Quality Account 2010/11 - James Paget University Hospitals

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Contents Page Foreword by Chief Executive 1 Part 1 Introduction 3 Statement of Directors’ Responsibilities 6 Part 2 Priorities for 2010/11 7 Board Statements of Assurance 17 Review of Services 18 Participation in Clinical Audits 19 NICE Compliance 26 Research 27 Data Quality 27 NHS Number and GMC coding validity 28 Information Governance Toolkit 28 Clinical Coding Error Rate 29 What others say about the Trust 30 Part 3 Review of Quality Performance 31 Patient Safety 31 Clinical Outcomes and Effectiveness 43 Patient Experience 46 Endorsement 59 Glossary of abbreviations 61 James Paget University Hospitals NHS Foundation Trust Quality Account 2010/11 Page 2 of 62
James Paget University Hospitals NHS Foundation Trust Quality Account 2009/10 Part 1 1 Introduction Welcome to the third Quality Account report for James Paget University Hospitals NHS Foundation Trust. Quality Accounts are a means to improve organisational accountability, to enable review of services and identify areas for improvement and to demonstrate change. They provide an opportunity for providers of healthcare to work with clinicians to rigorously analyse the quality of care that is being delivered in order to assure commissioners, patients and the public that trust boards are continuously scrutinising the quality of their services. Quality Accounts are also an opportunity to drive forward our local quality improvement plans and to be accountable to the public and stakeholders for these improvements. This year has again seen a period of unprecedented demand for the Trust’s services; there has been a 5.2% increase in emergency admissions and a 1.7% increase in Accident and Emergency (A&E) attendances over the year; and yet we have still provided high quality care for our patients and are continuing to strive to improve services further. During 2010/11 we cared for the following numbers of patients: Elective admissions 29,590 Emergency admissions 26,682 Day cases 24,147 1 st outpatient appointments 65,206 Follow up outpatient appointments 162,910 A&E attendances 65,665 This equates to an average of 512 emergency admissions each week (73 each day) and an average of 1,260 attendances each week (180 each day) at our Accident and Emergency Department. To achieve this, the Trust has utilised 9,076 escalation bed 1 days. This equates to an average of 25 escalation beds per day this year with the Trust on ‘Black Alert’ 2 on 131 occasions. In order to appropriately care for emergency admissions to the Trust we have postponed nearly 600 operations this year. Furthermore, our society is changing with our local population living longer. An additional factor we need to highlight is that our local population is living longer. The area of Great Yarmouth and Waveney has a greater proportion of older people than England or East of England averages, a smaller proportion of working age people between 20 and 50 and a smaller proportion of children under 10. The population is forecast to age, with the 65+ age band likely to increase the most in future years. 1 Escalation beds: extra beds put in place to cope with unexpected increase in demand. 2 Black alert: The status of the hospital when it is full to capacity, escalation beds are in use, patients are waiting in A&E for beds, routine surgery is cancelled and the Trust is working with community partners to discharge patients. James Paget University Hospitals NHS Foundation Trust Quality Account 2010/11 Page 3 of 62
Page 1: James Paget University Hospitals NH
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 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
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Quality Account 2010/11 - James Paget University Hospitals

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