.npsa.nhs.uk/resources/?q=workbooks)
As in previous years, PUs and falls have together accounted for the majority of the
recorded SIs during the period covered by this report. In respect of PUs, the wards where
they occur are monitored closely to identify trends or to highlight opportunities for
61
improvements in clinical care. Full RCAs are carried out on all cases, with the learning
outcomes shared with the clinical teams. Serious incident figures are reported monthly to
the Trust Board via the Clinical Safety Sub-Board, and learning points are disseminated to
appropriate staff groups.
Patient Safety – Never events
‘Never Events’ are a sub-set of Serious Incidents and are defined as ‘serious, largely
preventable patient safety incidents that should not occur if the available preventative
measures have been implemented by healthcare providers.’ Some types of never events
hold high potential for significant harm, and are designated never events regardless of the
actual degree of harm that occurred. Some types of incidents are designated never events
only if death or severe harm results.”
The list of 14 Never Events are:
Wrong site surgery
Wrong implant/prosthesis
Retained foreign object post-procedure.
Mis-selection of a strong potassium containing solution
Wrong route administration of medication
Overdose of Insulin due to abbreviations or incorrect device
Overdose of methotrexate for non-cancer treatment
Mis-selection of high strength midazolam during conscious sedation
Failure to install functional collapsible shower or curtain rails
Falls from poorly restricted windows
Chest or neck entrapment in bedrails
Transfusion or transplantation of ABO-incompatible blood components or organs
Misplaced naso- or oro-gastric tubes
Scalding of patients (by water used for washing/bathing)
In our hospitals there were three never events during the period covered by this Quality
Report (2013/14 = 4). All three events related to one specialty – ophthalmology - where
in the first two cases (which occurred in June 2014 and January 2015) Lucentis was
injected into the incorrect eye, firstly at Cromer Hospital and then at the Norfolk and
Norwich Hospital. In both instances the error was recognised immediately and the patient
was informed, and no long term harm was caused by either event. In the third case,
which occurred in February 2015, a surgical instrument was retained post-surgery.
Thorough RCA was carried out on all three events, especially in the light of the errors
being repeated within a short timeframe within the same specialty, and the learning
points were disseminated to the team and an action plan drawn up and implemented.
Some of the actions are shown in the following table:
Actions taken
All Ophthalmology & theatre staff at NNUH & Cromer have already been made aware
that they MUST follow the agreed protocol and that the operating surgeon MUST mark
the eye for injection
An email has been sent from the Director of Nursing (09/06/2014) to all theatre staff at
62
both the NNUH and Cromer Hospital sites, stating that if a patient is brought into the
operating theatre for injection and eye is not marked in accordance with the agreed
protocol, theatre staff should refuse to proceed until the eye has been marked by the
operating surgeon
All operating surgeons within Ophthalmology have been made aware that they MUST
be fully engaged in and lead on the completion of the WHO checklist.
All Theatre staff in Cromer Allies Unit have been made aware of the need to ensure
that they follow the agreed theatre protocol for the injection of Lucentis
All Ophthalmology surgeons were asked to sign a document to confirm that they have
read and understand the current theatre protocols
The Ophthalmology clinical governance lead and the Matrons for Cromer and NNUH
Theatres were asked to ensure that there is a planned audit programme to monitor
compliance to the agreed Ophthalmology theatre protocols both at Cromer and at the
NNUH
A review is also underway regarding the process and documentation which is currently
used for the prescribing and administration of medications which are inserted into the
eye, and for recording compliance to the WHO checklist.
63
Patient Safety – Reducing Falls in the Hospital
Falls are usually locally defined as ‘unintentionally coming to rest on the ground, floor or
other lower level’, and so encompass faints, epileptic seizures and collapses as well as
slips and trips.
Reducing the number of falls and, in particular, those that cause serious harm, has always
been a key safety priority for us as our patient demographic is older than the national
average. There has been no recently published national data on the number of falls that
take place in hospitals in England, but it is thought that at least 280,000 falls occur in
hospitals and mental health units annually, costing approximately £15 million. Most
hospital fallers are aged over 75 years, and many have multiple long term and acute
illnesses. The following graphs show our falls incidence over the past two years.
IP falls
Dec-14
Jan-15
Feb-15
Dec-14
Jan-15
Feb-15
Mar-15
Nov-14
Nov-14
Oct-14
Sep-14
Aug-14
Jul-14
Jun-14
May-14
Apr-14
Mar-14
Feb-14
Jan-14
Dec-13
Nov-13
Oct-13
Sep-13
Aug-13
Jul-13
Jun-13
May-13
Apr-13
270
260
250
240
230
220
210
200
190
180
170
Source: NNUH data, national definition used
IP falls causing moderate harm or above
7
6
5
4
3
2
1
Mar-15
Oct-14
Sep-14
Aug-14
Jul-14
Jun-14
May-14
Apr-14
Mar-14
Feb-14
Jan-14
Dec-13
Nov-13
Oct-13
Sep-13
Aug-13
Jul-13
Jun-13
May-13
Apr-13
0
Source: NNUH data, national definition used
As mobility and independence are important factors in the recovery process, all falls
cannot be avoided. To do so would require the imposition of inappropriate restrictions on
people’s independence, dignity and privacy. However, research has shown that falls’
incidence can be reduced by between 20% and 30% through multi-factorial assessments
and interventions.
64
We encourage our staff to report every single slip, trip or fall, even seemingly
inconsequential ones, so that we can gain a complete picture of where, when and why
patients fall, to improve our understanding and help us to make effective changes to
reduce the risk. We also recognise that even falls resulting in ‘no harm’ can be the
beginning of a negative cycle, whereby ‘fear of falling’ leads an older person to limit their
activity, to the detriment of their overall quality of life.
Every fall that results in moderate or severe patient harm is followed by a thorough RCA,
with the Director of Nursing, to determine the contributory factors and identify any
learning points.
Some of the initiatives and actions that we have implemented during the year as a result
of our falls project work, or from carrying out RCAs on falls, have included:
Issue
Recommendation
Incomplete, inaccurate
falls risk assessment.
To promote accurate and timely completion of the falls risk
assessment, via team meetings and ward newsletter. To
remind staff the importance of obtaining an accurate
history of any falls prior to admission.
No safety sides
assessment
Promote use of safety sides’ assessment/matrix via team
meetings and raise awareness of safety sides matrix
through the Falls OWL.
Incomplete
intentional/care rounding
For timely care rounding, with documented evidence of
contact with patients. Promote through team meetings.
Physiotherapy cover
Ward sister to discuss with physio lead, regarding possible,
potential changes to ward physio cover.
We have also started to produce a Falls OWL, which will highlight the learning points from
falls RCAs and bring the attention of staff to any new initiatives or guidance that could
potentially help to reduce the risk of our patients coming to harm in our care.
65
Clinical Effectiveness – Achieving cancer referral and treatment times
Our performance against the national cancer targets is shown in the table below.
2014/15
Indicator
Max waiting time of 31
days for subsequent
treatments for all
cancers – surgery
Max waiting time of 31
days for subsequent
treatments for all
cancers – anti cancer
drugs
Maximum waiting time
of 31 days for
subsequent treatments
for all cancers radiotherapy
98%
94%
Max waiting time of 62
days for referral to
treatment for all cancers
– GP referral
85%
Max waiting time of 62
days for referral to
treatment for all cancers
– consultant screening
service
90%
Max waiting time of 31
days diagnosis to
treatment for all cancers
96%
2 week wait from
referral to date first seen
– all cancers
93%
2 week wait from
referral to date first seen
– symptomatic breast
cancers
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Nat
Avg.%
86.0
90.0
89.1
86.1
99.0
99.5
98.8
Q4
99.4
99.4
Q4
100
100
Q1
Q2
Q3
95.9
96.0
97.4
95.9
96.0
97.4
Q1
Q2
Q3
98.8
98.9
98.2
98.8
98.8
98.2
Q4
97.9
97.9
Q4
97.4
97.5
Q1
Q2
Q3
Q4
Q1
Q2
Q3
77.4
75.5
70.7
76.0
91.7
93.3
95.3
83.9
83.3
83.6
82.1
93.8
94.1
93.5
Q1
Q2
Q3
Q4
Q1
Q2
Q3
85.8
85.5
85.0
85.0
93.0
93.9
97.7
85.7
85.2
85.0
84.2
93.0
93.9
97.7
Q4
95.4
91.4
Q4
86.4
92.0
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
96.7
96.5
96.6
96.2
93.2
94.1
95.9
96.6
95.6
94.4
97.0
97.9
97.8
97.7
97.8
97.5
93.5
93.6
94.7
94.7
90.3
93.5
94.9
94.7
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
97.1
96.1
97.4
97.6
96.6
96.3
96.9
95.9
96.4
93.9
96.0
95.7
97.2
96.1
97.4
97.3
96.6
96.3
96.9
95.0
96.4
93.9
96.0
93.9
Goal
94%
93%
2013/14
Actual
%
94.9
94.0
89.8
96.0
100
100
100
Actual
%
86.0
90.0
89.1
86.1
99.0
100
98.9
Goal
94%
98%
94%
85%
90%
96%
93%
93%
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Nat
Avg.%
94.9
94.0
89.8
96.0
100
100
100
Source: NNUH data, national definitions used; national averages: source National Cancer Waiting Times
Database (NWTDB), national definitions used.
For clarity of reporting, the overall, annual performance for the past two years (i.e. not
split by quarter) is shown in the table on the following page:
66
2014/15 overall
Max waiting time of 31 days for
subsequent treatments for all cancers –
surgery
Max waiting time of 31 days for
subsequent treatments for all cancers –
anti cancer drugs
Maximum waiting time of 31 days for
subsequent treatments for all cancers radiotherapy
Max waiting time of 62 days for referral to
treatment for all cancers – GP referral
Max waiting time of 62 days for referral to
treatment for all cancers – consultant
screening service
Max waiting time of 31 days diagnosis to
treatment for all cancers
2
–
2
–
week wait from referral to date first seen
all cancers
week wait from referral to date first seen
symptomatic breast cancers
Goal
Actual
%
94%
87.8
98%
Nat
Avg.
%
2013/14 overall
Nat
Avg.
%
Goal
Actual
%
87.8
94%
93.7
94.9
99.2
99.2
98%
100
100
94%
96.8
96.8
94%
98.3
98.8
85%
74.9*
83.2
85%
85.2
85.7
90%
93.8
93.2
90%
94.1
93.0
96%
96.5
97.7
96%
97.1
97.2
93%
94.9
94.1
93%
96.4
96.6
93%
96.2
TBA
93%
95.5
96.4
Source: NNUH data, national definitions used; national averages: source National Cancer Waiting Times
Database (NWTDB), national definitions used.
*
This indicator has been subject to independent assurance. PwC's assurance report can be
found in Annex 3. For the definition of this indicator please see Annex 4.
The reason for the failure of the 62 day target has been due to surgical capacity in the
gynaecology and head and neck cancer services, where we are a specialist site taking
referrals from other hospitals. Theatre lists have been reviewed and additional lists have
been provided to both cancer teams. Escalation processes have been put in place to
ensure cancer patient are treated with appropriate priority.
Our head and neck surgical capacity is also constrained by the availability of specialist
surgeons. Successful recruitment has taken place which will resolve this issue and the
candidate is due to start work in March. NHS England is currently exploring a temporary
change in pathway for 62 day GP patients from other referring hospitals in order to
reduce waiting times.
Delays in radiology (specifically CT) are a concern that is affecting all body sites requiring
CT exams. Additional CT capacity has been identified for cancer patients and all processes
have been strengthened to ensure that these patients are prioritised.
The reason for the failure of the 31 day subsequent treatment target has been due to
capacity constraints in plastic surgery and dermatology.
67
The majority of the patients in plastic surgery and dermatology require specialist
procedures such as Mohs’ surgery and wider local excisions including sentinel lymph node
biopsy. A locum consultant was appointed in November and is undertaking additional
sentinel node lymph biopsy and wider excision lists.
Additional staff are being recruited to meet the demand for Mohs’ surgery. At the time of
writing, the 31 day subsequent treatment target is expected to achieve from March 2015.
A robust monitoring process has been put in place to inform escalation and an action plan
has been agreed with our Commissioners for remedying performance. Progress against
this plan is being monitored fortnightly.
NHS England requested a review by the Cancer Network on the current challenges and
actions being put in place. This visit took place on the 13th January with a draft report
being shared with us for review. The report highlights diagnostic capacity and demand as
a concern. We are considering how best to increase capacity in the short and longer term.
Daily management of the cancer patient target list is now carried out by the cancer
manager, operational managers and patient pathway coordinators with escalation as
appropriate.
Clinical Effectiveness – Achieving 18 week waiting times
Over the period covered by this report, we have seen a rise in the number of patients
waiting over 18 weeks, due to the significant emergency pressures that we are under and
the impact this has had on the elective programme in terms of bed availability and
cancellations.
794
cancelled
operations
Waiters
up from
4764 to
6,355
During the period August 2014 to March 2015, due to a lack of
either beds or operating time (with the theatre schedule
invariably being delayed due to the lack of beds). In January
alone, 160 patients were cancelled for the reasons above – this
is the largest volume of cancellations ever recorded within a
single month.
The admitted waiting list grew from 4,764 patients at
the end of March 2013 to 6,355 patients at the end
of March 2015. This is occurring as the number of
beds being occupied by emergency patients’
continues to increase. Our view is that the right
thing to do is to treat the clinically urgent patients as
a priority followed by the longest waiting patients.
68
Number of admitted patients waiting > 18 weeks
2000
1800
1600
1400
1200
1000
800
600
400
200
0
Apr
May
Jun
Jul
Aug
Sep
2013/14
Oct
Nov
Dec
Jan
Feb
Mar
2014/15
As part of the recovery plan for 18 weeks we will send as many patients as possible to the
independent sector as part of a national initiative to reduce patients waiting over 18
weeks. At the time of writing this report, 392 patients had agreed to transfer to local
independent providers, which have offered to treat up to 528 patients through to March
2015.
The biggest risk to reducing the number of patients waiting over 18 weeks is the impact
of non-elective admissions. The NHS Elective Care Intensive Support Team (ECIST) was
therefore commissioned to undertake a full review of capacity across the system and
ensure that this is allocated according to need. This review took place in February 2015,
and the ECIST recommendations have been developed into an action plan, with progress
to be monitored by the Trust Board.
69
Clinical Effectiveness - Performance against Monitor’s Compliance
Framework
Indicator
C Difficile (post 72 hours)
– year on year reduction
MRSA (HAI only) – year
on year reduction
Max waiting time of 18
weeks from point of
referral to treatment in
aggregate – admitted
Max waiting time of 18
weeks from point of
referral to treatment in
aggregate – Non admitted
Max waiting time of 18
weeks from point of
referral to treatment in
aggregate – patient on an
incomplete pathway
A&E – Total time in A&E
2014/15
Actual
Q1 – 12
Q2 – 8
50
Q3 – 12
Q4 – 9
Q1 – 0
Q2 – 0
0
Q3 – 0
Q4 – 0
Q1 92.0%
Q2 87.5%
90%
Q3 85.0%
Q4 77.3%
Q1 95.0%
Q2 92.7%
95%
Q3 94.6%
Q4 93.9%
Q1 93.4%
Q2 93.0%
92% Q3 91.4%
Q4 89.9%
Goal
95%
Certification against
compliance with
requirements regarding
access to healthcare for
people with a learning
disability
N/A
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
94.4%
91.8%
87.7%
86.4%
All met
All met
All met
All met
2013/14
Actual
Q1 – 17
Q2 – 9
37
Q3 – 11
Q4 – 10*
Q1 – 0
Q2 – 0
0
Q3 – 0
Q4 – 0
Q1 86.1%
90% Q2 94.6%
Q3 92.8%
Q4 89.8%
Q1 96.4%
95% Q2 96.1%
Q3 94.9%
Q4 93.6%
Q1 94.6%
Q2 95.5%
92%
Q3 93.6%
Q4 92.8%
Goal
95%
N/A
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
95.2%
96.0%
95.3%
96.2%
All met
All met
All met
All met
2012/13
Actual
Q1 – 7
Q2 – 14
51
Q3 – 8
Q4 – 10
Q1 – 0
Q2 – 0
4
Q3 – 0
Q4 – 0
Q1 85.9%
Q2 90.4%
90%
Q3 91.1%
Q4 91.0%
Q1 97.5%
Q2 97.2%
95%
Q3 97.3%
Q4 97.1%
Q1 93.1%
Q2 92.5%
92% Q3 93.8%
Q4 93.5%
Goal
95%
N/A
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
96.7%
96.0%
95.1%
92.1%
All met
All met
All met
All met
Source NNUH data, national definitions used.
The standard national definitions for many of these indicators are included within the
Technical Guidance for the 2012/13 Operating Framework: http://www.gpcwm.org.uk/wpcontent/uploads/file/AZ%20DOWNLOADS/T%20DOWNLOADS/Technical_guidance_for_the_2012_13_operating_framework_22_dec
_11.pdf
The overall table forms part of the performance dashboard, which is submitted monthly to
commissioners and quarterly to Monitor. The green shading indicates that performance
was within agreed tolerance levels, whereas the red shading indicates where performance
exceeded the agreed tolerance levels. Cancer targets are not included in the above table,
as they are shown in the table on page 66.
Comparative performance data is available for all other Foundation Trusts on the Monitor
website (http://www.monitor-nhsft.gov.uk/about-nhs-foundation-trusts/nhs-foundation-trustperformance/actual-performance/risk-ratings)
For clarity of reporting, the overall, annual performance for the past two years (i.e. not
split by quarter) is shown in the following table:
70
Max waiting time of 18 weeks from point
of referral to treatment in aggregate –
admitted
Max waiting time of 18 weeks from point
of referral to treatment in aggregate – non
admitted
Max waiting time of 18 weeks from point
of referral to treatment in aggregate –
patient on an incomplete pathway
2014/15
Actual
Goal
%
2013/14
Actual
Goal
%
90%
85.5
90%
90.9
95%
94.1
95%
95.5
92%
91.8*
92%
94.1
*
This indicator has been subject to independent assurance. PwC's assurance report can be
found in Annex 3. For the definition of this indicator please see Annex 4.
Throughout the period covered by this report, demand pressures have contributed to our
failure to achieve the 18 week referral to treatment targets and the A&E targets. In
Monitor’s latest published figures, which relate to Q3, our ‘continuity of service’ rating
remains 3, reflecting Monitor’s investigation of governance and financial concerns
triggered by our breaches of the A&E, referral to treatment, cancer waiting times and C.
difficile targets and a deterioration in our financial position.
Patient Experience - National Cancer Patient Experience Survey 2014
Nationally responses were received from 70,141 patients; a response rate of 64%. The
number of respondents for the NNUH was 1,191; a response rate of 72%.
Compared to the survey in 2013 we have achieved a higher score in 34 questions
(statistically significantly higher in 2 of these), the same in 11 and lower in 24.
Compared with other Trusts within this survey, we were assessed as providing care
benchmarked within the best performing Trusts in 9 out of 59 questions.
We were amongst the worst performing Trusts in 2 questions which were:
Always/ nearly always enough nurses on dut y
Hospital staff did everything to help me control pain all of the time
Questions where we featured in the Bottom 20% or with a >5% negative deviation from
the national average were tabled into an action plan.
Patients were also invited to submit free text comments which were then anonymised and
combined into a single NNUH report, again grouped by the tumour site of the patient’s
primary diagnosis. These were shared with MDT Leads during November 2014 and at
Governance Meetings. The actions will be monitored at local and Divisional level and the
Caring and Patient Experience Sub-Board will receive updates on progress within this
work via the matron for Oncology services.
71
Patient Experience - CQC Inspection and Intelligent Monitoring
The Care Quality Commission (CQC) carried out an unannounced visit to the hospital in
March 2015 and their final report was published on 19th May. We are drafting an action
plan to address the issues highlighted in the report.
The inspectors reported that it was apparent that our staff work really hard and care
about what they do. These are behaviours that are easy to overlook or take for granted,
hence the external recognition was particularly gratifying; we have shared the feedback
with our staff.
In our latest CQC Intelligent Monitoring report, published in December 2014), we were
rated as having three ‘risks’ and no ‘elevated risks’. The three risks related to our
incidence of ‘never events’, the possibility that we under-reported the number of our
patient safety incidents that resulted in death or severe harm in the period June 2013 to
May 2014, and our knee-related PROMs figures.
In respect of the patient safety incident risk, it transpired that we had uploaded some
incidents to the NRLS where patients had died but not as a result of the harm. These
findings were confirmed by an internal audit. Robust processes have been in place since
March 2015, March so in time this alert will be eliminated as our new baseline is
established.
In respect to the risk regarding our PROM scores for knee surgery, the poor score covers
the period to March ’14. Since that point, improvements have been put in place, including
the establishment of a hip and knee school, and ensuring that co-morbidities such as
obesity are coded. The improvements should improve our PROM score over time, but the
impact is unlikely to be seen immediately.
Patient Experience – Meeting Nutritional Needs
We are committed to identifying opportunities to improve our performance in meeting our
patients’ nutritional needs, and improving the patient experience in respect of our food
and beverage provision.
The table on the following page outlines just some of the initiatives that are currently
underway to ensure that we meet or exceed our patients’ expectations in respect of food,
drink and nutritional support.
72
Curren
nt Initiativ
ves
An e-lea
arning packkage for nasso-gastric (N
NG) tube placement / care
c
has beeen developed
and is in
n use.
The MU
UST nutrition
n risk screening score tthat triggers referral to
o a dietitiann has been
reduced
d from 4 to 2 to make referrals
r
mo
ore timely and
a approprriate
We tookk part in the
e Worldwide
e Nutrition Day for the
e first time in Novembeer 2014. This
providess us with a unique chance to mon
nitor and be
enchmark ou
ur nutritionaal care on an
a
internattional level.
Ward ca
atering and retail staff have been trained on allergens, particularly
p
regarding
preventting cross co
ontaminatio
on of allergeens during food
f
produc
ction or servvice.
In respe
ect of the 5 hospital food standard
ds, a joint gap
g analysiss and actionn plan is beiing
develop
ped with Serrco and ourr adherencee to these sttandards will be monitoored throug
gh
the annual PLACE assessment
a
t
An audit of the me
eal ordering system and
d delivery of
o meals to patients
p
waas carried ou
ut
on four wards in th
he hospital. Concerns identified were
w
reviewe
ed by the D
Dietetic
Servicess Manager and
a taken to the Nutrittion Steering Group forr monitoringg of trends
and actiions require
ed
MUST a
audit resultss will be sha
ared with Maatrons and Sisters / Ch
harge Nursees and an
action p
plan for imp
provement im
mplemented
d.
There a
are plans to establish a Dementia aand Nutritio
on Group to
o ensure thaat we are
providin
ng enhanced
d catering standards
s
fo
or patients with
w demen
ntia nutritionnal needs. In
addition
n, a scoping
g exercise on the underrtaking of MUST
M
assesssments in ooutpatients
will be u
undertaken.
ated Nutritio
on Steering Group to coordinate th
hese variouus work-stre
eams.
We have a designa
73
Patien
nt Experie
ence – Dementia Sttrategy
Ou
ur Dementia
a Clinical Leaad and Serv
vice
Ma
anager are fully
f
engageed with the
me
eetings and initiatives oof the Norfo
olk
De
ementia Projject Group, Norwich CC
CG
and
d North Norrfolk CCG D
Dementia
Ste
eering Groups and Taskk and Finish
h
Groups,, and Norfollk and Suffo
olk Dementiia Alliance. Our Demen
ntia Clinical Lead and
Dementtia Services Manager have contrib
buted to the
e newly published Norfoolk Public Health
H
Needs A
Assessment and will co
ontinue to w
work with th
he hospital, with comm
missioners an
nd
external provider services
s
to meet
m
the reccommendattions. Our Dementia
D
Cllinical Lead is
mber of the new Norfol k Dementia
a Strategy Implementattion Board
also an active mem
which d
directly repo
orts to Norfo
olk Health aand Wellbein
ng Board.
Demen
ntia Friend
dly Environ
nments
A core group of re
epresentativ
ves from Serrco, Octago
on, Trust Estates and FFacilities,
Hospita
al Arts Co-ordinator and
d Health an
nd Safety ha
as been esta
ablished to ensure besst
practice
e in dementtia friendly design for T
Trust refurb
bishment an
nd new buildds. Currentlly
the gro
oup are working on the
e new devel opments in the Emergency Deparrtment.
Environ
nmental work has alrea
ady been caarried out on
n Elsing Wa
ard, which sspecialises in
the care of patientts with dem
mentia, inclu
uding colourr coding bay
ys and toiletts to help
guide p
patients around, large local
l
landsccape photog
graphs on th
he walls, annd books,
videos and games to help pattients to rem
minisce. Ite
ems such as grab rails aand toilet
seats are brightly coloured
c
to help them to stand ou
ut, and therre are clockks that show
w
both th
he time and date to hellp orient pa tients and to
t help them
m understannd when
meals w
will be serve
ed, and whe
en visitors w
will arrive.
Visual Identifiers
s
Followin
ng consultattion with pa
atients and carers via the
t Patient Experience Working Grroup,
a seriess of measure
es have bee
en agreed tto clearly ide
entify patients who havve a diagno
osis
of deme
entia using the locally and
a nationaally recognissed forget-m
me-not flow
wer and including
the use of a plain blue
b
wristba
and in addittion to ID wristband
w
for in-patientss with a
diagnossis of demen
ntia.
The Perrsonalised Plans
P
of Care Documen
nt is being amended
a
to incorporatee the forgett-menot sym
mbol and to prompt the
e use of wrisstbands and
d ‘This is me’ for patiennts with a
diagnossis of demen
ntia.
74
Patient Experience – Patient-Led Assessments of the Care Environment
(PLACE)
PLACE was introduced in April 2013 to replace the former Patient Environment Action
Team (PEAT) programme.
We have now carried out almost three years’ worth of ‘mini-PLACE’ internal assessments,
as indicated by the graph below, which maps our weighted environment score at monthly
intervals.
PLACE Average first audit scores
98%
96%
94%
92%
90%
88%
86%
Source: NNUH data, local definitions applied
Although these mini-PLACE scores are not published externally, they are reported
internally as part of the Chief Executive’s monthly performance dashboard, and they have
provided assurance that improvements introduced to the non-clinical environment are
proving effective.
Patient Experience – Complaints Handling
We have a long-established processe for investigating, managing and learning from
formal complaints and related activity.
The General Medical Council (GMC) reported in July 2014 a doubling of complaints to it
about doctors in the period 2007 – 2012. Research commissioned by the GMC has
suggested a number of underlying trends, or causes. In particular, the research from
Plymouth University suggests that the development of social media, and negative press
coverage of the medical profession, have had played a role in making the public more
prone to complain about their doctors.
75
Total Complaints by quarter
350
300
250
200
150
100
50
0
Source: NNUH data, local definition
It is anticipated that the full-year figures for 2014/15 are likely to indicate that the
number of complaints, as a percentage of activity, is consistent with that in previous
years.
There is regular national criticism of the NHS’s response to complaints, and a poll carried
out on behalf of the Consumer Group ‘Which?’ in July 2014 found that only 25% of
complainants were satisfied with the way that their NHS complaint had been handled (up
from 16% in 2012). The survey found that more than half of complainants felt that their
complaint had been ignored.
We carry out an ongoing questionnaire of complainants to obtain feedback on our
complaints process and to ascertain whether the national criticism is applicable locally.
The results of that feedback show that our processes achieve significantly better
outcomes than the national benchmarks.
Over 60% feel our
complaints process is
useful or worthwhile
[national average = 36%]
Over 60% felt their
concerns were ‘properly
listened to’
[national average <50%]
Over 60% were mainly or
very satisfied at the
conclusion of the process
[national average = 30%]
In order to ensure that complaints are used to learn lessons and propel service
improvements for patients, every complaint is reported to the relevant
divisional/departmental manager and clinical director. The file remains open until
confirmation has been received that the complaint has been reviewed, and any necessary
actions taken.
To ensure that the Trust’s complaints processes are ‘fit for purpose’ and are being
followed, they are regularly reviewed by Internal Audit. The last such review was in
February 2015. The draft report has been received and will be reported the Audit
Committee in the usual way. No recommendations for change were made. The control
framework relating to complaints was found to be well-designed and to be complied with.
76
er to provide
e additiona l assurance, we contac
cted Healthw
watch Norfo
olk
In addittion, in orde
and havve invited an
n external review
r
of a representattive sample of our com
mplaints filess.
The inte
ention is to obtain an in
ndependentt view on ‘ssofter’ or jud
dgement-baased elemen
nts of
the proccess, for exxample whetther:
- the invvestigation was proporrtionate to tthe issues ra
aised;
- the ressponse wass easy to un
nderstand a nd approprriately respe
ectful and syympathetic;;
- the ou
utcome wass fair to stafff and comp
plainant alike.
The follo
owing table
e gives exam
mples of acttions or cha
anges in pra
actice that rresulted from
complaints received
d the period
d covered b
by this report.
Ref.
Com
mplaint sum
mmary
DT.14.0
0241 Erro
or in discha
arge
med
dication.
DT.14.0
0118 Clea
aning proce
ess for
scan
nning equip
pment.
DT.14.0
0128 Dela
ay in deparrtment.
DT.14.0
0291 Una
able to ame
end
appointment due to wrong
g
telep
phone num
mber on
corrrespondenc
ce.
DT.14.0
0131 No foot
f
stool available
a
forr
elevvating leg.
Outcome
Correc
ct process discussed
d
w
with nurses
s
concerrned and att clinical goovernance and
a
medicines manag
gement meeetings.
Checklist introduc
ced to ensuure room and
scanning equipment is confiirmed as
cleane
ed after eve
ery use. Ouutcome - “Very
satisfie
ed”.
Appoin
ntment lette
er template amended to
explain
n process to
o be follow
wed and pro
ocess
of scan
n, blood tes
sts and connsultant rev
view
in one appointme
ent
Templa
ate letter co
orrected. O
Outcome - “Very
“
satisfie
ed”.
Additio
onal stools purchased .
Source: N
NNUH data
Feedbacck from com
mplainants includes
i
thee following:
“D
Dear Mrs Dugdale,
D
thank
t
you
u very mu
uch for yo
our responnse to my
y
complaint ….
… I and my
m brotherr are happ
py with th
he explanaation…Very
y
Ms J (May 2014)
2
DT.1
14.0055)
sattisfied”. (M
“W
Well pleased
d with the outcome””. (Ms T (Ju
uly 2014) DT.14.0409
D
9)
“M
My complain
nt has bee
en fully ansswered.” (M
Ms G (Aprill 2014) DT
T.13.0926)
“The Compla
aints Proce
edure wass an easy and efficie
ent processs. I would
d
like
e to thankk everyone
e involved for the professiona
p
l way my complaintt
wa
as handled…Very satisfied”. (Ms T (April 2014)
2
DT.1
14.0092)
77
Staff and Patient Experience - Meeting Equality and Diversity Standards
The Director of Nursing and the Director of Workforce have joint executive responsibility
for Equality and Diversity matters across the organisation; the Director of Nursing for
Patient Care aspects and the Director of Workforce for staff and employment aspects.
As an organisation we are committed to being an equal opportunities employer and to
building equality, diversity and inclusiveness in to everything that we do. Our goal is to
ensure that everyone – whether staff members, volunteers, patients, partners or
members of the general public – is treated fairly and with dignity and respect. To achieve
this goal we promote a culture whereby employees are able to seek, obtain and hold
employment within a productive environment free from any form of discrimination or
harassment, and where diversity is encouraged, so that the differences between
individuals within the workforce and among patients and service users are valued and
respected.
Our Equality and Diversity Group assists the Workforce Sub Board and Caring and Patient
Experience Sub Board in promoting Equality and Diversity across the Trust and its
services. Its role is to review and monitor equality and diversity practice, to make
recommendations for action and to encourage a greater awareness and understanding
across the organisation. It is committed to:•
Proactively developing and progressing Equality Action Plans and monitoring
progress across the service
•
Educating and raising awareness with regards to the Equality and Diversity
agenda.
•
Reporting to the Care and Patient Experience and Workforce Sub-Boards on a
quarterly basis.
•
Keeping up to date with Equality legislation and best practice.
•
Promoting a zero tolerance culture towards any discriminatory practice.
Equality and Diversity is part of the mandatory training programme for all staff across the
Trust.
Our LGBT Staff Support Network is for lesbian, gay, bisexual and transgender staff and
their supporters. It was set up in 2012 by staff who wanted to make sure that our
hospitals were inclusive for all people, aiming to develop a positive workplace
environment that celebrates the contribution of LGBT staff, and is free from homophobia,
transphobia, discrimination and harassment. The group also seeks to increase the
knowledge and understanding of all Trust staff about the needs of LGBT patients, carers
and their families.
Other groups that promote equality and diversity include the Patient Experience Working
Group, the Learning Disabilities, Mental Capacity and Autism group and the Dementia
Strategy Group.
78
Building a more supportive work environment
In light of the results from the latest national staff survey, we are encouraging as many
staff as possible to be part of building a more supportive work environment. Many have
already been involved in consultation about our values, and nearly 1000 pieces of
feedback have already been received, giving us vital insight into the issues that our staff
feel are important and the values that they believe every member of staff should
associate with working at NNUH.
The core values that emerged from this exercise were shared with and approved by our
governors, and are shown below.
P
R
I
D
E
Patients First
Respect
Integrity
Dedication
Excellence
I will always
put the needs
of our
patients first,
work to ensure
our hospitals
are safe for
patients,
visitors and
colleagues and
‘speak up’ if I
think safety is
being
compromised
I will always
act with
compassion,
kindness and
sensitivity,
treating others
as I would
wish to be
treated
I will always
act with
honesty, strive
to do the
right thing
and maintain
the highest
professional
standards to
uphold the
trust of our
patients and
staff
I will always
uphold the
importance of
teamwork and
communication,
and carry out my
duties to the best
of my ability
I will always
strive to
continuously
learn and
improve in
order to
achieve the
highest
quality of
care and best
outcomes for
our patients,
including
through the
integration of
leading
research to
establish NNUH
as a leader in
healthcare
79
Innova
ation in practice
p
NNUH first acute
e hospital to
t use elecctronic mu
usical reco
ord with pa
atients wh
ho
have dementia
We are the first acute hospital in the cou ntry to use an electron
nic musical record, called
Musical Mirrors, to help staff communicat
c
te and reminisce with patients
p
whho have
dementtia.
The Musical Mirrorss project inv
volves train
ning staff to catalogue the musicall memories of
patientss with deme
entia, creating an electtronic record
d with links to clips on YouTube.
Hospital volunteer Heather Ed
dwards startted the projject, drawin
ng on her exxperience as a
a. Heather also
a plays thhe keyboard
d
musician and carerr for her father who haad dementia
twice a month on Elsing
E
Ward
d, which speecialises in the
t care of patients witth dementia
a.
New Po
odcasts fo
or Patients
s with Diab
betes
The Dia
abetes department laun
nched a new
w series of free
f
podcassts to help i mprove peo
ople's
self-man
nagement of
o their own
n diabetes. D
Delivered by
b leading ex
xperts, theyy provide
valuable
e advice and
d support on
o topics ran
nging from diabetes prrevention annd diagnosis, to
how ind
dividuals can
n manage the conditio n in the besst way and avoid compplications.
es preventio
on and diagn
nosis podcaasts aimed at
a children with
w diabetees have bee
en
Diabete
available on our we
ebsite since
e 2009, and so far they
y have been
n played neaarly 16,000
The new serries is specifically for o
older patientts, and for those
t
with ttype 2 diabe
etes.
times. T
eople will ha
ave diabetees in the UK
K.
National trends esttimate that by 2025 fivve million pe
Increase
ed awarene
ess of the risks, lifestylee changes and
a improve
ed self-mannagement
among people with
h diabetes are
a becomin
ng increasin
ngly importa
ant.
DNA sc
cheme tha
at could rev
volutionise
e cancer treatment
As part of the East of England
d Genomic M
Medicine Ce
entre, we arre at the forrefront of a
newly a
announced genetics
g
pro
oject that co
ould revoluttionise treattment for inndividual cancer
patientss.
Under the scheme,, over the next
n
three yyears, we wiill be inviting 2,500 pattients with
ncers to allo
ow their tum
mours and some
s
of the
eir healthy ttissue to be
e
certain ttypes of can
analysed geneticallly. There will then be a compariso
on between the two sa mples to look
ations in DN
NA which may
m be caus ing the tum
mours. It is hoped
h
this sstudy will
for muta
eventua
ally lead to better-desig
b
gned treatm
ment for eacch individua
al patient wiith cancer. The
T
project will be unde
ertaken in collaboratio
c
n with Cam
mbridge, as well
w as ten other centrres in
England
d.
80
Organisation Wide Learning (OWLs)
We have launched a series of regular electronic bulletins that disseminate key learning
points to staff from a variety of sources such as RCAs, audits, investigations and national
reports, alerts and recommendations. Staff are notified of a new OWL bulletin through our
weekly Communications Circular and all current and past copies of the bulletins are easily
accessible via our intranet. To date, we have OWLs in respect of medications, falls,
pressure ulcers, information governance, mortality reviews, risk and patient safety. In
addition to summarising learning points from recent RCAs, each OWL also provides an indepth focus on one single key issue, which will enable an archive of learning to be
amassed that will benefit both existing and new staff members.
Patient Experience - Internal Quality Assurance Audits
We remain very proud of our comprehensive and far-reaching internal Quality Assurance
Audit programme, which we believe remains the only one of its type in the country. The
programme aims to ensure that between 1 and 3 inpatient or out-patient areas are
audited every weekday; most areas are audited approximately every 4-6 weeks.
The audit teams consist of senior nursing staff and volunteer external auditors, who
represent a host of organisations, including Norfolk Social Services; Families House; St
John’s Ambulance; NHS Norfolk; Gender Identity Services; GPs; Learning Difficulties
Partnership; UEA; NHS Retirement Fellowship; MND society; The Norwich Older People’s
Strategic Partnership Forum; Norwich MIND; The Older People’s Partnership;
Healthwatch; Age UK; Deaf UK; Crossroads Care; The Alzheimer’s Society and Trust
Governors.
Patient-centred discharge support
As part of our initiative to promote patient centred discharge, we have implemented a raft
of innovative service improvements that support patients in the immediate post-discharge
period. These include employing two dedicated discharge drivers and providing them with
wheelchair accessible vehicles that enable them to respond very quickly to requests to
transport patients to their onward destination. Since its inception in December 2014 the
service has transported almost 50 patients per week, with almost 80% of the journeys
commencing within one hour of the transport request.
From April 2015 this service will be complemented by a ‘settle-in’ service, whereby
volunteers accompany vulnerable patients on discharge and carry out checks to ensure
that they have everything they will need in their first few days back at home. The
volunteers’ tasks will include checking utilities (heating, water etc.) and food supplies,
making any essential purchases, and completing falls environment risk assessments.
81
Internship Programme
We have developed an innovative internship programme, in partnership with UEA, that
was initially open to graduates of the business school, and is now being extended to other
faculties, including sciences and arts, to enable us to spot talent early and develop
graduates keen to make a career in the NHS.
Leadership Development Programme
We are very proud of our Leadership Development Programme, which develops those
individuals with the potential to be leaders for the future. The course is now in its third
year and blends lectures, simulation exercises, practical tasks and exposure to other
organisations, including the commercial and private sector. The course exposes the
participants to an eclectic and exciting mix of learning that includes team building in a
variety of different environments, service improvement and process redesign, learning
about emotional intelligence (EI), how to develop their own EI and the impact this has on
others. Our existing leaders share their experiences - both good and bad - of their own
development, and the participants also spend time with their peers in other hospitals,
seeing how those other organisations develop their people and establish their strategies
and values. Residential sessions expose the participants to new and different healthcare
sectors, and in 2015 we visited NASA to see how NASA develops its approach to safety,
exploring the potential benefits of applying the underlying principles to the healthcare
setting. Course participants undertake a project, jointly or individually, which supports the
hospital in its ongoing improvement programme, and the participants carry their learning
back into the daily workings of the hospital to improve care, efficiency and morale.
Norfolk and Suffolk Dementia Alliance
We took a leading role in setting up the Norfolk and Suffolk Dementia Alliance, which is at
the forefront nationally of improving the care of patients with dementia. The Alliance has
promoted an integrated, ground-breaking approach that engages with patients, their
families, carers, commissioners, hospitals, private community healthcare providers, further
and higher education providers, voluntary organisations and local media organisations.
The Alliance provides education and training to both paid and unpaid carers of people
with dementia, and raises awareness in the wider community of the needs of people with
dementia.
82
Awards and Commendations
National awards for End of Life Education Programme
A training project for end of life care, led by Emma Harris, Specialist Palliative Care Nurse,
has won two national awards. At the International Journal of Palliative Nursing Awards
2014 the project scooped the top award in the Multidisciplinary Teamwork award and was
third in the Development award.
The aim of the project was to improve the training of health and social care staff to
support patients with end of life care. The project brought together a broad mix of
different professions for end of life care training sessions, including paramedics, social
workers, physiotherapists and health care assistants. It was funded by the NHS East of
England to ensure high quality end of life care is available to all who need it, irrespective
of diagnosis or place of care.
Over the three year project a total of 10,000 staff were trained, with the aim to improve
confidence of health care professionals dealing with end of life patients and to reduce
unnecessary hospital admissions.
Rate of survival figures for trauma patients treated at NNUH best in the region
New figures show a rise in the number of patients treated at the Norfolk and Norwich
University Hospital who survive after trauma. The figures published by the Trauma Audit
and Research Network show that between January 1st 2011 and December 31st 2013 the
NNUH had an extra 1.2 addition survivors out of every 100 patients – the best outcomes
in the region.
Dermatology Nurse Consultant wins prestigious award
Dermatology Nurse Consultant Carrie Wingfield has
been given a prestigious lifetime achievement
award by her peers. Carrie was presented with the
Stone Award by the British Dermatological Nursing
Group (BDNG) at their annual conference on 30th
June. The Stone Award is named after the founder
of the BDNG and first recipient of the award
Lynnette Stone CBE, and recognises the work of an
individual who has made a consistently significant
contribution in the field of dermatology nursing.
Carrie has worked in dermatology for 20 years and
at NNUH for 17 years. She was our first nurse
prescriber and our first nurse consultant.
As a nurse consultant she has had extra specialist
training and works independently alongside other
consultants within the dermatology department.
She holds clinics and carries out skin surgery on patients to remove cancerous lesions at
NNUH and Cromer Hospital.
83
National Award for NNUH Radiography Team
Our radiography team has been awarded the UK and regional Radiographer Team of the
Year. The Radiographer of the Year annual awards, organised by the Society of
Radiographers, aim to recognise the hard work and dedication of radiographers across the
country.
Our team was praised for their collective knowledge, experience and enthusiasm as well
as their commitment to highlighting best practice and raising standards in CT cardiac
imaging for patients.
The award acknowledged the CT cardiac advanced practice radiographers’ commitment to
improving services for patients undergoing a CT coronary angiography examination. The
procedure is used to assess any disease that may be present in the coronary arteries. The
CT scanner is used to take detailed images of a patient’s heart and may involve injecting
an iodine-based dye into the blood stream to highlight the blood vessels.
Karen Reid, senior radiographer cardiac team lead said: “As a team, we are proud and
delighted to receive the award. This award recognises our commitment to raising the
profile of advanced practice and diagnostic radiography as a profession. Without the
direct support and encouragement of our forward thinking radiologists, this level of
advanced practice to improve patient care in CT coronary angiography examinations
would not have been achievable. We see this as a tribute to our department, recognising
the contribution of our radiographers, nurses, radiology assistants and administrative
colleagues.”
Top in the country for its Oesophago-Gastric Cancer Team
We have been named as top in the country in the National Oesophago-Gastric Cancer
Audit 2014.The national data shows that patients treated at NNUH in 2012/13 have the
lowest mortality rate (0.5%) compared with every major cancer centre in the country. In
addition, we have low operative complications and the shortest length of hospital stay (8
days) after major complex operations for cancer of the oesophagus (gullet) and stomach.
The unit is one of the few in Europe to perform totally minimally invasive
oesophagectomy, whereby the entire operation is done through a keyhole method
(laparoscopic and thoracoscopic oesophagectomy). The keyhole or laparoscopic surgery is
less traumatic to the body and the patient recovery from a major complex cancer
operation is significantly faster and better.
Mr Edward Cheong, Consultant Oesophago-gastric and Laparoscopic Surgeon, and Upper
GI Cancer Lead said: “This is the result of the continuous hard work, dedication and
commitment from the whole oesophago-gastric cancer team at the NNUH. The
introduction of minimally invasive oesophagectomy surgery for the last four and half years
has brought enormous benefits to our patients.” In addition, our enhanced recovery
programme ensures that patients are active participants in their own recovery process.
84
Appendix A - National Clinical Audit – Actions to
improve quality
Audit and Survey
Title
Myocardial
Ischaemia
National Audit
Project (MINAP)
data quality
validation
(2013/14)
Myocardial
Ischaemia
National Audit
Project (MINAP)
completion of
key fields (Target
90%)
National Audit of
Cardiac
Rehabilitation
(NACR)
National
Emergency
Laparotomy Audit
(NELA)
Results/Actions Taken / Planned
This audit looked at data accuracy in 20 selected data fields held on the
MINAP database. The audit results found that we achieved an overall
%age of 95% against the National average of 92%. We scored 100& for
13 fields, 95% in 2 fields, 85 % in three fields. Two fields were identified
which could be improved: a) smoking status (80 %) and b)
Thienopryidene (75 %). As a result of the audit, the figures were rechecked and it was discovered that for patients being prescribed
clopidogrel instead of thienopryidene a ‘No’ was being put in this field
instead of ‘Not indicated. This will be amended for next year so next year
the compliance figures should improve.
The audit was undertaken to determine the data accuracy in 19 selected
fields held on the MINAP database. We achieved an average of 98.1 %
data completeness score. For 16 of the data fields we scored 100 %, for
the 3 remaining fields we scored 94 %, 99 % and 68 %. The 68% score
for the ‘discharged on thienopyridene’ field is due to the confusion
between clopidogrel and the new field ‘ticagrelor’. For example if a patient
was discharged on ticagrelor, a ‘no’ was put in the discharged on
clopidogrel box rather than ‘not indicated’. A computer generated
response will be developed to improve this.
The NACR aims to increase the availability and uptake of cardiac
rehabilitation, promote best practice and improve service quality in
cardiac rehabilitation programmes. The national report on Cardiac
Rehabilitation was published in December 2014. The NACR report shows
an uptake of 45 % for cardiac rehab nationally, locally we achieve over
80% uptake for patients after Percutaneous Coronary Intervention and
Myocardial Infarction. The report highlights the need for programmes to
start rehab earlier and to ensure rehab is of the recommended duration.
Recent changes mean that patients do start rehab within the
recommended times. Duration of the programme is not at recommended
standard but increasing individualisation of programmes allows this to be
met where needed. Recent database changes have resulted in better
outcome collection and ensuring that patients are all offered and
reoffered rehab in line with report guidance. Work is required over the
next year with NACR towards uploading data electronically; this will then
enable us to look for national certification of our programme. A business
case is being compiled for patients with heart failure which if successful
will improve access to rehabilitation for these patients.
The National Emergency Laparotomy audit examines the care of adult
patients undergoing an emergency laparotomy. Information about the
patient is submitted to the audit directly by clinicians via a web tool.
The National Emergency Laparotomy Audit has published a report of their
85
Oesophagogastric Cancer
Audit
Falls and Fragility
Fractures Audit
Programme
Sentinel Stroke
National Audit
Programme
(SSNAP)
findings from the organisational audit. 190/191 hospitals which carry out
emergency laparotomies participated in the audit. The audit made eleven
recommendations in their report. A review of our service was carried out
and there is only one recommendation we do not meet fully due to
staffing issues; ‘routine daily input from elderly medicine should be
available to elderly patients undergoing emergency laparotomy’. This will
be discussed further.
The National Oesophago-Gastric Cancer Audit covers the quality of care
given to patients with oesophageal and gastric (OG) cancer. The audit
evaluates the process of care and the outcomes of treatment for all OG
cancer patients, both curative and palliative. The national data shows that
patients treated at NNUH have the lowest mortality rate (0.5%) compared
with every major cancer centre in the country. In addition, NNUH has low
operative complications and the shortest length of hospital stay (8 days)
after major complex operations for cancer of the oesophagus (gullet) and
stomach. The unit is one of the few in Europe to perform totally minimally
invasive oesophagectomy whereby the entire operation is done through a
keyhole method (laparoscopic and thoracoscopic oesophagectomy). The
keyhole or laparoscopic surgery is less traumatic to the body and the
patient recovery from a major complex cancer operation is significantly
faster and better.
The next scheduled National Audit of Inpatient Falls is due in May 2015.
The only part of FFFAP to run during 2014/15 was the National Hip
Fracture Database (NHFD). Data for this was routinely collected and
submitted for every patient admitted with a hip fracture and a report of
their findings was published in September 2014.
The points for improvement are being addressed in terms of a
programme of measures to improve flow through Accident & Emergency
and increased input from Older Peoples Medicine (OPM) to try and
improve post-operative outcomes. Documentation has been improved
within the OPM Department to show who is present at each multidisciplinary team meeting in line with NHFD recommendations. Actions
are in progress to ensure that any patient over the age of seventy-five
with an Abbreviated Mental Test Score (AMTS) of less than seven will
receive a dementia risk assessment.
The aim of this audit was to benchmark services, monitor progress,
support clinicians in identifying where improvements are needed and to
empower patients to ask searching questions.
Performance in the SSNAP clinical audit has improved gradually over the
past year. This is a result of staff engagement and concentrated effort on
specific areas. The number of stroke consultants has been increased to
six and as a result seven day cover to the stroke unit can be provided,
and therefore consultant led ward rounds seven days a week. This has
also enabled consultants to assess stroke patients when they are on
outlying wards. There has also been an increase in middle grade doctors
from two to five which means there is nine am to nine pm cover seven
days a week. This increase means that a doctor will be available to the
rehabilitation ward over the weekend for any emergencies which should
help to prevent readmissions.
86
Pleural
Procedures
(British Thoracic
Society Audit)
National Joint
Registry (NJR)
Medical and
surgical clinical
outcome review
programme:
National
confidential
enquiry into
patient outcome
and death
(NCEPOD)
Trauma Audit
Research
Network (TARN)
on going audit
National Diabetes
Inpatient Audit Patient
This audit was undertaken to help improve the quality of care and
services provided for patients with respiratory conditions. It found that
the NNUH is performing better overall than the national average as
compared with other hospitals. Most patients are cared for by a
respiratory team on a specialist respiratory ward. Length of stay is 1 day
less than the median national stay. Majority of drains (95 %) are inserted
by experienced operators (ST3 +) as opposed to the national average of
66.9%. Actions are in progress to ensure the site of insertion of the drain
consent is clearly documented in notes.
The National Joint Registry (NJR) for England, Wales and Northern Ireland
collects information on joint replacement surgery and monitors the
performance of joint replacement implant. The National Joint Registry
published its eleventh annual report in September 2014. The report shows
very positive results nationally with numbers dying in 2013 after surgery
halved from 2003, and the risk of having the implant replaced within ten
years less than 5%. The report was reviewed locally and no further
actions were required.
The National Confidential Enquiry of Patient Outcomes and Death
(NCEPOD) aims to improve standards of clinical and medical practice by
reviewing the management of patients, by undertaking confidential
surveys and research, and by maintaining and improving the quality of
patient care by publishing and generally making available the results of
such activities. During 2014/15 NCEPOD published the results of two
studies to which the Norfolk and Norwich Hospital had contributed. One
project was in management of patients with tracheostomy and the other
was reviewing patients who died following lower limb amputation. The
recommendations of each report were reviewed with a GAP analysis
completed for each study and action plans are in place.
The Trauma Audit and Research Network (TARN) was established
following recommendations by the Royal College of Surgeons of England
in the 1980s. Its aim is to provide accurate and relevant information
around trauma care throughout the UK to aid in improvement of services.
The most recent benchmarked data shows that our survival rates are
currently the best in the region at 2.8 additional survivors per 100 for
2013/14. Additionally we have four times as many unexpected survivors
than unexpected deaths.
The number of trauma cases submitted is below the recommended 80%
of the Hospital Episode Statistics (HES) data. A review of submissions
identified some inconsistencies in criteria leading to an inflated expected
number of cases. Our methodology for selecting cases has been modified
to take account of the changes and TARN have agreed to remove
irrelevant cases such as readmissions, spontaneous onset of injury or long
standing injuries. Data quality is marginally below the 95% target. Two
new parameters, pupil size and reactivity, which previously were nonmandatory, have been included by TARN. These will now be routinely
entered where available. Our trauma lead will continue to review TARN’s
themed reports to identify any trends.
This re-audit was undertaken as part of the National Diabetes Inpatient
Audit (NaDIA) to reflect patient’s views of their hospital admission. The
audit results showed patients would like more involvement from the
87
Questionnaire
specialist diabetes staff. Patients were not always aware that their feet
were being examined as this was often part of a general examination.
Patients said they would like more information regarding any change to
their current treatment due to their admitting condition. Patients would
like more involvement in the planning of their diabetes treatment and
would like to be able to test their own blood sugar level whilst in hospital.
As a result of the audit extra resources have been found in order to
increase Diabetic Inpatient Specialist Nurses (DISN) hours and
recruitment is in progress. Nursing documentation has changed to
incorporate a foot examination and doctors have been reminded to
specifically mention to the patient that they are examining their feet.
88
Appendix B - Local Clinical Audit – Actions to
improve quality
Audit and Survey
Title
Audit of Referrals for
patients with Syncope
Audit on the
variability of block
taking in breast
specimens
Audit of Betahdroxybutyrate (BOBH) as
an indicator for early
termination of 72 hr
fast for spontaneous
hypoglycaemia
Re-audit of
Hypoglycaemic
episodes during
admission
Results/Actions Taken / Planned
The aim of the patient audit was to determine if the syncope service
was useful to patients. The results showed that patients found the
service useful; they had the opportunity to ask questions and discuss
their symptoms; they had a better understanding of their diagnosis
after their appointment; they felt supported by the arrhythmia nurse;
they found the written information useful and they received enough
information about their treatment plan; they would recommend the
service and the advice given has made a difference to them.
The audit was undertaken to determine the average number of
blocks taken in mastectomies and wide local excision (WLE)
specimens in both invasive disease and ductal carcinoma in situ
(DCIS) by each pathologist and explain any discrepancies found.
The audit found that there is minimal variability in the number of
blocks for invasive between consultants. There were only a small
number of DCIS cases which therefore made this aspect of the
results inconclusive. As a result of this audit it is being considered
whether there is a need for quadrant blocks.
This audit was carried out to determine if a level of Betahydroxybutyrate (BOHB) above 2.7mmol/L can indicate a negative fast. The
standard investigation for spontaneous hypoglycaemia is the 72
hours assisted fast. According to the Evaluation and Management of
Adult Hypoglycemic Disorders” guideline published in 2009, a BOHB
level below 2.7mmol/ is one of the criteria for diagnosing
spontaneous hypoglycaemia. The audit results found that a rise in
BOHB >2.7mmol/l is an excellent surrogate marker for relative
hypoinsulinaemia, therefore 74% of the patients in the study could
have terminated the study earlier than the allotted 72 hours. This is
better for the patient, and saves time and money. As a result of the
audit, the directorate want to expand the audit to include more
patients, to increase the reliability of the data and if successful aim to
change the management of these patients.
This re-audit was undertaken following the introduction of bed time
snacks to assess the impact of this action. The results of the audit
showed improved glucose control and patients had less
hypoglycaemic episodes compared to the audit in 2013.
As a result of the audit there was unanimous support from the ward
matrons to continue the initiative, provided that Serco deliver enough
snacks so there will be no danger of running short, and there is a
sticker added to the prescription chart so diabetic patients are clearly
identifiable in all cases.
89
Audit of Malnutrition
Universal Screening
Tool (MUST)
Audit of Hepatitis B
(Chronic) against
National Institute of
Health and Care
Excellence Guidance
(CG165)
Gastroenterology Unit
Endoscopy Comfort
Levels Audit
This audit was undertaken as part of the annual Malnutrition
Universal Screening Tool (MUST) Audit. The Audit assessed Trust
wide practice relating to the use of and actioning of MUST risk
assessments. Following the audit it was identified that the accuracy
of MUST score calculation required some improvement. This will be
actioned via the Nutrition Steering Group. The audit also found that
the use of ‘High Calorie/High Protein’ diet signs needs to be
promoted and this and a number of additional actions to ensure early
commencement and charting of supplements are being actively
considered. A re-Audit will be undertaken in 2015/16.
Chronic hepatitis B is a spectrum of disease and in some people can
progress to liver fibrosis, cirrhosis and hepatocellular carcinoma
(HCC). There is already well established antiviral therapy guidance
issued by the National Institute of Health and Care excellence, but
more recently they have combined this guidance into an overarching
clinical guideline. This audit was designed to assess our current
practice in light of this guidance. The findings showed that adults
newly referred in 2013 were offered transient elastography as the
initial test for liver disease as per guidance. No patient had an
inappropriate biopsy therefore achieving the standard. The majority
of patients not taking antiviral treatment were not offered an annual
reassessment of liver disease using transient elastography; however
annual fibroscan has only become a standard in the department in
2014 so this will now need to be reaudited.
The main actions arising from this audit are that new patients will be
offered a fibroscan on first appointment, known HBV patients not
taking antiviral treatment will have routine yearly fibroscans and all
patients will be seen in a dedicated clinic to ensure a high standard
of clinical care is achieved.
This annual audit was undertaken as part of our commitment to
participate in the Global Rating Scale for endoscopy (GRS). The
findings illustrated some endoscopists sat at the slightly higher end
of the discomfort scale but additional analysis concluded they were
not outliers and sedation doses did not vary significantly between
endoscopists or correlate with comfort scores. As a result the new
endoscopy reporting system will be designed to allow for patient
reported outcomes and facilitate a more uniform approach in the
definition of comfort.
90
Audit to Global Rating
Scale for endoscopy
(GRS) quality and
safety measures
Regional Audit - Audit
of Management of
13-16 year olds
Re-audit on
management of HIV
patients – National
British Human
Immunodeficiency
Virus Association
(BHIVA) guidelines
Audit of Management
of Non-specific
Urethritis (NSU)
The Global Rating Scale for endoscopy (GRS) is a quality
improvement and assessment tool for the gastrointestinal endoscopy
service and is managed by the Joint Advisory Group (JAG) for
endoscopy. Gastric ulcer follow-up audit: 100% compliance to the
standard.
Colonoscopy completion rates: An average 96% completion rate was
achieved between the team, with a range between 84.2% and
100%. Poor bowel preparation was seen to be the main causative
factor in not being able to complete the procedure.
ERCP Successful biliary cannulation type one: results demonstrated
an average 96% successful biliary cannulation.
This round of reviews has offered reassurance that current practice is
within accepted norms and no changes are indicated.
This regional audit was undertaken to review compliance to national
guidelines. Standards were on screening for sexually transmitted
infections, undertaking risk assessments, documenting child
protection issues and discussing contraception use. 100% compliance
was achieved to all aspects bar the latter standard where 2 of the 25
cases reviewed had no documentation around discussion of
contraception. Results were discussed at clinical governance and
staff were reminded of the importance of documentation, no further
actions were considered necessary.
The National British Human Immunodeficiency Virus Association
(BHIVA) guidelines recommend newly diagnosed HIV-1 infected
patients should be routinely investigated and monitored. This audit
was carried out to ensure that the above recommendations are
applied in practice. The results found that the genito-urinary clinic is
equal to or above the national targets for the majority of parameters.
Findings were discussed at clinical governance and as a result of the
audit the importance of cardio vascular disease (CVD) risk calculated
within 1 year of first presentation and within 3yrs if taking antiretroviral therapy was reiterated.
This audit was designed to assess clinical practice in the Grove Clinic
against BASH guidelines for management of non-specific urethritis
(NSU). Two standards were reviewed; men with NSU should be
offered treatment with a recommended antibiotic regimen and
symptomatic men should be offered microscopy of a Gram-stained
urethral smear or 1st void urine. Results showed 100% compliance to
both standards so no changes in practice were indicated.
91
National Confidential
Enquiry of Patient
Outcome and Death
(Subarachnoid
Haemorrhage) Audit
Audit of 'Intra Uterine
Device (IUD)'
guideline
Audit of under 16s
attendance at Clinic
Audit of
'Sacrocolpopexy'
guidelines
This audit was planned following the publication of the national
confidential enquiry into patient outcomes and death (NCEPOD) for
subarachnoid haemorrhage (SAH). This audit was undertaken to
assess our compliance with standard guidelines on management of
subarachnoid haemorrhage. The records of 35 patients who had
aneurysmal SAH between the 1st April 2013 and the 31st March 2014
were reviewed. The findings demonstrated that thorough
neurological examination (including vital observations, Glasgow Coma
Score, pupils, fundi and peripheral exam) was not always
documented, computerised tomography brain scan was not
performed within 1 hour of request for 29% of cases and nimodipine
was not prescribed in 45% of cases. As a result a protocol for the
management of patients with SAH is in progress.
This audit was carried out to ensure our Guideline for Intrauterine
Methods of Contraception was being followed.
The audit found that overall the results were very good; the
proforma was being used and 100% compliance with pregnancy risk
assessment was achieved.
This audit was carried out to determine the levels of satisfaction with
the service in the under-16 population attending the Contraception
and Sexual Health (CASH) clinic. The audit results found that the
service has delivered the atmosphere and non-embarrassment
culture for young people regarding warmth, privacy, posters,
receptionist and professionals. The clinic was easily accessible and
the clinic times were convenient for young people.
This audit was carried out to determine the symptoms at
presentation among women presenting with pelvic organ prolapse,
the operating time and intra-operative complications of the
procedure and to assess the efficacy in improvement of symptom at
3 months after the surgery. The audit results found that of the 17
patients included all had symptoms of pelvic organ prolapse (POP),
while 41% had overactive bladder, 29% had stress incontinence and
41% had bowel symptoms. There was primary prolapse surgery in
47% and secondary surgery in 53%. The mean operating time was
115 minutes and there were no intra-operative complications. Wound
infection seen in 1 was the only post-operative complication noted.
At the 3 month follow up prolapse symptoms were improved in 94%
and the overactive bladder (OAB) symptoms improved in 85%. One
of the 5 patients who had stress incontinence continued to have
symptoms post-operatively. As a result of the audit, surveillance
using a database will continue, as will the follow-up to see symptom
relief / recurrence. A non-comparative study to measure outcomes is
also being planned.
92
Audit of 'Thyroid
disease in pregnancy'
guideline
Audit of 'Vaginal birth
after Caesarean
section' guideline
Audit of 'Group B
Haemolytic
Streptococcus
Carriers' guideline
This audit was carried out to ensure our Guideline for The
Management of Thyroid Disease in Pregnancy was being followed, to
highlight any problems with the current guideline and to improve
adherence to the guideline should a problem be found. It was found
that 100% compliance was only achieved in one area – not
undertaking extra scans in euthyroid patients. The scanning
standards for the audit were hard to measure as the correct
antibodies were not being measured at the correct time for
hyperthyroid patients. Writing to the General Practitioners (GP) at
booking appointments, or sending the Neonatal Intensive Care Unit
(NICU) alerts to the NICU team are also points that could be
improved upon.
As a result of the audit a flowchart for antenatal clinic to attempt to
simplify the investigations needed for hyperthyroid patients will be
produced and case notes will be reviewed for those patients who
were not scanned appropriately. A discussion with paediatricians
regarding the benefits of NICU alerts in these patients and whether
an electronic system should be developed will be held. A reminder
will be sent round that all hyperthyroid patients should be seen in
maternal medicine antenatal clinic.
This audit was carried out to determine whether the current standard
of care delivered to women who have had previous caesarean
section(s) meets the Norfolk and Norwich University Hospital (NNUH)
hospital guideline, ‘Trust Guideline for the Management of: Vaginal
Birth After Caesarean. The audit results found that good VBAC rates
were achieved with high success rates, however documentation
could be improved. As a result of the audit, women who have had a
previous caesarean section will be asked to liaise early with Central
Delivery Suite (CDS) whether they are having a VBAC or Elective
Repeat Caesarean Section (ERCS). Post-natal debriefing will be
improved, as will contraceptive advice.
This audit was carried out to ensure the guideline Trust Guideline for
the Management of women known to be carriers of group B
streptococcus was being followed. The audit results found that
mothers who were identified to have group B streptococcus (GBS)
before delivery were offered and given intravenous (IV) antibiotics.
The intrapartum antibiotics were appropriately prescribed and
documented on the drug chart. Unfortunately there was no evidence
of any mother receiving a GBS information leaflet. A re-audit has
been planned for within 3 years (2017/18), and staff are actively
ensuring each mother identified receives GBS leaflet.
93
The vulval clinic was set up in the Norfolk and Norwich University
Hospital (NNUH) in July 2012 to streamline the care provided to
women with complex vulval problems. This audit was carried out to
obtain patient feedback on this new service, to assess whether
patients feel involved in decision making and to identify areas of
improvement. The audit results found that the organisation and staff
Audit of Vulval service introducing themselves were 100%, that 88% of patients strongly
agree they had enough privacy, that 100% of patients felt involved in
decision making, that 96 % of patients felt that the follow up and
obtaining results were clear and the satisfaction rate was around
73% for verbal/written information. Overall 85% were very satisfied
and 96% would return to the clinic. Following a review of privacy and
dignity comments a re-audit has been planned for 3 years (2017/18).
This audit was undertaken to evaluate and obtain feedback on the
Audit of the outcomes service being offered at the Norfolk & Norwich University Hospital for
of possible Cataract
patients to have their outpatient, assessment and cataract surgery in
Surgery
one day. The feedback was very positive and as a result, no
immediate actions were required.
This audit was undertaken to review the free tissue transfers
performed. The aim was to determine number of free tissue transfers
performed, identify types of free tissue transfers performed by subAnnual free flaps
specialty within Plastic Surgery, determine demographics of patients
audit (Head & Neck,
having free tissue transfer and to identify mortality and morbidity of
Breast, trauma data)
free tissue transfer patients. Overall the results showed that our Flap
salvage rate is excellent and that our data supports no gross
technical problems.
This audit was undertaken to review upper limb flexor tendon repairs
looking at rupture rate of repair and development of contractures.
The audit highlighted that delays of greater than 48 hours to surgery
have negative impact on patients with Zone II injuries resulting in
poorer outcomes. Also 50% (n=2) of the ruptures occurred with
Flexor tendon repairs
zone II injuries repaired with Strickland core suture (double kessler
audit
4.0 prolene + 4.0 PDS mattress). Strickland type repairs have higher
rate of rupture and poorer outcome in mobility and function.
As a result of the audit, it was decided to standardize core suture
materials and techniques at departmental level and to prioritise
patients with zone II injuries for urgent repairs.
This audit examined the number of patients who are dialysed
through a permanent fistula at start of treatment and whether a
permanent fistula is still in use for patients dialysed for 90 days.
Information was collected and analysed on a monthly basis by the
Dialysis Access Nurse Specialist. The audit results were collated and
Haemodialysis
discussed at a quarterly vascular access meeting by the renal team.
vascular access audit At the latest meeting in November 2014 the results showed that 78%
of patients starting haemodialysis had a working fistula (national
target of 65%. In the cohort of patients who have been dialysed for
90 days, 82% of them were dialysing via a working fistula (national
target of 85%). The Renal department will continue to audit this
regularly and have added this audit to their audit plan for 2015/16.
94
Adequacy of
haemodialysis audit
Audit against Trust
Discharge Standard –
inpatients are
provided with
relevant information
prior to discharge and
this is documented in
the Discharge
documentation in the
patients’ medical
notes for inpatients
Audit to look at the
quality of
documentation in
Occupational Therapy
Care Quality
Commission
fundamental
Standards Audit –
Effective, Responsive,
Well-led, Safety,
Caring and Patient
Experience
Pressure Ulcers Audit
Audit of Compliance
to Policy on
Procedural
documents
An audit was carried out on all patients currently undergoing
haemodialysis at NNUHT using measures recommended by the Renal
Association. Patients on haemodiafiltration were not included in the
audit. It was found that there were 8 patients out of the 45 in the
audit for whom efficacy was below recommended levels. Each of
these patients has had their management plan reviewed and will be
reviewed again in 3 months’ time.
This audit was undertaken to assess the feedback from Care Homes
relating to the concerns and suggestions with regards to our
Discharge Process and to establish whether general improvements
have been made with changes implemented.
The feedback raised both positive and negative aspects of discharge
and as a result it was decided that we should print and use the
transfer of care document from the care homes to NNUH. In addition
to the above, many of the elements of discharge were also audited
as part of the larger Trust wide Documentation Audit.
This audit was undertaken to assess the quality of Occupational
Therapy Documentation to ensure that documentation is accurate,
clear and appropriately documented. The audit highlighted the need
to educate staff on printing name as well as signature.
These audits are based on enhanced Care Quality Commission
Outcome standards. They are undertaken on a daily basis by our
matrons, sisters, charge nurses and allied professional colleagues,
alongside our team of external auditor volunteer patient
representatives. Results are shared with all relevant clinical and
managerial teams and are reported monthly to the Trust Board. The
audit programme runs continuously. Feedback from patients is
actively sought, especially by our external audit team members and
is used to help inform on-going improvements in services.
This on-going surveillance audit reviews all PUs in the hospital.
Various methods are utilised for the audit these include: review of
Datix, review of ward documentation during CQC Quality Assurance
rounds and ward staff review of documentation. A weekly PU report
of any Grade 2 or above PU is circulated to Senior Staff. An RCA is
undertaken by ward staff and the Director of Nursing for any
reported Grade 2 or above PU. An action plan is formulated following
the RCA.
This re-audit of compliance to our Policy on Procedural documents
reviewed 71 procedural documents on Trustdocs. Overall compliance
had improved since the previous audit. However the audit found that
an urgent review of all documents marked as a ‘procedure’ on
Trustdocs should be undertaken. It was recommended that
gatekeepers who can approve and upload documents to Trust docs
should be limited. Since the audit a Procedural Documents Manager
has been employed. The post holder with support from a Band 2
post is reviewing and formatting documents into the correct form. A
re-audit will be undertaken in 15/16.
95
Clinical Audit Policy
Monitoring of
Compliance Audit
Implementation of
National Institute of
Health Excellence
(NICE) Policy
Monitoring of
Compliance Audit
Implementation of
Best Practice NCE
Policy compliance
audit
Clinical Handover of
Care Audit
Audit of compliance
to Discharge Policy
Spinal Cord
Stimulation Audit
This re-audit of compliance to our Clinical Audit Policy reviewed a
random selection of 32 Audit evidence folders from the 13/14 Trust
Audit Plan. The audit found that not all facilitators were using the
central drive to maintain evidence. A number of actions were
undertaken following the audit to ensure compliance to the policy.
These included: individual feedback to facilitators, introduction of an
evidence sheet for each audit, paperwork was reviewed so that it
was simplified and ensured no duplication of paperwork was
undertaken. A re-audit will be undertaken in 15/16.
This re-audit of compliance to our Implementation of National
Institute of Health and Care Excellence Policy reviewed a random
selection of the central evidence folders (April 2013- April 14) and
the central NICE Spread sheet. The audit found that a minor
amendment to the Policy was required and that evidence was
available from Divisional Boards when formal risk assessments
relating to NICE presented. A re-audit will be undertaken in 15/16.
This was a re-audit of compliance to the National Confidential
Enquiries Policy. The audit found that compliance to the Policy was
good with only one amendment to the Policy required. A re-audit will
be undertaken in 15/16.
Following the implementation of new nursing documentation regular
audits have been undertaken to look at different components of the
transfer processes and compliance with the guidelines.
Key audit findings were that compliance with relevant documentation
and, therefore, evidencing of risk assessment and appropriate
actions having been undertaken requires improvement. Actions
undertaken to improve this include; profile of the requirements
regarding documentation around the transfer risk assessment
process and handover documentation raised with the publication of
updated documentation guidelines; dissemination of results to
relevant teams and engagement of Early Warning Score Links Group
in embedding improvements in practice; compliance with transfer
documentation added to Matrons’ Rounds proforma and Quality
Assurance Audit prompts; a process has been set up whereby ‘out of
hours’ transfers (08.00-20.00hrs) can be audited and a pilot has
been undertaken; the transfer risk assessment tool and designated
place to document risk assessments and actions have been placed in
a draft ‘Risk Assessment Booklet’.
An audit of compliance with the completion of the Home
Circumstances and Discharge documentation demonstrated little
improvement from that undertaken the previous year. The results
have been disseminated to all clinical leads but an on-going audit
throughout the year has been established that will enable wardspecific feedback to be provided with the aim of effecting improved
performance.
This audit was undertaken to determine patient satisfaction who
were the on the Spinal Cord Stimulation (SCS) Pathway. The audit
found high levels of patient satisfaction had been maintained from a
previous audit.
96
Audit of
Gastroenterology Unit
Patient Experience
Big C centre
information day
evaluation audit
Diabetes Eye
Screening Audit - Pt
Questionnaire
Dacrocystorhinoscopy
Audit
Young Persons'
Epilepsy audit
Audit of Patient
satisfaction with the
Urology One Stop
Clinic (2014)
This audit forms part of the requirements of the Global Rating Scale
for endoscopy (GRS). The overall aim is to ensure patients
experience the optimum level of care and that their feedback is
considered in service provision. The questionnaire has been
specifically designed to incorporate the GRS performance measures.
The findings show that the Gastroenterology Unit continues to
provide a service in concordance with recommendations and patients’
views on this service remain very positive.
The National Cancer Survivorship Initiative (NCSI) is a partnership
between NHS England and Macmillan Cancer Support. They
recommend an intervention called “The Recovery Package”, which
includes patient education and support events (health and wellbeing
clinics) designed to give the person affected by cancer all the
information they need to enable rehabilitation and self- management.
This audit was undertaken to ascertain patient satisfaction from the
May information day. Feedback was very positive and supported the
continuation of these events.
This audit was undertaken to assess the satisfaction of patients
attending for Diabetes Eye Screening and to highlight any areas
where practice could be improved. The feedback received was very
positive and as a result, no immediate actions were required. This
will be re-audited again in 2015/16
This audit was designed to measure the level of symptom severity
post treatment whilst establishing an effective tool to measure the
treatment. Patients reported high levels of satisfaction, the
questionnaire was well answered and all questions asked on the
questionnaire were relevant. There was a 68% response rate. It was
agreed that the questionnaire would be revised for future use based
on the feedback received.
The Nurse–led young person’s epilepsy clinic supports young people
transferring to adult services. The audit was undertaken as part of
routine monitoring to establish if the clinic is providing a relevant and
appropriate service. The audit did not highlight any deficiencies in
practice therefore no specific actions were required.
This re-audit was undertaken to establish whether the One Stop
clinic continues to provide a high quality service without worsening
wait times or reduced patient satisfaction. The findings demonstrated
that patients continue to be happy to have investigations in one
sitting, despite a slight increase in waiting times compared to the
previous audit in 2013. The only negative comment was regarding
the number of toilets available for patients. As a result of the audit
an action plan to review toilet facilities will be undertaken in which
information about where to find additional toilets in the area will be
displayed in the clinic.
97
Patient Advice and
Liaison Service
Satisfaction audit
Audit of World Health
Organisation (WHO)
surgical checklist
(Gastroenterology)
Audit to World Health
Organisation (WHO)
check list for Genital
biopsy
Audit of Venous
Thromboembolism
(VTE)
Thromboprophylaxis
(TPX)
Medicines
Reconciliation audit
This was the first audit undertaken by Patient Advice and Liaison
Service (PALS) to evaluate their service. The audit was an electronic
questionnaire with a link being distributed to enquirers who
contacted PALS by email. The responses were evaluated and no
immediate causes for concern/action needed for improvement were
identified.
This audit was focused on the use of the World Health Organisation
(WHO) surgical check list in endoscopy. It aimed to ascertain if there
was documented evidence that the check list had been used. As a
result of the audit new endoscopy unit care plans are currently being
developed and a pre-printed section to replace the stamp has been
incorporated. It is recognised than an observational audit would be
required to ascertain if the check list has been used appropriately
and this is planned for 2015-16
The WHO surgical checklist is a safety checklist for completion for all
surgical procedures. The Audit in GUM was a retrospective audit on
the completion of the form for all patients who had had a genital
biopsy between 1st April 2013 and 31st March 2014.
Twelve biopsies were reviewed and the findings showed that for
each one the surgical checklist was completed 100% and therefore
no improvements were deemed necessary.
These Trust-wide quarterly audits on the use of the drug chart
Thrombosis Risk Assessment (TRA) were undertaken as the
inconsistent use of prophylactic measures for venous
thromboembolism (VTE) in hospital patients has been widely
reported and has been made a national health service priority. The
findings of the audits show that between 90 and 93% of patients had
a completed risk assessment with between 28 and 32% being
reassessed in 24 hours. As a result the latter target has been made
the focus of educational training and thromboprophylaxis is a core
item of the planned VTE link nurse/midwife study day.
This audit was undertaken to determine that we are compliant with
National institute for Health and Care Excellence /National Patient
Safety Agency technical patient safety solutions for medicines
reconciliation. This guidance states that on admission to hospital all
adult patients should receive pharmacist-led medicines reconciliation.
This audit found that pharmacy led-medicines reconciliation can be
achieved within 48 hours of admission for patients admitted SundayThursday. However, patients admitted on a Friday / Saturday were
unlikely to receive pharmacist-led medicines reconciliation before 48
hours. Recent actions to address this include: Asking pharmacists to
return to the ward late on a Friday afternoon to carry out medicines
reconciliation for any patients admitted later in the day. Pharmacy
are piloting a 12 hour, 7 day a week service based in A&E to
determine the impact on medicines reconciliation.
98
Prescribing Audit
Audit of Missed Doses
in patients with
Parkinson’s Disease
Audit of Saving Lives
High Impact
Interventions
Infection Prevention
and Control: Central
Line Surveillance
Audit
This audit was undertaken to determine compliance with the legal
requirements for the safe prescribing of drugs. The standards are
taken from our Medicines Policy and Procedures. This audit found
that overall prescribing is good, however there are a number of key
areas requiring improvement, such as the cancelling of prescriptions
in accordance with our Medicines Policy, documentation of allergies
and ensuring completeness of prescribing when required medication
(i.e. prescription states a maximum dose and indication). As a result
of this audit, a number of interventions have been introduced to
improve the standards of prescribing. This includes: the provision of
a ward pharmacy service, Datix reporting when standards are not
met, the pharmacist intervention project and more recently, the
introduction of electronic prescribing (EPMA).
This audit was undertaken to determine if medicines for the
treatment of Parkinson’s Disease are not avoidably missed due to
stock unavailability. When it is found that medicines are avoidably
missed the reasons for this are reviewed and changes made to help
resolve similar omissions occurring in the future. The most recent
audit found that no medicines were missed due to unavailability.
Actions of previous audits include addition of various Parkinson’s
drugs to various ward stock lists and ensuring availability of nonformulary Parkinson’s drugs.
These are on-going audits undertaken across the hospital. Agreed
actions to improve practice include: divisional audit Surveillance
Nurses carry out spot checks on wards/departments and the findings
identified are disseminated to the staff; Surveillance Nurses actively
promote best practice to all the staff on Trust policy regarding care
and management of: Central Venous Catheters (CVC) / Peripheral
Inserted Central Catheters (PICC) & Urinary Catheters and
completing care plans; ward based/departmental training sessions
(linked closely to the practice development department) are
undertaken covering all aspects of care for indwelling devices.
The Central Venous Catheter Surveillance programme was
undertaken to record infection rates related to Central Venous
Catheters in adults outside the Critical Care Complex. The
Surveillance found that the infection rates related to CVC lines are
well below the Matching Michigan bench mark of 1.4 per 1000 line
days. Three infections found were in long term lines. Two were used
for Total Parental Nutrition and were admitted from home. As a
result of this surveillance we have been reassured that infections
have not been reported in temporary lines inserted during the
inpatient stay. The Nutrition team also have this data to support their
work with patients with total parental nutrition in the community.
99
Infection Prevention
and Control: Surgical
Site Infection (SSI)
Surveillance Audit
Audit of Compliance
to Consent Policy
Audit of Health
Record-Keeping
Standards
Slips, Trips & Falls
(Patients) audit
The Vascular Surgical Site Infection Surveillance programme was
undertaken to record Surgical Site Infection rates in patients
following vascular operations, with an aim to reduce rates. The
surveillance found that the SSI rate had dropped since 2013 but
work is on-going to reduce it further. As a result of this surveillance
SSI bundle practice audits have been introduced, an information
leaflet including information for patients around recognising SSI and
what to do in this instance is awaiting approval and antibiotic
prophylaxis has been changed.
This audit included a retrospective review of consent forms to
ascertain compliance against Trust Policy. The audit demonstrated
good compliance with required signature evidence from healthcare
professional staff and patients. An opportunity was identified for
enhancing compliance with the documentation of alternative
treatments and the giving of patient information leaflets. This
involves an active drive to develop more procedure specific consent
forms and to make the approval of these more streamlined. In
addition, it was recognised that future audits would be enhanced if
minor differences within the current suite of consent were made to
ensure more uniformity. These actions are in progress.
This was a detailed re-audit of compliance with the Nursing and
Patient Care Record (PCR) documentation undertaken at the end of
September 2014. Over 100 PCRs, Discharge Checklists and Nursing
Assessments and Plans of Care were reviewed and a very ‘literal’
assessment made of compliance with documentation of something in
each section of the documentation where required. The results of
the audit were disseminated to senior clinical staff and to the Clinical
Safety Sub-Board. From January 2015 a rolling programme of health
care record keeping standards will be undertaken for adult in-patient
wards. This will allow more documentation to be reviewed for each
area to enhance reliability of results and allow clinical areas to create
action plans targeted specifically for their ward.
Over 100 Nursing and Patient Care Records were audited in
September 2014. The audit demonstrated that overall performance
has deteriorated in relation to documentation of falls risk
assessments in nursing documentation. The results were
disseminated to all relevant leads and clinical staff for review and
action in their areas if required. A Risk Assessments and Care Plans
booklet was developed and introduced to make requirements clearer,
easier to document and to avoid any duplication. From January 2015,
regular on-going audits to be undertaken and results appropriately
disseminated that detail ward-specific compliance and are included
within the Nursing Quality dashboards.
100
Moving & Handling
Audit
Do Not Attempt
Cardio Pulmonary
Resuscitation
Documentation Audit
Over 100 Nursing and Patient Care Records were audited in
September 2014. The audit demonstrated good compliance when
manual handling needs were identified in nursing documentation.
The results were disseminated to all relevant leads and clinical staff
for review and action in their areas if required. A Risk Assessments
and Care Plans booklet was developed and introduced to make
requirements clearer, easier to document and to avoid any
duplication. From Jan 2015, regular on-going audits to be undertaken
and results appropriately disseminated that detail ward-specific
compliance and are included within the Nursing Quality dashboards.
Audits of our documentation as stipulated in our ‘Do Not Attempt
Cardio-Pulmonary Resuscitation’ (DNACPR) policy, including
documentation of conversations in relation to DNACPR status, have
been undertaken using 2 different methodologies during the period.
The first audit included review of clinical notes for handwritten
evidence of discussions with patients or their families, when these
had not been indicated within the designated section of the PCR.
The second audit reviewed only the DNACPR section on the front
page of the Patient Care Record (PCR) for evidence that discussion
with patients and / or their families had taken place. Comparison
between the audits demonstrated a drop in performance; suggesting
those conversations with patients and / or their families may not
always be indicated in the relevant designated section afterwards.
Whilst all DNACPR decisions had been documented by those with
appropriate seniority, counter-signature within 24 hours by a
consultant had dropped within the second audit.
In response to these and the full audits’ findings, actions taken have
included: feedback of the results to clinical staff; commencement of
an on-going audit of the designated DNACPR section of the PCR
within a planned rolling audit of compliance with health-record
keeping standards to provide ward-level compliance to effect
improvement; imminent production and distribution across the
organisation of a patient information leaflet to help support patients,
relatives and staff in discussions around DNACPR status.
101
Early Warning Score
(EWS)
Observation
Documentation,
Recording and Early
Warning Scoring
(NHSLA 4.8) Audit
Audit of Medical
Devices Training
Local Induction of
Temporary Staff Audit
A monthly audit programme of a sample of patients who have
triggered the EWS is in place. These results and distributed across
the organisation to consultants, doctors, senior nurses and ward
sisters and also appear on Nursing Dashboard Matrix, so
performance is discussed with senior nursing staff and the Director of
Nursing. Areas not performing well have visit from Director of
Nursing and Critical Care Outreach Team Lead to discuss how
improvements can be made. The focus is on key set targets. Actions
undertaken over the year include; revision of our observation chart
has occurred and a new call out cascade has been implemented;
information has been disseminated regarding changes through EWS
Links; ward sisters, senior nurses, doctors induction training days
undertaken by the team; each ward has an EWS results poster
delivered on a monthly basis showing % compliance with both EWS
trigger response and the quarterly observation completeness and
accuracy; information available on the intranet on the use of the
EWS has been updated and given higher visibility with a link via an
EWS logo.
This audit was undertaken to demonstrate how we identify
permanent staff who are authorised to use equipment listed on the
inventory, the training required, the frequency of training required
and records all permanent staff complete training. We were found to
be compliant with all but one standard (the frequency of training
required) which is being addressed via the Medical Devices Training
Group.
This re- audit was undertaken to demonstrate compliance to NHSLA
Standard 3.3 and forms part of the CQC Key Lines of Enquiry under
Workforce. The audit looked at a random selection of temporary staff
files from medical staffing, nurse bank and the radiotherapy
department. Significant improvements in compliance were
demonstrated in all areas. A re-audit in therapies will be undertaken
in the Year 15/16 and a re-audit of medical staffing and nurse bank
in 2016/17.
102
Annex 1 - Statements from Clinical
Commissioning Boards, Local Healthwatch
organisations and Overview and Scrutinty
Committees
Statement from NHS North Norfolk CCG
North Norfolk Clinical Commissioning Group (NNCCG), as the host commissioning
organisation for Secondary care services on behalf of Norfolk CCG’s, confirm that the
Norfolk and Norwich University Hospital Foundation Trust (NNUHFT) have consulted and
invited comment on their Quality Report for 2014/15.
NNCCG have reviewed the report and confirm that it provides a fair reflection of both the
challenges and achievements experienced by the Trust over the past year.
NNUHFT have, along with a number of other Trusts around the Country, faced significant
challenges in delivery of national standards which have been impacted upon by a range of
internal and external pressures, increased activity and demand upon hospital services.
While this has no doubt resulted in additional pressure on staff and certainly there were
some worsening of staff satisfaction noted within the staff survey results, it is reassuring to
see that there remains a clear focus on the drive for quality of care and continued
improvements within the organisation, and that staff remain innovative and quick to
identify solutions whenever a deficit in care is detected, demonstrating the key
foundations for a learning organisation.
The Trust has made every attempt to be open and transparent around their delivery of
services, maintaining regular Quality Assurance Audits to wards and units for both internal
and external auditors. We have been encouraged by the Trust’s openness in engaging
commissioners in the review of services and Root cause analysis alongside clinical teams
and positively engaging in monthly Clinical Quality Review meetings with commissioners
in order to provide assurance around the range of challenges that the Trust are currently
tackling.
The review undertaken by the Emergency Care Intensive Support Team (ECIST) during
December and January provided a useful backdrop for identifying a range of possible
areas of improvement in patient flow pathways both within the Trust and across the wider
Health and Social Care system. The report was readily received by the Trust, and they
have been keen to learn from it and implement a programme of change to develop more
effective discharge processes for patients.
During the 1ST Quarter of 2015/16 it is expected that we will see the essential recovery of
delays in Cancer Care waiting times and A&E performance and, as the year progresses,
the 18 week referral to treatment waiting time. While there are robust systems in place to
ensure that those patients with the highest need are seen as a matter of priority and
urgency, it is hoped that the necessary improvements to capacity, resources and patient
flow will ensure improved access for all patients.
103
Key areas of response to the National Stroke Care standards have been variable across
the year, again this has been effected by the internal pressures experienced by the Trust,
we expect to see more consistent access to hyper-acute stroke beds and the timely
intervention of the specialist support services they offer to patients over the coming
months and we will be monitoring this with the Trust.
Recognising the demographic profile of Norfolk, in particular growth within the population
especially with regards the increase of our ageing population across Norfolk, it is
important that CCG’s work with NNUHFT to adequately “futureproof “ Norfolk’s acute
health services and ensure ongoing quality for our patients. Recruitment of medical and
nursing staff is fundamental to its maintenance, as is ensuring that clinical staff have the
opportunity and time to embed learning and development as part of their work, therefore
some detail around workforce development and sustainability within the Quality report
would have provided surety that there is a clear plan to build a skilled an adequate
workforce to meet future acute health demands going forward.
Challenges within Norfolk’s Health and Care economy are unlikely to reduce over the
coming year and continued collaborative work through the Local Health and Social Care
System Resilience Group and the Quality and Performance arenas are vital in order to
shape and improve patient care pathways and prevent unnecessary delays, ensuring that
we work together to deliver care to patients at the right time and in the right time, we
look forward to continuing this work with the NNUHFT throughout 2015/16.
Mark Taylor
Chief Officer, NHS North Norfolk CCG
18th May 2015
104
Statement from Norfolk Health Overview and Scrutiny Committee
The Norfolk Health Overview and Scrutiny Committee has decided not to comment on any
of the Norfolk provider Trusts' Quality Accounts for 2014-15 and would like to stress that
this should in no way be taken as a negative comment. The Committee has taken the
view that it is appropriate for Healthwatch Norfolk to consider the Quality Accounts and
comment accordingly
Regards
Maureen Orr
Democratic Support and Scrutiny Team Manager
Norfolk County Council
12th May 2015
Statement from Healthwatch Suffolk
Thank you for the reminder, we aren't intending to respond to the quality account this
year because we haven't received very many comments regarding the hospital. Please
continue to send us future QA's as we may well receive more next year.
Many thanks and kind regards
Jenny Ward
Information Services Officer
Healthwatch Suffolk
30th April 2015
Statement from Healthwatch Norfolk
Healthwatch Norfolk appreciates the opportunity to make comments on the Quality
Account.
In terms of the format of the document we are pleased to note that there is an executive
summary (which acknowledges failures to meet key performance targets in the light of
unprecedented demand, as well as acknowledging success). In terms of accessibility,
there is no mention of braille or other formats or how to obtain the document in other
languages. We believe that the use of green on green for the quotes and blue italics
throughout will result in the document not being accessible for those with visual
impairment.
We note the document clearly defines where more progress is needed to achieve priorities
in 2015-16 and where action plans and measures have been developed for each quality
priority. HWN welcomes the 2015-16 goals including:
Patient Safety:
•
Review of all emergency patients by senior clinician with 12 hours of admission
•
100% compliance with the sepsis bundle
•
reduce avoidable pressure ulcers
•
reduce number of outliers
105
Clinical Quality and Effectiveness
•
Improve infection prevention, focussing on C Diff and surgical site infection
•
CT scan within 60 minutes for patients with suspected stroke on arrival in hospital
•
Ensure radiological investigation requested on emergency admissions are
performed with 24 hours or earlier if clinical needs dictates
Patient Experience
•
Treat patients with dignity and respect
•
Improve discharge process
•
Improve patient repatriation services for patients transferred here from other
trusts
We note there is no reference to equality in the document and would have liked to have
seen inclusion of progress against Public Sector Equality duties and objectives included in
the Patient Experience section.
Patient experience – National Cancer Patient Experience Survey 2014:
With regard to the National Cancer Patient Experience Survey 2014 we are pleased to
note that the Trust is assessed as providing care benchmarked within the best performing
trusts in 9 out of 59 questions but amongst the worst performing trusts in 2 questions:
always/nearly always enough nurses on duty and hospital staff did everything to help me
control pain at all times. We will seek reassurance that the proposed action plan is
completed to improve these two elements.
Ideally HWN would like to see a breakdown of complaints information specific to the Trust
in terms of ethnicity, age, disability etc. Similarly, details of the results of the national
staff survey for the Trust would be useful.
HWN welcome sight of the formal feedback from CQC following the unannounced
inspection in March 2015 for a re-assessment of 'respecting and involving, privacy and
dignity' and implementation of an appropriate action plan by the Trust.
HWN welcomes the introduction of new initiatives including plans to establish a dementia
and nutrition group and the development of an action plan regarding hospital food
standards.
We will continue to work with the Trust to ensure that the views of patients, carers and
their families are taken into account and to make recommendation for change where
appropriate.
Alex Stewart
Chief Executive
6th May 2015
106
Trust Response
In response to the above feedback, several minor changes were made to the Quality
Report. Information was provided regarding how to obtain the report in other languages
or in braille, and in order to improve the accessibility of the report for visually impaired
readers, the italics were changed from blue to orange, and the font colour for all quotes
presented on a green background was changed from green to black.
A section was also added on Equality and Diversity (page 75).
With regard to breaking down the complaints data and the staff survey results in terms of
ethnicity, age, disability etc., we are not currently able to provide this breakdown in
respect of the current year’s report; however, we will seek to include this additional level
of detail in all future quality reports.
Statements from Governors
Quite a big read, it was! And also very reassuring that amidst all the concerns about
funding, A&E facilities, beds availability and targets the impression I am left with is that
the NNUH - management and staff - did everything they could to maintain good patient
care. As Anna put it in her introduction, the NHS has had a difficult year but there is also
a great deal to celebrate and commend.
* While it is regrettable that our Staff score is down, an over 80% score on the Friends &
Family is gratifying - especially the Feb '15 highest ever score in the busiest ever month.
* The continued focus on the essentials of care is exactly as it should be: as long as our
medical care remains good, our food nutritious and our pre- and after-care measures are
sound, we fulfil our responsibilities as an acute hospital. In this respect I was impressed
with the very comprehensive list of AUDITS (at the end of the document) which
demonstrates thorough attention to detail.
* The inclusion of the AWARDS underlined the fact that, mostly, the staff do get it right.
* In the report on TARGETS, it was not good to see so many reds compared to 2013/14
and particularly in respect of Cancer referral and treatment times it is regrettable that we
fell far short of the goal (94%) even though we were not much worse than the national
average. However, I accept the explanation that these are largely due to surgical capacity
issues in gynaecology and neck cancers and trust that the extra surgeon who started in
March will soon help us get back on track consistently.
* We have heard and spoken about the Henderson ward, and the 2 wheelchair-friendly
vehicles (with their drivers) should relieve and improve the discharge process where there
was obvious room for improvement.
* The 3 'never' events in ophthalmology should never have happened, but we don't live in
a perfect world and what is important is that nothing was hidden and everything was
done to guard against this happening in the future.
* Under PATIENT SAFETY PRIORITIES, I read with satisfaction that the trial of electronic
prescribing of medicines has gone well and that it will be fully rolled out soon.
* Early Warning Scores, Pressure ulcer prevention, Review of all emergency patients by
senior clinician and the Sepsis Bundle practice complete the picture of protecting
vulnerable patients.
107
* Worth mentioning is the OWLS regular bulletins - a simple graphic shows our people are
not just stern enforcers of medical standards, but can think in user-friendly terms too.
* I am participating next week in the PLACE Assessments and look forward to getting
first-hand impressions of how this valuable tool can help us.
* Finally, please convey my compliments on the compilation of the document: the what,
why, action plan/s and reporting mechanisms are easily followed and just wading my way
through this hugely comprehensive book of facts and figures impressed on me what a
mammoth task its construction was. I know its publication is a requirement, but its
execution deserves commendation.
Best wishes,
Evelyn Hinks
23rd April 2015
I am writing further to Terry Nye's Lead Governor update of March 2015 regarding
Governor comments on the 2014/15 Quality Report. I have been grateful to be able to
read through the full report, and although it has been quite a task has allowed an insight
into the rigorous reporting requirements required of NHS Trusts. We were required to
write to you by 30 April, and I would like to make the following observations.
Part 2a - Page 10 E-Prescribing
As a participant in the repeat prescription of medication I was interested and encouraged
to read the following:
a) Careful note to be kept of patients known allergies
b) Potential drug-drug interactions, enabling prompt "dropping off" of drugs supplied by
repeat prescription. This is re-assurance for patients by "backing-up" the patients reading
of instructions in the drug pack, and advice from doctor/ nurse prescribing additional or
new medication.
c) Would be interested to know if any "piloting" has been part of project development.
Hope I have understood the basis of these changes - my prescribing is normally carried
out by my G.P. of course.
Page 11 - Unified Drug Chart
I am not sure whether this is one chart for all types of Trusts – i.e. Acute Hospitals,
Mental Health, and Community.
Page 13 - Early Warning Score
It seems that improvement is needed in response to the 1 hour requirement.
Page 18 - Patient Safety Priority 4
Definition of a Senior Clinician carrying out a review within 12 hours of admission.
Layman's clarification required - is this a medical member of staff, and if so what level.
The audit week-end stats are impressive, and indicate a tight level of control in recording
information for audit purposes.
108
Page 19 - Patient Safety Priority 5
"Sepsis bundle" - Objective of 100% compliance is being monitored carefully by Governor
group ahead of 2015/16 Quality Report.
Page 23 - Patient Experience Priority 2
Have noted:- "delayed transfer of care unlikely to be significantly reduced until additional
Community capacity in place": - the 6 initiatives listed on page 24, and the details at
page 30 for patients with complex discharge needs.
Clinical Effectiveness Pages 26 - 29
Noted Infection Control as a key priority, and whilst the Trusts performance is very good,
the focus of infection prevention and control is being rigorously maintained.
Page 31 CT Scan - suspected Strokes. Is Stroke medical cover provided on an On- Call
Basis for evenings and week-ends?
Part 2b
From page 49 - Performance against the national quality indicators. Comments as
follows:Page 54 - Responsive to personal needs of patients
Performance level below national average, and nearer worst F T performance level
than best. Rather disappointing although no 2014/15 figures shown.
Most of rest of comparisons seem good.
Kind Regards
Brian Cushion
Public Governor - Broadland.
23rd April 2015
Trust Response
In response to the above feedback, several minor changes were made to the Quality
Report.
The section on ‘reducing medication incidents’ was amended to confirm that a 3 month
pilot of e-prescribing took place on two wards prior to full roll-out (page 10) , and further
detail was added on the unified drug chart (page 11).
A layman’s definition of a ‘Senior Clinician carrying out a review within 12 hours of
admission’ was added to page 18.
Confirmation was included that stroke medical cover is provided on an on-call basis at
evenings and weekends outside core hours (page 31).
109
Annex 2 - Statement of Directors’
responsibilities in respect of the Quality
Report
The directors are required under the Health Act 2009 and the National Health Service
(Quality Accounts) Regulations to prepare Quality Accounts for each financial year.
Monitor has issued guidance to NHS foundation trust boards on the form and content of
annual quality reports (which incorporate the above legal requirements) and on the
arrangements that NHS foundation trust boards should put in place to support the data
quality for the preparation of the quality report.
In preparing the Quality Report, directors are required to take steps to satisfy themselves
that:
the content of the Quality Report meets the requirements set out in the NHS
Foundation Trust Annual Reporting Manual 2014/15 and supporting guidance
the content of the Quality Report is not inconsistent with internal and external sources
of information including:
o board minutes and papers for the period April 2014 to May 2015
o papers relating to Quality reported to the board over the period April 2014 May 2015
o feedback from commissioners dated 18/05/2015
o feedback from governors dated 23/04/2015
o feedback from local Healthwatch organisations dated 30/04/2015 and 06/05/2015
o feedback from Overview and Scrutiny Committee dated 12/05/2015
o the trust’s complaints report published under regulation 18 of the Local Authority Social
Services and NHS Complaints Regulations 2009, dated 28/11/2014 and 24/04/2015
o The 2014 national staff survey dated 24/02/2015;
o The 2013 national patient survey dated May 2014
o the Head of Internal Audit’s annual opinion over the trust’s control environment dated
22/05/2015
o CQC Intelligent Monitoring Report dated December 2014
the Quality Report presents a balanced picture of the NHS foundation trust’s
performance over the period covered
the performance information reported in the Quality Report is reliable and accurate
110
there are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Report, and these controls are subject to review to
confirm that they are working effectively in practice
the data underpinning the measures of performance reported in the Quality Report is
robust and reliable, conforms to specified data quality standards and prescribed
definitions, is subject to appropriate scrutiny and review and
the Quality Report has been prepared in accordance with Monitor’s annual reporting
guidance (which incorporates the Quality Accounts regulations) (published at
www.monitor.gov.uk/annualreportingmanual) as well as the standards to support data
quality for the preparation of the Quality Report (available at
www.monitor.gov.uk/annualreportingmanual).
The directors confirm to the best of their knowledge and belief they have complied with
the above requirements in preparing the Quality Report.
By order of the board
Chairman
Date
26/05/2015
Chief Executive
Date
26/05/2015
111
A
Annex
x 3 - Indep
I
pende
ent Au
uditorr Rep
port
Indepe
endent Aud
ditors’ Lim
mited Assu rance Rep
port to the Council of Governo
ors of
Norfolk
k and Norw
wich Unive
ersity Hosp
pitals NHS
S Foundatiion Trust o
on the Ann
nual
Quality
y Report
e Council off Governorss of Norfolk and Norwicch Universitty
We have been engaged by the
Hospitals NHS Foun
ndation Tru
ust to perforrm an indep
pendent asssurance enggagement in
n
respect of Norfolk and
a Norwich Universityy Hospitals NHS Foundation Trustt’s Quality
Report ffor the yearr ended 31 March 2015
5 (the ‘Quallity Report’)) and speciffied perform
mance
indicato
ors containe
ed therein.
Scope a
and subject matter
t year ended 31 Marrch 2015 su
ubject to lim
mited assuraance (the
The indicators for the
ed indicatorrs”); marked
d with the ssymbol
in the Quality Report, consist of the
t
“specifie
following national priority
p
indiccators as m
mandated by
y Monitor:
Specifie
ed Indicattors
Sp
pecified ind
dicators cr
criteria
x Perce
entage of in
ncomplete pathways
p
within 18 weekss for patientts on
mplete path
hways at the
e end of thee
incom
reporting period
d
Details of the critteria for thhe indicator
A
4 of tthe Quality
can be found at Annex
Report (see page 206).
x Maximum waitin
ng time of 62
6 days from
m
urgent GP referrral to first treatment fo
or
all ca
ancers
Details of the critteria for thhe indicator
can be found at Annex
A
4 of tthe Quality
Report (see pagess 206 – 207)).
112
Respective responsibilities of the Directors and auditors
The Directors are responsible for the content and the preparation of the Quality Report in
accordance with the specified indicators criteria referred to on pages of the Quality Report
as listed above (the "Criteria"). The Directors are also responsible for the conformity of
their Criteria with the assessment criteria set out in the NHS Foundation Trust Annual
Reporting Manual (“FT ARM”) and the “Detailed requirements for quality reports 2014/15”
issued by the Independent Regulator of NHS Foundation Trusts (“Monitor”).
Our responsibility is to form a conclusion, based on limited assurance procedures, on
whether anything has come to our attention that causes us to believe that:
x
The Quality Report does not incorporate the matters required to be reported on as
specified in Annex 2 to Chapter 7 of the FT ARM and the “Detailed requirements
for quality reports 2014/15”;
x
The Quality Report is not consistent in all material respects with the sources
specified below; and
x
The specified indicators have not been prepared in all material respects in
accordance with the Criteria and the six dimensions of data quality set out in the
“2014/15 Detailed guidance for external assurance on quality reports”.
We read the Quality Report and consider whether it addresses the content requirements
of the FT ARM and the “Detailed requirements for quality reports 2014/15; and consider
the implications for our report if we become aware of any material omissions.
We read the other information contained in the Quality Report and consider whether it is
materially inconsistent with the following documents:
x
x
Board minutes and papers for the period April 2014 to May 2015;
Papers relating to Quality reported to the Board over the period April 2014 to May
2015;
x
Feedback from the Commissioners NHS North Norfolk CCG dated 18/05/2015;
x
Feedback from Governors dated 23/04/2015;
x
Feedback from local Healthwatch Norfolk dated 05/05/2015 and Healthwatch
Suffolk dated 30/04/2015;
x
Feedback from Norfolk Health Overview and Scrutiny Committee dated
12/05/2015;
113
x
The trust’s complaints report published under regulation 18 of the Local Authority
Social Services and NHS Complaints Regulations 2009, dated 28/11/2014 and
24/04/2015;
x
The 2013 national patient survey dated May 2014;
x
The 2014 national staff survey dated 24/02/2015;
x
Care Quality Commission Intelligent Monitoring Report dated December 2014;
x
The Head of Internal Audit’s annual opinion over the Trust’s control environment
dated 18/05/2015.
We consider the implications for our report if we become aware of any apparent
misstatements or material inconsistencies with those documents (collectively, the
“documents”). Our responsibilities do not extend to any other information.
We are in compliance with the applicable independence and competency requirements of
the Institute of Chartered Accountants in England and Wales (“ICAEW”) Code of Ethics.
Our team comprised assurance practitioners and relevant subject matter experts.
This report, including the conclusion, has been prepared solely for the Council of
Governors of Norfolk and Norwich University Hospitals NHS Foundation Trust as a body,
to assist the Council of Governors in reporting of Norfolk and Norwich University 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 2015, to
enable the Council of Governors to demonstrate they have discharged their governance
responsibilities by commissioning an independent assurance report in connection with the
indicators. To the fullest extent permitted by law, we do not accept or assume
responsibility to anyone other than the Council of Governors as a body and Norfolk and
Norwich University 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 ‘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:
x
reviewing the content of the Quality Report against the requirements of the FT
ARM and “Detailed requirements for quality reports 2014/15”;
114
x
reviewing the Quality Report for consistency against the documents specified
above;
x
obtaining an understanding of the design and operation of the controls in place in
relation to the collation and reporting of the specified indicators, including controls
over third party information (if applicable) and performing walkthroughs to confirm
our understanding;
x
based on our understanding, assessing the risks that the performance against the
specified indicators may be materially misstated and determining the nature,
timing and extent of further procedures;
x
making enquiries of relevant management, personnel and, where relevant, third
parties;
x
considering significant judgements made by the NHS Foundation Trust in
preparation of the specified indicators;
x
performing limited testing, on a selective basis of evidence supporting the
reported performance indicators, and assessing the related disclosures; and
x
reading the documents.
A limited assurance engagement is less in scope than a reasonable assurance
engagement. The nature, timing and extent of procedures for gathering sufficient
appropriate evidence are deliberately limited relative to a reasonable assurance
engagement.
Limitations
Non-financial performance information is subject to more inherent limitations than
financial information, given the characteristics of the subject matter and the methods
used for determining such information.
The absence of a significant body of established practice on which to draw allows for the
selection of different but acceptable measurement techniques which can result in
materially different measurements and can impact comparability. The precision of
different measurement techniques may also vary. Furthermore, the nature and methods
used to determine such information, as well as the measurement criteria and the
precision thereof, may change over time. It is important to read the Quality Report in the
context of the assessment criteria set out in the FT ARM the “Detailed requirements for
quality reports 2014/15 and the Criteria referred to above.
115
The nature, form and content required of Quality Reports are determined by Monitor. This
may result in the omission of information relevant to other users, for example for the
purpose of comparing the results of different NHS Foundation Trusts.
In addition, the scope of our assurance work has not included governance over quality or
non-mandated indicators in the Quality Report, which have been determined locally by
Norfolk and Norwich University Hospitals NHS Foundation Trust.
Basis for Disclaimer of Conclusion – Percentage of incomplete pathways within
18 weeks for patients on incomplete pathways
The Trust reports monthly to Monitor on the Incomplete 18 Weeks indicator, based on the
waiting time of each patient who has been referred to a consultant but whose treatment
is yet to start. The Trust has not retained detailed reports to support each of the monthly
submissions to Monitor and as such it has not been possible to reconcile the information
reported back to the patient administration system. As a result, we have been unable to
access accurate and complete data to verify the waiting period from referral to treatment
reported across the year.
Conclusion (including disclaimer of conclusion on the Incomplete Pathways
indicator)
Because the data required to support the indicator is not available, as described in the
Basis for Disclaimer of Conclusion paragraph, we have not been able to form a conclusion
on the Incomplete Pathways indicator.
Based on the results of our procedures, nothing has come to our attention that causes us
to believe that for the year ended 31 March 2015,
x
x
x
The Quality Report does not incorporate the matters required to be reported on as
specified in Annex 2 to Chapter 7 of the FT ARM and the “Detailed requirements
for quality reports 2014/15”;
The Quality Report is not consistent in all material respects with the documents
specified above; and
The maximum waiting time of 62 days from urgent GP referral to first treatment
for all cancers indicator has not been prepared in all material respects in
accordance
116
with the Criteria and the six dimensions of data quality set out in the "Detailed
guidance for external assurance on quality reports 2014/15."
PricewaterhouseCoopers LLP
Southampton
Date:
The maintenance and integrity of the Norfolk and Norwich University Hospitals NHS
Foundation Trust’s website is the responsibility of the directors; the work carried out by
the assurance providers does not involve consideration of these matters and, accordingly,
the assurance providers accept no responsibility for any changes that may have occurred
to the reported performance indicators or criteria since they were initially presented on
the website.
117
Annex 4 - Mandatory performance indicator
definitions
The following indicator definitions are based on Department of Health guidance, including
the ‘NHS Outcomes Framework 2013/14 Technical Appendix’.
Where the HSCIC Indicator Portal does not provide a detailed definition of the indicator
this document continues to use older sources of indicator definitions.
Percentage of incomplete pathways within 18 weeks for patients on
incomplete pathways
Source of indicator definition and detailed guidance
The indicator is defined within the technical definitions that accompany 'Everyone counts:
planning for patients 2014/15 - 2018/19' and can be found at www.england.nhs.uk/wpcontent/uploads/2014/01/ec-tech-def-1415-1819.pdf
Detailed rules and guidance for measuring referral to treatment (RTT) standards can be
found at http://www.england.nhs.uk/statistics/statistical-work-areas/rtt-waiting-times/rttguidance/
Detailed descriptor
E.B.3: The percentage of incomplete pathways within 18 weeks for patients on incomplete
pathways at the end of the period
Numerator
The number of patients on an incomplete pathway at the end of the reporting period who
have been waiting no more than 18 weeks
Denominator
The total number of patients on an incomplete pathway at the end of the reporting period
Accountability
Performance is to be sustained at or above the published operational standard. Details of
current operational standards are available at: www.england.nhs.uk/wpcontent/uploads/2013/12/5yr-strat-plann-guid-wa.pdf (see Annex B: NHS Constitution
Measures).
Indicator format
Reported as a percentage
118
Maximum waiting time of 62 days from urgent GP referral to first treatment for
all cancers
Detailed descriptor1
PHQ03: percentage of patients receiving first definitive treatment for cancer within 62
days of an urgent GP referral for suspected cancer
Data definition
All cancer two-month urgent referral to treatment wait
Numerator
Number of patients receiving first definitive treatment for cancer within 62 days following
an urgent GP (GDP or GMP) referral for suspected cancer within a given period for all
cancers (ICD-10 C00 to C97 and D05)
Denominator
Total number of patients receiving first definitive treatment for cancer following an urgent
GP (GDP or GMP) referral for suspected cancer within a given period for all cancers (ICD10 C00 to C97 and D05)
Accountability
Performance is to be sustained at or above the published operational standard. Details of
current operational standards are available at: /www.england.nhs.uk/wpcontent/uploads/2013/12/5yr-strat-plann-guid-wa.pdf (see Annex B: NHS Constitution
Measures).
1 Cancer referral to treatment period start date is the date the acute provider receives an urgent
(two week wait priority) referral for suspected cancer from a GP and treatment start date is the
date first definitive treatment commences if the patient is subsequently diagnosed. For further
detail refer to technical guidance at
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_13188
0
119
Emergency re-admissions within 28 days of discharge from hospital2
Indicator description
Emergency re-admissions within 28 days of discharge from hospital
Indicator construction
percentage of emergency admissions to a hospital that forms part of the trust occurring
within 28 days of the last, previous discharge from a hospital that forms part of the trust
Numerator
The number of finished and unfinished continuous inpatient spells that are emergency
admissions within 0 to 27 days (inclusive) of the last, previous discharge from hospital
(see denominator), including those where the patient dies, but excluding the following:
those with a main speciality upon re-admission coded under obstetric; and those where
the re-admitting spell has a diagnosis of cancer (other than benign or in situ) or
chemotherapy for cancer coded anywhere in the spell.
Denominator
The number of finished continuous inpatient spells within selected medical and surgical
specialities, with a discharge date up to 31 March within the year of analysis. Day cases,
spells with a discharge coded as death, maternity spells (based on specialty, episode type,
diagnosis), and those with mention of a diagnosis of cancer or chemotherapy for cancer
anywhere in the spell are excluded. Patients with mention of a diagnosis of cancer or
chemotherapy for cancer anywhere in the 365 days prior to admission are excluded.
Indicator format
Standard percentage
More information
Further information and data can be found as part of the HSCIC indicator portal.
2 This definition is adapted from the definition for the 30 days re-admissions indicator in the NHS
Outcomes Framework 2013/14: Technical Appendix. We require trusts to report 28 day emergency
re-admissions rather than 30 days to be consistent with the mandated indicator requirements of
the NHS (Quality Accounts) Amendment Regulations 2012 (S.I. 2012/3081).
120
Minimising delayed transfer of care
Detailed descriptor
The number of delayed transfers of care per 100,000 population (all adults, aged 18
plus).
Data definition
Commissioner numerator_01: Number of Delayed Transfers of Care of acute and nonacute adult patients (aged 18+ years)
Commissioner denominator _02: Current Office for National Statistics resident population
projection for the relevant year, aged 18 years or more
Provider numerator_03: Number of patients (acute and non-acute, aged 18 and over)
whose transfer of care was delayed, averaged over the quarter. The average of the three
monthly SitRep figures is used as the numerator.
Provider denominator_04: Average number of occupied beds3
Details of the indicator
A delayed transfer of care occurs when a patient is ready for transfer from a hospital bed,
but is still occupying such a bed.
A patient is ready for transfer when:
[a] a clinical decision has been made that the patient is ready for transfer AND
[b] a multidisciplinary team decision has been made that the patient is ready for transfer
AND
[c] the patient is safe to discharge/transfer.
To be effective, the measure must apply to acute beds, and to non-acute and mental
health beds. If one category of beds is excluded, the risk is that patients will be relocated
to one of the ‘excluded’ beds rather than be discharged.
Accountability
The ambition is to maintain the lowest possible rate of delayed transfers of care.
Good performance is demonstrated by a consistently low rate over time, and/or by a
decreasing rate. Poor performance is characterised by a high rate, and/or by an increase
in rate.
Detailed guidance and data
Further guidance and the reported SitRep data on the monthly delayed transfers of care
can be found on the NHS England website.4
3 In the quarter open overnight.
4 /www.england.nhs.uk/statistics/statistical-work-areas/delayed-transfers-of-care/
121
C. difficile5
Detailed descriptor
Number of Clostridium difficile (C. difficile) infections, as defined below, for patients aged
two or over on the date the specimen was taken.
Data definition
A C. difficile infection is defined as a case where the patient shows clinical symptoms of C.
difficile infection, and using the local trust C. difficile infections diagnostic algorithm (in
line with Department of Health guidance), is assessed as a positive case. Positive
diagnosis on the same patient more than 28 days apart should be reported as separate
infections, irrespective of the number of specimens taken in the intervening period, or
where they were taken. In constructing the C. difficile objectives, use was made of rates
based both on population sizes and numbers of occupied bed days. Sources and
definitions used are:
For acute trusts: The sum of episode durations for episodes finishing in 2010/11 where
the patient was aged two or over at the end of the episode from Hospital Episode
Statistics (HES).
Basis for accountability
Acute provider trusts are accountable for all C. difficile infection cases for which the trust
is deemed responsible. This is defined as a case where the sample was taken on the
fourth day or later of an admission to that trust (where the day of admission is day one).
To illustrate:
• admission day; • admission day + 1; • admission day + 2; and
• admission day + 3 – specimens taken on this day or later are trust apportioned.
Accountability
The approach used to calculate the C. difficile objectives requires organisations with
higher baseline rates (acute trusts and primary care organisations) to make the greatest
improvements in order to reduce variation in performance between organisations. It also
seeks to maintain standards in the best performing organisations.
Appropriate objective figures have been calculated centrally for each primary care
organisation and each acute trust based on a formula which, if the objectives are met, will
collectively result in a further national reduction in cases of 26% for acute trusts and 18%
for primary care organisations, whilst also reducing the variation in population and bed
day rates between organisations.
Timeframe/baseline
The baseline period is the 12 months, from October 2010 to September 2011. This means
that objectives have been set according to performance in this period.
5 The QA Regulations requires the C. difficile indicator to be expressed as a rate per 100,000 bed
days. If C. difficile is selected as one of the mandated indicators to be subject to a limited
assurance report, the NHS foundation trust must also disclose the number of cases in the quality
report, as it is only this element of the indicator that we intend auditors to subject to testing.
122
Percentage of patient safety incidents resulting in severe harm or death6
Indicator description
Patient safety incidents (PSIs) reported to the National Reporting and Learning Service
(NRLS), where degree of harm is recorded as ‘severe harm’ or ‘death’, as a percentage of
all patient safety incidents reported.
Indicator construction
Numerator: The number of patient safety incidents recorded as causing severe harm
/death as described above.
The ‘degree of harm’ for PSIs is defined as follows;
‘severe’ – the patient has been permanently harmed as a result of the PSI, and
‘death’ – the PSI has resulted in the death of the patient.
Denominator: The number of patient safety incidents reported to the National Reporting
and Learning Service (NRLS).
Indicator format:
Standard percentage.
6 This definition is adapted from the definition for the 30days readmissions indicator in the NHS
Outcomes Framework 2012/13: Technical Appendix
123
Glossary of terms
Acute Medical Unit (AMU)
CQUIN
Dementia
Rapid assessment and
diagnosis unit for
emergency patients
Commissioning for
Quality and Innovation.
Schemes to deliver
quality improvements
which carry financial
rewards in the NHS.
The loss of cognitive
ability (memory,
language, problemsolving) in a previouslyunimpaired person,
beyond that expected of
normal aging
Bacteraemia
An infection resulting
from presence of bacteria
in the blood
BCIS
British Cardiovascular
Intervention Society
Clinical Audit
The process of reviewing
clinical processes to
improve them
Clinical Governance
Processes that maintain
and improve quality of
patient care
Clostridium difficile, C
difficile or C.diff
A bacterium that can
cause infection
Coding or clinical coding
An internationally agreed
system of analysing
clinical notes and
assigning clinical
classification codes
CQC, or Care Quality
Commission
The independent
regulator of all health
and social care services
in England.
CT scan
Computed Tomography
scanning, a technique
which combines special
x-ray equipment with
computers to produce
images of the inside of
the body.
DAHNO
Data for Head and Neck
Oncology, a database of
information on head and
neck cancer patients
Data Quality
The process of assessing
how accurately the
information and data we
gather is held
Dr Foster
A company that has
developed a Hospital
Standardised Mortality
Rate and other data
comparisons across the
NHS
Drugs, Therapeutics and
Medicines Management
Committee (DTMM)
An internal committee
that considers all drug
related issues
Early Warning Score
(EWS)
Decile
A clinical checklist
process used to identify
rapidly deteriorating
patients
A statistical term,
meaning one tenth of the
whole.
East of England
Ambulance Service
(EEAST)
Delayed Transfers of
Care, or DToCs
Term for patients who
are medically fit to leave
a hospital but are waiting
for social care or primary
care services to facilitate
transfer
The Ambulance Service
that covers Bedfordshire,
Cambridgeshire, Essex,
Hertfordshire, Norfolk
and Suffolk.
124
Escherichia coli or E.coli
Part of the normal
intestinal microflora in
humans and warmblooded animals. Some
strains can cause disease
in humans, ranging from
mild to severe.
GPs
General Practitioners i.e.
family doctors
Health Protection Agency
(HPA)
An independent body
that protects the health
and well-being of the
population.
HPV
Human papillomavirus –
a DNA virus from the
papillomavirus family that
is capable of infecting
humans.
Hospital Standardised
Mortality Ratio (HSMR)
An indicator of healthcare
quality that measures
whether the death rate at
a hospital is higher or
lower than should be
expected.
ICNARC CMP
Intensive Care National
Audit and Research
Centre Case Mix
Programme
LoS
Length of stay
MDT
Multi-disciplinary Team,
composed of doctors,
nurses, therapists and
other health professionals
MI or Myocardial
Infarction
A heart attack, usually
caused by a blood clot,
which stops the blood
flowing to a part of the
heart muscle
MINAP
Myocardial Infarction
Audit Project
MRSA
Methicillin Resistant
Staphylococcus aureus, a
strain of bacterium that is
resistant to one type of
antibiotic
MSSA
Methicillin-sensitive
Staphylococcus aureus, a
strain of bacteria that is
sensitive to one type of
antibiotic
NBOCAP
National Bowel Cancer
Audit Programme
NCAA
National Cardiac Arrest
Audit, the national,
clinical audit for inhospital cardiac arrest
NCE - National
Confidential Enquiries
A system of national
confidential audits which
carry out research into
patient care in order to
identify ways of
improving its quality.
Neonates
Medical term for babies
born prematurely in the
first 28 days of life
NHFD
National Hip Fracture
Database
NICE
National Institute for
Health and Clinical
Excellence
NICU - Neonatal
Intensive Care Unit
The unit in the hospital
which cares for very sick
or very premature babies
NIHR
National Institute for
Health Research
NLCA
National Lung Cancer
Audit
Norovirus
Sometimes known as the
winter vomiting bug, the
most common stomach
bug in the UK, affecting
people of all ages
NNAP
National Neonatal Audit
Programme
NRLS
National Reporting and
Learning System - A
database of patient
safety information
125
Palliative Care
Pressure Ulcer
Form of medical care that
concentrates on reducing
the severity of disease
symptoms to prevent and
relieve suffering
Pressure ulcers are a
type of injury that breaks
down the skin and
underlying tissue. They
are caused when an area
of skin is placed under
pressure.
Paediatrics
The branch of medicine
for the care of infants,
children and young
people up to the age of
16.
Perinatal
Defines the period
occurring around the
time of birth (five months
before and one month
after).
PLACE – Patient Led
Assessment of Clinical
Environment
A national programme
that replaced PEAT from
April 2013.
PPCI - Primary
Percutaneous Coronary
Intervention.
A treatment for heart
attack patients which
unblocks an artery by
opening a small balloon,
or stent, in the artery
Prescribing
The process of deciding
which drugs a patient
should receive and
writing those instructions
down on a patient’s drug
chart or prescription
They are also sometimes
known as "bedsores" or
"pressure sores".
PROM - Patient Reported
Outcome Measures
A national programme
whereby patients having
particular operations fill
in questionnaires before
and after their treatment
to report on the quality of
care
Quartile
A statistical term,
referring to one quarter
of the whole.
RCA or Root Cause
Analysis
A method of problem
solving that tries to
identify the root causes
of faults or problems
Screening
Assessing patients who
are not showing
symptoms of a particular
disease or condition to
see if they have that
disease or condition
Sepsis
Sometimes called blood
poisoning, sepsis is the
systemic illness caused
by microbial invasion of
normally sterile parts of
the body.
Serco
The company that
provides support services
like catering, cleaning
and engineering to the
Norfolk and Norwich
University Hospital
STEMI - ST segment
elevation myocardial
infarction
A heart attack which
occurs when a coronary
artery is blocked by a
blood clot.
Stent
A small mesh tube used
to treat narrow or weak
arteries. Arteries are
blood vessels that carry
blood away from your
heart to other parts of
your body.
Streptococcus
A type of infection
caused by a type of
bacteria called
streptococcal or ‘strep’
for short. Strep infections
can vary in severity from
mild throat infections to
pneumonia, and most
can be treated with
antibiotics.
Stroke
The rapidly developing
loss of brain function due
to a blocked or burst
blood vessel in the brain.
126
Surgical Site Infection
(SSI)
Thromboprophylaxis
TARN
The process of a clot
forming in veins or
arteries
stops for a brief period of
time. A person will have
stroke-like symptoms for
up to 24 hours, but in
most cases for 1 - 2
hours. A TIA is felt to be
a warning sign that a
true stroke may happen
in the future if something
is not done to prevent it.
Trauma Audit and
Research Network
Thrombus
Tissue Viability (TV)
Thrombolysis or
thrombolysed
A clot which forms in a
vein or an artery
The medical specialism
concerned with all
aspects of skin and soft
tissue wounds including
acute surgical wounds,
pressure ulcers and leg
ulcers
Occurs when microorganisms enter the part
of the body that has
been operated on and
multiply in the tissues.
The breakdown of blood
clots through use of clotbusting drugs
Any measure taken to
prevent coronary
thrombosis
Thrombosis
TIA or Transient
Ischaemic Attack
This happens when blood
flow to a part of the brain
127
Norfolk and Norwich University Hospitals NHS Foundation Trust
Colney Lane
Norwich
NR4 7UY
Tel: 01603 286286
Website: www.nnuh.nhs.uk
E-mail: communications@nnuh.nhs.uk
129
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