Quality Account 2010/11 - James Paget University Hospitals
Quality Account 2010/11 - James Paget University Hospitals
Quality Account 2010/11 - James Paget University Hospitals
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<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong><br />
NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong><br />
<strong>2010</strong>/<strong>11</strong><br />
Toward excellent Where you quality come care, first together
Foreword<br />
Statement on <strong>Quality</strong> by Chief Executive<br />
The year has featured both achievement and challenge for the Trust across<br />
all service areas, with major developments set against an increasing demand<br />
for healthcare in our community. The Trust and its staff have responded<br />
strongly to meet the need for change and improvement.<br />
There has been an increased demand for emergency healthcare throughout<br />
the year, with particularly high levels of activity during the winter months. We<br />
always plan for an increase at this time but the surge in January and<br />
February was extreme and unusual. All healthcare providers experienced extreme<br />
emergency demand during this period which led to extra patients coming to acute hospitals.<br />
The level of demand contributed to some patients having a poor experience in several of our<br />
clinical areas, which led to concerns being identified. Some wards had particularly high<br />
numbers of patients who required assisted feeding and/or increased supervision which wards<br />
with standard nursing ratios would find difficult to manage. A programme of actions is now<br />
underway to ensure that high quality essential care can be maintained at all times. Part of<br />
this programme will deliver enhanced staffing levels, particularly at meal times.<br />
The Essential Care Project brings renewed focus on the wellbeing and fundamental care of<br />
patients and relatives during a hospital stay. This work supports the maintenance of high<br />
quality care at all times, whilst meeting high demand across the system. There is also work<br />
ongoing to aid the care of dementia patients who require acute medical and surgical<br />
intervention to make their experience better and recovery quicker, giving quality and<br />
efficiency benefits.<br />
The Leading Improvement in Patient Safety scheme (LIPS) has been implemented and well<br />
established. Further development of safety across 10 key metrics remains a Trust objective<br />
for the coming year. There have already been improvements including VTE assessment,<br />
patient falls and pressure sores. The Patient Experience project has greatly expanded to<br />
include patient feedback, Experience Based Design Group and the incorporation of specific<br />
issues from regular Patient Story presentations to the Board of Directors.<br />
During the year our Maternity Services achieved Level 2 status against the new Clinical<br />
Negligence Scheme for Trusts (CNST) standards, reflecting the quality service provided for<br />
mothers and babies locally.<br />
Over the year the Trust has achieved its financial and quality targets with the exception of 18<br />
week waits for 100% of cases. The exceptional winter demand unfortunately meant that the<br />
elective surgery programme was affected, with some specialties not meeting this target. The<br />
response of staff in all departments to deliver services against a difficult background has<br />
been recognised and is greatly appreciated by the Board, Governors and our patients.<br />
The Trust has worked closely with partner organisations to develop new ways of working<br />
across health and social care provision. This work forms a key part of meeting the funding<br />
challenge in the public sector. Our staff have participated in this work, giving important<br />
clinical input to the service changes. The commitment of staff has been truly commendable<br />
during the year and I acknowledge the great contribution and achievement they have made.<br />
We have much to accomplish during the coming year to ensure that we continue to meet the<br />
needs of our community. Together we can take forward services and developments, building<br />
on those achieved during the last year.<br />
Wendy Slaney, Chief Executive<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 1 of 62
Contents<br />
Page<br />
Foreword by Chief Executive 1<br />
Part 1<br />
Introduction 3<br />
Statement of Directors’ Responsibilities 6<br />
Part 2<br />
Priorities for <strong>2010</strong>/<strong>11</strong> 7<br />
Board Statements of Assurance 17<br />
Review of Services 18<br />
Participation in Clinical Audits 19<br />
NICE Compliance 26<br />
Research 27<br />
Data <strong>Quality</strong> 27<br />
NHS Number and GMC coding validity 28<br />
Information Governance Toolkit 28<br />
Clinical Coding Error Rate 29<br />
What others say about the Trust 30<br />
Part 3<br />
Review of <strong>Quality</strong> Performance 31<br />
Patient Safety 31<br />
Clinical Outcomes and Effectiveness 43<br />
Patient Experience 46<br />
Endorsement 59<br />
Glossary of abbreviations 61<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 2 of 62
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> 2009/10<br />
Part 1<br />
1 Introduction<br />
Welcome to the third <strong>Quality</strong> <strong>Account</strong> report for <strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS<br />
Foundation Trust. <strong>Quality</strong> <strong>Account</strong>s are a means to improve organisational accountability, to<br />
enable review of services and identify areas for improvement and to demonstrate change.<br />
They provide an opportunity for providers of healthcare to work with clinicians to rigorously<br />
analyse the quality of care that is being delivered in order to assure commissioners, patients<br />
and the public that trust boards are continuously scrutinising the quality of their services.<br />
<strong>Quality</strong> <strong>Account</strong>s are also an opportunity to drive forward our local quality improvement plans<br />
and to be accountable to the public and stakeholders for these improvements.<br />
This year has again seen a period of unprecedented demand for the Trust’s services; there<br />
has been a 5.2% increase in emergency admissions and a 1.7% increase in Accident and<br />
Emergency (A&E) attendances over the year; and yet we have still provided high quality care<br />
for our patients and are continuing to strive to improve services further. During <strong>2010</strong>/<strong>11</strong> we<br />
cared for the following numbers of patients:<br />
Elective admissions 29,590<br />
Emergency admissions 26,682<br />
Day cases 24,147<br />
1 st outpatient appointments 65,206<br />
Follow up outpatient appointments 162,910<br />
A&E attendances 65,665<br />
This equates to an average of 512 emergency admissions each week (73 each day) and an<br />
average of 1,260 attendances each week (180 each day) at our Accident and Emergency<br />
Department. To achieve this, the Trust has utilised 9,076 escalation bed 1 days. This equates<br />
to an average of 25 escalation beds per day this year with the Trust on ‘Black Alert’ 2 on 131<br />
occasions. In order to appropriately care for emergency admissions to the Trust we have<br />
postponed nearly 600 operations this year. Furthermore, our society is changing with our<br />
local population living longer.<br />
An additional factor we need to highlight is that our local population is living longer. The area<br />
of Great Yarmouth and Waveney has a greater proportion of older people than England or<br />
East of England averages, a smaller proportion of working age people between 20 and 50<br />
and a smaller proportion of children under 10. The population is forecast to age, with the 65+<br />
age band likely to increase the most in future years.<br />
1 Escalation beds: extra beds put in place to cope with unexpected increase in demand.<br />
2 Black alert: The status of the hospital when it is full to capacity, escalation beds are in use, patients are waiting<br />
in A&E for beds, routine surgery is cancelled and the Trust is working with community partners to discharge<br />
patients.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 3 of 62
The old and the very young are known to increase demand on health. This <strong>Quality</strong> <strong>Account</strong><br />
summarises some of the quality achievements and initiatives undertaken throughout<br />
<strong>2010</strong>/<strong>11</strong>, despite all of the pressures highlighted above. It demonstrates our continued<br />
commitment to the three key quality drivers:<br />
1. Patient Safety;<br />
2. Clinical Outcomes and Effectiveness;<br />
3. Patient Experience.<br />
This report will be published on the NHS Choices website and the Trust’s own website by 30<br />
June 20<strong>11</strong>. The report can be made available in different languages and formats if required.<br />
Please contact Anna Hills, Assistant Director of Governance, Safety and Compliance on<br />
(01493) 453684, anna.hills@jpaget.nhs.uk.<br />
If you would like to provide feedback regarding this <strong>Quality</strong> <strong>Account</strong> or make suggestions for<br />
the content of future years’ reports please contact the Assistant Director of Governance,<br />
Safety and Compliance as above.<br />
Please also see the <strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Trust Annual Report <strong>2010</strong>/<strong>11</strong><br />
which can be obtained from the Trust website or the Trust Secretary ann.filby@jpaget.nhs.uk<br />
from August 20<strong>11</strong>.<br />
Trust Objectives 20<strong>11</strong>/12<br />
The Trust has developed a five year strategy through to 2014/15.<br />
This strategy outlines our vision for continuing to work towards excellent quality care set out<br />
in four key priorities for the Trust in the coming five years;<br />
1 Maintaining and strengthening our core services to achieve year onyear<br />
improvements in clinical, operational and financial performance of the acute and<br />
community services that form the backbone of our Trust.<br />
2 Meeting the comprehensive needs of our high risk population.<br />
We aim to take a proactive role in managing and delivering care pathways for growing<br />
patient populations, in particular the elderly and those suffering from long term<br />
conditions. This includes working in partnership with others to address the needs of<br />
the community and support NHS Great Yarmouth and Waveney in reducing health<br />
inequalities.<br />
3 Enhancing the overall experience of our patients to ensure all patients of the Trust<br />
experience high quality care in a professional environment, treated with dignity and<br />
respect. Listening to the experience of our patients will be key to further improving our<br />
services.<br />
4 Being an excellent employer. We want to be recognised as an employer that is<br />
committed to the development of our staff, recruiting the most capable and dedicated<br />
employees who share our vision for excellent patient care. Clear and consistent<br />
leadership for our staff and investment in their ongoing training and development are<br />
important commitments we aim to deliver during this period.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 4 of 62
We have ensured our strategy is in line with the direction and priorities set out in national,<br />
regional and local health strategies; Lord Darzi’s Next Stage Review, the NHS East of<br />
England’s ‘Towards the Best, Together’ and NHS Great Yarmouth and Waveney’s local<br />
strategy.<br />
We believe that pursuing this strategy will result in excellent services that will deliver better<br />
outcomes for the people of Great Yarmouth and Waveney and will contribute towards<br />
building a healthier community for the future.<br />
The Trust has agreed a number of strategic objectives for the coming year which will promote<br />
delivery of the five year strategy and directly cascade to team and individual objectives:<br />
1. Improve the care and experience of patients, with a specific focus on older people<br />
and those with dementia, by working internally and with partner agencies.<br />
2. Deliver further improvements against the 10 key metrics of the Leading Improvement<br />
in Patient Safety scheme across the Trust, e.g. infection and falls preventions<br />
3. Continue to implement a range of transformation and quality improvements across all<br />
care pathways, with particular focus on length of stay.<br />
4. Deliver all financial targets.<br />
5. Demonstrate further progress towards a reduction in carbon emissions at the Trust of<br />
20% by 2015.<br />
6. Achieve national performance standards that underpin the provision of excellent<br />
services to our community.<br />
These objectives to be supported by a framework of educational and development<br />
support for staff.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 5 of 62
Statement of directors' responsibilities in respect of the quality accounts<br />
The directors are required under the Health Act 2009 and supporting regulations to prepare<br />
<strong>Quality</strong> <strong>Account</strong>s for each financial year. In preparing these accounts, directors are required<br />
to take steps to satisfy themselves that:<br />
• the <strong>Quality</strong> <strong>Account</strong>s present a balanced picture of the NHS foundation trust’s<br />
performance over the period covered;<br />
• the performance information reported in the <strong>Quality</strong> <strong>Account</strong>s is reliable and accurate;<br />
• there are proper internal controls over the collection and reporting of the measures of<br />
performance included in the <strong>Quality</strong> <strong>Account</strong>s, and these controls are subject to<br />
review to confirm that they are working effectively in practice;<br />
• the data underpinning the measures of performance reported in the <strong>Quality</strong> <strong>Account</strong>s<br />
is robust and reliable, conforms to specified data quality standards and prescribed<br />
definitions, and is subject to appropriate scrutiny and review; and<br />
• the <strong>Quality</strong> <strong>Account</strong>s have been prepared in accordance with relevant requirements<br />
and guidance issued by Monitor.<br />
The directors confirm to the best of their knowledge and belief that they have complied with<br />
the above requirements in preparing the <strong>Quality</strong> <strong>Account</strong>s.<br />
........................................................................................... Chairman<br />
........................................................................................… Chief Executive<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 6 of 62
Part 2<br />
Priorities for improvement 20<strong>11</strong>/12<br />
Our <strong>Quality</strong> Strategy continues to focus on the three key areas of patient safety, clinical<br />
outcomes and effectiveness, and patient experience. Hence, our four key priorities for<br />
20<strong>11</strong>/12 are as follows:<br />
• Patient safety – Reduction in In-Patient Falls;<br />
• Patient safety – Reduction in standardised mortality rates;<br />
• Patient Experience – To embed the Trust Values; and<br />
• Clinical Outcomes and Effectiveness – Achievement of the CQUIN goals.<br />
Delivery of these priorities will be overseen by the Transformation Board which is responsible<br />
for delivery of the productivity and effectiveness, patient safety and patient experience<br />
agendas via three project streams. Each project stream is driven by a dedicated project<br />
director and a clinical champion who oversees delivery of an action plan, underpinned by<br />
‘lean’ methodology.<br />
The Transformation Board monitors delivery of the action plans and reports directly to the<br />
Board of Directors of the Trust as well as contributing to the system wide Great Yarmouth<br />
and Waveney Transformation Board and the East of England arrangements.<br />
Priority 1a: Patient safety – Reduction in In-Patient Falls<br />
AIM: To reduce in-patient falls by 10%<br />
This will be measured via the Patient Safety Programme key metrics. The percentage<br />
reduction in falls will be measured against the <strong>2010</strong>/<strong>11</strong> baseline using the per 1000 bed days<br />
calculation.<br />
Executive Sponsor: Director of Nursing<br />
Responsible officer: Patient Safety Project Director<br />
During <strong>2010</strong>/<strong>11</strong> there were 1063 in-patient falls across the Trust compared to <strong>11</strong>49 in<br />
2009/10 (7.5% reduction). Nationally there were 283,438 slips, trips and falls reported to the<br />
National Patient Safety Agency (NPSA) between October 2008 and September 2009. Inpatient<br />
falls continued to be the Trust’s highest category of adverse incidents reported during<br />
<strong>2010</strong>/<strong>11</strong>.<br />
During <strong>2010</strong>/<strong>11</strong> there was a Local Improvement Aim linked to a CQUIN 3 to achieve:<br />
1. 20% reduction in the number of in-patient falls.<br />
2. The use of risk assessments across the Trust to ensure patients are appropriately<br />
assessed and preventative measures introduced as a result of their level of risk of falls.<br />
3 The Commissioning for <strong>Quality</strong> and Innovation (CQUIN) payment framework is a national framework for locally agreed quality<br />
improvement schemes.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 7 of 62
Current position:<br />
Patient Falls<br />
120<br />
<strong>11</strong>1<br />
Monthly Total (Total = 1063)<br />
Trajectory<br />
<strong>11</strong>1<br />
Number of Incidents<br />
100<br />
80<br />
60<br />
40<br />
99<br />
96<br />
92 91<br />
88<br />
85<br />
83<br />
78<br />
76 76 76 76 76 76 76 76 76 76 75 76 76<br />
49<br />
20<br />
0<br />
Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-<strong>11</strong> Feb-<strong>11</strong> Mar-<strong>11</strong><br />
Month and Year<br />
During <strong>2010</strong>/<strong>11</strong> 18 patients suffered a fracture as a result of a fall whilst in our care; 14 hip<br />
fractures, 1 fractured nose, 1 fractured shoulder and 2 fractured wrists. All of these incidents<br />
were comprehensively investigated.<br />
A number of significant improvements have been achieved during <strong>2010</strong>/<strong>11</strong> to help reduce inpatient<br />
falls. These include:<br />
• Significantly raised awareness<br />
• 10 Key Responsibilities for falls prevention<br />
• Revised documentation in all ward areas<br />
• Communication cascade regarding falls prevention care<br />
• Assistive Technology – Sensor Care Trigger Alert<br />
• Patient Safety Action Planning & Development Day for nursing staff<br />
• Dedicated resource to support the change process<br />
• Refocussed Trust Falls Steering Group<br />
• Redesign of mandatory training package and inclusion of falls prevention in induction<br />
• Hospital at night (H@N) team link nurse involvement to achieve promotion of the<br />
standards 24/7<br />
• Allocation of Strategic Workforce Investment Fund for Tomorrow (SWIFT) funding for<br />
falls prevention<br />
• Increased regional networking – proposal for standardised practice expectation<br />
across Norfolk.<br />
However, there remain a number of concerns including:<br />
• Volume of in-patient falls;<br />
• Volume of fractures sustained as a result of an in-patient fall; and<br />
• Current capacity and demand issues and perceived impact on ability to maintain<br />
prevention standards.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 8 of 62
The further reduction in in-patient falls will be achieved by embedding the 10 key<br />
responsibilities below:<br />
Case Study 1: Assistive Technology<br />
Technology is also a part of our falls prevention work. The Trust has recently invested in a<br />
sensitivity trigger alarm system called Sensor Care.<br />
The Sensor Care Alarm System is a device that has been developed to alert staff when a patient<br />
at risk of falls has moved from their bed or chair.<br />
The device works by having a sensitivity plate under the bed mattress or chair cushion. The<br />
sensitivity level on the plate is programmed in accordance with the patient’s size. When the<br />
patient stands up or moves sufficiently to change the sensitivity level an alert is created through<br />
a bleep which is specifically paired with the plate or cushion e.g. if bleep 1 alarmed, it would be<br />
telling you that the patient on mattress 1, is trying to get out of bed or has succeeded. This acts<br />
as an alert to investigate what the patient is doing and therefore reduce the level of risk of the<br />
patient falling if you didn’t know they were moving.<br />
At the current time we have enough systems to cover the top floor of the hospital. A bid is being<br />
developed to try to extend this to cover all areas of the hospital. Lowestoft Hospital already has<br />
the sensor care system in place.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 9 of 62
Priority 1b: Patient safety – Reduction in mortality rates<br />
AIM: To integrate HSMR measures into clinical and managerial<br />
processes<br />
The Hospital Standardised Mortality Ratio (HSMR) is an indicator of healthcare quality that<br />
measures whether the death rate at a hospital is higher or lower than you would expect. Like<br />
all statistics, HSMRs are not perfect. If a hospital has a high HSMR, it cannot be said for<br />
certain that this reflects failings in the care provided by the hospital. However, it can be a<br />
warning sign that things are going wrong.<br />
The HSMR compares the expected rate of death in a hospital with the actual rate of death for<br />
a number of diagnoses, for example, heart attacks, strokes or broken hips. For each group<br />
of patients it is possible to work out how often, on average, across the whole country, they<br />
survive their stay in hospital. This is achieved by taking into account their age, the severity of<br />
their illness and other factors, such as whether they live in a more or less deprived area. This<br />
provides a figure for how many patients we would expect to die at each hospital. This is then<br />
compared with the number of patients that actually die. If the two numbers are the same, the<br />
hospital gets a score of 100. If the number of deaths is ten per cent less than expected they<br />
get a score of 90. If it is ten per cent higher than expected, they score <strong>11</strong>0.<br />
Care is needed in interpreting these results. Just through chance, some hospitals will have a<br />
higher mortality rate and some a lower rate. It is inevitable that half the hospitals will have a<br />
worse than average result and that some will be quite a lot worse than the average. It is<br />
important to focus on "outliers". These are hospitals where the results lie outside the normal<br />
range, or particular groups of conditions where results lie outside the normal range, for a<br />
particular hospital.<br />
An HSMR 14 point action plan has been approved by the Trust’s Board of Directors and<br />
Management Team, to integrate the use of HSMR data with other tools. Specialties with a<br />
higher than average mortality rate can understand why this has occurred and take any<br />
necessary steps to improve. The action plan will be owned by the Trust’s Management Team<br />
and progress against the actions will be monitored through the existing performance<br />
management processes. A regular update on progress will be provided to both the Board of<br />
Directors and Management Team throughout the year.<br />
Executive Sponsor: Medical Director<br />
Responsible officer: Deputy Director of Performance<br />
Objectives: The Trust aims to reduce its overall and specialty specific HSMR to less than<br />
100 throughout 20<strong>11</strong>/12.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 10 of 62
Current position:<br />
Hospital Standardised Mortality Ratio (HSMR) for <strong>2010</strong>/<strong>11</strong><br />
100<br />
90<br />
80<br />
70<br />
Relative risk<br />
60<br />
50<br />
40<br />
30<br />
20<br />
10<br />
0<br />
Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-<strong>11</strong> Feb-<strong>11</strong> Mar-<strong>11</strong><br />
Actual 94 98.6 86.8 81.1 92.8 87.7 100.5 75.5 74.5<br />
Priority 2: Patient Experience – To embed the Trust Values<br />
AIM: To improve the patient experience by embedding the Trust<br />
values into all that we do<br />
This will be measured by the Trust Values Steering Group.<br />
Executive Sponsor: Director of Workforce and Estates<br />
Responsible officer: Head of Learning and Organisational Development<br />
The Trust has received feedback from our patients and the public via complaints, PALS<br />
enquiries and other sources which has indicated that at times our communications require<br />
improvement.<br />
In response to this the Trust has agreed a set of core values which it expects all staff to<br />
demonstrate in order to improve the experience of our patients and visitors.<br />
The Board is determined to see the Trust’s values as a critical and integral part of the <strong>Paget</strong><br />
experience. The values must be understood by all staff and embedded in the organisation<br />
resulting in patients and service users experiencing these values when they are in contact<br />
with our staff. A steering group has been established to ensure this happens and to monitor<br />
progress.<br />
The steering group comprises key senior individuals from across the organisation including a<br />
Non Executive Director. It has been established to develop and implement a set of action<br />
plans that will ensure the Trust’s values are embedded in the organisation. It will monitor and<br />
evaluate the effectiveness of the action plans and report on progress to the Board during the<br />
year.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page <strong>11</strong> of 62
Five work streams have been agreed and steering group members have responsibility for<br />
each area:<br />
• Human Resources processes and procedures<br />
• Internal and external Communication<br />
• Organisational processes and policies<br />
• Patient and Stakeholder experience of values<br />
• Leadership and values.<br />
The objectives for <strong>2010</strong>/<strong>11</strong> were:<br />
• 80% of employees will be able to articulate the values;<br />
• 50% of patients will know about our values;<br />
• The values will be incorporated in all people management and development<br />
processes; and<br />
• The Board will be assured that the values are integral to a patient safety<br />
culture.<br />
A baseline audit was conducted from September to December <strong>2010</strong> and questions on the<br />
values were added into the Patient Experience Tool (PET). 52% of the 696 respondents<br />
indicated that they knew the Trust had a set of values, however only 18% could name them.<br />
Staff knowledge of the values was measured in a variety of ways during March 20<strong>11</strong>, which<br />
included:<br />
• Face to face sessions with staff<br />
• Intranet survey<br />
• Paper questionnaires distributed to 300 members of staff<br />
• Patient experience tool situated in the staff restaurant<br />
• Questioning staff at training sessions and after induction.<br />
The total number of staff who participated or responded was 1043; 734 (86%) were able to<br />
articulate the values.<br />
The Values Steering Group will continue to function during 20<strong>11</strong>/12. The focus of the group<br />
will be to continue to raise awareness of the values with staff through embedding the values,<br />
concentrating on the behavioural change required and supporting senior managers and<br />
clinicians in the role modelling of the values.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Values:<br />
Putting patients first, and they will:<br />
Provide the best possible care in a safe clean and friendly environment,<br />
Treat everybody with courtesy and respect,<br />
Act appropriately with everyone.<br />
Aiming to get it right, and they will:<br />
Commit to their own personal development,<br />
Understand theirs and others roles and responsibilities,<br />
Contribute to the development of services<br />
Recognising that everyone counts, and they will:<br />
Value the contribution and skills of others,<br />
Treat everyone fairly,<br />
Support the development of colleagues.<br />
Doing everything openly and honestly, and they will:<br />
Be clear about what they are trying to achieve,<br />
Share information appropriately and effectively,<br />
Admit to and learn from mistakes.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 12 of 62
Priority 3: Clinical Outcomes and Effectiveness – Achievement of the CQUIN<br />
goals.<br />
AIM: To utilise the CQUIN scheme to drive quality improvements<br />
across a number of specific areas<br />
Achievement of the CQUINs will be monitored via the Transformation Board.<br />
Executive Sponsor: Medical Director<br />
Responsible officer: Project Lead for Effectiveness and Productivity<br />
The Commissioning for <strong>Quality</strong> and Innovation (CQUIN) payment framework is a national<br />
framework for locally agreed quality improvement schemes. It makes a proportion of provider<br />
income conditional on the achievement of ambitious quality improvement goals and<br />
innovations agreed between commissioner and provider, with active clinical engagement.<br />
The CQUIN framework is intended to reward excellence, encouraging a culture of continuous<br />
quality improvement in all providers.<br />
A CQUIN scheme is the locally agreed package of quality improvement goals and<br />
indicators, which in total, if achieved, enables the provider to earn its full CQUIN<br />
payment (calculated as 1.5% of the Actual Outturn Value of the provider contract in<br />
20<strong>11</strong>/12). A CQUIN scheme should address the three domains of quality: safety,<br />
effectiveness and patient experience; and reflect innovation.<br />
A CQUIN goal describes a quality improvement objective which is being incentivised<br />
through a CQUIN scheme. A goal may be measured using several indicators.<br />
A CQUIN indicator is a measure which determines whether a goal or an element of the<br />
goal has been achieved, and on the basis of which payment is made.<br />
CQUIN targets were agreed between the Trust and the commissioning PCT, NHS Great<br />
Yarmouth and Waveney, at the beginning of the financial year. Achievement of these was<br />
monitored throughout the year.<br />
The table overleaf describes achievement of the CQUINs for <strong>2010</strong>/<strong>11</strong> at the time of writing<br />
this report. The total value of the CQUIN scheme for <strong>2010</strong>/<strong>11</strong> was £1.8 million.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 13 of 62
No<br />
Commissioning for<br />
<strong>Quality</strong> and Innovation<br />
(CQUIN)<br />
CQUIN GOAL<br />
CQUIN INDICATOR<br />
Achieving<br />
Not Currently Achieving<br />
On Plan to Achieve<br />
Area of Concern<br />
1<br />
2 Dementia<br />
3 Patient Responsiveness<br />
4 End of Life - choice<br />
5<br />
Maternity Services user<br />
responsiveness<br />
8 Day Case Basket<br />
9 Reduce falls in hospital<br />
10 Case note audits<br />
Reduce avoidable death, disability and<br />
chronic ill health from Venousthromboembolism<br />
(VTE)<br />
Development and implementation of an<br />
integrated Dementia Pathway across<br />
mental health & learning disability,<br />
community and acute sectors:<br />
Improve response to personal needs of<br />
patients<br />
Provide Palliative and End of Life care<br />
using the nationally defined end of life<br />
care tools<br />
Maternity user responsiveness<br />
Improve rate for Audit Commission<br />
basket of 25 procedures performed as a<br />
day case<br />
Reducing Falls whilst in Hospital<br />
Mortality audits and case note reviews<br />
for harm events<br />
1. % of all adult inpatients<br />
who have had a VTE risk<br />
assessment on admission<br />
to hospital using the<br />
national tool<br />
2. % of inpatient &<br />
obstetric patients excluding<br />
non obstetric day cases<br />
who have had appropriate<br />
thrombopropyhlaxis<br />
Leading and working on<br />
Acute Trust elements of<br />
the pathway in partnership<br />
with all key stakeholders.<br />
The indicator will be a<br />
composite, calculated from<br />
5 survey questions. Each<br />
describes a different<br />
element of the overarching<br />
theme: “responsiveness to<br />
personal needs"<br />
1. Provision of palliative<br />
and EOL care using the<br />
nationally defined EOL<br />
care tools<br />
2. Reduction in the number<br />
of palliative/EOL patients<br />
dying in the acute care<br />
setting<br />
Introduction of ongoing<br />
user survey and<br />
subsequent audit/response<br />
to improve patient<br />
experience.<br />
% of all operations from<br />
the Audit Commission<br />
basket of 25 procedures<br />
performed as a day case<br />
Reduce in-patient falls by<br />
20% compared to 2009/10<br />
baseline.<br />
1. Baseline review:<br />
Mortality 100 sets of notes<br />
& Harm events, 40 sets of<br />
notes<br />
2. Ongoing monthly<br />
reviews: Mortality 20 sets<br />
of notes & Harm events, 20<br />
sets of notes.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 14 of 62
No<br />
Commissioning for<br />
<strong>Quality</strong> and Innovation<br />
(CQUIN)<br />
CQUIN GOAL<br />
CQUIN INDICATOR<br />
Achieving<br />
Not Currently Achieving<br />
On Plan to Achieve<br />
Area of Concern<br />
<strong>11</strong><br />
12<br />
Pressure ulcers<br />
Patient safety walk<br />
rounds<br />
13 C. difficile<br />
Measurable reduction in hospital<br />
acquired pressure ulcers<br />
Patient Safety Walkrounds – these are<br />
recommended by LIPS, Patient Safety<br />
First and IHI and are clear drivers for<br />
quality improvements. These would<br />
greatly enhance the safety culture of the<br />
organisation.<br />
Enhanced surveillance: Hosting and<br />
maintaining a system-wide<br />
register/database of C. difficile cases<br />
using HPA’s web-based EPIDATA<br />
database.<br />
20% reduction in the rate<br />
between the final indicator<br />
period and the 2009/10<br />
baseline for inpatient<br />
hospital acquired pressure<br />
ulcers<br />
24 patient safety<br />
walkrounds to be<br />
conducted during <strong>2010</strong>/<strong>11</strong><br />
Need to reduce C. difficile<br />
infections across the whole<br />
system. HPA guidance<br />
suggests whole-system<br />
case register of C difficile<br />
patients<br />
14 Accrediting practitioners<br />
15<br />
16<br />
17<br />
Innovation - pathways &<br />
delivery of care -<br />
Diabetes<br />
Participation on Clinical<br />
Transformation Board<br />
Weekend TIA carotid<br />
imaging<br />
Accrediting and ongoing supervision of<br />
practitioners in primary and community<br />
care with a special interest<br />
To develop and implement a dataset in<br />
Diabetes clinic in JPUH to support high<br />
quality care<br />
Support to clinical transformation<br />
strategy<br />
Weekend TIA service<br />
1. Accreditation and<br />
learning needs of new<br />
primary & community care<br />
practitioners supported.<br />
2. Ongoing supervision<br />
and learning needs met.<br />
3. Evidenced by records of<br />
interactions.<br />
Implement and utilise a<br />
data capture system for<br />
outpatient management of<br />
Diabetes.<br />
Integration and<br />
involvement of Trust<br />
clinicians in delivery of<br />
NHS GY&W Strategy and<br />
Operating Plan<br />
1. Percentage of high risk<br />
TIAs presenting at<br />
weekends receiving carotid<br />
imaging within 24 hours.<br />
2. Percentage of all high<br />
risk TIAs assessed and<br />
investigated within 24<br />
hours of first NHS contact<br />
(excluding admitted TIAs).<br />
18<br />
Psychological<br />
assessment<br />
To deliver access to psychological<br />
assessment (including cognitive<br />
assessment) and support for Stroke<br />
Proportion of Stroke<br />
patients who have had<br />
specialist psychological<br />
assessment or treatment<br />
by 6 months post stroke (at<br />
least 75% of which need to<br />
be undertaken as an<br />
inpatient)<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 15 of 62
No<br />
Commissioning for<br />
<strong>Quality</strong> and Innovation<br />
(CQUIN)<br />
CQUIN GOAL<br />
CQUIN INDICATOR<br />
Achieving<br />
Not Currently Achieving<br />
On Plan to Achieve<br />
Area of Concern<br />
19 Preventable strokes<br />
20<br />
21<br />
Stroke - managing high<br />
risk TIA patients<br />
Stroke - Direct<br />
admissions to stroke<br />
ward<br />
22 Stroke - Access to CT<br />
23 Demand Management<br />
The number of these patients who were<br />
discharged on anticoagulation or with a<br />
date to commence anticoagulation via<br />
anticoagulation team documented on<br />
discharge summary<br />
Management of high risk TIA patients -<br />
Clinic Appointment<br />
Timely access to acute stroke units<br />
prevents death and increases<br />
independence<br />
Access to timely imaging for eligible<br />
patients admitted having had a stroke<br />
Development and implementation of<br />
demand management initiatives and<br />
pathway redesign across primary,<br />
secondary, community and social care<br />
sectors<br />
Proportion of patients<br />
presenting with stroke with<br />
AF anti-coagulated on<br />
discharge or with clear<br />
plans documented in the<br />
discharge communication<br />
to commence<br />
anticoagulation at a<br />
clinically appropriate time<br />
post discharge<br />
Number of High Risk TIA<br />
patients investigated and<br />
treated within 24 hours of<br />
first NHS contact excluding<br />
those admitted<br />
Patients admitted within 4<br />
hours to the stroke unit<br />
Eligible patients admitted<br />
having had a stroke who<br />
receive CT within 60<br />
minutes of admission<br />
Leading and working on<br />
acute trust elements of the<br />
pathway in partnership with<br />
all key stakeholders<br />
A proportion of <strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust’s income in<br />
<strong>2010</strong>/<strong>11</strong> was conditional on achieving quality improvement and innovation goals<br />
agreed between <strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust and any<br />
person or body entered into a contract, agreement or arrangement with for the<br />
provision of NHS services, through the Commissioning for <strong>Quality</strong> and Innovation<br />
payment framework.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 16 of 62
Board Statements of Assurance:<br />
Review of services<br />
The National Health Service (<strong>Quality</strong> <strong>Account</strong>s) Regulations <strong>2010</strong> require that a number of<br />
statements are included within the <strong>Quality</strong> <strong>Account</strong> so that there is common content between<br />
providers making the accounts comparable. These statements are contained within the<br />
boxes which follow:<br />
During <strong>2010</strong>/<strong>11</strong> the <strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust provided and/or<br />
sub-contracted the NHS services listed in the table on page 18.<br />
The <strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust has reviewed all the data<br />
available to them on the quality of care in all of these NHS services.<br />
The income generated by the NHS services reviewed in <strong>2010</strong>/<strong>11</strong> represents 100% percent of<br />
the total income generated from the provision of NHS services by the <strong>James</strong> <strong>Paget</strong><br />
<strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust for <strong>2010</strong>/<strong>11</strong>.<br />
The <strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust provides services to the whole<br />
population of Great Yarmouth and Waveney at two locations:<br />
1. <strong>James</strong> <strong>Paget</strong> <strong>University</strong> Hospital; and<br />
2. Lowestoft Hospital.<br />
As well as a number of community clinics.<br />
The service types provided at these locations are:<br />
1. Acute services;<br />
2. Hospice services;<br />
3. Community healthcare services; and<br />
4. Dental services.<br />
The regulated activities which the Trust is registered to provide, as defined by the Health and<br />
Social Care Act 2008 (Regulated Activities) Regulations 2009 schedule 1, and carried out by<br />
the Trust are as follows:<br />
• Personal care;<br />
• Treatment of disease, disorder or injury;<br />
• Surgical procedures;<br />
• Diagnostic and screening procedures;<br />
• Maternity and midwifery services;<br />
• Termination of pregnancies; and<br />
• Family planning services.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 17 of 62
The services provided by <strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust include<br />
the following:<br />
Division<br />
Emergency<br />
Elective<br />
Women & Child Health<br />
Core Clinical<br />
Specialties and services:<br />
Accident and Emergency (A&E)<br />
General Medicine<br />
Gastroenterology<br />
Endocrinology<br />
Diabetes<br />
Haematology<br />
Cardiology<br />
Dermatology<br />
Nephrology and renal dialysis<br />
Genitourinary Medicine<br />
Rheumatology<br />
Respiratory Medicine<br />
General Surgery<br />
Vascular Surgery<br />
Breast Surgery<br />
Gastro-intestinal Surgery<br />
Urology<br />
Trauma and Orthopaedics<br />
Ear, Nose and Throat<br />
Oral Surgery<br />
Ophthalmology<br />
Gynaecology<br />
Obstetrics<br />
Maternity services<br />
Community midwifery<br />
Neonatology<br />
Parentcraft<br />
Antenatal screening<br />
Fertility services<br />
Diagnostic Imaging<br />
• X-ray services<br />
• Specialist Imaging<br />
• Ultrasound services<br />
• Mammography services<br />
• MRI & CT services<br />
Medical illustration<br />
Pharmaceutical services<br />
Lowestoft Hospital<br />
Care of the elderly<br />
GP beds<br />
Care of the Elderly<br />
Diabetic Liaison<br />
Clinical Measurement<br />
Coronary Care<br />
Endoscopy<br />
Rehabilitation<br />
Intensive Care Services<br />
Hyperbaric services<br />
Oncology<br />
Sandra Chapman Centre (day treatment<br />
for adults with haematological disease<br />
and cancer)<br />
Therapies e.g. physiotherapy<br />
Anaesthetics<br />
Clinical Specialties of Continence and<br />
Stoma Care<br />
Audiology<br />
Dental and Orthodontics<br />
Community Dental Services<br />
Pain Management<br />
Palliative Care<br />
Paediatrics<br />
Paediatric Surgery<br />
Children’s Centre<br />
Community Paediatric Service<br />
School Nursing (GY)<br />
Safeguarding children<br />
Community services<br />
Chemical Pathology<br />
Immunology and Serology<br />
Microbiology<br />
Haematology<br />
Blood Transfusion<br />
Bereavement Services<br />
Pharmaceutical Services<br />
Social Work Support<br />
Reviews of the quality of services provided by the Trust for all its locations and all of the<br />
service types and regulated activities have taken place during <strong>2010</strong>/<strong>11</strong>. The processes used<br />
are described in Part 3 of this report.<br />
A number of external assessments were conducted during <strong>2010</strong>/<strong>11</strong>, including:<br />
• Health and Safety Executive review of Microbiology laboratory;<br />
• National Cancer Peer Review<br />
• Clinical Negligence Scheme for Trusts (CNST) review of Maternity Services<br />
• External <strong>Quality</strong> Assessment of the Diabetic Retinal Screening Service<br />
• Human Fertilisation and Embryology Authority (HFEA) review of Fertility Service<br />
• Intensive Care Unit/High Dependency Unit peer review audits<br />
• Care <strong>Quality</strong> Commission Review of Support for Families with Disabled Children<br />
• Fire Risk Assessments Trust-wide<br />
• Patient Environment Action Team<br />
• Environmental health.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 18 of 62
During 20<strong>11</strong>/12 a number of further service reviews are planned which will be aligned to the<br />
Trust’s CQUIN targets with our commissioners and the <strong>Quality</strong> Innovation, Productivity and<br />
Prevention projects (QIPP).<br />
Participation in Clinical Audits<br />
During <strong>2010</strong>/<strong>11</strong>, 33 national clinical audits and two national confidential enquiries covered NHS<br />
services that the <strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust provides.<br />
During that period <strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust participated in 88%<br />
(29/33) of the national clinical audits and 100% of the national confidential enquiries which it was<br />
eligible to participate in.<br />
The national clinical audits and national confidential enquiries that <strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong><br />
NHS Foundation Trust was eligible to participate in during 2009/10 are listed in the table overleaf.<br />
The national clinical audits and national confidential enquiries that <strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong><br />
NHS Foundation Trust participated in, and for which data collection was completed during <strong>2010</strong>/<strong>11</strong>,<br />
are listed in the table on page 20. This includes the number of cases submitted to each audit or<br />
enquiry as a percentage of the number of registered cases required by the terms of that audit or<br />
enquiry 4 .<br />
The table overleaf describes the list of national audits drawn up by the National Clinical Audit<br />
Advisory Group of the Department of Health. Although national audits are not mandatory,<br />
Trusts are recommended to participate in those audits of services which they provide.<br />
The CQC uses information from national audits in its <strong>Quality</strong> and Risk Profiles to identify<br />
whether a Trust is at risk of not complying with the registration requirements. There is now a<br />
formalised process in place whereby the Clinical Effectiveness Committee reviews national<br />
audits to make a corporate decision whether or not participation is cost effective and<br />
achievable.<br />
4 Where this information was available at the time of reporting<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 19 of 62
Clinical Audits<br />
Audit Name Applicable Trust Lead Percentage of Cases<br />
Submitted<br />
Peri - and Neonatal<br />
Perinatal Mortality (CEMACH)<br />
Neonatal intensive and special care (NNAP)<br />
Children<br />
<br />
<br />
<br />
Carol Mutton 100%<br />
Laurie Howarth 100%<br />
Paediatric pneumonia<br />
(British Thoracic Society)<br />
John Chapman Data collection ongoing<br />
Paediatric asthma<br />
John Chapman Data collection ongoing<br />
(British Thoracic Society)<br />
<br />
Paediatric fever<br />
Donna Wade Data collection ongoing<br />
(College of Emergency Medicine) <br />
Childhood epilepsy<br />
Dr Nirmal Data collection ongoing<br />
(RCPH National Childhood Epilepsy Audit) <br />
Paediatric Intensive Care (PICANet) John Chapman No participation<br />
Paediatric Cardiac surgery<br />
(NICOR Congenital Heart Disease Audit)<br />
Diabetes<br />
(RCPH) National Paediatric Diabetes Audit)<br />
Acute Care<br />
Emergency use of oxygen<br />
(British Thoracic Society)<br />
Adult community acquired pneumonia<br />
(British Thoracic Society)<br />
Non-invasive ventilation (NIV)-adults (British<br />
Thoracic Society)<br />
Pleural procedures<br />
(British Thoracic Society<br />
Cardiac Arrest<br />
(National Cardiac Arrest Audit)<br />
Vital signs in majors<br />
(College of Emergency Medicine)<br />
Adult Critical Care<br />
(Case Mix Programme)<br />
Potential donor audit<br />
(NHS Blood & Transplant)<br />
Long Term Conditions<br />
Diabetes<br />
(National Adult Diabetes Audit)<br />
Heavy Menstrual bleeding<br />
(RCOG National Audit of HMB)<br />
Chronic Pain<br />
(National Pain Audit)<br />
Ulcerative colitis & Crohn’s disease<br />
(National IBD Audit)<br />
Parkinson’s disease<br />
(National Parkinson’s Audit)<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
John Chapman<br />
Dr Raman<br />
Dr Cotter<br />
Dr Cotter<br />
Dr Cotter<br />
Dr Cotter<br />
Pam Cushing<br />
Dr Crawfurd<br />
Donna Wade<br />
Adam Devany<br />
Dr Karlikowski<br />
Lynn Everett<br />
No participation<br />
Data collection ongoing<br />
No participation<br />
No participation<br />
No participation<br />
Data collection ongoing<br />
65 cases submitted<br />
100%<br />
100%<br />
Jean Jennings 100%<br />
Mrs Rashid<br />
Dr Notcutt<br />
Dr DeSilva<br />
Dr Huston forward<br />
Dr Woodward<br />
Dr Shields<br />
No participation<br />
Data collection ongoing<br />
Data collection ongoing<br />
Data collection ongoing<br />
No participation<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 20 of 62
Audit Name Applicable Trust Lead Percentage of Cases<br />
Submitted<br />
COPD<br />
(British Thoracic Society/European Audit)<br />
Adult Asthma<br />
(British Thoracic Society)<br />
Bronchiectasis<br />
(British Thoracic Society)<br />
Elective Procedures<br />
Hip, knee and ankle replacements (National<br />
Joint Registry)<br />
Elective Surgery<br />
(National PROMs Programme)<br />
Cardiothoracic Transplantation (NHSBT UK<br />
Transplant Registry)<br />
Liver Transplantation<br />
(NHSBT UK Transplant Registry)<br />
Coronary angioplasty<br />
(NICOR Adult cardiac interventions audit)<br />
Peripheral vascular surgery<br />
(VSGBI Vascular Surgery Database)<br />
Carotid interventions<br />
(Carotid Intervention Audit)<br />
CABG and valvular surgery<br />
(Adult cardiac surgery audit)<br />
Cardiovascular disease<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 21 of 62<br />
<br />
<br />
<br />
<br />
<br />
Dr Cotter<br />
Dr Cotter<br />
Dr Cotter<br />
Caroline Scarll<br />
Helen French<br />
Dr Ryding<br />
Dr Ryding<br />
Dr Ryding<br />
Dr Ryding<br />
No participation<br />
No participation<br />
No participation<br />
No participation<br />
Proms Results April<br />
2009 – Sept <strong>2010</strong><br />
Site<br />
Varicose<br />
Vein<br />
Participation<br />
rate JPUH<br />
Pre-op<br />
questionnaires<br />
51%<br />
Groin hernia 65.7%<br />
Knee 88.7%<br />
Hip 79.6%<br />
All<br />
75.5%<br />
procedures<br />
No participation<br />
No participation<br />
No participation<br />
No participation<br />
No participation<br />
No participation<br />
Familial hypercholesterolaemia (National<br />
Dr Ryding No participation<br />
Clinical Audit of Mgt of FH)<br />
Acute Myocardial Infarction and other ACS<br />
Dr Ryding Data collection ongoing<br />
(MINAP)<br />
Janet Shreeve<br />
Heart Failure<br />
(Heart Failure Audit) Janet Shreeve 100%<br />
Pulmonary hypertension<br />
Dr Ryding No participation<br />
(Pulmonary Hypertension Audit)<br />
Acute Stroke (SINAP)<br />
Dr Ryding No participation<br />
Dr George<br />
Stroke Care<br />
Evie Cooper 100%<br />
(National Sentinel Stroke Audit) <br />
Renal Disease<br />
Renal replacement therapy<br />
(Renal Registry)<br />
Mark Prentice<br />
Data included in Norfolk<br />
and Norwich <strong>University</strong><br />
<strong>Hospitals</strong> NHS<br />
Foundation Trust<br />
return.<br />
Renal Transplantation Mark Prentice No participation.
(NHSBT UK Transplant Registry)<br />
Audit Name Applicable Trust Lead Percentage of Cases<br />
Submitted<br />
Patient transport<br />
(National Kidney Care Audit)<br />
Renal Colic<br />
(College of Emergency Medicine)<br />
Cancer<br />
Lung cancer<br />
(National Lung Cancer Audit)<br />
Bowel Cancer<br />
(National Bowel Cancer Audit Programme)<br />
Head & Neck Cancer (DAHNO)<br />
Trauma<br />
Hip fracture<br />
(National Hip Fracture Database)<br />
Severe trauma<br />
(Trauma Audit & Research Network)<br />
Falls and non-hip fractures<br />
(National Falls & Bone Health Audit)<br />
Psychological conditions<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
Mark Prentice 100%<br />
Donna Wade<br />
Dr Mahadevan<br />
Linda Hayes<br />
Steve Wright<br />
Mr Premachandra<br />
Tracey Church<br />
Data collection ongoing<br />
Data collection ongoing<br />
Data collection ongoing<br />
100%<br />
Louise Hebdon 100%<br />
Louise Hebdon<br />
Dr Zaidi<br />
Data collection ongoing<br />
Data collection ongoing<br />
Depression & anxiety<br />
(National Audit of Psychological Therapies)<br />
Kirk Lower<br />
Occ Health<br />
No participation<br />
Prescribing in mental health services<br />
No participation –<br />
(POMH)<br />
Mental Health<br />
National Audit of Schizophrenia (NAS) No participation –<br />
Mental Health<br />
Blood Transfusion<br />
O neg blood use<br />
(National Comparative Audit of Blood<br />
Transfusion)<br />
Platelet use<br />
(National Comparative Audit of Blood<br />
Transfusion)<br />
<br />
<br />
Julie Jackson<br />
Julie Jackson<br />
9 cases submitted<br />
27 cases submitted<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
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Locally developed clinical audits are reviewed at various multidisciplinary meetings across<br />
the Trust. During <strong>2010</strong>/<strong>11</strong> the following numbers of local audits were reviewed and<br />
discussed at internal meetings and actions to improve clinical services were subsequently<br />
agreed:<br />
Paediatric Audit Meeting 13<br />
Perinatal Morbidity & Mortality Meeting 2/3 case presentations per meeting<br />
Emergency Clinical Governance Meeting 4<br />
Combined Audit Elective Division<br />
7 (+ Surgical Mortality Review cases)<br />
The following case studies provide examples of where clinical audits have directly led to<br />
improvements in patient services.<br />
Case Study 1: Re-audit Compliance with Trust Antibiotic Guideline<br />
Objectives<br />
• To investigate compliance with the Trust Antibiotic Guideline<br />
• To highlight any possible areas of improvement.<br />
Following this audit the following actions were agreed:<br />
Action Plan<br />
• Educate new doctors in the right way of prescribing antibiotics via induction training<br />
sessions.<br />
• Drug chart to be redesigned for antibiotic prescribing which would include a space for<br />
review date and indication for the antibiotics.<br />
• A separate antibiotic sticker to be trialled in EADU which indicates a review/stop date<br />
and the indication for prescribing.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
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Case Study 2: Upper Gastrointestinal Bleed Audit<br />
Aim<br />
A re-audit of the management of Upper Gastrointestinal bleeds (UGIB) according to the<br />
SIGN (Scottish Intercollegiate Guidelines Network) guidelines (also adopted by Royal<br />
College of gastroenterology and NICE) in view of implementing Trust guidelines.<br />
Objectives<br />
100% of patients admitted with suspected upper GI bleed should meet the criteria set out<br />
below:<br />
1 Assessed using an upper GI bleed scoring system to categorise risks<br />
2 Observations including BP and pulse<br />
3 Blood tests including Hb and Urea<br />
4 Rectal examination performed at time of first assessment<br />
5 Patients scoring 0 on Blatchford score are discharged for outpatient endoscopy<br />
6 Clo test results clearly documented and acted on<br />
7 Receive early endoscopy, defined as being performed on the day or following day<br />
of request being made<br />
8 Use of proton pump inhibitors (PPIs) if there is no 24 hour endoscopy service<br />
available or PPI have been recommended post endoscopy by the endoscopist<br />
Conclusions<br />
• Significant improvement in use of UGIB scoring system<br />
• Education of junior doctors required regarding rectal examination at first<br />
assessment, awareness of significance of Clo Testing and treatment<br />
• Documentation throughout medical notes could be improved<br />
• Concise Trust guidelines for the management of patients admitted with Upper GI<br />
Bleed are required.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
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Case Study 3: Patient Hospital Paper Health Records Documentation Audit <strong>2010</strong><br />
Objectives<br />
Comparative audit for Trust and specific areas; to highlight adherence to NHS and JPUH<br />
policy criteria<br />
Rationale: Ongoing audit (NHSLA) of correctness of Patient Paper Health Records<br />
Audit Sample: 5 sets of notes were reviewed per Specialty; covering 31 Specialties, out<br />
of a possible 46 (67%), which resulted in 319 professional entries being individually<br />
assessed for compliance with criteria<br />
Data collection:<br />
Data Source:<br />
Data Collection:<br />
Retrospectively<br />
(admissions reviewed from 10th June to 8th December <strong>2010</strong>)<br />
Patient Paper Health Records<br />
Undertaken by Junior Doctors, Nurses and Clinic Staff<br />
Results compare 2008, 2009 + <strong>2010</strong> audits<br />
Conclusions<br />
• There has been a year on year improvement since 2008 in the quality of Health<br />
Care Files<br />
• Timings of entries is only 70%<br />
• All entries (including alterations/additions) identify author by reference to Nursing<br />
<strong>Account</strong>ability Record is only 55%<br />
• Common anecdotal complaints of numerous documents not filed correctly, not in<br />
chronological order or loose etc are untrue with 90%+ being correct. Still room for<br />
improvement!<br />
• Allergy notation has greatly improved<br />
Overall conclusions<br />
• Shows that progress made with the documentation work streams around the<br />
Trust and that the importance of correct documentation can now be shown to be<br />
a vital part of improving patient safety and patient outcomes<br />
Recommendations:<br />
• To evaluate the audit paperwork to make it easier to understand<br />
• To evaluate the audit process so it is embedded into the Trust and that key staff<br />
groups are signed up to undertake the audit work rather than the ad hoc<br />
approach at present<br />
• To disseminate the findings and create an action plan of actions and hence<br />
improvements in areas of need<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
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The Trust has a dedicated lead for National Confidential Enquiry into Patient Outcome and<br />
Death (NCEPOD) who provides regular reports regarding the Trust’s progress with<br />
implementing the recommendations from the published reports. Self assessments have<br />
been carried out using the NCEPOD tools and action plans are in place to ensure<br />
implementation of the recommendations.<br />
There were three confidential enquiries published by NCEPOD during <strong>2010</strong>/<strong>11</strong>, two of which<br />
were applicable to the Trust:<br />
• Parenteral nutrition; and<br />
• Elective and Emergency Surgery in the Elderly.<br />
The Trust is in the process of implementing the recommendations detailed within these two<br />
confidential enquiries.<br />
There were no reports published by the Centre for Maternal and Child Enquiries (CMACE)<br />
during <strong>2010</strong>/<strong>11</strong>.<br />
There were no reports published by the National Confidential Inquiry into Suicide and<br />
Homicide by People with Mental Illness (NCI/NCISH) during <strong>2010</strong>/<strong>11</strong> applicable to the Trust.<br />
National Institute for Health and Clinical Excellence (NICE) compliance<br />
A NICE Implementation Group is in place and meets regularly to review new guidance,<br />
technology appraisals, interventional procedures and other guidance issued by NICE. This<br />
group also monitors those publications which are relevant for our patients but have yet to be<br />
fully implemented due to barriers such as funding, training needs or facilities required. This<br />
ensures that robust action plans are in place and progress is being made towards<br />
implementation.<br />
The table below details the number of materials issued by NICE to date and the Trust’s<br />
status in terms of compliance. For guidelines/guidance which has yet to be fully implemented<br />
plans are in place to expedite this.<br />
NICE<br />
Number issued by end<br />
of March 20<strong>11</strong><br />
(relevant to JPUH)<br />
Compliance rate at<br />
end of March 20<strong>11</strong><br />
Technology Appraisal Guidance 106 88.7%<br />
Interventional Procedure Guidance 46 71.7%<br />
Clinical Guidelines 101 73.3%<br />
Patient Safety Guidance 2 50%<br />
Public Health Guidance 26 57.7%<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
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Research<br />
The number of patients receiving NHS services provided or sub-contracted by the<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust in <strong>2010</strong>/<strong>11</strong>, that were recruited<br />
during that period to participate in research approved by a research ethics committee, was<br />
712.<br />
Participation in clinical research demonstrates the <strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS<br />
Foundation Trust’s commitment to improving the quality of care we offer and to making<br />
our contribution to wider health improvement. Our clinical staff stay abreast of the latest<br />
possible treatment possibilities and active participation in research leads to successful<br />
patient outcomes.<br />
The <strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust was involved in conducting<br />
12 clinical research studies in Cancer during <strong>2010</strong>/<strong>11</strong>. It is not possible at the time of<br />
writing this report to provide data relating to mortality amenable to healthcare/mortality<br />
rate from causes considered preventable as these studies are not yet completed and the<br />
data has not yet been analysed. The participation in such studies at the Trust<br />
demonstrates a commitment to clinical research which it is anticipated will lead to better<br />
treatments for patients.<br />
There were 44 (19 nurses and 25 doctors) of clinical staff participating in research<br />
approved by a research ethics committee at the <strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS<br />
Foundation Trust during <strong>2010</strong>/<strong>11</strong>. These staff participated in research covering 14 of<br />
medical specialties.<br />
In the last three years, we are unaware of any publications that have resulted from our<br />
involvement in NIHR research as most studies are long term and have yet to complete. It<br />
is likely that there have been publications generated by Chief investigators from other<br />
Trusts where we have acted solely as additional research sites. We are largely a trial<br />
hosting site and are not in receipt of any NIHR grants at present. Our engagement in<br />
multi-centre studies also demonstrates the <strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS<br />
Foundation Trust commitment to testing and offering the latest medical treatments and<br />
techniques.<br />
Data <strong>Quality</strong><br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust will be taking the<br />
following actions to improve data quality :<br />
• Monthly meetings with NHS Great Yarmouth and Waveney to discuss data quality<br />
issues. These are minuted and an action log is maintained to ensure all issues are<br />
recorded and left open until resolved;<br />
• Data <strong>Quality</strong> report to the Information Governance Action Group based on the SUS<br />
Data <strong>Quality</strong> Dashboard provided by the Health and Social Care Information<br />
Centre. This report includes recommendations to the Board which are followed up<br />
at the next meeting; and<br />
• Regular reports are sent to the clinical Divisions identifying data quality issues that<br />
need resolving at source before being submitted to SUS. This is monitored via a<br />
local reporting system that mirrors the SUS Data <strong>Quality</strong> Dashboard.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
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NHS number and GMC code validity<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust submitted records during<br />
<strong>2010</strong>/<strong>11</strong> to the Secondary Uses Service for inclusion in the Hospital Episode Statistics<br />
which are included in the latest published data.<br />
The percentage of records in the published data which included the patient’s valid NHS<br />
number was:<br />
99.81% for admitted patient care;<br />
99.80% for outpatient care; and<br />
99.02% for accident and emergency care.<br />
The percentage of records in the published data which included the patient’s valid<br />
General Medical Practice Code was:<br />
100% for admitted patient care;<br />
100% for out patient care; and<br />
98.40% for accident and emergency care.<br />
This data is based on the latest published figures up to Month 10.<br />
Information Governance Toolkit<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust Information Governance Toolkit<br />
assessment score. Overall score for <strong>2010</strong>/<strong>11</strong> was 45/45.<br />
Information governance is a systematic approach to ensuring that all aspects of the<br />
processing of personal and sensitive information, both paper and electronic, meet<br />
prescribed standards. It aims to ensure that performance is subject to continuous<br />
improvement. The Information Governance framework has four dimensions:<br />
• Management: structures, policies, procedures, etc.<br />
• Systems: access controls, application security, validation, etc.<br />
• Processes: protocols, records management, data quality, etc.<br />
• People: education, training, development, guidance, etc.<br />
As a key part of the Information Governance agenda, the Department of Health and NHS<br />
Connecting for Health jointly produced an Information Governance Toolkit. The current<br />
version of the Toolkit is scored using a simple Red/Green (Satisfactory/Unsatisfactory)<br />
metric. The Toolkit is designed to assist organisations to achieve the aims of Information<br />
Governance and currently encompasses:<br />
• Information Governance Management<br />
• The NHS Confidentiality Code of Practice<br />
• The Caldicott Guidelines<br />
• Data Protection Act 1998<br />
• Information Security Management NHS Code of Practice<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
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• Information <strong>Quality</strong> Assurance<br />
• Records Management NHS Code of Practice<br />
• Freedom of Information Act 2000<br />
It is the tool by which organisations can assess their compliance with current legislation,<br />
standards and national guidance. The Trust achieved a Level 2 score in 45 of the 45<br />
requirements in the Toolkit Assessment, which is rated as ‘Satisfactory’ performance.<br />
Clinical Coding Error rate 5<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust was subject to the<br />
Payment by Results clinical coding audit during <strong>2010</strong>/<strong>11</strong> by D&A Clinical<br />
Coding Consultancy Limited. The error rates reported in the latest published<br />
audit for that period for diagnoses and treatment coding (clinical coding)<br />
were:<br />
• Primary Diagnoses Incorrect 9.5%;<br />
• Secondary Diagnoses Incorrect 13.8%;<br />
• Primary Procedures Incorrect 4.9%; and<br />
• Secondary Procedures Incorrect 4.5%.<br />
The table below shows the coding accuracy overall results in comparison to the <strong>2010</strong><br />
audit. Please note different specialties were audited each year.<br />
Correct (%) 2009/10 Correct (%) <strong>2010</strong>/<strong>11</strong><br />
Primary Diagnosis 92.50 90.50<br />
Secondary Diagnosis 92.13 86.21<br />
Primary Procedures 95.83 95.04<br />
Secondary Procedures 88.89 95.52<br />
The <strong>2010</strong> audit reviewed the following specialties:<br />
Gynaecology<br />
General Surgery<br />
Trauma and orthopaedics<br />
Ophthalmology<br />
General Medicine.<br />
5 Please note: These results should not be extrapolated further than the actual sample audited.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
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What others say about the Trust<br />
Care <strong>Quality</strong> Commission<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust is required to register with the<br />
Care <strong>Quality</strong> Commission and its current registration status is registered without<br />
conditions.<br />
The Care <strong>Quality</strong> Commission has not taken enforcement action against <strong>James</strong> <strong>Paget</strong><br />
<strong>University</strong> <strong>Hospitals</strong> NHS Trust during <strong>2010</strong>/<strong>11</strong>.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust has not participated in any<br />
special reviews or investigations by the CQC during the reporting period.<br />
The Trust has been registered with the Care <strong>Quality</strong> Commission without conditions since<br />
April <strong>2010</strong> for the following services:<br />
• Termination of pregnancies at <strong>James</strong> <strong>Paget</strong> Hospital;<br />
• Family planning at <strong>James</strong> <strong>Paget</strong> Hospital;<br />
• Maternity and midwifery services at <strong>James</strong> <strong>Paget</strong> and Lowestoft <strong>Hospitals</strong>;<br />
• Diagnostic and screening procedures at <strong>James</strong> <strong>Paget</strong> and Lowestoft <strong>Hospitals</strong>;<br />
• Surgical procedures at <strong>James</strong> <strong>Paget</strong> Hospital; and<br />
• Treatment of disease, disorder or injury at <strong>James</strong> <strong>Paget</strong> and Lowestoft <strong>Hospitals</strong>.<br />
Patient Environment Action Team (PEAT)<br />
The table below demonstrates the PEAT results 20<strong>11</strong> for environment, food, privacy and<br />
dignity for each hospital within the Trust. This demonstrates an improvement on the <strong>2010</strong><br />
scores where the Trust scored ‘good’ in all areas.<br />
Environment<br />
Privacy &<br />
Food Score<br />
Site Name<br />
Score<br />
Dignity Score<br />
Lowestoft Hospital Good Excellent Good<br />
<strong>James</strong> <strong>Paget</strong> Hospital Good Excellent Good<br />
Health and Safety Executive (HSE)<br />
The Trust was visited by the HSE in November <strong>2010</strong> to conduct a routine review of the<br />
Trust’s Microbiology laboratory. This resulted in a very positive report with only minor areas<br />
for improvement identified. All of the improvements suggested have since been<br />
implemented.<br />
A follow up visit was also conducted in March 20<strong>11</strong> to ensure that appropriate actions had<br />
been taken following a small formaldehyde spillage in Theatres. The inspector was very<br />
pleased with our response to this incident and closed the investigation without any further<br />
recommendations.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
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Part 3<br />
Review of <strong>Quality</strong> Performance<br />
Patient Safety<br />
Leading Improvement in Patient Safety (LIPS)<br />
LIPS is a nationally led safety improvement programme developed and delivered by the<br />
Institute of Innovation and Improvement. The programme is designed to support NHS Trusts<br />
to develop robust organisational plans that will facilitate measurable and sustainable<br />
improvements in patient safety throughout the organisation.<br />
The Trust’s Patient Safety Project formally commenced in March <strong>2010</strong>. It complements the<br />
national and international drive to make demonstrable improvements that will reduce the<br />
volume of harm events experienced by patients in our care. In the UK it is currently estimated<br />
that harm events are experienced by 1 in 10 patients (National Patient Safety Agency -<br />
NPSA 2007). LIPS offers a variety of improvement tools to help increase capacity and<br />
capability to make these achievements. In particular, we are using the Model for<br />
Improvement as a framework for setting the objectives and targets of the overall project plan.<br />
This is complemented with the use of Plan, Study, Do and Act (PDSA) cycles as a means for<br />
performing small tests of change prior to more wide scale implementation.<br />
Following thorough analysis of local incident data and exploration of relevant national and<br />
regional driving forces, improvement aims for the Trust were agreed. These have been<br />
categorised as high level and system level aims.<br />
High Level Improvement Aims<br />
• Year on year reduction in harm events of at least 10%<br />
• Overall reduction in harm events of ≥ 50% over five years<br />
• 25% reduction in all falls by March 20<strong>11</strong>.<br />
10 work streams have been set up to deliver the high level aims. The work around Falls<br />
prevention has been described in part 2. The other metrics are detailed below.<br />
Metric 2 – Pressure Ulcer Prevention<br />
National Context:<br />
High Impact Actions (<strong>2010</strong>) estimated 4 -10% of patients admitted to hospital experience a<br />
pressure ulcer grade 2 6 or above.<br />
Local Improvement Aim (and CQUIN):<br />
1. 25% reduction of the 2009/10 baseline of hospital acquired grade 2 and above.<br />
2. 60% of all inpatients receive Waterlow risk assessments on admission.<br />
6 There are four recognised grades of pressure ulcers in the European Pressure Ulcer Advisory Panel (EPUAP)<br />
Wound Classification system which health professionals use to describe the severity of pressure ulcers.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
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Current Position:<br />
Inpatient Pressure Ulcers Grade 2 and above (inc.'not stated April and May 10)<br />
25<br />
Number of Incidents<br />
20<br />
15<br />
10<br />
20<br />
19<br />
18<br />
17 17<br />
16<br />
16<br />
13<br />
14<br />
13 13<br />
<strong>11</strong><br />
13<br />
12<br />
14<br />
13 13<br />
14<br />
13 13 13 13 13 13<br />
10<br />
9<br />
8<br />
Grade 2<br />
Grade 3<br />
Grade 4<br />
Practice Development<br />
Trajectory<br />
5<br />
0<br />
0 0 0 0 0 0<br />
1<br />
0 0 1<br />
0 0 0 0<br />
Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-<strong>11</strong> Feb-<strong>11</strong> Mar-<strong>11</strong><br />
Month and Year<br />
During March 20<strong>11</strong> 87.6% of patients had a pressure ulcer risk assessment (Waterlow) on<br />
admission.<br />
Successes:<br />
• Significantly raised awareness<br />
• Review of evidence base<br />
• Review of Trust documentation<br />
• Working on the principle of 8 Key Responsibilities for pressure ulcer prevention<br />
• Revised documentation in all ward areas<br />
• Communication cascade regarding pressure ulcer prevention care<br />
• Hospital at Night team link nurse involvement – promotion of standards 24/7<br />
• Dedicated resource to support change process<br />
• Inclusion of pressure ulcer prevention training as part of Trust Practice Development<br />
Training Programme.<br />
Concerns:<br />
• Reporting system(s) ineffective<br />
• Under reporting<br />
• Inaccurate reporting<br />
• Under use of the mattress loan store<br />
• Pressure ulcer classification tool used inaccurately<br />
• Volume of patients admitted with existing pressure ulcer.<br />
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<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
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Metric 3 – Venous Thromboembolism (VTE)<br />
An all Party Parliamentary Thrombosis Group in 2005 estimated there were 25,000<br />
preventable deaths per annum nationally due to VTE.<br />
Local Improvement Aim (and CQUIN)<br />
1. 90% of patients receive an admission VTE risk assessment.<br />
2. 80% of inpatient and obstetric patients receive appropriate thromboprophylaxis.<br />
Current Position:<br />
VTE Risk Assessment Compliance Rates <strong>2010</strong>/<strong>11</strong><br />
100<br />
90<br />
80<br />
70<br />
% Compliance<br />
60<br />
50<br />
40<br />
Monthly Compliance<br />
Trajectory %<br />
30<br />
20<br />
10<br />
0<br />
Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-<strong>11</strong> Feb-<strong>11</strong> Mar-<strong>11</strong><br />
Month and Year<br />
Data collected from medication charts indicates a consistent achievement of between 90-<br />
95% compliance with appropriate thromboprophylaxis prescribing.<br />
Successes:<br />
• The Trust has achieved VTE Exemplar Site status<br />
• Bespoke IT system developed to register risk assessment completion<br />
• Inclusion of VTE on induction and mandatory training<br />
• General raised awareness of VTE<br />
• Attendance at external training attendance<br />
Concerns:<br />
• Delays in registration of risk assessment<br />
• Variation in compliance with risk assessment completion<br />
• Process for supporting Waveney GPs when patients are transferred to Lowestoft<br />
Hospital<br />
• Lack of resources within Patient Safety Team to support implementation of remaining<br />
NICE VTE <strong>Quality</strong> Standards.<br />
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Metric 4 – Documentation and Record Keeping<br />
“The purpose of a medical record is to provide a clear account of patient management so as<br />
to facilitate current treatment and to establish a reliable past medical history and thereby<br />
provide healthcare professionals with evidence supporting the adequacy of their care”.<br />
Guidance provided by John Chapman, Trust Solicitor, June <strong>2010</strong><br />
Local Improvement Aims:<br />
1. Documentation will be multidisciplinary by the end of March 2012<br />
2. Format and style enables each episode of care to create chronological history<br />
3. Complete review of nursing documentation.<br />
Successes:<br />
• Essentials of nursing care record sheet trial completed and roll out commenced<br />
January 20<strong>11</strong><br />
• Specific care plans completed for falls, pressure ulcer prevention and tracheostomy<br />
• Specific pieces of documentation being reviewed e.g. fluid charts, observation chart<br />
• Early stages of drafting multidisciplinary record<br />
• Standardising ‘inpatient episode’ folder throughout Trust<br />
• Multidisciplinary engagement.<br />
Excellent progress continues to be made with the development of a multidisciplinary<br />
healthcare record. Significant changes have been introduced to nursing documentation. The<br />
principle is to simply but effectively evidence the patient’s journey and their individual care<br />
needs. The notion that the reliability of a safety intervention is increased by standardising<br />
and reducing variation has been applied to all new pieces of documentation that guide<br />
practice. The aim is that all patients, regardless of where their care is being delivered, should<br />
receive consistent standards of essential care that is generic to the majority of patients in<br />
hospital.<br />
Metric 5 – Infection Prevention<br />
Matching Michigan is a quality improvement project based on a model developed in the<br />
United States which, over 18 months, saved around 1,500 patient lives. It took place at<br />
Intensive Care Units (ICUs) in Michigan and introduced technical interventions (changes in<br />
clinical practice) and non-technical interventions (linked to leadership, teamwork and culture<br />
change). When applied together they have been shown to significantly reduce the incidences<br />
of Central Venous Catheter bloodstream infections (CVC-BSIs).<br />
The Matching Michigan target is no more than 1.4 CVC – BSI per 1000 catheter days.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 35 of 62
Monthly CVC BSI Rates<br />
14<br />
12<br />
Rate of CVC BSI 1000 Catheter days<br />
10<br />
8<br />
6<br />
4<br />
Series1<br />
2<br />
0<br />
Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10<br />
Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-<strong>11</strong> Feb-<strong>11</strong> Mar-<strong>11</strong><br />
Surviving Sepsis is a campaign that has been introduced to reduce mortality and morbidity<br />
associated with delays in recognition and treatment of sepsis. If not treated in a timely way,<br />
sepsis can become a medical emergency. Evidence suggests that a specific bundle of care<br />
interventions, initiated at point of diagnosis improve patient outcomes. The Trust focus at the<br />
current time is to improve sepsis recognition. Initiation treatment is being focussed on A&E<br />
and EADU. Plans are in place to roll out the ‘sepsis bundle’ throughout the Trust this year.<br />
Surgical Site Infection Surveillance is mandatory, with periodic surgical site surveillance<br />
undertaken following hip and knee joint replacement surgery. Results issued last year report<br />
that over the preceding five year period the following infection rates were seen:<br />
• national average for hip replacement 1.1% (JPUH = 1.2%)<br />
• national average for knee replacement 1.1% (JPUH = 1.3%)<br />
Some changes to practice have been implemented that should further improve wound care in<br />
the orthopaedic areas.<br />
World Health Organisation (WHO) Surgical Safety Checklist - In England and Wales,<br />
129,419 incidents relating to surgical specialities were reported to the NPSA from 1 st January<br />
– 31 st December 2007. The WHO Surgical Checklist is designed to reduce the number of<br />
errors and complications resulting from surgical procedures. There are ten core standards<br />
that WHO recommend should remain, even if local adaptation to the checklist is made. At the<br />
<strong>James</strong> <strong>Paget</strong> we have integrated the checklist into our electronic theatre information system<br />
and have introduced a visual prompt in each. Audit results from October <strong>2010</strong> to March 20<strong>11</strong><br />
demonstrate that more than 99% of the checklist has been appropriately completed.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 36 of 62
Metric 6 – Mortality and Case Note Reviews (using Global Trigger Tool)<br />
50% of harm events are thought to be avoidable (NPSA 2007). The use of triggers to identify<br />
adverse events during a manual record review has been used extensively to measure the<br />
overall level of harm in health care organisations.<br />
Local Improvement Aims:<br />
1. 100 baseline random mortality reviews to be completed by end March <strong>2010</strong>.<br />
2. 40 baseline random case note reviews (harm events) to be completed by end March<br />
<strong>2010</strong>.<br />
3. 20 random mortality reviews to be completed every month from April <strong>2010</strong> onwards.<br />
4. 20 random non mortality case note reviews to be completed every month from April <strong>2010</strong><br />
onwards.<br />
Successes:<br />
• Excellent learning opportunities identified<br />
• Highlighted trends that are being incorporated into improvement projects e.g. delays in<br />
appropriate escalation of concerning patients, poor fluid management and completion of<br />
fluid charts, poor clinical record keeping<br />
Concerns:<br />
• Medical capacity to commit to review process<br />
• Overlap with existing mortality review groups<br />
• Timely administrative process to arrange reviews.<br />
Metric 7 – Medicines Management<br />
Between September 2006 and June 2009 27 deaths, 68 severe harms and 21,383 other<br />
patient safety medicines incidents were reported to the NPSA nationally.<br />
Local Improvement Aim:<br />
1. Ensure reasons for drug admissions are appropriately documented on the drug chart<br />
2. Improve pain management processes and patient outcomes<br />
3. To evidence other medicines management actions required from adverse event trends.<br />
Successes:<br />
• Multidisciplinary focus<br />
• Working on the principle of 7 key responsibilities for medicines management<br />
• Working directly with Medicines Management Action Group.<br />
Concerns:<br />
Although progress has been made there is room for further improvements. As a result<br />
medicines management will have a more targeted focus in the forthcoming year to identify<br />
ideas and innovations and how we can make more of a difference.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 37 of 62
Metric 8 – Nutrition & Hydration<br />
Malnutrition (in the form of under nourishment) affects over 3 million people in the UK. It is<br />
often unrecognised and untreated. This metric links very closely with the deteriorating<br />
patient project work stream and the Trust’s dementia care project.<br />
Local Improvement Aim:<br />
1. Malnutrition Universal Screening Tool (MUST) Nutritional Risk Assessment completed<br />
on admission<br />
2. MUST Nutritional Risk Assessment reviewed at least every seven days<br />
3. 100% of patients who require food/fluid charts have them completed correctly<br />
4. 100% compliance with the Trust’s Nil By Mouth policy.<br />
Successes:<br />
• Building on work of Trust Nutrition Group and Nutrition Link Group<br />
• Multi disciplinary focus<br />
• Linking in with Trust Dementia project<br />
• ‘Hospital at Night’ link nurse involvement to promote the standards 24/7.<br />
Concerns:<br />
Improvements have been made. However the standards required remain unmet and work to<br />
further improve outcomes from this metric will be more targeted in the coming year. This will<br />
involve a complete review of some of the systems we currently have in place to manage and<br />
prevent malnutrition/dehydration and ensure we reliably deliver best practice nutritional care.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 38 of 62
Metric 9 – Executive Leadership Patient Safety Walk Rounds<br />
National Perspective: Executive Leadership Patient Safety Walk Rounds are a nationally<br />
and internationally recognised methodology for increasing engagement with frontline staff on<br />
issues that impact on their ability to provide care in a safe environment.<br />
Local Improvement Aim (CQUIN):<br />
1. A minimum of 24 walk rounds to be performed during <strong>2010</strong>/<strong>11</strong><br />
2. Up to three safety actions will result from each walk round.<br />
The target of 24 walk rounds has been significantly exceeded and the benefits are<br />
noticeable. In particular the presence of Executive and Non Executive Directors on the shop<br />
floor has made staff feel they are being given an opportunity to share their experiences<br />
regarding patient safety.<br />
Patient Safety team<br />
Metric 10 – Observations and the Deteriorating Patient<br />
National Context:<br />
Clinical deterioration can occur at any time in a patient’s illness but is more common<br />
following an emergency admission, during recovery from serious illness and following<br />
operations.<br />
Local Improvement Aim:<br />
1. Increase compliance with observation policy to 100% by end December <strong>2010</strong><br />
2. Increase compliance with Early Warning Score (EWS) escalation to 100% by end July<br />
<strong>2010</strong><br />
The improvement aims for this metric have not been achieved in the timescales originally<br />
agreed. However, the aims and objectives of this work stream were reviewed part way<br />
through <strong>2010</strong> to establish if the targets we had set ourselves were realistic and achievable. It<br />
was agreed that the timescales should be extended and since that time good progress has<br />
been made with the vital sign and EWS observations elements of this metric.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 39 of 62
Patient Safety Incidents<br />
As at 18 th May 20<strong>11</strong> the graphs below detail the number and type of adverse incidents<br />
reported via the Trust internal reporting mechanisms.<br />
350<br />
PSI Incidents 10/<strong>11</strong><br />
Number of PSI Incidents<br />
300<br />
250<br />
200<br />
150<br />
236<br />
303<br />
242<br />
265 266<br />
244<br />
272<br />
281<br />
234<br />
288<br />
194<br />
205<br />
100<br />
01.04.10 to 31.03.<strong>11</strong> (Total Number = 3030)<br />
50<br />
0<br />
Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-<strong>11</strong> Feb-<strong>11</strong> Mar-<strong>11</strong><br />
Month and Year<br />
PSI Incidents by Category<br />
1200<br />
01.04.10 to 31.03.<strong>11</strong> (Total = 3030)<br />
1065<br />
1000<br />
Number of Incidents<br />
800<br />
600<br />
400<br />
200<br />
0<br />
2<br />
255<br />
99<br />
127<br />
66<br />
6<br />
71<br />
47<br />
5<br />
133<br />
5<br />
80<br />
16<br />
247<br />
2<br />
122<br />
1<br />
403<br />
172<br />
7 28<br />
8<br />
63<br />
Anaesthetics<br />
Assessment,Diagnosis,Scans,Tes<br />
Consent, Confidentiality,Commu<br />
Health & Safety<br />
Information Governance<br />
IT<br />
Medical Equipment (Electrical)<br />
Neonatal<br />
Paediatrics (Inc Community)<br />
Records Management<br />
Security And Fraud<br />
Theatres (Inc Anaesthetics)<br />
Cause Group<br />
All adverse incidents are investigated to ascertain the root causes and appropriate<br />
improvement actions are then taken.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 40 of 62
For all Serious Untoward Incidents (SUIs) a full root cause analysis investigation is<br />
undertaken and a detailed action plan is developed and monitored to ensure that any<br />
learning is implemented into practice across the Trust. The number and type of SUIs<br />
reported to the PCT and Strategic Health Authority during <strong>2010</strong>/<strong>11</strong> are set out below.<br />
SUI's 10/<strong>11</strong><br />
6<br />
01.04.10 to 31.03.<strong>11</strong> (Total Number =<br />
29)<br />
5<br />
5<br />
4<br />
4<br />
Number of Incidents<br />
3<br />
2<br />
2<br />
3<br />
2<br />
3<br />
2<br />
3 3<br />
1<br />
1<br />
1<br />
0<br />
Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-<strong>11</strong> Feb-<strong>11</strong> Mar-<strong>11</strong><br />
Month and Year<br />
SUI's by Category<br />
12<br />
10<br />
01.04.10 to 31.03.<strong>11</strong> (Total Number = 29)<br />
10<br />
Number of Incidents<br />
8<br />
6<br />
4<br />
2<br />
2<br />
3<br />
5<br />
1 1 1 1<br />
4<br />
1<br />
0<br />
Appts, Admission, Discharge, T<br />
Assessment,Diagnosis,Scans,Tes<br />
Clinical/Medical Treatment/Pro<br />
Consent, Confidentiality,Commu<br />
Infection Control<br />
Information Governance<br />
Cause Group<br />
Medicines Management (Inc Gase<br />
Patient Care,Monitoring, Revie<br />
Records Management<br />
Slips, Trips And Falls<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 41 of 62
Never Events<br />
Never Events are serious, largely preventable patient safety incidents that should not occur if<br />
the available preventative measures have been implemented.<br />
The core list of Never Events for <strong>2010</strong>/<strong>11</strong> is detailed. This has been increased to a list of 25<br />
for 20<strong>11</strong>/12:<br />
• Wrong site surgery<br />
• Retained instrument post-operation<br />
• Wrong route administration of chemotherapy<br />
• Misplaced naso or orogastric tube not detected prior to use<br />
• Inpatient suicide using non-collapsible rails<br />
• Escape from within the secure perimeter of medium or high secure mental health<br />
services by patients who are transferred prisoners<br />
• In-hospital maternal death from post-partum haemorrhage after elective caesarean<br />
section<br />
• Intravenous administration of mis-selected concentrated potassium chloride.<br />
The Trust has introduced a number of control measures to prevent Never Events from<br />
occurring. However, during <strong>2010</strong>/<strong>11</strong> there were two Never Events, both of which involved<br />
the retention of a small swab following suturing after an instrumental vaginal delivery. A<br />
detailed programme of training, awareness and checklists has now been introduced to<br />
prevent a similar occurrence in the future. An audit will be conducted during summer 20<strong>11</strong> to<br />
ensure these improvements have been embedded into practice.<br />
Case Study: Patient Fall (SUI)<br />
Incident: Patient found on the floor beside the bed having been recently transferred from<br />
the admissions unit (within one hour of transfer). Patient was diagnosed with a fractured<br />
neck of femur (broken hip). The family were informed and the incident was investigated<br />
formally using Root Cause Analysis techniques.<br />
Findings: Patient was transferred into the ward at lunchtime when staff were busy with<br />
medicine administration and feeding patients, hence all falls prevention options were not<br />
considered upon admission.<br />
Improvements:<br />
Patients at high risk of falls are now cohorted into one bay and staff are allocated to monitor<br />
the patients (additional staff are booked).<br />
Staff are encouraged to consider the use of falls prevention equipment such as falls beds<br />
and sensocare equipment.<br />
Falls risk assessments are conducted on admission and then weekly; each bay has an<br />
allocated day for the assessment to be completed which is advertised at the end of each<br />
bay.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 42 of 62
Patient Safety Alerts<br />
At the time of this report the Trust is compliant with all patient safety alerts which are<br />
monitored by the Central Alert Service. The Trust has a robust process in place for ensuring<br />
that alerts are received and circulated to the relevant individuals promptly so that any<br />
necessary actions can be taken within the timescales prescribed.<br />
NHSLA and CNST<br />
The Trust was assessed and achieved NHS Litigation Authority (NHSLA) Level 2 in May<br />
2008. The Trust will be reassessed against the 20<strong>11</strong>/12 standards for acute trusts in early<br />
May 20<strong>11</strong> when it is hoped that Level 2 will be retained.<br />
The Maternity Service was reassessed in March 20<strong>11</strong> against the Clinical Negligence<br />
Scheme for Trusts (CNST) <strong>2010</strong>/<strong>11</strong> Maternity Standards. The service achieved Level 2<br />
against these standards.<br />
Clinical Outcomes and Effectiveness<br />
<strong>Account</strong>ability Framework – Nursing Care Metrics<br />
A key piece of work undertaken by the Chief Matron and the Patient Safety Project Director,<br />
to support the aims of the Patient Safety project, has been the development of an<br />
<strong>Account</strong>ability Framework for nursing staff. The primary aim of the framework is to provide<br />
clarity for staff regarding the standard of practice that is expected. Secondly, that any<br />
variation in the standards of care our patients receive will reduce, and our organisational and<br />
departmental approaches will become appropriately standardised.<br />
The framework consists of 15 Care Metrics within which there are 77 evidence based Key<br />
Performance Indicators (KPIs). Performance is monitored on a monthly basis via audit data<br />
collection. Feedback is provided to the relevant Ward Manager and Matron. The first audits<br />
took place in November <strong>2010</strong> and this data has been used as the baseline. As expected, the<br />
first set of results were variable amongst the different areas included. However, it is already<br />
evident that Ward Managers are embracing the concept of the framework as a tool to<br />
strengthen their team’s performance and capability to improve patient outcomes.<br />
Once we have established and embedded the Nursing <strong>Account</strong>ability metrics and KPIs into<br />
practice we will introduce a further set of metrics at ward level that will reflect other patient<br />
sensitive areas where Allied Health Professionals and medical colleagues lead e.g.<br />
medicines management and documentation. In addition we need to ensure that the Nursing<br />
<strong>Account</strong>ability Framework links clearly with the Divisional performance score cards and<br />
performance meetings led by the Director of Finance and Performance.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 43 of 62
Existing Commitments and National Priorities <strong>2010</strong>/<strong>11</strong><br />
2009/10 2009/10 <strong>2010</strong>/<strong>11</strong> <strong>2010</strong>/<strong>11</strong><br />
Target Performance Target Performance<br />
Total Time In A&E : 4 hours or Less 98% 98.34% 95% 97.21%<br />
Cancelled Operations 0.80% 1.04% 0.80% 0.52%<br />
Delayed Transfers of Care<br />
No Target set<br />
by CQC 1.50% 3.50% 2.25%<br />
Access To GUM Clinics: offered an<br />
appointment within 48 hours 98% 100% 100% 100%<br />
Access To GUM Clinics: Seen within<br />
48 hours 95% 96% 95% 96.68%<br />
Time To Reperfusion For Patients who<br />
have had a heart attack<br />
Rapid Access Chest Pain Clinic 98%<br />
99%<br />
No >26wk<br />
Elective Inpatient Waiting Times<br />
waits 0%<br />
No >13wk<br />
Outpatient Waiting Times<br />
waits<br />
0%<br />
100% 99.5%<br />
All Cancers - 2 Week Wait 93% 93.21% 93% 97.17%<br />
2 Week Breast symptoms urgent<br />
referral to first outpatient appointment<br />
waiting times 93%<br />
96.91%<br />
All Cancers - 1 Month Diagnosis To<br />
Treatment 96% 100% 96%<br />
99.35%<br />
All Cancers - 2 Month GP Urgent<br />
Referral To Treatment 85% 90.92% 85%<br />
88.37%<br />
All Cancers - 1 Month Diagnosis To<br />
Treatment Of Anti Cancer Drug<br />
100%<br />
Regimen 98%<br />
All Cancers - 1 Month Diagnosis To<br />
Treatment Of Surgery 94% 100%<br />
All Cancers - 2 Month From Consultant<br />
Upgrade to Treatment 86% 91.18%<br />
All Cancers - 2 Month From Screening<br />
Services Referral To Treatment 90% 98.37%<br />
Incidence of MRSA 10 4 4 2<br />
Incidence of Clostridium Difficile 60 36 35 29<br />
18 Week Referral to Treatment:<br />
Admitted Patients (at March) 90% 90.92% 90% 94.50%<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 44 of 62
2009/10<br />
2009/10<br />
Performance<br />
<strong>2010</strong>/<strong>11</strong> <strong>2010</strong>/<strong>11</strong><br />
18 Week Referral to Treatment: Non<br />
Admitted Patients (at March) 95% 97.82% 95% 99.06%<br />
Smoking during pregnancy - data<br />
completeness 95% 97% 95% 98.12%<br />
Smoking during pregnancy 29.03% 26.31%<br />
Patient Experience<br />
National In-patient Survey <strong>2010</strong><br />
476 responses were received which equates to 57% of surveys distributed.<br />
Question Area<br />
Admission<br />
The Hospital and Ward<br />
Doctors<br />
Nurses<br />
Care and Treatment<br />
Operations and<br />
Procedures<br />
Leaving Hospital<br />
Overall<br />
Conclusions<br />
Trust scores in relation to other Trusts on patient admission are<br />
generally higher.<br />
Overall Trust scores on patient admission issues have fallen back since<br />
last year.<br />
Trust scores in relation to other Trusts on issues relating to the hospital<br />
and ward environment are mixed.<br />
Overall Trust scores on hospital and ward environment issues have<br />
improved since last year.<br />
Trust scores in relation to other Trusts on issues relating to doctors are<br />
generally higher.<br />
Overall Trust scores on doctors have fallen back since last year.<br />
Trust scores in relation to other Trusts on issues relating to nurses are<br />
generally higher.<br />
Overall Trust scores on nurses have fallen back since last year.<br />
Trust scores in relation to other Trusts on issues relating to care and<br />
treatment are generally higher.<br />
Overall Trust scores on care and treatment have fallen back since last<br />
year.<br />
Trust scores in relation to other Trusts on issues relating to operations<br />
and procedures are generally lower.<br />
Overall Trust scores on operations and procedures have fallen back<br />
since<br />
last year.<br />
Trust scores in relation to other Trusts on issues relating to leaving<br />
hospital are generally lower.<br />
Overall Trust scores on leaving hospital have improved since last year.<br />
Trust scores in relation to other Trusts on issues relating to the patients’<br />
overview of their stay are generally lower.<br />
Overall Trust scores on the patients’ overview of their stay have fallen<br />
back since last year.<br />
The following chart shows the range of responses on some key questions in the survey. It<br />
shows three things:<br />
• The range of scores achieved by all Trusts surveyed by <strong>Quality</strong> Health on a<br />
particular group of questions. The range is graded from green to red.<br />
• The national mean score achieved by all Trusts for each of the questions. This is<br />
shown as a blue arrow pointing toward each scale.<br />
• The Trust’s score on each key question. This is shown on the scale as a yellow<br />
diamond.<br />
The national mean score and the Trust’s score is shown without any weighting or<br />
standardisation of the data.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 46 of 62
Our best scores (15 areas) – the Trust scored in the top 20% of acute trusts in England for<br />
the following:<br />
• Being treated with respect and dignity<br />
• Having enough privacy when being examined or treated<br />
• Patient feeling they waited the right amount of time on the waiting list<br />
• Patients not having their admission date changed<br />
• Short length of time to get to a bed on the ward<br />
• Not sharing a sleeping area with patients of the opposite sex<br />
• Cleanliness of ward areas<br />
• Cleanliness of toilets and bathrooms<br />
• Rating hospital food as very good<br />
• Patients being given enough help from staff to eat their meals<br />
• Patients having confidence and trust in the nurses<br />
• Patients having confidence and trust in the doctors<br />
• Nurses washing hands between patients<br />
• Having enough privacy when discussing condition or treatment<br />
• Not needing to complain about their care in hospital.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 47 of 62
An action plan has been developed for those areas where the Trust scored less well:<br />
Issue<br />
For being bothered by noise at<br />
night from staff<br />
Action<br />
Continue with initiatives commenced in <strong>2010</strong>: ear plugs<br />
offered at night to suitable patients and a regular noise<br />
audit.<br />
Information to be placed in patient lockers to raise patient<br />
awareness.<br />
For always being offered a<br />
choice of food<br />
Staff completely explaining<br />
how the operation had gone in<br />
a way the patient could<br />
understand<br />
To review menu provision on EADU to implement normal<br />
ward menu and increase choice offered.<br />
Staff reminded to check patient understanding following<br />
information giving (Remember I’m a patient leaflet)<br />
Values (customer care) training<br />
Encourage patient responsibility through posters in clinics/<br />
ward areas ‘Have you understood what was said to you?<br />
Do you need to ask again/do you need to ask any other<br />
questions?’<br />
Staff completely telling<br />
patients how they would feel<br />
after the operation/treatment<br />
Staff completely explaining<br />
risks and benefits before the<br />
operation<br />
Staff completely explaining<br />
what would happen during<br />
operation/treatment<br />
Staff completely answering<br />
questions before the operation<br />
in a way the patient could<br />
understand<br />
Staff completely telling<br />
patients what danger signals to<br />
watch for at home<br />
Staff completely giving family/<br />
someone close to the patient<br />
information on how to help care<br />
for them<br />
Patient being asked to give<br />
their views on care quality<br />
As above<br />
As above<br />
As above<br />
As above<br />
Posters to be developed: ‘Red means danger – if the<br />
wound feels hot or red following the procedure contact the<br />
ward or GP’<br />
Review discharge leaflets.<br />
Pilot information: ‘Discharge from hospital into care setting’<br />
– covering medications, diagnosis, skin condition,<br />
treatment to be adapted for family/carer use.<br />
Add information to website asking patients to give their<br />
views on the quality of care using the PET devices.<br />
Link to NHS Choices website on Trust website.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 48 of 62
Experience Based Design<br />
Experience based design (EBD) is a method of designing better experiences for patients,<br />
carers and staff and captures the experiences of those involved in healthcare services. The<br />
approach has been produced through the work of the NHS Institute for Innovation and<br />
Improvement (www.institute.nhs.uk/ebd) working in collaboration with NHS organisations and<br />
external agencies. This approach focuses on the experience of care.<br />
Experience based design uses four key steps:<br />
1. Capture the experience; getting patients and staff involved<br />
2. Understand the experience; identifying emotions, mapping highs and lows, finding<br />
touchpoints<br />
3. Improve the experience; co-design, turning experience into action; and<br />
4. Measure the improvement; evaluate and sustain the improvement.<br />
Trust staff were invited to approach patients to ask if they would like to be involved in the<br />
work to improve their experience of care at the Trust. Norfolk LINks, Suffolk Family Carers,<br />
Deaf Connexions and Norfolk and Norwich Association for the Blind were also approached<br />
for interested participants. This resulted in 25 staff and 14 patients/carers attending an<br />
experience event. 25 staff and patients were also involved in co-design events.<br />
Feelings and experience were captured by asking everyone to complete an experience<br />
questionnaire. This questionnaire is a tool to gather people’s emotions at certain points along<br />
the patient journey through the hospital. We adapted the questionnaire to reflect the inpatient<br />
journey and the out-patient journey so patients could share their experiences of either<br />
or both. The staff were asked to reflect on how they felt about the care they gave at particular<br />
points along the patient journey.<br />
Separate staff and patient events were held followed by a joint co-design event where the<br />
results were discussed, collated, themed and ranked.<br />
The findings were merged into three main action groups:<br />
1. Special needs training/carer involvement<br />
2. Environment/car parking<br />
3. Communication/attitudes/team working/resource pressures/clinics/technology<br />
The information gained has been fed into a number of Trust projects/action plans:<br />
• Carer involvement links into the Dementia project<br />
• Mental health training and special needs training for staff<br />
• Values and Customer Care training<br />
• Understanding how Choose & Book works and patient information<br />
• Car parking<br />
• Discharge information given to patients.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 49 of 62
Maternity National Survey<br />
The response rate for the Trust was 47% (<strong>11</strong>6 usable responses from a final sample of 245).<br />
Question Area Conclusions Recommended Actions<br />
Early Pregnancy<br />
Antenatal Check-ups<br />
Tests and Scans<br />
During Pregnancy<br />
Trust scores in comparison to other<br />
Trusts on issues relating to care at<br />
the start of pregnancy are more<br />
positive.<br />
Trust scores on issues relating to<br />
care at the start of pregnancy have<br />
improved compared to 2007.<br />
Trust scores in comparison to other<br />
Trusts on issues relating to<br />
antenatal check-ups are more<br />
positive.<br />
Trust scores on issues relating to<br />
antenatal check-ups have improved<br />
in respect of staff continuity<br />
compared to 2007.<br />
Trust scores in comparison to other<br />
Trusts on issues relating to tests<br />
and scans are about the same.<br />
Trust scores in comparison to other<br />
Trusts on issues relating to care<br />
during pregnancy are mixed.<br />
Trust scores on issues relating to<br />
care during pregnancy have<br />
remained about the same compared<br />
to 2007.<br />
Increase the number of women who<br />
are given a choice of where to have<br />
their baby including a home birth.<br />
Ensure that information is given<br />
about the choices available to women<br />
on where to have their baby.<br />
Ensure all women who need one are<br />
given a copy of The Pregnancy Book.<br />
Ensure that all women are given<br />
information about the NHS Choices<br />
website.<br />
Ensure that women are given as<br />
much choice as is possible about<br />
where they have their antenatal<br />
check-ups and who will do them.<br />
Increase continuity of care from<br />
midwives so that women see the<br />
same midwife as often as possible.<br />
Look at ways of increasing the<br />
continuity of care from hospital<br />
doctors so that women see the same<br />
doctor as often as possible.<br />
Ensure that all women have a choice<br />
about whether they have a screening<br />
test for Down’s syndrome.<br />
Take action to improve explanations<br />
about the reasons for testing for<br />
Down’s syndrome.<br />
Ensure that women get clear<br />
explanations about the reasons for<br />
dating scans and mid-trimester scans<br />
and feel they have a choice about<br />
having these scans.<br />
Ensure that all women are given a<br />
contact number in case they are<br />
worried during their pregnancy.<br />
Ensure that both verbal and written<br />
information is easily understood by<br />
women, and that all information and<br />
explanations required are given.<br />
Ensure that all women are treated<br />
with respect and dignity, kindness<br />
and understanding during their<br />
pregnancy.<br />
Ensure that women are involved as<br />
much as possible in decisions about<br />
their care.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 50 of 62
Question Area Conclusions Recommended Actions<br />
Antenatal Classes<br />
During Labour<br />
The Baby’s Birth<br />
Trust scores in comparison to other<br />
Trusts on issues relating to<br />
antenatal classes are more positive.<br />
Trust scores on issues relating to<br />
antenatal classes have improved<br />
compared to 2007.<br />
Trust scores in comparison to other<br />
Trusts on issues relating to labour<br />
are about the same.<br />
The Trust score on getting the pain<br />
relief wanted has remained about<br />
the same.<br />
Trust scores in comparison to other<br />
Trusts on issues relating to the birth<br />
of the baby are about the same.<br />
Review the provision of NHS<br />
antenatal classes given the high<br />
proportion of women not attending<br />
NHS classes and in particular, those<br />
not attending any classes at all.<br />
Examine alternative times and places<br />
for classes given the number of<br />
women saying they were not<br />
convenient.<br />
Ensure that women are told when<br />
partners/others can attend classes<br />
with them.<br />
Ensure that there are enough classes<br />
to meet women’s needs.<br />
Ensure that women are given a<br />
choice as far as is possible about<br />
whether they are induced.<br />
Examine ways of increasing the<br />
number of women able to move<br />
around and choose the position that<br />
makes them most comfortable during<br />
labour.<br />
Ensure that women are given pain<br />
relief in a timely manner to meet their<br />
needs.<br />
Consider whether the Trust’s level of<br />
caesarean sections can be brought<br />
down.<br />
The Staff<br />
Trust scores on issues relating to<br />
the birth of the baby have improved<br />
compared to 2007.<br />
Trust scores in comparison to other<br />
Trusts on issues relating to the staff<br />
are mixed.<br />
Trust scores on issues relating to<br />
the staff are mixed compared to<br />
2007.<br />
Ensure that women are cared for by<br />
the same midwives as far as is<br />
possible during labour and the birth<br />
of their baby and if possible by<br />
midwives they have met previously.<br />
Ensure that husbands and partners<br />
are able to be present for the whole<br />
of labour and the birth of the baby if<br />
requested.<br />
Examine reasons why some women<br />
feel they are left alone at times which<br />
they find worrying.<br />
Ensure that both verbal and written<br />
information is easily understood by<br />
women, and that all the information<br />
and explanations required are given.<br />
Ensure that all women are treated<br />
with respect and dignity, kindness<br />
and understanding during labour and<br />
the birth of their baby.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 51 of 62
Question Area Conclusions Recommended Actions<br />
Post-natal Hospital<br />
Care<br />
Feeding Baby<br />
Care at Home After<br />
Birth<br />
Trust scores in comparison to other<br />
Trusts on issues relating to hospital<br />
care after the birth are more<br />
positive.<br />
Trust scores on issues relating to<br />
hospital care after the birth have<br />
fallen back compared to 2007.<br />
Trust scores in comparison to other<br />
Trusts on issues relating to feeding<br />
baby are less positive.<br />
Trust scores on issues relating to<br />
feeding baby have remained about<br />
the same compared to 2007.<br />
Trust scores in comparison to other<br />
Trusts on issues relating to care at<br />
home<br />
after the birth are more positive.<br />
Trust scores on issues relating to<br />
care at home have improved in<br />
respect of the overall rating of care<br />
compared to 2007.<br />
Examine ways of increasing the<br />
number of women who feel involved<br />
in decisions about their care during<br />
labour and the birth of their baby.<br />
Examine reasons why some women<br />
think their stay in hospital was too<br />
short.<br />
Ensure that women are given all the<br />
information they require about their<br />
own recovery after the birth of their<br />
baby.<br />
Ensure that all babies have a<br />
newborn examination before<br />
discharge.<br />
Ensure that both verbal and written<br />
information is easily understood by<br />
women, and that all the information<br />
and explanations required are given.<br />
Ensure that all women are treated<br />
with respect and dignity, kindness<br />
and understanding during their<br />
postnatal stay in hospital.<br />
Ensure that women have infant<br />
feeding discussed with them during<br />
their pregnancy by midwives.<br />
Ensure that women are given full<br />
support and encouragement,<br />
practical help and consistent advice<br />
about feeding their baby, particularly<br />
in relation to breast feeding.<br />
Look at ways of increasing the<br />
number of women breast feeding<br />
Ensure that women have a contact<br />
number in case they are worried by<br />
anything when at home after the<br />
baby’s birth.<br />
Review the number and frequency of<br />
midwives visits in the light of<br />
respondents’ views.<br />
Review the provision of information<br />
about looking after baby in the light of<br />
the number of women who say they<br />
either did not get information or that<br />
they only got it to some extent.<br />
Ensure that all women have postnatal<br />
check-ups for their own health.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 52 of 62
Compliments and Complaints<br />
As a Trust we are encouraged that our patients, their families<br />
and visitors can access ways to provide us with feedback and<br />
we welcome their comments.<br />
A total of 334 formal complaints were received by the Trust<br />
during <strong>2010</strong>/<strong>11</strong> on a range of issues as detailed in the graphs<br />
below. This equates to 4.2 complaints per 1000 admissions.<br />
All complaints are seen and responded to by the Chief<br />
Executive and we regularly review trends and change our<br />
practices as a direct result of this invaluable feedback. For an<br />
example of changes to practice following a complaint see case<br />
study below.<br />
Complaints <strong>2010</strong>/20<strong>11</strong><br />
40<br />
01.04.10 to 31.03.<strong>11</strong> (Total Number = 334)<br />
38<br />
Number of Complaints<br />
35<br />
30<br />
25<br />
20<br />
15<br />
35<br />
31<br />
26<br />
29<br />
20<br />
23 23<br />
33<br />
21<br />
28<br />
27<br />
10<br />
5<br />
0<br />
Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-<strong>11</strong> Feb-<strong>11</strong> Mar-<strong>11</strong><br />
Month and Year<br />
Complaint Issues <strong>2010</strong>/20<strong>11</strong><br />
300<br />
250<br />
262<br />
01.04.<strong>11</strong> to 31.03.<strong>11</strong> (Total Number = 576)<br />
Number of Complaint Issues<br />
200<br />
150<br />
100<br />
84<br />
91<br />
50<br />
0<br />
25<br />
8<br />
6<br />
30<br />
1<br />
20<br />
10<br />
4 4 1<br />
16<br />
1<br />
7 3 2 1<br />
Admiss, Disch &<br />
Trans Arrang<br />
Aids, Appliance<br />
Equit, Premise<br />
All Aspects Clinical<br />
Treatment<br />
Appoints<br />
Delay/cancel (IP)<br />
Appoints<br />
Delay/cancel (OP)<br />
Attitude Of Staff<br />
Comms/Inf To<br />
Patients<br />
Dementia<br />
Essence Of Care<br />
Failure To Follow<br />
Procedures<br />
Hotel Services<br />
Infection Control<br />
Other<br />
Paitent<br />
Privacy/Dignity<br />
Patient<br />
Discrimination/Status<br />
Patients Property &<br />
Expenses<br />
Personal Records<br />
(Inc Medical)<br />
Policy & Systems<br />
Transport (Amb &<br />
Other)<br />
Category Type<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 53 of 62
Case Study: Health Service Ombudsman<br />
During <strong>2010</strong>/<strong>11</strong> five cases were referred to the Health Service Ombudsman for review.<br />
None were accepted for investigation. However, one complaint was upheld and investigated by<br />
the Ombudsman in <strong>2010</strong> although it was reported in 2009.<br />
The Trust received a complaint from the relatives of a lady who was taken ill whilst on holiday in<br />
the area. She attended a local GP who telephoned our Emergency Assessment and Discharge<br />
Unit (EADU) for advice as this lady had a rare congenital disorder. The Consultant gave advice<br />
over the telephone that the patient should see her specialist on her return home. The patient<br />
returned home immediately but passed away the next day.<br />
The family complained and stated the patient died because she was not admitted to hospital for<br />
assessment. The case was referred to the Health Service Ombudsman who investigated the<br />
complaint and the complaint was upheld, as the Trust was unable to provide sufficient evidence of<br />
the conversation between our consultant and the GP on the telephone.<br />
As a result of the Ombudsman’s report into this complaint the Trust developed an action plan to<br />
prevent a similar occurrence in the future. This included:<br />
Telephone Advice: The Trust had no information on the patient because it was a telephone<br />
enquiry for advice which had not been documented in EADU. The patient was on holiday and<br />
therefore had no hospital notes. The Trust now utilises the EADU referral forms to document<br />
telephone advice given to GP's which are retained on the unit. The Trust now ensures that when<br />
GPs telephone the unit they are given advice regarding what to do if a patient deteriorates,<br />
including a reminder that GPs are able to admit directly to EADU if they are concerned.<br />
The Trust accepted the Ombudsman’s recommendations and a copy of the action plan was<br />
shared with the family, together with an apology.<br />
A number of complaints were received by the Trust throughout February and March 20<strong>11</strong>,<br />
which resulted in some negative media reports, where the standard of care at the Trust was<br />
being questioned.<br />
Maintaining the reputation of the Trust, our staff and the services we provide is a priority at all<br />
times. We have, where possible, provided accurate information to the media without<br />
compromising patient confidentiality. We have also acknowledged where mistakes have been<br />
made, apologised where appropriate and agreed on ways forward to resolve the issues.<br />
We have also received many positive comments and compliments from users of our services<br />
via thank-you cards, letters, emails and correspondence on the NHS Choices website:<br />
“What impressed me most was that I was treated as an individual.”<br />
“Throughout I was nursed with care and compassion.”<br />
“Thanks for everything.<br />
I could not have wished for better treatment.<br />
The staff were great, all of them.<br />
The Food was excellent.<br />
The bed was very comfortable.<br />
The level of care un-surpassable.”<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 54 of 62
PALS<br />
The Patient Advice and Liaison Service (PALS) supports patients, relatives, carers and<br />
members of the public who need information about the healthcare system. They deal with<br />
general enquiries about the healthcare services available, resolve problems by identifying the<br />
right people to talk to and explain how to make a complaint if a concern is unresolved.<br />
During <strong>2010</strong>/<strong>11</strong> there were 806 enquiries via PALS, as demonstrated by the graphs below.<br />
100<br />
90<br />
86<br />
PALS Enquiries 10/<strong>11</strong><br />
01.04.10 to 31.03.<strong>11</strong> (Total Number =<br />
755)<br />
80<br />
80<br />
Number of Enquirers<br />
70<br />
60<br />
50<br />
40<br />
56<br />
64<br />
67<br />
61<br />
63<br />
60<br />
38<br />
48<br />
65<br />
67<br />
30<br />
20<br />
10<br />
0<br />
Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-<strong>11</strong> Feb-<strong>11</strong> Mar-<strong>11</strong><br />
Month and Year<br />
Case Study 4:<br />
Patients and visitors raised with PALS the lack of staff available at lunchtimes to<br />
give help to patients (to encourage patients with confirmed dementia/or the<br />
inability to eat their main hot meal).<br />
Family members sometimes cannot attend during the week, due to work or family<br />
commitments, and the staff do not always have the time to assist all the patients<br />
who require one on one support at lunchtimes. With this in mind we decided to<br />
have mealtime service providers that are given training and liaise with the sister<br />
on the ward to find out which patients need encouragement or some help.<br />
Patients who require assistance at mealtimes have red jugs and red trays so they<br />
can be easily identified. We now have a strong team of nine volunteers that<br />
attend at lunchtimes Monday – Friday and are in the process of recruiting more<br />
meal time helpers.<br />
This will improve the wellbeing of our patients by stimulating and encouraging<br />
them to eat their main lunchtime meal. This aids a quicker recovery and makes<br />
the patient’s journey through the hospital that little bit easier for them and their<br />
families.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 55 of 62
Patient Experience Measures<br />
Patient experience measures 2009/10 Actual <strong>2010</strong>/<strong>11</strong> Actual<br />
PROMS - % of questionnaires completed<br />
(All surgeries - April to October 2009)<br />
• Hip replacement surgery<br />
April to October inclusive rates only available<br />
• Knee replacement surgery<br />
April to October inclusive rates only available<br />
• Varicose vein surgery<br />
April to October inclusive rates only available<br />
• Groin hernia surgery<br />
April to October inclusive rates only available<br />
Patient Feedback – % patients who would recommend<br />
this hospital to friends or family<br />
National Inpatient survey score for cleanliness –<br />
bathrooms/toilets/wards (Q 22)<br />
National Inpatient Survey – number of question areas<br />
where responses are ‘better’ than other trusts<br />
National Inpatient Survey – number of question areas<br />
where responses are in the top 20% compared to other<br />
trusts<br />
National Inpatient Survey score for dignity and respect<br />
(Q 72)<br />
National Inpatient Survey score rating for hospital food<br />
(Q 28)<br />
National Inpatient Survey score rating for patients<br />
experiencing a delay to discharge (Q 61)<br />
National Inpatient Survey score for patients<br />
understanding answers to important questions from<br />
doctors (Q 31)<br />
Patient feedback – having confidence and trust in the<br />
staff treating them (Q 32)<br />
National Inpatient Survey score for length of time on<br />
waiting list before admission (Q 9)<br />
April 09 to 75.5%<br />
October 09 data<br />
67%<br />
73% 79.6%<br />
77% 88.7%<br />
37% 51%<br />
40% 65.7%<br />
80% 2009/10 Local<br />
PET tool score 8<br />
out of 10 (80%)<br />
92 91<br />
9 0<br />
‘about the same’<br />
on all areas<br />
34 15<br />
91 90<br />
64 63<br />
73 76<br />
84 83<br />
90 91<br />
87 87<br />
Formal Complaints – total number 325 334<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 56 of 62
Staff Experience<br />
Staff Survey <strong>2010</strong><br />
The findings can be summarised as follows:<br />
• The Trust scored better than its 2009 score and/or than other trusts in 49 questions<br />
• The Trust scored the same as its 2009 score and/or than other trusts in 14 questions<br />
• The Trust scored lower than its 2009 score and/or than other trusts in 44 questions<br />
• The Trust scored better than its 2009 score but lower than other trusts in 10 questions<br />
The table below details some of the questions within the staff survey and the responses<br />
received compared to the average score for all other trusts:<br />
Item<br />
<strong>2010</strong> Trust<br />
Data<br />
Work Life Balance<br />
% of staff working more than <strong>11</strong> unpaid hours a week 2% 3%<br />
% of staff agree that the Trust committed to helping staff balance 47% 35%<br />
home and work life<br />
% of staff who can approach their immediate manager to talk openly 51% 43%<br />
about flexible working<br />
% of staff who agree their manager gives clear feedback on their work 43% 38%<br />
% of staff who agree that team members have shared objectives 62% 62%<br />
% of staff who agree that the team regularly meets to discuss<br />
43% 45%<br />
effectiveness<br />
% of staff who agree that team members have to communicate closely 55% 57%<br />
to achieve the team’s objectives<br />
% of staff who agree that they often think about leaving the trust 16% 20%<br />
% of staff who agree that they will leave the Trust once they have 5% 9%<br />
found another job<br />
% of staff who have seen any errors, near misses or incidents that 18% 21%<br />
could have hurt staff<br />
% of staff who have reported a staff error, near miss or incident 43% 52%<br />
% of staff who have seen any errors, near misses or incidents that 25% 29%<br />
could have hurt patients<br />
% of staff who have reported a patient error, near miss or incident 58% 59%<br />
% of staff who agree that the Trust treats staff who are involved in an 43% 40%<br />
error, near miss or incident are treated fairly<br />
% of staff who agree that the Trust encourages staff to report errors,<br />
near misses or incidents<br />
68% 66%<br />
The chart below shows three things:<br />
Mean score<br />
for all Trusts<br />
• The range of scores achieved by all trusts surveyed on a particular group of questions.<br />
The range is graded from green to red.<br />
• The National mean score achieved by all trusts for each of the questions. This is shown<br />
as a blue arrow pointing toward each scale.<br />
• The Trust score on each question, shown as a yellow diamond.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 57 of 62
•<br />
100<br />
Key Scores Comparison<br />
90%<br />
80%<br />
70%<br />
60%<br />
50%<br />
40%<br />
30%<br />
20%<br />
10%<br />
0%<br />
Trust help<br />
staff work<br />
Appraisal/re<br />
view in last<br />
Have<br />
planned<br />
Disagree<br />
cannot meet<br />
conflicting<br />
Satisfied<br />
with extent<br />
Trust values<br />
Senior<br />
managers<br />
Care of<br />
patients top<br />
Management<br />
/ staff<br />
communicatio<br />
n effective<br />
No work<br />
related<br />
stress in last<br />
Local Staff Feedback<br />
The local Patient Experience Tool (electronic survey device) has been utilised within the<br />
Trust to ascertain staff opinion and input into a range of areas. The devices have been<br />
positioned in the staff canteen and main foyer and analysis is pending.<br />
Involvement<br />
This <strong>Quality</strong> <strong>Account</strong> has been developed in close collaboration with the Governors Council,<br />
who represent the Trust members, our patients and the local population.<br />
A draft version of this document was shared with our main commissioners during <strong>2010</strong>/<strong>11</strong>,<br />
NHS Great Yarmouth and Waveney, the local GP commissioners Health East CIC, Local<br />
Involvement Networks (LINks) and the Health and Overview Scrutiny Committees for their<br />
comments. The following statements have been provided by these organisations for<br />
inclusion in this report.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 58 of 62
Endorsement<br />
Local Involvement Networks<br />
Norfolk LINk and Suffolk LINk thanks the <strong>James</strong> <strong>Paget</strong> <strong>University</strong> Hospital Trust<br />
Board for the opportunity to comment on the <strong>Quality</strong> <strong>Account</strong> for <strong>2010</strong> - 20<strong>11</strong>.<br />
It was pleasing to see that cognisance had been taken of the previous comments<br />
made. The report was well presented with appropriate language for the general<br />
public to understand.<br />
The Trust is making good use of the national guidelines, CQUINN, and internal<br />
audits, etc to measure progress against defined targets when assessing progress<br />
against their four stated objectives of Reduction in Falls/ Reduction in Patient<br />
Mortality/ Patient Safety/ and Clinical Outcomes and Effectiveness.<br />
The Trust proposals are built upon the progress of the previous year and utilising<br />
specific equipment regarding falls throughout the hospital. This approach within the<br />
Trust and across the locality can only be good for patients and is pleasing to see.<br />
Improved patient safety has been put as a high value within the work across the Trust<br />
and this is to be commended. Norfolk LINk and Suffolk LINk look forward to the<br />
improved patient experience across the Trust.<br />
Internal audits are essential for the improvement of services.<br />
Norfolk LINk and Suffolk LINk are pleased to see the Trust is looking to ensure that<br />
the NICE Guidelines are embedded in all aspects of the work and commends the<br />
Trust on its recent good PEAT inspection and other external audits.<br />
Norfolk LINk and Suffolk LINk look forward to working with <strong>James</strong> <strong>Paget</strong> <strong>University</strong><br />
Hospital NHS Foundation Trust in 20<strong>11</strong>/2012 and hearing of the continued<br />
improvements in the services that the hospital provides.<br />
Marion Fairman-Smith<br />
Suffolk LINk Chairman<br />
Patrick Thompson<br />
Norfolk LINk Chairman<br />
Health Overview and Scrutiny Committee<br />
The Norfolk Health Overview and Scrutiny Committee has decided not to comment on any of<br />
the Norfolk NHS Trusts <strong>Quality</strong> <strong>Account</strong>s for <strong>2010</strong>/<strong>11</strong> and would like to stress that this should<br />
in no way be taken as a negative statement.<br />
The Suffolk Scrutiny Committee is confident with the relationships built up with NHS trusts in<br />
Suffolk over the past year. This work should be developed to ensure delivery of the best<br />
possible health services for the people of Suffolk. The Suffolk Scrutiny Committee has<br />
decided not to comment on any of the Suffolk provider NHS trust's <strong>Quality</strong> <strong>Account</strong>s for<br />
<strong>2010</strong>/<strong>11</strong> and would like to stress that this should in no way be taken as a negative comment.<br />
The Committee has taken the view that it is appropriate for Suffolk's Local Involvement<br />
Network (LINk) to consider the <strong>Quality</strong> <strong>Account</strong> and comment accordingly.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 59 of 62
NHS Great Yarmouth & Waveney<br />
NHS Great Yarmouth & Waveney thanks the <strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS<br />
Foundation Trust for the opportunity to comment on their <strong>Quality</strong> <strong>Account</strong> for <strong>2010</strong>/20<strong>11</strong>.<br />
NHS Great Yarmouth & Waveney confirms that the <strong>Quality</strong> <strong>Account</strong> is based on a<br />
reasonable interpretation of available data.<br />
The continued involvement of the trust in the NHS Great Yarmouth & Waveney Patient and<br />
Carer Experience Board was welcomed. Going forward in 20<strong>11</strong>/12, with NHS Great<br />
Yarmouth & Waveney’s revised Patient Safety Experience and <strong>Quality</strong> Committee, we hope<br />
to build on this partnership with all stakeholders to ensure that patient safety and experience<br />
are promoted.<br />
We note the continued reductions in Healthcare Associated Infection, the introduction of<br />
executive-led patient safety walk-rounds, and the <strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS<br />
Foundation Trust’s innovation in the <strong>2010</strong>/<strong>11</strong> CQUIN Programme. We note the embedding of<br />
the Leading Improvement in Patient Safety Programme.<br />
The Trust also continued to demonstrate a reduction in Hospital Standardised Mortality Ratio<br />
rates. We acknowledge <strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust’s<br />
involvement in planning for the management of the demand on local services across the<br />
system. We welcome the continued partnership with <strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS<br />
Foundation Trust in the Clinical Transformation Board, as the Trust transforms its local<br />
services through increasing clinical engagement and leadership, and look forward to the<br />
Trust’s active engagement in the System Leadership Board, whose prime purpose is to set<br />
the strategic direction for health and social care in Great Yarmouth and Waveney, and<br />
oversee the delivery of the area’s transformation, governance, QIPP and workforce plans.<br />
Going forward in 20<strong>11</strong>/2012 NHS Great Yarmouth & Waveney will encourage clear and<br />
reported outcome measures for patients. A particular focus will be reducing avoidable harm,<br />
and ensuring lessons and good practice are shared, through the Leading Improvement in<br />
Patients Safety Programme, and the analysis of patient experience, clinical incidents and<br />
complaints.<br />
The Board of NHS Great Yarmouth & Waveney will continue to monitor and review all<br />
relevant providers against the Mid-Staffordshire recommendations, the Ombudsman’s Report<br />
‘Care and Compassion and Maintaining <strong>Quality</strong> Through Transition’ and associated<br />
initiatives, and note that the Board of Directors of <strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS<br />
Foundation Trust is monitoring this key area.<br />
NHS Great Yarmouth & Waveney look forward to encouraging further quality achievements<br />
in 20<strong>11</strong>/2012 with <strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust and to receiving<br />
the next <strong>Quality</strong> <strong>Account</strong>.<br />
Andrew Morgan<br />
Chief Executive<br />
NHS Great Yarmouth and Waveney<br />
Governors Council<br />
This report shows that in spite of an increasingly aged population, a great increase in the<br />
number of emergency admissions and having to make vast financial savings, the Trust<br />
continues to deliver an excellent service of a high standard to the majority of its patients and<br />
provides a good working environment for its staff.<br />
In any organisation there are bound to be criticisms and it is note worthy that the number of<br />
formal complaints has increased this year. However, it is important that people make known<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 60 of 62
their concerns so that the matters can be investigated and actions put in place to make<br />
certain they do not recur.<br />
The Governors have been particularly keen that the patient should come first in all matters<br />
and this has been taken on board by the organisation. Much time and effort has been put<br />
into improving the patient’s experience and care and it is good to see that again national<br />
surveys have shown that in the majority of measures the Trust remains in the top 20% of<br />
trusts. Where this is not the case action plans have been developed to improve the<br />
performance.<br />
Each year the number of emergency admissions increases and this has been particularly<br />
severe this year. As a result, nearly 600 elective operations were postponed. This is very<br />
distressing for patients and their carers and puts added strain on all grades of staff. In<br />
addition, extra time and money has to be spent to find alternative times to perform these<br />
operations. Enabling the admission of patients for elective operations without cancelling<br />
emergency admissions is one of the biggest challenges facing the Trust.<br />
In spite of these pressures the Hospital Standardised Mortality Ratio remains low indicating<br />
an overall very good standard of care.<br />
In these particularly challenging times the Trust is to be congratulated that it has managed to<br />
maintain its high standards – and in some instances to improve upon them. The Governors<br />
welcome the frequent and open exchanges which they have with management and are<br />
pleased to play their part in helping to maintain and improve standards.<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 61 of 62
Glossary of Abbreviations<br />
A&E<br />
C diff<br />
CMACE<br />
CQC<br />
CQUIN<br />
CRT<br />
EWS<br />
GUM<br />
H@N<br />
HFEA<br />
HSE<br />
HSMR<br />
ICAS<br />
IHI<br />
IOG<br />
LINks<br />
LIPS<br />
LOS<br />
MCDC<br />
MUST<br />
NCEPOD<br />
NCISH<br />
NHSLA<br />
NICE<br />
NIHR<br />
NSF<br />
PCT<br />
PEAT<br />
PET<br />
PROMs<br />
QIPP<br />
SUS<br />
SWIFT<br />
TIA<br />
TTO<br />
VTE<br />
Accident and Emergency Department<br />
Clostridium difficile<br />
Centre for Maternal and Child Enquiries<br />
Care <strong>Quality</strong> Commission<br />
Commissioning for <strong>Quality</strong> and Innovation<br />
Customer Research Technology<br />
Early Warning Score<br />
Genitourinary medicine<br />
Hospital at Night<br />
Human Fertilisation & Embryology Authority<br />
Heath and Safety Executive<br />
Hospital standardised mortality rate<br />
Independent Complaints Advocacy Service<br />
Institute for Health Improvement<br />
Improving outcomes guidance<br />
Local Involvement Networks<br />
Leading Improvement in Patient Safety programme<br />
Length of stay<br />
Marie Curie Delivering Choice programme<br />
Malnutrition Universal Screening Tool<br />
National Confidential Enquiry into Patient Outcome and Death<br />
National Confidential Enquiry into Suicide and Homicide<br />
National Health Service Litigation Authority<br />
National Institute for Health and Clinical Excellence<br />
National Institute of Health Research<br />
National Service Framework<br />
Primary Care Trust<br />
Patient Environment Action Team<br />
Patient Experience Tool<br />
Patient Reported Outcome Measures<br />
<strong>Quality</strong>, Innovation, Productivity and Prevention<br />
Secondary Uses Service<br />
Strategic Workforce Investment Fund for Tomorrow<br />
Transient Ischaemic Attack<br />
To Take Out (medications)<br />
Venous thromboembolism<br />
<strong>James</strong> <strong>Paget</strong> <strong>University</strong> <strong>Hospitals</strong> NHS Foundation Trust<br />
<strong>Quality</strong> <strong>Account</strong> <strong>2010</strong>/<strong>11</strong> Page 62 of 62