Download Quality Report 2016 - Hampshire Hospitals NHS Foundation Trust

Quality Report
2016
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Quality Report
Part 1: Chief Executive’s statement
This is the Quality Report for Hampshire Hospitals NHS Foundation Trust for 2015/16. It is the fifth Quality
Report for Hampshire Hospitals NHS Foundation Trust, a Trust that provides hospital services across
multiple sites including Andover War Memorial Hospital, Basingstoke and North Hampshire Hospital and
Royal Hampshire County Hospital in Winchester.
This Quality Report enables us to demonstrate our commitment to providing each patient with the best
possible care and treatment. It reports our progress on the priorities identified last year and sets out the
areas that we, our stakeholders and partners have identified as priorities for improvement in the coming
year.
In July 2015 the Care Quality Commission (CQC) carried out an inspection of the Trust and Hampshire
Hospitals received a CQC rating of “Good”, with a rating of “Outstanding” for the care provided.
All three of the Trust’s hospitals were recognised as providing ‘Outstanding’ care to patients nearing the
end of their lives. We are not complacent and there are areas we can and are improving upon. This year, I
am pleased to report that we have carried out a number of initiatives to improve patient safety, patient
experience and clinical effectiveness.
Patient Safety
The annual Trust Quality Event was a great success this year and took place in June 2015. A superb range of
work was presented and awards were given to the best presentations and posters as judged by attendees
and members of the Board of Directors. A wide range of innovative quality and safety initiatives were
covered and included:
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Learning from the ‘Hospital Antibiotics Prudent Prescribing Indicators’ audit;
Actions taken to ‘improve physical health on the Mother & Baby Mental Health Unit’ in Winchester,
and
Information about ‘Simulation Training incorporating a Smartphone App for Cardiac Arrests’.
The National Sign up to Safety Campaign runs regular webinar sessions to share good practice and local
quality improvement initiatives across the country. In 2015/16 HHFT staff have participated in these,
leading two presentations. One was in relation to the how HHFT has embedded SBARR (Situation,
Background, Assessment, Recommendation and Response), an internationally recognised communication
tool, into teaching about the local handover tool the NEWS (National Early Warning Score) escalation
process for deteriorating patients. The other related to improving clinical practice in the administration of
intravenous fluids.
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Patient experience
Our staff have taken the initiative to improve the experience of elderly patients within our hospitals, this
included a visit to over 30 patients by a barn owl called Biscuit from the Soft Landing Animal Aid Association
which was arranged by one of the HHFT Activity Co-ordinators. The reaction from the patients was
amazing, patients were engaged during the session and the experience provided a great conversational
topic and stimulation. Another Activity Coordinator arranged a surprise 65th Wedding Anniversary
celebration in the physio gym for a couple who were apart because one partner was in hospital.
A Befriending service run by the hospitals’ volunteers has been introduced to offer social companionship to
patients with a chronic or life limiting illness and who might be isolated and lonely. HHFT is one of only a
few sites in England to have received the funding to provide this new service in conjunction with Hospice
UK.
The Play Team at HHFT has been asked to share their innovative idea across the region, they developed a
CT scanner made out of LEGO© to help reduce the scariness of having a scan for younger people. The
children make a mini LEGO© figure of themselves and go through the scenario of having a scan using the
model. The model CT scan room has been made to the correct dimensions as the scanner and the model
has reduced the need for an anaesthetic for some of the children.
In May 2015 ‘John’s Campaign’ was implemented across the Trust. ‘John’s Campaign’ is an initiative that
gives the main carer of people with dementia the option to stay with the patient during their time in
hospital, and to have open visiting hours. HHFT was one of the first 100 hospitals to implement this across
all of our wards. This approach is already supported in children’s services and the same approach can
benefit distressed patients who have been removed from their normal environment.
To support the wider roll out of ‘John’s Campaign’, the Trust Dementia Nurse Specialist and colleagues
made a film talking about why HHFT is supporting the campaign and how our staff have made it possible.
Clinical Effectiveness
Women can now have diagnostic hysteroscopies in an outpatient setting at Basingstoke Hospital. This new
service was supported by the North Hampshire Medical Fund, which bought 5 hysteroscopes. Patients have
said they appreciate the service because waiting times are shorter and they are up and out within hours of
the procedure and are able to go home quickly.
In September 2015 the launch took place of Research Hubs in the libraries at Basingstoke and Winchester
Hospitals. The Hubs are developing into one-stop shops for staff interested in getting involved in research,
audit and service improvement, including academic research for a qualification. The launch was supported
by HHFT staff and the University of Winchester joining together to network, discuss projects and celebrate
the launch.
Orthopaedic surgeon, Professor Wilson was the keynote speaker at the Joint Preservation Congress where
he delivered a lecture on the development in knee ligament surgery and our contribution to the advances,
including several techniques we have now made popular worldwide.
Foundation doctors from HHFT attended the National Foundation Doctor Presentation Event to present
projects on audit, research, clinical governance and patient safety. The projects covered a wide range of
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Performance against 2015-2016 quality improvement priorities
Patient Safety Priorities
Priority 1
We will reduce the length of time emergency patients are nil by mouth for emergency procedures
(Safe/Patient Safety)
Reason for choice:
We selected this priority because we had made improvements in this area in relation to planned care and
the intention was to build on this and extend it to emergency care.
This was an area of improvement identified when reviewing Serious Incidents Requiring Investigations
(SIRI) and reducing the time a patient spends as nil by mouth is important for patient safety and improves
patient outcomes.
Measuring, monitoring and reporting:
This quality priority was developed, measured and monitored within the surgical division with regular
reporting to the Executive Committee, Board of Directors and the Council of Governors through the
governance paper on progress.
Achievement:
We have achieved this target, there were no standards in relation to the length of time emergency patients
were nil by mouth before surgery, each patient was starved for 4 hours or until operated on. A review of
best practice was carried out and shared with clinical teams. This resulted in a review of the current
practice and the implementation of two new standards:
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
free fluids up to 2 hours before surgery; and
start intravenous fluids if nil by mouth for more than 6-8 hours.
The baseline audit established that 38% of patients had a drink within 6 hours of their operation. Of the
62% that did not have a drink within the last 6 hours 38.7% were given intravenous fluids. Therefore, the
new standards allow free fluids up to 2 hours before surgery, and where a patient has been nil by mouth
for more than 6 hours they receive intravenous fluids. The implementation of these standards is being reaudited to measure the extent of the achievement.
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Priority 2
We will help patients understand their medicines and the side effects associated with them (Safe/Patient
Safety)
Reason for choice:
This was a quality priority for HHFT during 2014/15 and it was our intention to build on what we achieved
and continue with this initiative. During 2014/15 we achieved the target of 75% of patients answering yes
to the question: ‘Did a member of staff explain the purpose of the medicines you were to take home, in a
way that you could understand?’ in the 2013 inpatient survey (which was reported in 2014). This related to
patients with medications who needed an explanation (data source Picker Inpatient Survey). We also
carried out other surveys to determine the impact of the quality and format of the information shared with
patients about their medications and side effects associated with them. We took action in the year to
respond to the findings of these surveys; this also informed the actions we have taken in 2015/16.
Measuring, monitoring and reporting:
We provided updates to the Executive Committee, Board of Directors and Council of Governors through
the governance paper on progress against this quality priority. The findings of surveys carried out by
volunteers in the Patient Voice Forum (PVF) were also discussed and shared with staff.
Achievement:
We have achieved this target. Information is provided to patients by ward nursing and pharmacy staff. This
is in the format of leaflets and access to the patient medicines helpline business cards. It is now possible to
capture data on the number of patients who are counselled by the pharmacy staff on the in-patient
electronic prescribing system for high risk medicines. This is a new initiative initially started with
anticoagulant therapy but has been successfully extended.
Education sessions are offered to all patients referred to the anticoagulant team at HHFT either face to face
or by telephone. In addition the anticoagulant team are now supported by a consultant anticoagulation
pharmacist. Patients initiated on novel anticoagulants are given a telephone consultation 2 weeks after
starting treatment with an anticoagulant practitioner to identify any side effects or issues and reiterate
previous counselling.
Use of the medicines helpline has increased its profile and is now receiving 20 calls a month compared with
10 a month last year.
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Priority 3
We will eliminate all grade 4 hospital acquired pressure ulcers and reduce in hospital pressure ulcers,
grade 2 and 3 by 50% (Safe/Patient Safety)
Reason for choice:
This was identified as a quality priority because it is an important patient safety initiative and we recognise
this as an area of improvement for the Trust. We also included this initiative as a Sign up to Safety pledge
for the Trust as well as it being a local quality measure in the contract we have with our commissioners in
North Hampshire.
Measuring, monitoring and reporting:
We recognised at the outset that this was a challenge and so set a stretch target for the Trust. We reported
monthly on progress to the Executive Committee and Board of Directors through the governance paper on
progress.
Achievement:
We have partially achieved our aims for this quality priority. We achieved an 18% reduction in grade 2-4
hospital acquired pressure ulcers from 307 to 252 and we have more than halved the number of grade 4
hospital acquired pressure ulcers from 7 to 3.
In May 2015 the Associate Medical Director for Governance reported on a review he completed of pressure
area damage management, it focused on:
1.
2.
3.
4.
Comparing HHFT data from 2013/14 to 2014/15;
How the Trust compares with national benchmarks (Safety Thermometer dashboard);
The source of data; and
Other sources of relevant data in the Trust.
Having reviewed the available information and discussed with all the stakeholders the main conclusions
included:

The Trust missed the 2014/15 national CQUIN target for a 50% reduction in the incidence of trustacquired grade 2-4 pressure ulcers over the course of the year. This is primarily because the target
was over-optimistic (but non-negotiable as nationally set). For comparison, the reported national
incidence of pressure ulcers has fallen by only 30% over 3 years (2012-15).

There has been an increase in reporting pressure damage on all areas of the body such as the nose,
ears and elbows (rather than just sacrum and heels) in 2014/15 compared with 2013/14.

There is limited evidence of embedded improvements across the organisation following internal and
an external investigation.
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It is not clear if all skin damage is ultimately preventable but, based on the static performance of the
last 3 years, there is a significant risk of the Trust becoming a permanent outlier if the current
national data continues to improve.
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The main recommendations were:
1. The Trust must review the efficacy of its existing audits of documentation of basic nursing care.
Specifically, a plan is required for monitoring, understanding and responding to the results of the
audits across the Trust.
2. A root cause analysis of a selection of grade 2 ulcers should be undertaken to look for common
factors that are contributing to this milder - and possibly more easily preventable - degree of skin
damage.
3. This important patient safety project requires increased senior support and leadership
4. A detailed re-examination of the quality and effectiveness of pressure ulcer incidence and
interventions should be carried out no less frequently than annually.
These recommendations informed the pressure damage prevention strategy and the work being led by the
Associate Director of Nursing (clinical standards). Over the last 12 months the specialist tissue viability team
has been developed to provide a 7 day service on the two main hospital sites to ensure there is the
provision of timely intervention and support for staff as well as increasing access to ward based training.
In January 2016 a new initiative of “hot debriefs” was introduced to support the wider quality improvement
work that is being done to reduce the incidents of pressure damage. The early debrief with staff and
patients creates an opportunity for on the spot learning and feedback as to why an incident occurred and
engagement in generating solutions that will make a difference.
When an incident of pressure damage is reported on the incident reporting system, Datix, a member of the
tissue viability team, a senior nurse and member of the patient safety team (governance) attend within 48
hours to meet with the ward staff and the patient.
Positive results to date include:
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Ward staff appreciation of the early intervention, advice and education that is given at the time of
the hot debrief;
Amendments to care plans can be implemented immediately resulting in prevention of further
damage to patients; and
The engagement of the whole team helps to identify the little things that will make a big impact,
e.g. ensuring documentation is clear to staff using it.
Feedback from the hot debriefs has also identified what additional training or amendments to training will
be most helpful. Full root cause analysis (RCA) incident investigations will continue to take place for all
incidents of hospital acquired pressure damage, grade 3 or 4, and these will continue to be reviewed at the
Serious Event Review Group (SERG).
We have also launched a Rapid Spread Programme, learning from others’ successes and incorporating
learning from the Associate Medical Director’s review, to sustainably reduce pressure damage and
standardise tissue viability management in the Trust. This initiative is using rapid spread methodology and
has the following aims:
•
•
To achieve a 50% reduction of avoidable grade 2 pressure ulcers by March 2017; and
Eliminate avoidable grade 3 and 4 pressure ulcers by March 2017.
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Patient Experience Priorities
Priority 1
We will improve patients’ awareness of how they can prevent VTE on admission to hospital
(Caring/Patient Experience)
Reason for choice:
We have implemented VTE risk assessment and we intend to implement in full the NICE Quality Standards
and ensure patients admitted to hospital are informed about VTE, how to help themselves prevent it and
how to recognise and act on symptoms.
Measuring, monitoring and reporting:
The lead for this quality priority was the Associate Medical Director for Governance and Consultant
Haematologist. A programme to disseminate the information and carry out a repeat audit to assess the
spread was undertaken and progress was monitored at the Thrombosis Committee, with regular reporting
to the Executive Committee, Board of Directors and Council of Governors through the governance paper.
Achievement:
We have achieved this quality priority and copies of the “what is my risk of a blood clot” leaflet were
circulated to all ward areas in 2015 and ward sisters and charge nurses are aware that every patient
requiring a VTE risk assessment needed a leaflet. The Electronic Patient Record (EPR) discharge summary
has been adapted and now states the patient’s personal VTE risk in patient friendly language.
Priority 2
We will achieve a reduction in the number of complaints relating to poor staff attitude (Caring/Patient
Experience)
Reason for choice:
We have identified that this is a key area for improvement for the Trust. Care and compassion are core
values for the Trust and it is important that these are evident throughout the Trust.
Measuring, monitoring and reporting:
We completed the national monthly reporting regarding the categorisation of complaints received and
reported on themes, lessons learnt and actions taken to the Executive Committee, Board of Directors and
Council of Governors through the governance paper.
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Achievement:
We have not achieved this quality priority. There has been a 3% increase in the proportion of formal
complaints received relating to values and behaviours of staff. Overall the number of all formal complaints
received in 2015/2016 has increased by 11% from 2014/2015. The number of formal complaints received
for 2014/2015 relating to staff manner and attitude was 105 (17% of all complaints received) and the
number of formal complaints received for 2015/2016 relating to values and behaviours (the new category
of coding following introduction of new KO41a subject codes from 1/04/15) was 138 (20% of all complaints
received). This represents a 31% increase in the number of complaints relating to staff manner and
attitude. When the number of complaints received relating to values and behaviour are viewed by quarter
there was a reduction from Q1 to Q2 and Q3 with the numbers rising again in Q4.
The Trust receives compliments about staff attitudes and customer care and in 2015/16 there were 1,243
WOW! Awards nominations received in the category of customer care. This is an increase from 928 in
2014/15 for the category of customer care.
The numbers of people responding to Friends and Family Test question “How likely are you to recommend
this hospital (on the individual cards it says ward/unit/service) to friends and family if they needed similar
care or treatment” has increased and positive staff attitude is the main reason that patients would
recommend our services.
In response to the complaints received relating to values and behaviour, a number of actions have been
taken within the divisions and these include:
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The provision of bespoke customer care training;
The sharing of feedback in the complaints with members of staff involved in complaints for their
reflection and learning;
The introduction of the Clinical Matron role to help raise awareness and improve patient
experience;
The review of complaints and trends at the monthly divisional governance and performance
meetings;
Within the Family and Clinical Support Services division an additional meeting (quality priorities)
has been introduced where trends are reviewed across the division and actions are reviewed; and
The “through your eyes” patient listening sessions have been implemented successfully.
Priority 3
Patient Listening sessions – “through your eyes " will be established across the Trust for patients to share
their experiences of our services with us face to face (Responsive/Patient Experience)
Reason for choice:
This was a quality priority for 2014/15 and we see this as an opportunity to build on our success in this area
and extend this to the other divisions.
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Measuring, monitoring and reporting:
Each division took and applied the learning from the “through your eyes” sessions, sharing the learning
across the Trust. We reported regularly on progress and learning to the Executive Committee, Board of
Directors and Council of Governors through the governance paper.
Achievement:
We have achieved this quality priority and all the divisions have benefited from implementing “through
your eyes” sessions. In addition to this in child health staff initiated “hear I am” sessions in March. These
are 4 half-day sessions which provide the opportunity to listen to the voices of patients and carers using
child health services.
The roll out of the “through your eyes” sessions was supported by staff participating in a session hosted by
cancer services. This provided the opportunity for those who would be implementing the sessions in other
divisions to participate in a well-established session. As a result of the sessions actions and themes were
identified, discussed and monitored at senior management meetings. Recurring themes were identified
and these informed training, for example communication and staff attitude informed localised customer
care training.
These sessions will continue as a key opportunity to hear the patient and carer experience in a unique way.
Priority 4
We will provide accessible and effective interpreter services for people using our services
(Responsive/Patient Experience)
Reason for choice:
We identified this as a quality priority from feedback we received through our complaints handling.
Measuring, Monitoring and Reporting:
Progress against this quality priority has been reported at the Trust Health and Wellbeing Committee and
this will continue with the implementation of the Accessible Information Standard.
Achievement:
We have achieved this quality priority. A review of the information that was available to patients and staff
in relation to interpretation services was carried out as well as conversations with stakeholders. A wide
range of interpretation services are available to staff and it became apparent that staff required
information about how to access these services and the importance of timely access.
In response to the findings actions were taken to improve the access to interpreter services for staff across
the Trust and raise awareness, through methods such as the Midweek Message email and the Quality
Matters newsletter.
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Through the stakeholder discussions a work stream emerged to engage with local community groups and
Healthwatch to tailor innovative new ways to provide information and advice on interpreter services and
this will continue into 2016/17.
The Trust is also committed to the implementation of the Accessible Information Standard (AIS) and this is
also a standing agenda item on the Health and Wellbeing Committee agenda, which includes Executive
Director oversight. In addition to completing the baseline assessment and development of an
implementation plan all the new clinical matrons were briefed on the standard and their role in it at their
induction in February 2016.
Clinical Effectiveness Priorities
Priority 1
We will improve the management of sepsis across the Trust and aim to become an exemplar
(Effective/clinical effectiveness)
Reason for choice:
We selected this quality priority because it is recognised as an important area of improvement locally and
nationally. It provided us with the opportunity to build on the good work that was happening in the Trust
and make further improvements to patient outcomes. To achieve the quality priority we worked with the
Wessex Academic Science Network patient safety work stream to share best practice and learning.
Measuring, Monitoring and Reporting:
This quality priority has also been a Sign up to Safety pledge and a CQUIN so progress has been reported
and measured through the preventing harm from deterioration patient safety work stream and the
Contract Quality Review Group with commissioners and through the governance paper to the Board of
Directors and Executive Committee.
Achievement:
We have achieved this quality priority and the Trust has been an active participant in the regional Patient
Safety Collaborative to deliver quality improvement initiatives for sepsis. This work was celebrated in
February 2016 when the Trust sepsis team won top prize in the “Collaborative Team Award”. The delivery
team was multidisciplinary including Consultants from Acute Medicine and Emergency Medicine,
Emergency Department Nurse Practitioners, Pharmacists and Quality Improvement practitioner project
manager.
Initial data in April 2015 showed that we were screening around 25% of patients for sepsis in the
emergency department and by January 2016 this had increased to 100%. This is significant because the
earlier sepsis is recognised the greater the chances of survival and prevention of long-term effects of sepsis.
Other achievements include:
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The delivery of multidisciplinary training;
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Innovative ways to raise staff awareness, for example, the paediatric team developed the “sing a
song of sepsis”, sung to the tune of the nursery rhyme “sing a song of sixpence”;
Working with external partners to develop patient pathways; and
The use of a common language in relation to sepsis across all health sectors e.g. HHFT, GPs and
Ambulance professionals.
Priority 2
We will improve the management of the deteriorating patient (Effective/clinical effectiveness)
Reason for choice:
This has been identified as an area for improvement through the patient safety work stream and from our
learning from incidents.
Measuring, monitoring and reporting:
A number of measures were identified to monitor this quality priority through the Reducing Harm from
Deterioration Group, including audits, cardiac arrest calls, number of avoidable deaths and those not seen
by a consultant at point of deterioration (via peer case note review).
Achievement:
We have achieved this quality priority. The National Early Warning Score (NEWS) observation charts used
by the Trust were revised for all adult in-patients (excluding maternity that have separate observation
parameters) in response to the review of several patient safety incidents where failings in the NEWS
escalation process were identified. The multidisciplinary review was part of the work of the Reducing Harm
from Deterioration Group and the Critical Care Outreach Team led the roll out of the new documentation.
The main areas of focus and training delivered were to:
•
•
•
•
•
•
Follow the simplified escalation plan on NEWS chart
Empower nurses and foundation doctors to speak to seniors and consultants directly
Senior decision makers to see patient more quickly
Early appropriate management plans
Ensure ceiling of care and Do Not Resuscitate discussions occur before crisis moment
Early appropriate referrals, including critical care
The escalation guidance was updated and laminated copies were placed by telephones on all the wards as
well as printed on the back of the observation charts. In addition guidance for the recognition of sepsis and
override parameters for those patients with chronic severe physiological derangement have been included
into the documentation.
A sticker system that was been successfully trialled on a number of wards has now been incorporated and
this supports the use of the SBAR tool (Situation, Background, Assessment, Recommendation) for improved
communication, appropriate documentation and auditing. To help improve data capture on patients whose
condition was deteriorating, changes were made to the incident reporting system Datix.
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The Trust intends to participate in the regional Wessex Patient Safety Collaborative focusing on patient
deterioration in 2016/17.
Priority 3
We will share and embed lessons learnt from Serious Incidents Requiring Investigation (SIRIs) (Well
led/clinical effectiveness)
Reason for choice:
We identified that while we had an established mechanism for sharing learning across the Trust there was
more that we can do to ensure learning was embedded. We selected this quality priority to make the
improvements internally but also to share learning more widely across the health economy.
Measuring, monitoring and reporting:
We reviewed the way good practice was shared and identified actions for improvement. This work was led
by the Risk and Compliance Manager working with the divisional governance leads.
Achievement:
We have achieved this quality priority. This quality priority has been incorporated into the Serious Event
Review Group agenda as a standing item, to ensure that learning points are always identified for sharing.
Within the divisions the governance facilitators use the Trust template for local shared learning posters for
display in clinical areas and they share these across the divisions. Learning from incidents at HHFT has also
been shared across the Wessex locality.
As a result of sharing the learning and gathering feedback, a new tool has been implemented to support
this and from January 2016 a new “safety message of the month” has been implemented. The safety topic
is agreed between the central governance team and the divisional governance leads and is based on
learning from incidents. The safety message uses the SBAR (situation, background, assessment and
recommendation) communication format to ensure that it is clear and easy to understand.
The topics that have been shared to date relate to:
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

Reminding staff about the use of purple syringes for oral medications (National Patient Safety
Agency guidance 2007);
Improving awareness of staff in relation to the administration of insulin (Central Alert System Alert
2010); and
Raising awareness of staff to the importance of completing and acting on risk assessments.
Other examples of learning that has been shared include:
The “eureka” moment in the World Health Organisation (WHO) checklist - a review and analysis of two
serious incidents led to the implementation of the ‘eureka’ moment which is undertaken just before a
surgical procedure is started. The ‘eureka’ moment allows the surgeon to confirm the procedure in order
to prevent the wrong surgery occurring and complements the WHO surgical checklist. This learning is being
disseminated across all theatres.
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An internal Trust-wide alert was produced following a serious incident involving equipment that resulted in
harm to a patient. The alert was used to ensure all areas of the Trust were aware of the required review of
practice in areas where the equipment was used.
An audit of the completion and embedding of SIRI actions has been undertaken in March 2016. The audit
found that there was good evidence that actions had been completed. Evidence included revised policies
and procedures, minutes of meetings and presentations, updated patient information leaflets.
Other Quality and Safety Initiatives
Quality Priorities for 2016/17
As part of the annual Quality Report planning process, HHFT is required to identify a number of quality
priorities. Over the last 5 years the Trust has achieved this in a number of ways. For the 2016/17 quality
priorities the central governance team identified a long list of themes from incidents, complaints, national
clinical audits, HHFT performance in relation to patient safety, clinical effectiveness and patient experience
measures. These themes were then discussed and refined with staff, Governors, the Board of Directors and
the public.
Joint Board of Directors and Council of Governors Workshop
In January 2016 there was a joint Board of Directors and Council of Governors workshop where the refined,
proposed quality priority themes were discussed and those present had the opportunity to provide their
feedback on the suggestions, make other suggestions and vote for those they wished to see developed into
a quality priority for the Trust.
The outcome of the workshop was that the following four quality priorities were identified as the most
important:
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Frail Elderly: Improve the care of frail elderly through a variety of work streams which include
improving nutritional intake and partnership working;
Preventing Pressure Damage: Reduce/eliminate pressure damage through embedding best
practice and learning from others;
Medications: Embed best practice safety guidance for the prescribing and administration of
medicines; and
Outpatients: Improve patient experience through the reduction of outpatient appointments
cancelled late.
There was also a discussion about how we will work to achieve the 4 hour waiting time target in ED and
provide high quality care for patients with mental health issues. It concluded that these two areas are the
focus of the Trust Care Quality Commission (CQC) action plan following their visit in July 2015 and they both
are dependent of the help and support of HHFT partners. Therefore, they remain key priorities for the Trust
in their own right.
The Public Consultation
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In February 2016 an online survey was launched to seek the views of the public on the long list of quality
priorities.
The results
The survey ran online for 4 weeks and received over 300 responses, based on the highest public scores, the
top 4 preferences were:

NEWS - The proposed quality priority would be to continue implementation of the national early
warning score tools to ensure we respond appropriately to patients whose condition is
deteriorating;

Outpatients - The proposed quality priority would be to make improvements to ensure that
outpatient appointments aren’t cancelled at late notice;
Medicines - The proposed quality priority would be to embed best practice safety guidance for the
prescribing and administration of medicines; and
Pressure Damage - The proposed quality priority would be to reduce/eliminate pressure damage
through embedding best practice and learning from others who have managed to achieve this.


However, it was the written comments that have provided the really rich feedback which has informed this
process. This is summarised below and is combined with all the other streams of feedback to develop the
Quality Priorities for HHFT for 2016/17.
Improve the care of frail elderly - The proposed quality priority would be based on improving the care of
frail elderly through a variety of work streams which include improving nutritional intake and working with
partners.
There was recognition by the public that we are an ageing population and that care of this group of
individuals is important, particularly caring for them where possible in their homes or ensuring they are
able to return home quickly after a stay in the acute hospital. The feedback made it very clear that patients,
their families, loved ones and carers will be able to tell us if we improve the care we provide to the frail
elderly. Those who participated in the survey referred to the importance of involving individuals in their
care and the necessity for good training for staff who deliver care to this group of individuals. Some
feedback suggested volunteers to help at mealtimes and while, especially trained, volunteers do provide
much needed assistance at meal times across the HHFT sites, this is something we can do more to promote
and raise awareness of.
This was the most important priority identified at the Board of Directors and Council of Governors
workshop and so it will be a priority for HHFT for 2016/17.
Preventing Pressure Damage - The proposed quality priority would be to reduce/eliminate pressure
damage through embedding best practice and learning from others who have managed to achieve this.
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There were many comments that expressed surprise that this remained a quality priority, that we had not
yet achieved our original target. The public told us that this is a measure of basic nursing care and we
should improve outcomes for patients and eliminate pressure damage. There was a suggestion to involve
carers in helping to share best practice which can be incorporated into the immersion events that will be
rolled out across the Trust.
This was a key priority for the Board of Directors, Governors and the public and so will be a quality priority
for 2016/17.
Learning from Mortality Reviews - The proposed quality priority would be to establish a new mechanism
to apply learning from the mortality reviews that occur within the Trust to improve patient safety and care.
The responses from the public emphasised the importance of benchmarking our performance with others
and learning to reduce preventable deaths. There was surprise from some members of the public that the
Trust wasn’t already doing this. However, HHFT does have a mortality review programme with widespread
consultant engagement and this is reported on in the Governance papers to the Board of Directors. There
was acknowledgement in the feedback that patient safety must always be a priority and reviewing deaths
and sharing learning more widely will help to increase public confidence and maintain openness.
While this will not be a specific quality priority for HHFT for 2016/17 work will continue to implement the
latest NHS England Mortality Guidance and ensure that we continue to review deaths that occur at HHFT
and seek to increase engagement with GP colleagues where there has been extensive care delivered in the
community prior to a death. This is a quality indicator in the quality element of the contract with our
commissioners.
Improving Medicines Management - The proposed quality priority would be to embed best practise safety
guidance for the prescribing and administration of medicines.
When providing their feedback the public reiterated the importance of good medicines management to
build patient confidence. They referred to the importance of good medicines stewardship to help manage
costs and reduce unnecessary waste. The feedback included examples where patients themselves felt they
could be more involved in the administration of their own medicines, particularly those that are time
dependent and examples of the positive role of pharmacists in good medicines management.
This will be a quality priority for 2016/17, it was acknowledged as a high priority for the public and the
Board of Directors and Governors. It provides the Trust with the opportunity to build on the work that has
been carried out to date.
Reduce late cancellations of outpatient appointments - The proposed quality priority would be to make
improvements to ensure that outpatient appointments aren’t cancelled at late notice.
The public told us about the many ways they receive information to remind them of appointments from
others e.g. from their dentist, and they asked for more information in a timely way if clinics were to be
cancelled late. Again there was the recommendation to benchmark HHFT performance in this area with
others where that is possible. There was also the request for assurance that those most disadvantaged or
at risk as a result of a late cancellation have provision made for them. This does happen when there is
cause to cancel clinics and it will be audited in 2016/17. There was recognition by the public that
sometimes things are out of direct control but there was also a request to give greater clarity to those
Page | 18
areas where clinics are cancelled late more than once. The public responsibility was also referred to in the
feedback and the importance of sharing “Did Not Attend” information with a patient’s GP for example.
This was identified as a key quality priority for the Board of Directors, Governors and public and so will be a
quality priority for 2016/17.
Safe, effective invasive procedures - The proposed quality priority would be to implement the national
invasive procedure guidance and improve patient safety.
The national invasive procedure guidance was not included in the survey so the feedback from the public
was based solely on their experiences and views. They agreed that safety improvements should be ongoing and everyone’s responsibility. They said benchmarking our safety performance against others is
important and it supports an open culture.
This wasn’t identified as a key priority but the implementation of the national guidance will continue and is
a CQUIN as part of the quality element of the contract that HHFT has with Clinical Commissioning Groups
and so there will be a Trust wide focus on this in 2016/17.
Recognising and responding to patients whose condition deteriorates - The proposed quality priority
would be to continue implementation of the national early warning score tools to ensure we respond
appropriately to patients whose condition is deteriorating.
There was general support for this initiative and some lack of understanding or clarity about what this
refers to. While the information about this patient safety work-stream has been shared with the Board of
Directors in public, more can be done to raise the public’s awareness. There were several suggestions to
listen to a patient’s family, loved ones and carers because they are the individuals who know the patient
most and will be able to help identify a change in condition.
The public voted overwhelmingly for this to be a quality priority for 2016/17.
Learning from National Clinical Audits - The proposed quality priority would be to ensure we are learning
from the national clinical audits that we participate in and share this learning.
There were mixed comments about this proposal from concerns that there was too much measuring, a lack
of awareness of what clinical audit was, to requests to share the outcomes widely and a challenge to
demonstrate the improvements made not just report they have happened.
This feedback will be used in future clinical audit activity planning; however, this was not selected as a
quality priority for 2016/17.
Quality of Care in the Emergency Department for patients who wait over 6 and 12 hours
The governance team have carried out Quality Reviews in relation to the quality of care for patients waiting
over 6 and 12 hours in the Emergency Departments (ED) since April 2015. These quality reviews included
the analysis of incidents reported, review of patients’ notes (for those waiting over 12 hours in the
department), complaints received, Friends and Family Test (FFT) feedback and direct patient and carer
feedback from talking to patients who were inpatients at the time of the reviews.
Page | 19
To support the review of the quality of care of patients admitted via ED, an automated process was
implemented that enabled the monitoring of incidents for patients who were in the department for longer
than 4 hours, regardless of whether this wait resulted in a 4 or 12 hour breach, making it possible to link
Datix (the incident reporting system) records with patient records. The Associate Medical Directors for
Governance also carried out mortality reviews.
The findings of these reviews indicated that there was an increase in incidents relating to errors, delays and
communication that correlated to the increased pressures and demands within the ED departments,
however, the majority of these incidents were low or no harm incidents. The 5 incidents that resulted in
moderate harm are under investigation to be reported at the Trust Serious Event Review Group to ensure
that learning is identified and shared.
The negative feedback received from a small number of patients and their relatives showed that we could
improve communication with patients when they are waiting. This information was shared with
departmental staff and we continue to monitor impact of learning from this feedback.
The reviews also identified areas of good practice which included:





Recognition of need and action to place patients on beds for comfort rather than allowing them to
remain on trolleys;
Recognition of need to preserve privacy and dignity and evidence that this was achieved by
providing a private environment when required i.e. moving patients to have private conversations;
Recognition of nutrition and hydration management with evidence of the provision of drinks and
fluids and meals and snacks;
Evidence of the administration of appropriate pressure ulcer assessment and care; and
Maintenance of appropriate clinical observations.
Staffing levels were not identified as an issue in the root cause analysis reports for patients waiting over 12
hours in the ED and it was noted that extra staff where sourced to support the care of the patients in the
ED.
Quality Priorities for HHFT 2016/17
Priority
Reason for choice
Patient Experience / Caring
Recognised as a key priority with
aging population
An area we know we can improve
Care of Frail Elderly
Participate in programme to improve
care of frail elderly across HHFT
Key priority identified by Board Of
Directors (BOD), Council Of
Governors (COG) and Public
Local CQUIN for North Hampshire
Clinical Commissioning Group
(CCG)
Page | 20
Measuring, Monitoring and
reporting
Key measures will be identified in
the CQUIN programme and these
will be reported on monthly at
divisional level but also to the
Executive Committee, Board of
Directors and Council of
Governors.
Patient Experience / Caring
Pressure Damage
We will embed best practice for
pressure ulcer prevention across the
Trust
Patient Safety / Safe
It is an area that must improve, is a
vital part of basic care
Key priority identified by BOD, COG
and Public
Opportunity to learn from others
New model of nursing
management support the
immersion roll out planned
Identified in response to recent
never event and near misses
Medicines Management
Key priority identified by BOD, COG
and Public
We will embed best practice safety
guidance for the prescribing and
administration of medicines
Achievements in other areas of
medicines management provide
basis for this work
Patient Experience Responsive to
patient’s needs
Currently outlier for cancelled
outpatient appointments
Reduce late cancellations of
outpatient appointments
Make improvements to ensure that
outpatient appointments aren’t
cancelled at late notice
Clinical Effectiveness / Effective
Deteriorating patients
Embed revised NEWS charts and
escalation model to ensure timely
response to deteriorating patients
Measures identified in the
immersion programme – these
will be reported on at divisional
level but also to the Executive
Committee, Board of Directors
and Council of Governors.
The end of year report (March
2016) will identify actions required
for 2016/17.
The progress of these will be
reported on at MERG (Medicines
Event Review Group) and the DTC
(Drug and Therapeutic
Committee)also to the Executive
Committee, Board of Directors
and Council of Governors.
The performance measures
identified by the service manager
and through the internal
improvement programme will be
CQC require improvement
shared at divisional level but also
to the Executive Committee,
Key priority identified by BOD, COG
Board
of Directors and Council of
and Public
Governors.
Learning from serious incidents
(SIRIs) identifies need for
improvement
The progress against identified key
measures will be monitored at the
Preventing Harm from
Deterioration Group and also to
the Executive Committee, Board
Regional Patient Safety
of Directors and Council of
Collaborative is focussing on
Governors.
Reducing Harm from Deterioration
16/17
Key priority identified by Public
Builds on and incorporates work on
Sepsis which has been successful
Page | 21
Implementing the Duty of Candour
The Trust has developed a Duty of Candour policy which outlines its approach to implementing the Duty of
Candour. The policy identifies the steps staff should take in identifying and reporting notifiable patient
safety incidents as well as the steps to be followed to deliver the Duty of Candour.
An Associate Medical Director for Governance provides clinical leadership in this area and delivers training
for staff. There are also resources available for staff on the Trust intranet site.
The Trust Serious Event Review Group, whose membership consists of senior clinical and operational
leaders, has a monitoring role to ensure the Duty is complied with. This includes a monthly review of all
incidents that may be notifiable. Reports are also made to the Trust Clinical Quality and Safety Committee.
Patient safety improvement plan as part of the Sign Up To Safety campaign
HHFT has 5 Sign up to Safety pledges, which form part of our Patient Safety Framework. The 2016/17
pledges and how they link with the patient safety framework are:
•
Patient engagement – understanding side effects of medications, it is linked with the culture and
communication patient safety work stream. This was selected because patients identified this as an
area of concern for them particularly at discharge (in-patient survey; complaints; Walkrounds); it
was also a minor action following the CQC visit to the Trust and provides the opportunity to build
on the achievements made in 2015/16.
•
Improving the management of sepsis. While this is a key national priority it was identified as
important for HHFT following a review of mortality data and case notes. The work at HHFT is
supported by a local champion with a regional role. It links with the preventing harm from
deterioration patient safety work stream.
•
Falls prevention was selected, specifically a focus on reducing falls resulting in moderate harm,
severe harm or death. The target has been developed over the past 2 years to build on the
successful work done to reduce falls. It links with the preventing avoidable harm patient safety
work stream.
•
Pressure Ulcer prevention. This was identified as a local area of improvement (grade 2, 3 and 4
pressure ulcers) following case note review and patient safety incident and safety thermometer
data.
•
Learning lessons from Serious Incidents Requiring Investigation (SIRIs) identified the safety pledge
related to the interpretation of CTG machines in Maternity. The objective is to achieve a 50%
reduction of maternity SIRIs linked with misinterpretation of CTG by April 2017 (from baseline of 10
Jan 2012-Sept 2014). This links with the preventing avoidable harm patient safety work stream.
The Sign up to Safety campaign pledges will be reviewed in 2016/17 and objectives will be identified for
2017/18.
Page | 22
During 2015/16 HHFT staff participated in initiatives to share good practice outside of the Trust. These
included a webinar regarding the use of the standardised communication tool, SBARR (situation,
Background, Assessment, Recommendation, Read back or Response). It’s a structured method for
communicating critical information that requires immediate attention and action contributing to effective
escalation and increased patient safety. It can also be used effectively to enhance handovers between
shifts or between staff in the same or different clinical areas.
NHS Staff Survey results
For HHFT the most recent NHS Staff Survey results, from the Staff survey 2015, for indicators KF19 percentage of staff experiencing harassment, bullying or abuse from staff in the last 12 months are:


White 22%
BME 30%
The BME group has reported an increase in this category compared to last year. This is higher than the
2015 average for acute trusts (28%). The reported response for white staff has remained constant and this
is lower than the acute average (25%).
The most recent results for KF27 - percentage believing that Trust provides equal opportunities for career
progression or promotion, for the Workforce Race Equality Standard are:


White 88%
BME 78%
The percentage of BME staff that are confident in the Trust’s opportunities has reduced this year compared
to last year’s survey. However, the response is comparable with the acute average (75%).
CQC Ratings
The tables below illustrate the ratings for the three Hampshire Hospitals sites and the overall rating
awarded by the CQC following the hospital inspection carried out in July 2015.
Page | 23
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In response to the CQC Inspection and the findings a formal action plan to address the identified issues was
developed. The required actions were discussed with stakeholders at the Quality Summit following receipt
of the CQC report and this took place in December 2015. The final action plan was shared with the CQC in
January 2016.
Progress against the plan is monitored monthly and below is the latest version of the action plan with
progress indicated at 31 March 2016. Three actions were identified as being outside the sole control of
HHFT and require support and intervention from others, the deadlines on these actions reflects this.
Key for RAG rating:
All actions completed
Some actions completed, others underway being monitored next feedback 18 Mar 2016
Actions in progress, require support from partners / will not be complete by 31 Mar 2016
Page | 25
Finding
Actions required
Measurement of success and KPIs
(what was not being met)
Patient Safety - medicines
management:
(principle area)
Ensure medicines
are appropriately
managed and
stored (surgery)
(achievable milestones)
SOP written, agreed and implemented in each
clinical area with drug fridge
Minimum and maximum
drug fridge temperatures
were not being recorded so
it was not possible to
ensure that medicines
were being stored safely
Deadline for
completion
(timeliness)
SOP
15 Dec 2015
(Standards and guidance for the SOP have been
provided by the chief pharmacist)
Local audits of performance against SOP
recorded on AuditR will illustrate compliance
Review of medicines storage in all areas to
ensure that they are kept in a secure location i.e.
locked cupboards, restricted swipe access etc.
Monitoring ongoing
Reporting ongoing
Reported 16
Nov 2015
Monitoring ongoing
Page | 26
RAG
rating
Patient Safety - medicines
management:
It was not possible to tell if
pharmacists had checked
the controlled drugs on
AAU (BNHH)
Ensure there are
robust processes
in place to ensure
all drugs,
particularly CDs in
liquid form and
re-fridgerated
drugs are
managed and
stored
appropriately in
all medical wards
Digital locks for all medicine cupboards in AAU
ordered and treatment room doors to be locked
at all times
Making the
environment
secure
30 Nov 2015
Monthly audit to demonstrate pharmacy checks
take place
Monitoring ongoing
Pharmacy and ward staff will check fridge weekly
for out of date medicines
Out of date drugs and
yoghurts were stored in
the medicines fridge in
AAU (BNHH)
Reporting ongoing
Weekly audit will show no inappropriate storage
in drugs fridge
Overall review of medicines storage in all areas
to ensure that they are kept in a secure location
i.e. locked cupboards, restricted swipe access
etc.
Patient Safety - medicines
management:
MIU staff didn’t have
access to up to date
approved PGDs (Patient
Group Directions) (AWMH
MIU)
Patient Safety – staff
training:
MIU staff had not
completed mandatory
basic life support and only
38% of MIU staff have
completed infection
control training (AWMH)
Ensure PGDs used
in MIU are up to
date
Ensure MIU staff
are aware of the
PGDs, their use
and where to
access them
MIU staff to
complete basic
life support and
infection control
training (AWMH)
Out of date PGDs removed and alternative
arrangements made to meet patients’ needs
while revised PGDs were developed and
implemented
All areas reviewed the PGDs in use in their areas
to ensure that they are up to date and staff are
aware of them
100% staff will have completed basic life support
training by 31 Dec 2015
100% staff will have completed infection control
training by 31 Dec 2015
Page | 27
10 Nov 2015
Improvement
actions ongoing
31 Dec 2015
Monitoring ongoing
Patient Safety –
safeguarding:
Safeguarding adults and
children checks were not
consistently completed and
recorded in patient records
(AWMH/MIU)
Provide refresher
training to MIU
staff (and other
staff groups
across the Trust)
regarding
safeguarding
documentation
95% staff to complete safeguarding training
through drop in sessions provided by
safeguarding leads and booking onto courses
31 Dec 2015
Quarterly audits undertaken by safeguarding
team to demonstrate compliance
Monitoring ongoing
Complete an
audit of records
to assess
compliance with
requirement to
record
safeguarding
checks
Patient Safety –
Equipment:
There was no checklist on
the resuscitation
equipment to record that it
was checked daily
Resuscitation
equipment is to
be appropriately
checked and
equipment sealed
and tagged
Completion of daily check lists of resuscitation
equipment that include signatures for
accountability
Use of equipment tags sourced from
resuscitation team so as to seal the resuscitation
trollies
Complete audit of
records and
equipment
Some equipment on the
trolley had expired
Patient Safety Deteriorating patient:
The early warning score
was not being used
consistently across surgery
to identify patients whose
condition may deteriorate
31 Dec 2015
Reporting ongoing
Monthly audit of compliance with checklist
completion demonstrating compliance against
standard identified by the resuscitation team
Ensure that the
early warning
score is
consistently used
in surgery
Develop a
measure for use
in outpatient
departments
Programme of raised awareness of NEWS and
launch of refreshed NEWS tool to take place
across the Trust
Surgical staff who are new to the Trust will
receive specific training on NEWS at local
induction
In surgery locally NEWS will be linked with SBAR
communications
Page | 28
31 Jan 2016
Monitoring ongoing
Reporting ongoing
Patient safety – VTE:
Found not all surgical
patients had evidence of
VTE assessment on
admission
Staffing:
Radiographer worked
alone overnight covering
imaging services for the
hospital and the
emergency department.
Radiographers reported a
heavy workload and raised
manual handling issues
(RHCH)
Ensure venous
thromboembolis
m assessment
occurs on
admission for
surgical patients
All risk assessments completed within 6 hours
and be added to EPR
Ensure that
staffing in
radiology
complies with
guidance so that
staff do not have
heavy workloads
and are exposed
to manual
handling risks.
Complete Lone Worker Action Plan which
includes actions to set up a ‘buddy’ system with
ED
Review Manual Handling training & equipment
availability
Review out of hours demand to note whether
additional staff are required to be on duty which
would negate current lone working
Staff identified delays in
the process to authorise
request and provide advice
on imaging which meant
delays in the patient
diagnosis
Patient Safety – access to
services:
CQC were made aware of
two incidents where
children who had required
mental health support
following their admission
did not have immediate
support through the
Ensure the
outsourced
diagnostic
imaging service is
appropriately
managed and
monitored to
reduce delays
Reporting ongoing
31 Mar 2016
Ensure staff have
access to
appropriate
advice
Patient Safety –
Diagnostics:
Monitoring ongoing
Complete a review of the service provided
against the service specification
Use template for data collection to support ongoing assessment of contract performance
31 Jan 2016
Reporting ongoing
Complete audit of service provided, respond to
findings and re-audit n 3 months
Develop an
effective
partnership
working so that
children and
young people
with mental
health needs
(CAMHS) have
timely
assessments and
care reviews
Maintain regular communications with partners CAMHs service provided by Sussex Partnership –
and establish quarterly meetings
Utilise offer from HEE Wessex for support with
meeting training needs and developing training
posts
31 Mar 2016
Reporting ongoing
Review progress
31 Mar 2016
Page | 29
CAMHS team
Resolution of funding issues for specialist 1:1
care on acute units
Workshop topic 2
at the Quality
Summit 11 Dec
2015
Reporting ongoing
Three commitments from partners at the
Quality Summit:



Patient safety – access to
services:
Paediatric inpatient
physiotherapy was not
sufficient for children and
young people with Cystic
Fibrosis at the weekend
and this was a concern
Ensure children
with cystic
fibrosis are
supported by
appropriate
paediatric
physiotherapy
(RHCH)
Education – training and support
(mentoring) HEE Wessex
Learning from the community –
voluntary sector alliance Healthwatch
Joint appointments – learning from
what worked well - via Crisis
Concordat
Contingencies in place to ensure that specialist
support available out of hours and the whole
team is involved in planning for out of hours
Reporting ongoing
31 Oct 2015
Enhance on-call cover to increase out of hours
support by involving more of the existing team
31 Oct 2015
Consideration of business case for additional
workforce and alternative ways of service
delivery to meet patients’ needs
Monitoring ongoing
Patient experience –
Responsive:
The Trust is not meeting
the national emergency
access target for 95% of
patients to be transferred
to a ward or discharged
from ED within 4 hours
Ensure that
patients in ED are
admitted,
transferred or
discharged within
national target
times of 4 hours
Implement the Recovery Action Plan that has
been developed by HHFT with input from CCGs
Workshop topic 1
at the Quality
Summit 11 Dec
Page | 30
Reporting ongoing
2015
Three commitments from partners at the
Quality Summit:



Patient experience –
Responsive:
There is no appropriate
system to identify patients
with a learning disability
Ensure that there
is an appropriate
system in place to
identify patients
who have a
learning disability
Ensure the needs
of people with a
learning disability
using services are
met throughout
their care
pathway
Workshop topic 2
at the Quality
Summit 11 Dec
2015
Utilise the icon on the EPR (electronic patient
record) to identify patients with a learning
disability
Establish robust links with Southern Health to
ensure appropriate support and advice are
available when required
31 Jan 2016
31 Jan 2016
Three commitments from partners at the
Quality Summit:


Ensure there is a
clear hospital site
protocol for the
actions to take if
a patient
31 Jan 2016
Understand voluntary services and support
available in the community to utilise these as
appropriate (working with Healthwatch)

Patient Safety deteriorating patient:
Consider shared staff pool for health
and social care across Hampshire
Working together – System Resilience
Group or leadership daily
Build stronger relationships and TRUST
Education – training and support
(mentoring) HEE Wessex
Learning from the community –
voluntary sector alliance Healthwatch
Joint appointments – learning from
what worked well - via Crisis
Concordat
Remind staff on AWMH site to call 999
ambulance in the event of an emergency (as they
have done successfully in the past)
Page | 31
Reporting ongoing
15 Nov 2015
collapsed in an
emergency
There was a lack of clarity
on site about what action
to take if a patient
collapsed in an emergency
(AWMH)
Development of an SOP (standard operating
procedure) regarding actions in the event of a
collapsed patient at AWMH
Ensure all site
staff are aware of
the protocol and
what action to
take
31 Dec 2015
Review staff training needs in relation to life
support
31 Dec 2015
Link work to launch of deteriorating patient
NEWS score and SBAR communications
31 Jan 2016
Staffing – security:
Staff expressed concern
regarding the appropriate
security to protect staff
and patients in the MIU
(AWMH)
Complete a
robust review of
security
arrangements in
MIU and on the
AWMH site to
ensure there is
appropriate
security on site to
protect staff and
patients in MIU
Complete review and assessment of risks
30 Nov 2015
Increased presence of security officer and access
to portering staff out of hours
30 Nov 2015
Radios available in treatment rooms where staff
are isolated
30 Nov 2015
Panic button in reception linked directly to police
30 Nov 2015
Increased awareness for staff about the
management of situations that could pose a risk
30 Nov 2015
Doors to be fitted with Paxton swipe card access
- quote requested
Page | 32
31 Jan 2016
Staffing – Leadership
There were concerns
regarding the leadership in
MIU and in relation to the
nurse clinical lead and the
lead consultant
Take action to
address the
leadership
concerns in MIU
and ensure there
is effective
leadership from
the clinical nurse
lead and lead
consultant to
monitor and
maintain clinical
standards and
ensure
integration with
the other EDs
Increased clinical nursing and medical leadership
in place
Assessment by new clinical service lead of the
units compliance with clinical standards,
governance, safety and security
15 Nov 2015
Reporting ongoing
Monitoring ongoing
Develop unity between ED departments with a
common identity
Implement clinical supervision, clear allocation of
goals, roles and responsibilities
Patient Safety – access to
services:
The Trust is an outlier in
relation to cancelled
outpatient appointments
Ensure there are
appropriate
processes and
monitoring
arrangements in
place to reduce
the number of
cancelled
outpatient
appointments and
ensure patients
have appropriate
follow up
Increase access to training and development
Implement processes of daily monitoring of
cancelled clinics
15 Nov 2015
Implement rules to ensure that clinics aren’t
cancelled without alternatives being provided
Improved data for reporting and monitoring
Monitoring ongoing
Review of overall booking process included in
the productivity improvement work
Page | 33
Patient Safety – learning
from incidents:
There was little/no
evidence of clinical or
internal audits to monitor
clinical quality, clinical
standards weren’t followed
and learning from incidents
wasn’t consistently shared
(AWMH)
Review divisional
processes for
reviewing
business unit
governance and
ensure there is an
effective system
to identify, assess
and improve the
quality and safety
of MIU, day care
unit and
outpatient
services
Sharing of learning from complaints and
incidents will be shared at team/department
meetings
“Learning points” poster from SERG (serious
event review group) to be displayed and
discussed
31 Dec 2015
Monitoring ongoing
Increased awareness of the elements of
governance e.g. patient safety and incident
reporting and how these impact on patient care
Monitoring ongoing
Staff participation in audits through AuditR
Patient safety – Staffing:
The Trust was aware of
staffing shortages and had
put in place a number of
initiatives however, there
remained shortages
The Trust must
ensure that nurse
staffing levels
comply with safer
staffing levels
guidance
Workshop topic 3
at the Quality
Summit 11 Dec
2015
Monthly reporting on safer staffing compliance
with guidance to HHFT Board of Directors and
Commissioners
Daily local review of staffing and ensure
escalation processes are in place and are robust
Continue with active recruitment process and
pipeline
Monitoring ongoing
Reporting ongoing
Reporting ongoing
Reporting ongoing
Three commitments from partners at the
Quality Summit:
1.
2.
3.
Promote integration – link to
Devolution, explore alternative models
across health e.g. ACO
Support from the HASC to focus on
sustainable staffing
Centralise most acute to sustain
specialist staffing (or spend ++)
Page | 34
Monitoring ongoing
Reporting ongoing
Review of services
During 2015/16 Hampshire Hospitals NHS Foundation Trust provided and/or sub-contracted 45 relevant
health services.
Hampshire Hospitals NHS Foundation Trust has reviewed all the data available to it on the quality of care in
all 45 of these relevant health services.
The income generated by the relevant health services reviewed in 2015/16 represents 100 per cent of the
total income generated from the provision of relevant health services by the Hampshire Hospitals NHS
Foundation Trust for 2015/16.
When reviewing the quality of service delivery, Hampshire Hospitals NHS Foundation Trust uses the model
which incorporates patient safety, clinical effectiveness and patient experience. This is applied consistently
to all services provided and is monitored through the FT’s governance arrangements. This includes
reporting to the Board of Directors through the use of a quality scorecard incorporating the model thus
reporting on all three elements of patient safety, clinical effectiveness and patient experience. This model is
also used for reporting at divisional level and at the Clinical Quality and Safety Committee.
The domains of patient safety, clinical effectiveness and patient experience are also reviewed by
Commissioners through contract quality reporting meetings.
The amount of data available for review has not impeded this objective. For more information relating to
data quality please refer to page 10 of this report.
A proportion of Hampshire Hospitals NHS Foundation Trust’s income in 2015/16 was conditional on
achieving quality improvement and innovation goals agreed between Hampshire 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 2015/16 and for the following 12 month period are available
electronically at https://www.england.nhs.uk/nhs-standard-contract/cquin/
In 2015/16 the total income conditional upon achieving quality improvement and innovation goals was
£5,616,000 (2014/15: £5,581,000).
The Trust is currently assuming 100% for Specialist Commissioning and public health/dental contracts and
80% for all other commissioners pending confirmation of CQUIN outcomes after Q4 data submission in May
2016.
Care Quality Commission
Hampshire Hospitals NHS Foundation Trust is required to register with the Care Quality Commission and its
current registration status is licensed. Hampshire Hospitals NHS Foundation Trust has no conditions on
registration.
Page | 35
The Care Quality Commission has not taken enforcement action against Hampshire Hospitals NHS
Foundation Trust during 2015/16.
Hampshire Hospitals NHS Foundation Trust has not participated in any special reviews or investigations by
the CQC during the reporting period.
The CQC carried out a planned inspection of Hampshire Hospitals NHS Foundation Trust in July 2015 and
gave an overall rating of ‘Good’. The outcome of the investigation and associated action plan can be seen
on page 104 of this report.
Information on data quality
Hampshire Hospitals NHS Foundation Trust submitted records during 2015/16 to the Secondary Uses
Service for inclusion in the Hospital Episode Statistics which are included in the latest published data. This
is for the period 01 April 2015 – 31 January 2016.
The percentage of records in the published data which included the patient’s valid NHS Number was:



99.7 per cent for admitted patient care;
99.8 per cent for outpatient care; and
98.1 per cent for accident and emergency care.
The percentage of records in the published data which included the patient’s valid General Medical Practice
Code was:



99.9 per cent for admitted patient care;
99.9 per cent for outpatient care; and
99.8 per cent for accident and emergency care.
Hampshire Hospitals NHS Foundation Trust Information Governance Assessment Report overall score for
2015/16 was 80 per cent and was graded satisfactory.
Each year, Hampshire Hospitals NHS Foundation Trust must report our Information Governance compliance
by completing the IG Toolkit hosted by the Health and Social Care Information Centre (HSCIC). This report
assesses the Trust’s annual performance against national standards which includes; Information
Governance Management, Confidentiality and Data Protection Assurance, Information Security Assurance,
Clinical Information Assurance, Secondary Use Assurance and Corporate Information Assurance.
HHFT reported 1 incident to the Information Commissioner’s Office (ICO) in 2015/16 and was the subject of
1 complaint to the ICO.
The Trust reported a level 1 incident to the ICO via the IG Toolkit Incident reporting Tool. A staff member
had parked their car in the neighbouring housing estate as they could not get a space in the main car park
or overflow. The car had stapled pharmacy information sheets containing patient information visible on the
back seat – limited information about 6 patients was visible. A member of the public took a photograph
and informed the local media. A full investigation was completed and uploaded to the reporting tool.
Page | 36
Hampshire Hospitals NHS Foundation Trust was subject to the Payment by Results clinical coding audit
during the reporting period by the Audit Commission and the error rates reported in the latest published
audit for that period for diagnoses and treatment coding (clinical coding) were:




91 per cent
92 per cent
96 per cent
93 per cent
for primary diagnosis coded correctly;
for secondary diagnosis coded correctly;
for primary procedure coded correctly; and
for secondary procedure coded correctly.
The results should not be extrapolated further than the actual sample audited.
The audit reviewed the clinical coding accuracy of 200 Finished Consultant Episodes (FCEs) of activity
undertaken across Hampshire Hospitals NHS Foundation Trust. The audit sample was selected randomly
from FCEs completed during the period July – September 2015. This was a cross specialty audit, and the
services reviewed within this audit included:
•
Neonatal
•
Ophthalmology
•
Gastrointestinal
•
Obstetrics
•
Gynaecology
Hampshire Hospitals NHS Foundation Trust will be taking the following actions to improve data quality:
1. Implement a programme of clinical engagement to promote the clinical coding process, its
documentation requirements (especially discharge summaries) and encourage interaction between coders
and clinicians.
2. Review the source of capture for co-morbidities within Ophthalmology and Gastroenterology to support
the better capture of secondary diagnosis codes and supplement discharge summaries.
3. Implement a clinical validation or audit process with a focus on improving capture of procedures.
4. Feed back the specific findings identified in the audit to the relevant coding and clinical personnel.
5. Create a local policy relating to the coding of diabetic macular oedema and ensure this is implemented
across the hospital sites.
Following the audit of the quality report issues were identified with the accuracy of data relating to the
referral to treatment target. This identified concerns with the timeliness of patients being recorded as
entering treatment and also with the coding of patients to the correct pathway. An action plan has been
agreed to improve the quality of data reported for this target.
Page | 37
Research during 2015/2016
The number of patients receiving relevant health services provided or sub-contracted by Hampshire
Hospitals NHS Foundation Trust in 2015/16 that were recruited during that period to participate in research
approved by a research ethics committee was 1,178.
The Foundation Trust supports clinical research as a means of improving patient care, and contributing to
wider health improvement. The Foundation Trust is a member of the Wessex Clinical Research Network.
A total of 70 clinical staff led 160 clinical research studies, 145 of which were National Institute for Health
Research (NIHR) Portfolio adopted, which had been approved by a Research Ethics Committee, at
Hampshire Hospitals NHS Foundation Trust between 01 April 2015 and 31 March 2016. A total of 1,174
participants were recruited into studies, of which 1,123 were recruited into NIHR Portfolio studies.
A summary of the research topics for those studies adopted by the NIHR Portfolio are included in the table
below.
National Institute for Health Research (NIHR)
Division
Total studies per Division - Hampshire
Hospitals NHS Foundation Trust
Division 1 – Cancer
53
Division 2 – Diabetes, Stroke, Cardiovascular
disease, Metabolic and Endocrine disorders,
Renal disorders
Division 3 – Children, Genetics, Haematology,
Reproductive Health and Childbirth
Division 4 – Dementias and Neurodegeneration
(DeNDRoN), Mental Health, Neurological
Disorders
Division 5 – Primary Care, Ageing, Health
Services and Delivery research, Oral Health and
Dentistry, Public Health, Musculoskeletal
Disorders, Dermatology
Division 6 – Anaesthesia/peri-Operative,
Medicine and Pain Management, Critical Care,
Injuries / Emergencies, Surgery, ENT, Infectious
Diseases / Microbiology, Ophthalmology,
Respiratory
Disorders,
Gastroenterology,
Hepatology
16
28
10
17
21
Scotland
Achievements from 2015/16 included:



Four studies recruited the first global patients. These were achieved by Cardiology,
Gastroenterology, Haemophilia and Cancer.
HHFT exceeded site recruitment targets on 8 studies.
Research governance continues to be maintained through continued training in Good Clinical
Practice. The Trust currently has four staff trained to deliver the NIHR GCP course, the nationally
accredited and accepted training provision. Ten courses provided GCP training to 67 delegates.
Page | 38

Collaboration with University of Winchester and Hampshire Hospitals (HCHRE) is now supporting
the Dementia Care and the Arts study and a joint application to the Stroke Association for funding
to support the HELP study was submitted by the Stroke team and the University’s Sport and
Exercise Physiology Department.
During 2016/17 the FT’s Research and Development team will:






Increase the number of patients recruited into studies and set a target of 1,604 participants for the
period 2016/17.
Increase the number of specialties and investigators involved in research.
Increase the number of commercial research studies.
Continue to support the work of the Wessex Academic Health Science Network by becoming
directly involved in their research initiatives, including the 100,000 Genome project.
Continue to collaborate in the Arts in Health and Wellbeing; extend activity with the Sport and
Exercise Physiology Department; and further develop the programme of work on Patient Reported
Outcome Measures with the University of Winchester’s Psychology Department, as part of the
Hampshire Collaboration for Health Research and Education (HCHRE) strategic plan.
Continue to raise the profile of research in Hampshire Hospitals amongst clinical staff and patients
both locally and regionally with the support of the HHFT Patient and Public Involvement Working
Group and the Wessex Collaboration for Leadership in Applied Health Research and Care (CLAHRC).
Clinical audits
During 2015/16 36 national clinical audits and 5 national confidential enquiries covered relevant health
services that Hampshire Hospitals NHS Foundation Trust provides.
During that period Hampshire Hospitals NHS Foundation Trust participated in 97.2% per cent of national
clinical audits and 100 per cent of national confidential enquiries of the national clinical audits and national
confidential enquiries which it was eligible to participate in.
The national clinical audits and national confidential enquiries that Hampshire Hospitals NHS Foundation
Trust was eligible to participate in during 2015/16 are shown as follows in the table below.
The national clinical audits and national confidential enquiries that Hampshire Hospitals NHS Foundation
Trust participated in, and for which data collection was completed during 2015/16, are listed below
alongside the number of cases submitted to each audit or enquiry as a percentage of the number of
registered cases required by the terms of that audit or enquiry.
The reports of 21 national clinical audits and 2 national confidential enquiries reports were reviewed by the
provider in 2015/16 and Hampshire Hospitals NHS Foundation Trust intends to take forward actions to
improve the quality of healthcare provided, as identified in the table below.
Page | 39
National audit
Is HHFT
eligible to
participate
Is BNHH
participating
Is RHCH
participating
% submission
of number of
registered
cases
required
External
audit reports
published in
2015/16 and
reviewed
Outcome or actions taken as a
result of audit
100%
n/a
n/a
2
Self-assessment is undertaken for
the recommendation’s from all
the published reports, any
concerns will be escalated to the
Divisional Directors.
Acute Care
Adult critical care (ICNARC CMPD)
yes
yes
yes
National Confidential Enquiry into
Patient Outcome and Death including
yes
yes
yes
100%
Sepsis, Gastrointestinal Haemorrhage,
Acute pancreatitis & Mental Health
The Trust is achieving 80 to 100%
compliance in many of the
standards.
National Emergency Laparotomy
Audit
yes
yes
yes
100%
1
National Joint Registry (NJR)
yes
yes
yes
100%
1
An action plan is in place to
address the involvement of Care
of the Elderly Physicians which
the whole of the NHS in England
performed poorly in.
Report has been reviewed and
not an outlier for any hip or knee
revisions.
No actions required by HHFT.
Severe Trauma (Trauma Audit &
Research Network)
yes
yes
yes
100%
n/a
n/a
Non-invasive ventilation
yes
yes
yes
n/a
n/a
n/a
National Complicated Diverticulitis
Audit
yes
yes
yes
n/a
n/a
n/a
Emergency Use of Oxygen
yes
yes
yes
100%
n/a
n/a
Procedural Sedation in Adults (care in
emergency departments)
yes
yes
yes
100%
n/a
n/a
Vital signs in Children (care in
emergency departments)
yes
yes
yes
100%
n/a
n/a
VTE risk in lower limb immobilisation
(care in emergency departments)
yes
yes
yes
100%
n/a
n/a
1
Blood transfusion team will
continue to educate clinical staff
on patient blood management. A
Trust Protocol on Massive
Haemorrhage is to be
implemented.
1
Report has been reviewed and
HHFT is not an outlier for any of
the standards, with BNHH having
the lowest stoma rate following
rectal cancer surgery in the
country.
Blood and Transplant
National Comparative Audits of Blood
Transfusion
yes
yes
yes
50%
Cancer
Bowel Cancer (National Bowel Cancer
Audit Programme)
yes
yes
yes
Page | 40
100%
National audit
Is HHFT
eligible to
participate
Is BNHH
participating
Is RHCH
participating
% submission
of number of
registered
cases
required
External
audit reports
published in
2015/16 and
reviewed
Outcome or actions taken as a
result of audit
Lung Cancer (National Lung Cancer
Audit)
yes
yes
yes
100%
1
The report shows the Trust is
meeting 80% of the lung cancer
targets. Actions are in place to
address accurate recording of
pathology results. Outcomes will
be discussed at the forthcoming
annual cancer MDT meeting.
Oesopheo-gastric Cancer (National OG Cancer Audit)
no
n/a
n/a
n/a
n/a
n/a to Trust
Prostate Cancer
yes
yes
yes
100%
1
Report has been reviewed.
No actions required by HHFT.
Heart
Acute Myocardial Infarction & other
ACS (MINAP)
yes
yes
yes
100%
n/a
n/a
Cardiac Rhythm Management (CRM)
yes
yes
n/a
100%
n/a
n/a
Congenital Heart Disease
no
n/a
n/a
n/a
n/a
n/a
Coronary Angioplasty
yes
yes
n/a
100%
n/a
n/a
National Adult Cardiac Surgery Audit
no
n/a
n/a
n/a
n/a
n/a
National Adult Cardiac Arrest Audit
yes
yes
yes
100%
n/a
n/a
National Heart Failure Audit
yes
yes
yes
100%
1
Report has been reviewed.
No actions required by HHFT.
Report has been reviewed.
National Vascular Registry
yes
yes
yes
100%
1
No actions required by HHFT.
Pulmonary Hypertension
no
n/a
n/a
n/a
n/a
n/a
Long Term Conditions
Adult Diabetes (National Adult
Diabetes Audit)
no
n/a
n/a
n/a
n/a
n/a
National Diabetes Footcare Audit
yes
no
no
n/a
n/a
Not participated in audit 15/16,
plan to participate in 16/17.
1
Trust guidelines have been
updated to reflect the
recommendations from the
report.
National Pregnancy in Diabetes Audit
yes
yes
yes
100%
National Diabetes Inpatient Audit
yes
yes
yes
100%
n/a
n/a
Chronic kidney disease in primary
care
no
n/a
n/a
n/a
n/a
n/a
Page | 41
National audit
Is HHFT
eligible to
participate
Is BNHH
participating
Is RHCH
participating
% submission
of number of
registered
cases
required
External
audit reports
published in
2015/16 and
reviewed
Outcome or actions taken as a
result of audit
Paediatric Diabetes (RCPH National
Paediatric Diabetes Audit)
yes
yes
yes
n/a
n/a
n/a
Inflammatory Bowel Disease (IBD)
yes
yes
yes
100%
1
Report has been reviewed.
No actions required by HHFT.
National Chronic Obstructive
Pulmonary Disease (COPD) Audit
Programme
Renal Replacement Therapy (Renal
Registry)
Rheumatoid and early inflammatory
arthritis
no
n/a
n/a
n/a
n/a
n/a – rehab programme provided
by another Trust.
no
n/a
n/a
n/a
n/a
n/a
1
Report has been reviewed and
not an outlier for any of the
standards.
yes
yes
yes
100%
No actions required by HHFT.
Adult Asthma
yes
yes
yes
n/a
n/a
n/a
Mental Health
Mental health clinical outcome review
programme: National Confidential
Inquiry into Suicide and Homicide for
people with Mental Illness (NCISH)
no
n/a
n/a
n/a
n/a
n/a
Prescribing Observatory for Mental
Health (POMH)
no
n/a
n/a
n/a
n/a
n/a
3
Falls audit: HHFT is slightly below
the national average for harms
from falls. An action plan is in
place to improve some parts of
our assessment documentation.
Older People
Falls and Fragility Fractures Audit
Programme (FFFAP)
yes
yes
yes
100%
Hip Fracture mortality: HHFT is
below the national average for 30
day mortality rate.
Parkinson’s UK
yes
yes
yes
100%
n/a
n/a
Sentinel Stroke National Audit
Programme (SSNAP)
yes
yes
yes
100%
1
HHFT is providing a 24/7
Consultant delivered centralised
service and 100% eligible patients
receive thrombolysis.
Other
Elective Surgery
yes
yes
Yes
77.6%
2
No actions required by HHFT.
Ophthalmology
yes
yes
Yes
n/a
n/a
n/a
National Audit of Intermediate Care
no
n/a
n/a
n/a
n/a
n/a
(National PROMs Programme)
Women’s and Children’s Health
Page | 42
National audit
Is HHFT
eligible to
participate
Is BNHH
participating
Is RHCH
participating
% submission
of number of
registered
cases
required
External
audit reports
published in
2015/16 and
reviewed
Outcome or actions taken as a
result of audit
Paediatric Asthma
yes
yes
yes
100%
n/a
n/a
Maternal, Infant and Newborn
Programme (MBRRACE-UK)
yes
yes
yes
100%
3
Neonatal Intensive and Special Care
(NNAP)
yes
Report has been reviewed.
yes
yes
100%
1
No actions required by HHFT.
Report has been reviewed and
not an outlier for any of the
standards.
No actions required by HHFT.
Paediatric Intensive Care (PICANet)
no
n/a
Paediatric Pneumonia
yes
yes
yes
yes
Child health clinical outcome review
programme (NCEPOD Childrens)
n/a
n/a
n/a
n/a
yes
n/a
n/a
n/a
yes
n/a
n/a
n/a
Adolescent Mental Health
Note: n/a – is not applicable, it has been used in the above table to report for the following:



When an audit report has not yet been published;
When HHFT or site is not eligible to participate;
When the report has not been published and data for the audit is still being collected, analysed or not yet started, so %
submission of number of registered cases cannot be provided.
Local clinical audits
The reports of 104 local clinical audits were reviewed by the provider in 2015/16 and Hampshire Hospitals
NHS Foundation Trust intends to take the following actions to improve the quality of healthcare provided.
The tables below illustrate some of the actions taken or that are to be taken as a response to the local
clinical audits undertaken in various departments and specialities across the Trust in 2015/16.
Audit Outcome
Actions taken
An audit of doctor’s experience and confidence
of managing a cardiac arrest showed that 65%
of F2 doctors had attended less than 5 cardiac
arrests and only 5% of these doctors said that
they were confident in leading an arrest and
30% using a defibrillator.
Research has shown doctors have increased
confidence and improved performance of skills
following simulation based training.
Following two 90 minutes sessions of simulation
training the results improved.
The re-audit showed an improvement to 67.5% of F2
doctors being confident to lead a cardiac arrest and
97.5% had confidence in using defibrillators.
This audit examined the completion of ‘Do not
attempt cardio-pulmonary resuscitation’ (DNACPR)
Effective teaching sessions at junior doctors’
induction on the importance of the DNACPR policy
Page | 43
Audit Outcome
Actions taken
documentation including discussions with the
patients concerning DNACPR.
The results showed that there has been significant
improvement from previous audits in both
completing the DNACPR forms and the
documentation of patient discussions in the
medical notes. Documented reason for DNACPR
decision had improved from 88% in 2104 to 92% in
2015.
This audit was undertaken to examine if the
Paediatric Handover process was consistent with
guidance from the Royal College of Paediatrics,
“Good Practice in Handover”. The audit showed
that there was good practice with many of the
elements including: always a consultant lead
present; access to patient records; and good
medical attendance at handover. Areas to improve
included addressing clinically unstable children first
at handover.
has been introduced, this now also includes case law.
To improve patient awareness of DNACPR patient
information leaflets have been distributed throughout
the Trust.
This audit was designed to review antibiotic
prescribing within the surgical wards.
Antibiotic resistance is an increasing concern,
exacerbated by the inappropriate and
unnecessary prescription of antibiotics.
The re-audit has shown antibiotics correctly
prescribed increase from 61% in 2014 to 74%
in 2015. There was also improved
documentation and reviews of antibiotics.
Areas still to improve on included
consideration between switching antibiotic
from IV to oral, and stop dates.
Teaching sessions delivered by FY2s on antibiotic
prescribing and how to use the Electronic Prescribing
and Medicines Administration (JAC), have been
given to all their surgical colleagues. This included
awareness about documentation of planning IV to
oral antibiotics and the use of stop dates. This audit
will be repeated again in 2016.
This audit was undertaken to ensure compliance of
our bone bank with the Human Tissue Authority
(HTA) Standards of Practice. This included the
awareness amongst orthopaedic and theatre staff
of the bone bank protocol and process.
The results demonstrated an improvement
from the previous audit for all of the
standards. Identification of a consent form had
improved to 95% from 69% in the last audit.
Pre-assessment and theatre staff were well
informed about the bone bank process.
The bone bank had implemented a comprehensive
system of education with the consenting ‘process’
starting at the pre-op education classes where bone
banking is first discussed with the patients. This
system was praised in the last HTA report.
The paediatric consultant has developed ‘A guide to
handover’, which provides comprehensive details of
the handover process. This guide is now included in
all the new doctors’ induction packs.
Page | 44
Part 3: Reporting against core indicators
The tables below provide an overview of Hampshire Hospitals NHS Foundation Trust’s performance in
2015/16 against the key national priorities. Where possible this data is presented with comparisons with
the national average and other hospitals.
The data is presented for the last two reporting periods and the table includes notes on definitions, data
quality, improvement actions that have been taken or are planned and notes on data sources. Reference is
also made to the NHS Outcomes Framework Domains that are relevant to each indicator.
Page | 45
Indicator
PROMS Score –
Groin Hernia
Surgery
PROMS Score –
Varicose Veins
Surgery
PROMS Score – Hip
Replacement
Surgery - primary
PROMS Score –
Knee Replacement
Surgery - primary
2013/2014
2014/2015
Apr 15 –
Sep 15
0.105
0.100
*
National
Average
Apr 15 –
Sep 15
Best Figure
Apr 15 –
Sep 15
Worst
Figure Apr
15 – Sep 15
0.088
0.149
0.000
*
*
*
0.104
0.140
0.037
0.441
0.442
0.436
0.454
0.546
0.359
0.335
0.312
0.361
0.334
0.460
0.207
NHS
Outcomes
Framework
Domain
3. Helping
people to
recover from
episodes of
ill health or
following
injury
Definition
PROMS – Patient Reported Outcome Measures are a means of collecting information on the effectiveness of care delivered to NHS patients
as perceived by the patients themselves. It is reported at Trust level and the value for each procedure is the “case-mix adjusted average
health gain” as determined by the EQ-5D Index.
The Hampshire Hospitals NHS Foundation Trust considers that this data is as described for the following reasons – the PROMS
questionnaires and programme is handled by a provider on behalf of the Trust.
The Hampshire Hospitals NHS Foundation Trust intends to take the following action to improve this indicator and so the quality of its
services by continuing to provide the outcome data that is available at specialty level within the Trust. It is important that all specialties are
able to view the impact of the clinical services they provide at HHFT.
Notes on data sources
Data source – Health and Social Care Information Centre
The best and worst figures are for all providers not medium sized acute trusts
Data is not available for Oct 15-Mar 16 from the Health and Social Care Information Centre
*Insufficient data: due to reasons of confidentiality, small figures have been suppressed
Page | 46
Indicator
% of patients aged 015 readmitted within
28 days of discharge
% of patients aged
16 or over
readmitted within 28
days of discharge
BNHFT
2011/12
HHFT
2014/15
HHFT
2015/16
National
Average
2011/12
Best
Figure
Worst
Figure
11.43
Data not
available
Data not
available
10.01
0
14.94
Data not
available
Data not
available
11.45
9.59
0
15.70
NHS Outcomes
Framework Domain
3. Helping people to
recover from episodes
of ill health or
following injury
Definition
Readmission Rate - the percentage of patients readmitted to a hospital which forms part of the trust within 28 days of being discharged
from a hospital which forms part of the trust during the reporting period; aged: 0-15 and 16 or over.
The Hampshire Hospitals NHS Foundation Trust considers that this data is as described for the following reasons – audits carried out by
the trust in year identified a variety of reasons for patient readmissions.
The Hampshire Hospitals NHS Foundation Trust intends to take the following action to improve this indicator and so the quality of its
services by working with commissioners to identify specific areas for development by partners in primary care to help prevent
readmissions.
Notes on data sources
Data source – Health and Social Care Information Centre
The best and worst figures are for all providers not medium sized acute trusts
Data is not available for beyond 2011/12 from the Health and Social Care Information Centre
Indicator
2012/13
2013/14
2014/15
National
Average
2014/15
Best
Figure
2014/15
Worst
Figure
2014/15
NHS Outcomes
Framework Domain
Responsiveness to
personal needs of
patient
68.8
68.5
70.1
68.9
86.1
59.1
4. Ensuring that
people have a positive
experience of care
Definition
This is the Trust’s score with regard to its responsiveness to the personal needs of its patients during the reporting period. It is the
average weighted score of 5 questions relating to responsiveness to inpatients' personal needs (score out of 100).
The Hampshire Hospitals NHS Foundation Trust considers that this data is as described for the following reasons – it is taken from the
annual national Inpatient Survey in 2012/13, 2013/14 and 2014/15.
The Hampshire Hospitals NHS Foundation Trust has taken the following action to improve this indicator and so the quality of its services
by continuing to review patient feedback on their experiences in real time working with the Patient Voice Forum (PVF) as well as the
various walkabouts.
Notes on data sources
Data source – Health and Social Care Information Centre
The best and worst figures are for all providers not medium sized acute trusts
Data is not available for 2015/16 from the Health and Social Care Information Centre
Page | 47
Indicator
2013
2014
2015
National
Average
2015
Best
Figure
2015
Worst
Figure
2015
NHS Outcomes
Framework Domain
% of staff employed
who would
recommend the
trust as a provider of
care to their family
or friends
71
71
74
69
93
46
4. Ensuring that
people have a positive
experience of care
Definition
This the percentage of staff employed by, or under contract to, the trust during the reporting period who would recommend the trust as
a provider of care to their family or friends. The question was: If a friend or relative needed treatment I would be happy with the
standard of care provided by this organisation.
The Hampshire Hospitals NHS Foundation Trust considers that this data is as described for the following reasons – it is taken from the
annual staff survey.
The Hampshire Hospitals NHS Foundation Trust intends to take the following action to improve this indicator and so the quality of its
services by identifying all the actions required from the findings of the staff survey and gathering and responding to staff focus groups
feedback.
A&E
Friends
and
Family
Test Score
National
average
Inpatient
Friends
and
Family
Test Score
National
average
Maternity
Antenatal
Friends
Jan 2016
Dec 2015
Nov 2015
Oct 2015
Sep 2015
Aug 2015
Jul 2015
Jun 2015
May 2015
Apr 2015
Indicator
Mar 2015
Feb 2015
Notes on data sources
Data source – Health and Social Care Information Centre
The best and worse figures are for all acute trusts not medium sized acute trusts
The data is from the results of the Staff Surveys 2013, 2014 and 2015
% Would
Recommend
87
88
89
89
88
89
88
89
88
90
87
87
% Would not
Recommend
6
6
5
5
5
5
6
6
6
5
7
6
% Would
Recommend
88
87
88
88
88
88
88
88
87
87
87
86
% Would not
Recommend
6
6
6
6
6
6
6
6
7
7
7
7
% Would
Recommend
97
94
95
97
96
96
96
95
94
96
96
95
% Would not
Recommend
0
1
2
1
2
1
1
2
2
1
1
2
% Would
Recommend
95
95
96
96
96
96
96
96
96
96
96
96
% Would not
Recommend
2
2
2
1
1
1
1
2
1
1
2
1
% Would
Recommend
100
92
93
97
99
98
98
95
97
100
97
100
Page | 48
NHS Outcomes
Framework Domain
4. Ensuring that people
have a positive
experience of care
and
Family
Test Score
National
average
Maternity
Birth
Friends
and
Family
Test Score
National
average
Maternity
Post natal
Friends
and
Family
Test Score
National
average
Maternity
Post natal
Communi
ty Friends
and
Family
Test Score
National
average
Outpatien
ts Friends
and
Family
Test Score
National
average
% Would not
Recommend
0
4
3
0
0
1
1
0
0
0
0
0
% Would
Recommend
95
95
95
96
96
95
95
95
95
96
95
96
% Would not
Recommend
1
1
1
2
1
2
2
2
1
1
2
1
% Would
Recommend
96
98
98
99
96
95
99
98
100
98
99
100
% Would not
Recommend
1
1
0
0
3
1
1
1
0
1
0
0
% Would
Recommend
97
97
97
97
97
97
97
97
96
96
97
97
% Would not
Recommend
1
1
1
1
1
1
1
1
1
1
1
1
% Would
Recommend
93
96
95
97
95
92
91
96
97
96
97
96
% Would not
Recommend
2
1
0
0
2
4
2
1
1
2
1
1
% Would
Recommend
91
93
94
93
93
94
94
93
94
94
94
94
% Would not
Recommend
3
2
2
2
2
2
2
2
2
2
2
2
% Would
Recommend
90
100
100
100
100
100
% Would not
Recommend
0
0
0
0
0
0
% Would
Recommend
98
98
98
98
98
98
98
98
98
98
98
98
% Would not
Recommend
1
1
1
1
1
1
1
1
1
1
1
1
% Would
Recommend
91
92
91
93
93
94
95
96
97
94
% Would not
Recommend
3
3
3
2
2
2
1
2
1
2
% Would
Recommend
92
92
92
92
92
92
92
92
92
93
% Would not
Recommend
3
3
3
3
3
3
3
3
3
3
Definition
The Trust's Friends and Family Test score from a single question survey which asks patients whether they would recommend the NHS
service they have received to friends and family who need similar treatment or care.
The Hampshire Hospitals NHS Foundation Trust considers that this data is as described for the following reason - the trust monitors this
data on a monthly basis.
The Hampshire Hospitals NHS Foundation Trust intends to take the following actions to improve this indicator and so the quality of its
services by sharing the results of this survey with wards to enable them to take local actions for improvement.
Notes on data sources
Data source – Health and Social Care Information Centre.
Data is not available for Feb 16 from NHS England.
Page | 49
Indicator
2013/14
% of patients
admitted and were
risk assessed for
venous
thromboembolism
93.32
2014/15
95.72
Apr 15 –
Dec 15
95.61
National
Average
Apr 15 –
Dec 15
95.79
Best
Figure
Apr 15 –
Dec 15
100
Worst
Figure
Apr 15 –
Dec 15
NHS Outcomes
Framework Domain
80.56
5. Treating and caring
for people in a safe
environment and
protecting them from
avoidable harm
Definition
The percentage of patients who were admitted to hospital and who were risk assessed for venous thromboembolism (VTE)
during the reporting period.
The Hampshire Hospitals NHS Foundation Trust considers that this data is as described for the following reasons – the trust
continues to undertake robust data validation.
The Hampshire Hospitals NHS Foundation Trust has taken the following actions to improve this indicator and so the quality
of its services by implementing a unified data collection system and implementing the findings of the RCA (root cause
analysis) carried out on VTE events.
Notes on data sources
Data source – Health and Social Care Information Centre.
The best and worst figures are for all hospitals not medium sized acute trusts.
Data is not available for Q4 2015/16 from the Health and Social Care Information Centre.
Indicator
2012/13
Rate per 100,000
bed days of cases of
C Difficile
13.4
2013/14
15.9
2014/15
12.4
National
Average
2014/15
15.1
Best
Figure
2014/15
0
Worst
Figure
2014/15
NHS Outcomes
Framework Domain
62.2
5. Treating and caring
for people in a safe
environment and
protecting them from
avoidable harm
Definition
The rate per 100,000 bed days of cases of C.Difficile infection that have occurred within the trust amongst patients aged 2
or over during the reporting period.
The Hampshire Hospitals NHS Foundation Trust considers that this data is as described for the following reasons – the trust
continues to monitor this data on a monthly basis.
The Hampshire Hospitals NHS Foundation Trust intends to take the following actions to improve this indicator and so the
quality of its services by continuing to work with wards and departments to promote excellent infection control and
prevention.
Notes on data sources
Data source – Health and Social Care Information Centre.
The best and worst figures are for all hospitals not medium sized acute trusts.
Data is not available for 2015/16 from the Health and Social Care Information Centre
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Indicator
Number of
patient safety
incidents
Rate of
patient safety
incidents
Number of
patient safety
incidents that
resulted in
severe harm
including
deaths
% of patient
safety
incidents that
resulted in
severe harm
or deaths
Oct
12Mar
13
Apr 13
– Sep
13
Oct 13
– Mar
14
Apr 14
– Sep 14
3,510
3,204
3,107
3,262
Highest
Figure*
Oct 14
– Mar
15
Oct 14
– Mar
15
National
Average*
Oct 14 –
Mar 15
Lowest
Figure*
Oct 14
– Mar
15
3,498
4,539
443
12,784
Rate per 100
admissions**
13.7
7.46
7.24
24.65
26.45
37.15
3.57
82.21
45
31
24
31
36
23
2
128
1.3
0.9
0.8
0.9
1.1
0.6
0.0
5.2
NHS
Outcomes
Framework
Domain
Rate per 1000 bed days**
5. Treating
and caring
for people in
a safe
environment
and
protecting
them from
avoidable
harm
Definition
The number and, where available, rate of patient safety incidents that occurred within the trust during the
reporting period, and the percentage of such patient safety incidents that resulted in severe harm or death.
Following advice from the NRLS any pressure ulcers that occurred outside the organisation should no longer be
included in the data submitted. In addition internal data shows that the overall incident reporting rate has
remained static with a decreasing rate of moderate, severe harm and death incidents.
The Hampshire Hospitals NHS Foundation Trust considers that this data is as described for the following reason the trust encourages a reporting culture and this demonstrates a positive patient safety culture.
The Hampshire Hospitals NHS Foundation Trust intends to take the following actions to improve this indicator and
so the quality of its services by continuing to encourage reporting and continuing to review incidents and
ensuring that lessons are learnt and shared across the Trust.
Notes on data sources
Data source – Health and Social Care Information Centre.
From April 2014 the national average, highest and lowest figures are for acute non specialist trusts.
The data shown here is for October 2012 – March 2015.
Note
*From April 2014 the national average, highest and lowest figures are for acute non specialist trusts.
** From April 2014 the rate is based on per 1000 bed days. Previously NRLS reported the figures per 100
admissions.
Page | 51
Notes on data quality
Data has been taken from national data sources using national definitions where available. Where local
data is used the following should be noted:
Data changes from the 2014/15 Quality Report
Data taken from Dr Foster RTM has been updated to report full year data and to reflect changes in the Dr
Foster baseline.
Monitor Quality Indicators
The table below illustrates Hampshire Hospitals NHS Foundation Trust’s performance against the Monitor
quality indicators for 2015/16.
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The following information includes the definitions of the quality indicators which were subject to the
external assurance process:
There has been an external review of 2 indicators:
 Percentage of incomplete pathways within 18 weeks for patients on incomplete pathways at the
end of the reporting period; and
 A&E: maximum waiting time of four hours from arrival to admission/discharge/transfer.
Other information
The Trust has chosen a range of indicators reflecting patient safety, clinical effectiveness and patient
experience for inclusion in this section. The indicators were initially chosen after consultation with a range
of stakeholders, including patient groups, governors and Foundation Trust members. The Associate
Medical Directors (AMDs) of Governance have reviewed the indicators and confirm to the Board of
Directors that they best reflect the quality of the services we deliver.
The indicators reflect clinical effectiveness, patient safety and patient experience work carried out e.g. the
Patient Safety Framework. Where available the indicators are presented with historical and benchmarked
data and comments or explanatory notes are included.
Hampshire Hospitals NHS Foundation Trust additional indicators
Hampshire Hospitals NHS Foundation Trust continues to perform well on a range of patient safety
indicators. The rate of incidents resulting in moderate, severe harm or death continues to decrease year on
year whilst the overall rate of incidents reported is increasing. This is an indicator of a positive patient
safety culture.
Learning from serious incidents requiring investigation is shared across the organisation on a monthly basis,
cascaded through the Midweek Message and by the Chief Executive Officer at the monthly In Touch
sessions on all three hospital sites.
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The indicators for 2015/16 are presented below. Further information on patient safety indicators and
national benchmarking is available in this report.
Indicator
2012/13
2013/14
2014/15
2015/16
No. of serious incidents requiring investigation (excluding
Never Events)
48
67
101
38
5
1
0
6
3.67
3.71
3.11
3.43
2.89
2.78
1.72
2.13
1.49
1.15
1.28
0.99
83
76
65
67
Data source: staff incident reporting
No. of Never Events
Data source: staff incident reporting
No. of medication errors per 1000 bed days
(low numbers indicate better performance)
Data source: staff incident reporting
No. of patient falls resulting in injury per 1000 bed days
(low numbers indicate better performance)
Data source: staff incident reporting
No. of hospital acquired pressure ulcers per 1000 bed days
(low numbers indicates better performance)
Data source: staff incident reporting
No. of patient safety walkroundsTM
(high numbers indicate better performance)
Data source: patient safety programme
Date quality note: data is subject to refreshing following incident investigation and subsequent reclassification/downgrading and there was a
change in the national definitions of serious incidents requiring investigation
The programme of Executive patient safety WalkroundsTM continues across all hospital sites, in conjunction
with a range of other Executive visits. The following table includes examples where improvements have
been made in 2015/16 in response to these WalkroundsTM.
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Executive Patient Safety Walkround
TM
finding
Changes made
A patient said that she thought it would be less
confusing if the staff were able to write down a
schedule every day that explained what would be
happening.
To help patients know what’s happening to them on a
daily basis; at the start of the shift nurses introduce
themselves and explain to them what the plan is for
the day. The therapy staff are in the process of
developing a rehabilitation pathway/chart for
patients to follow.
The quality of the food at AWMH receives frequent
praise from patients and staff, however chefs do not
routinely visit the wards to speak to patients.
A new organisational structure is in place and as part
of their work schedules, chefs are to visit the ward on
a fortnightly basis.
One member of staff said that she has access to a
rotunda (movement aid) on a RHCH ward but not
when she works on the Orthopaedic wards in BNHH.
A new Rotunda was purchased and is in use.
The neonatal unit is a ‘Locked unit’. At the entrance
there is more than one buzzer to press and the
signage is not clear
The redundant buzzer has been removed and signage
is now clear to gain access to the unit
Clinical effectiveness
Clinical effectiveness and outcome measures are continuously monitored and remain stable or improved
for the majority of measures. Mortality rates continue to be monitored with a programme of peer reviews
for all deaths in place, with additional twice yearly reviews allowing appropriate action to be undertaken
where necessary.
Indicator
2012/13
Stroke – in hospital mortality rate (%)
(low % indicates better performance)
Data source: Dr Foster
Hip fracture – in hospital mortality rate (%)
2013/14
2014/15
17.87
18.69
17.82
17.82
(Apr 15 – Dec 15)
8.45
7.59
4.79
3.71
(Apr 15 – Dec 15)
9.23
6.78
9.62
8.01
(Apr 15 – Dec 15)
4.6
4.41
4.84
5.15
N/A
82.39
84.09
84.74
(low % indicates better performance)
Data source: Dr Foster
Acute myocardial infarction – in hospital mortality rate (%)
(low % indicates better performance)
Data source: Dr Foster
Average Length of Stay for in-patients (excluding day cases)
2015/16
(low figure indicates better performance)
Data source: Business Intelligence
Day case rate (% for all elective procedures)
(high % indicates better performance)
Data source: Business Intelligence
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Indicator
Jan 12-Dec 12
Jan 13-Dec 13
Jan 14-Dec 14
Jan 15-Dec 15
106.35
104.92
111.65
114.65
111.26
117.04
115.98
110.72
Weekday – hospital standardised mortality rate
(low figure indicates better performance)
Data source: Dr Foster
Weekend – hospital standardised mortality rate
(low figure indicates better performance)
Data source: Dr Foster
Date quality note: data is presented where available and time periods are stated in the table
Patient Experience
The data presented here relates to the 2014 National Inpatient Survey.
In response to the 2014 survey the results show that improvements have been made in some areas,
however there remain improvements to be made to ensure that patients are given the information they
require on leaving hospital and help for patients who require assistance to eat meals. In 2015/16 the Trust
has increased the number of mealtime and dementia volunteers.
The data from this annual national survey differs from the information received from patients in real time
which is referred to in Part 2 of this report. Work is underway to ensure that all patients receive the
information they require and improve the patient experience. The Patient Experience and Volunteer
Services Manager will continue to work with patients, staff, and volunteers to improve the overall patient
experience.
Indicator (% of patients)
2012
2013
2014
18
18
17
19
22
20
4
2
3
20
20
21
38
43
43
62
60
64
Overall rated experience less than 7/10
(low % indicates better performance)
Not treated with respect or dignity
(low % indicates better performance)
Room or ward not very or not at all clean
(low % indicates better performance)
Did not always have confidence and trust in doctors and nurses
(low % indicates better performance)
Wanted to be more involved in decisions
(low % indicates better performance)
Could not always find staff member to discuss concerns with
(low % indicates better performance)
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Indicator (% of patients)
2012
2013
2014
28
27
25
62
65
62
17
21
15*
37
38
45
Not always enough privacy when discussing
condition/treatment
(low % indicates better performance)
Not fully told side-effects of medication upon discharge
(low % indicates better performance)
Not told who to contact if worried after leaving hospital
(low % indicates better performance)
Did not always get enough help from staff to eat meals
(low % indicates better performance)
*Scores significantly improved since 2013 survey
Indicator (staff score)
Would recommend hospital (staff survey results – scores out of
5, not %)
2012/13
2013/14
2014/15
2015/16
3.66
3.74
3.74
3.85
(scores closest to 5 better)
The following data relates to formal complaints reported to the Customer Care Team at HHFT.
Indicator
Number of formal complaints
Number of formal complaints responded to within 25
working days
Number of formal complaints referred to the PHSO
Number of formal complaints upheld by the PHSO
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2013/14
606
2014/15
608
2015/16
676
54%
51%
38%
9
5
1 (partly
upheld)
3 (1 fully, 2
partly
upheld)
7
3 (1 fully
upheld, 2
partly
upheld)
Notes on data sources
Data sources – Inpatient Survey (Picker Institute Europe, 2015) and 2015 National NHS Staff Survey
The complaints indicator is new for 2015/16. The data source is the electronic risk management system,
Datix, where all formal complaints logged with the customer care team are recorded.
The response within 25 working days is an internal Trust target. There are no national targets set for this.
Where complaints are complex and require an extended period of time to investigate, this is negotiated
and agreed with the complainant.
Complainants who are dissatisfied with the response from the Trust are entitled to refer their complaint to
the Parliamentary Health Service Ombudsman (PHSO). Following their independent review of the evidence
and response made by the Trust the PHSO may uphold or reject the complaint.
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Healthwatch Hampshire Feedback on the Quality Report Process
Healthwatch Hampshire was invited to submit their view on the Trust’s Quality Report process but they do
not normally contribute to the Quality Accounts of the NHS bodies that they work with.
Governors Feedback on the Quality Report Process
The draft Quality Report was circulated to the Patient Experience Group (PEG), a working group of the
Council of Governors, to obtain their feedback on the contents of the report. While no formal statement
from the group was provided, the Chairman of the PEG co-ordinated the feedback on behalf of the
group. Overall, the response was that the report showed a positive outcome upon which to build future
progress. However, the Trust should not feel complacent or stop trying to improve patient care and
experience.
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 2015/16 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 2015 to April 2016;
o Papers relating to Quality reported to the board over the period April 2015 to April 2016;
o Feedback from Commissioners, West Hampshire Clinical Commissioning Group and North
Hampshire Clinical Commissioning Group dated 11 May 2016
o Feedback from governors dated 10 May 2016
o Feedback from local Healthwatch organisations
o Feedback from the Hampshire Health and Social Care Select Committee dated 10 May 2016
o The trust’s complaints report published under regulation 18 of the Local Authority Social
Services and NHS Complaints Regulations 2009
o The national inpatient survey
o The national staff survey
o The Head of Internal Audit’s annual opinion over the trust’s control environment dated
dated April 2016
o CQC Intelligent Monitoring Report
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 materially reliable and accurate;
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