Quality Account 2010/11 - James Paget University Hospitals

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The Trust has a dedicated lead for National Confidential Enquiry into Patient Outcome and Death (NCEPOD) who provides regular reports regarding the Trust’s progress with implementing the recommendations from the published reports. Self assessments have been carried out using the NCEPOD tools and action plans are in place to ensure implementation of the recommendations. There were three confidential enquiries published by NCEPOD during 2010/11, two of which were applicable to the Trust: • Parenteral nutrition; and • Elective and Emergency Surgery in the Elderly. The Trust is in the process of implementing the recommendations detailed within these two confidential enquiries. There were no reports published by the Centre for Maternal and Child Enquiries (CMACE) during 2010/11. There were no reports published by the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCI/NCISH) during 2010/11 applicable to the Trust. National Institute for Health and Clinical Excellence (NICE) compliance A NICE Implementation Group is in place and meets regularly to review new guidance, technology appraisals, interventional procedures and other guidance issued by NICE. This group also monitors those publications which are relevant for our patients but have yet to be fully implemented due to barriers such as funding, training needs or facilities required. This ensures that robust action plans are in place and progress is being made towards implementation. The table below details the number of materials issued by NICE to date and the Trust’s status in terms of compliance. For guidelines/guidance which has yet to be fully implemented plans are in place to expedite this. NICE Number issued by end of March 2011 (relevant to JPUH) Compliance rate at end of March 2011 Technology Appraisal Guidance 106 88.7% Interventional Procedure Guidance 46 71.7% Clinical Guidelines 101 73.3% Patient Safety Guidance 2 50% Public Health Guidance 26 57.7% James Paget University Hospitals NHS Foundation Trust Quality Account 2010/11 Page 26 of 62
Research The number of patients receiving NHS services provided or sub-contracted by the James Paget University Hospitals NHS Foundation Trust in 2010/11, that were recruited during that period to participate in research approved by a research ethics committee, was 712. Participation in clinical research demonstrates the James Paget University Hospitals NHS Foundation Trust’s commitment to improving the quality of care we offer and to making our contribution to wider health improvement. Our clinical staff stay abreast of the latest possible treatment possibilities and active participation in research leads to successful patient outcomes. The James Paget University Hospitals NHS Foundation Trust was involved in conducting 12 clinical research studies in Cancer during 2010/11. It is not possible at the time of writing this report to provide data relating to mortality amenable to healthcare/mortality rate from causes considered preventable as these studies are not yet completed and the data has not yet been analysed. The participation in such studies at the Trust demonstrates a commitment to clinical research which it is anticipated will lead to better treatments for patients. There were 44 (19 nurses and 25 doctors) of clinical staff participating in research approved by a research ethics committee at the James Paget University Hospitals NHS Foundation Trust during 2010/11. These staff participated in research covering 14 of medical specialties. In the last three years, we are unaware of any publications that have resulted from our involvement in NIHR research as most studies are long term and have yet to complete. It is likely that there have been publications generated by Chief investigators from other Trusts where we have acted solely as additional research sites. We are largely a trial hosting site and are not in receipt of any NIHR grants at present. Our engagement in multi-centre studies also demonstrates the James Paget University Hospitals NHS Foundation Trust commitment to testing and offering the latest medical treatments and techniques. Data Quality James Paget University Hospitals NHS Foundation Trust will be taking the following actions to improve data quality : • Monthly meetings with NHS Great Yarmouth and Waveney to discuss data quality issues. These are minuted and an action log is maintained to ensure all issues are recorded and left open until resolved; • Data Quality report to the Information Governance Action Group based on the SUS Data Quality Dashboard provided by the Health and Social Care Information Centre. This report includes recommendations to the Board which are followed up at the next meeting; and • Regular reports are sent to the clinical Divisions identifying data quality issues that need resolving at source before being submitted to SUS. This is monitored via a local reporting system that mirrors the SUS Data Quality Dashboard. James Paget University Hospitals NHS Foundation Trust Quality Account 2010/11 Page 27 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 20 and 21: The services provided by James Page
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 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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