Quality Account 2010/11 - James Paget University Hospitals

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The services provided by James Paget University Hospitals NHS Foundation Trust include the following: Division Emergency Elective Women & Child Health Core Clinical Specialties and services: Accident and Emergency (A&E) General Medicine Gastroenterology Endocrinology Diabetes Haematology Cardiology Dermatology Nephrology and renal dialysis Genitourinary Medicine Rheumatology Respiratory Medicine General Surgery Vascular Surgery Breast Surgery Gastro-intestinal Surgery Urology Trauma and Orthopaedics Ear, Nose and Throat Oral Surgery Ophthalmology Gynaecology Obstetrics Maternity services Community midwifery Neonatology Parentcraft Antenatal screening Fertility services Diagnostic Imaging • X-ray services • Specialist Imaging • Ultrasound services • Mammography services • MRI & CT services Medical illustration Pharmaceutical services Lowestoft Hospital Care of the elderly GP beds Care of the Elderly Diabetic Liaison Clinical Measurement Coronary Care Endoscopy Rehabilitation Intensive Care Services Hyperbaric services Oncology Sandra Chapman Centre (day treatment for adults with haematological disease and cancer) Therapies e.g. physiotherapy Anaesthetics Clinical Specialties of Continence and Stoma Care Audiology Dental and Orthodontics Community Dental Services Pain Management Palliative Care Paediatrics Paediatric Surgery Children’s Centre Community Paediatric Service School Nursing (GY) Safeguarding children Community services Chemical Pathology Immunology and Serology Microbiology Haematology Blood Transfusion Bereavement Services Pharmaceutical Services Social Work Support Reviews of the quality of services provided by the Trust for all its locations and all of the service types and regulated activities have taken place during 2010/11. The processes used are described in Part 3 of this report. A number of external assessments were conducted during 2010/11, including: • Health and Safety Executive review of Microbiology laboratory; • National Cancer Peer Review • Clinical Negligence Scheme for Trusts (CNST) review of Maternity Services • External Quality Assessment of the Diabetic Retinal Screening Service • Human Fertilisation and Embryology Authority (HFEA) review of Fertility Service • Intensive Care Unit/High Dependency Unit peer review audits • Care Quality Commission Review of Support for Families with Disabled Children • Fire Risk Assessments Trust-wide • Patient Environment Action Team • Environmental health. James Paget University Hospitals NHS Foundation Trust Quality Account 2010/11 Page 18 of 62
During 2011/12 a number of further service reviews are planned which will be aligned to the Trust’s CQUIN targets with our commissioners and the Quality Innovation, Productivity and Prevention projects (QIPP). Participation in Clinical Audits During 2010/11, 33 national clinical audits and two national confidential enquiries covered NHS services that the James Paget University Hospitals NHS Foundation Trust provides. During that period James Paget University Hospitals NHS Foundation Trust participated in 88% (29/33) of the national clinical audits and 100% of the national confidential enquiries which it was eligible to participate in. The national clinical audits and national confidential enquiries that James Paget University Hospitals NHS Foundation Trust was eligible to participate in during 2009/10 are listed in the table overleaf. The national clinical audits and national confidential enquiries that James Paget University Hospitals NHS Foundation Trust participated in, and for which data collection was completed during 2010/11, are listed in the table on page 20. This includes the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry 4 . The table overleaf describes the list of national audits drawn up by the National Clinical Audit Advisory Group of the Department of Health. Although national audits are not mandatory, Trusts are recommended to participate in those audits of services which they provide. The CQC uses information from national audits in its Quality and Risk Profiles to identify whether a Trust is at risk of not complying with the registration requirements. There is now a formalised process in place whereby the Clinical Effectiveness Committee reviews national audits to make a corporate decision whether or not participation is cost effective and achievable. 4 Where this information was available at the time of reporting James Paget University Hospitals NHS Foundation Trust Quality Account 2010/11 Page 19 of 62
Page 1: James Paget University Hospitals NH
Page 4 and 5: Contents Page Foreword by Chief Exe
Page 6 and 7: The old and the very young are know
Page 8 and 9: Statement of directors' responsibil
Page 10 and 11: Current position: Patient Falls 120
Page 12 and 13: Priority 1b: Patient safety - Reduc
Page 14 and 15: Five work streams have been agreed
Page 16 and 17: No Commissioning for Quality and In
Page 18 and 19: No Commissioning for Quality and In
Page 22 and 23: Clinical Audits Audit Name Applicab
Page 24 and 25: (NHSBT UK Transplant Registry) Audi
Page 26 and 27: Case Study 2: Upper Gastrointestina
Page 28 and 29: The Trust has a dedicated lead for
Page 30 and 31: NHS number and GMC code validity Ja
Page 32 and 33: What others say about the Trust Car
Page 34 and 35: Current Position: Inpatient Pressur
Page 36 and 37: Metric 3 - Venous Thromboembolism (
Page 38 and 39: Monthly CVC BSI Rates 14 12 Rate of
Page 40 and 41: Metric 8 - Nutrition & Hydration Ma
Page 42 and 43: Patient Safety Incidents As at 18 t
Page 44 and 45: Never Events Never Events are serio
Page 46 and 47: Existing Commitments and National P
Page 48 and 49: Patient Experience National In-pati
Page 50 and 51: An action plan has been developed f
Page 52 and 53: Maternity National Survey The respo
Page 54 and 55: Question Area Conclusions Recommend
Page 56 and 57: Case Study: Health Service Ombudsma
Page 58 and 59: Patient Experience Measures Patient
Page 60 and 61: • 100 Key Scores Comparison 90% 8
Page 62 and 63: NHS Great Yarmouth & Waveney NHS Gr
Page 64: Glossary of Abbreviations A&E C dif

Quality Account 2010/11 - James Paget University Hospitals

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