Quality Account 2010/11 - James Paget University Hospitals

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Metric 8 – Nutrition & Hydration Malnutrition (in the form of under nourishment) affects over 3 million people in the UK. It is often unrecognised and untreated. This metric links very closely with the deteriorating patient project work stream and the Trust’s dementia care project. Local Improvement Aim: 1. Malnutrition Universal Screening Tool (MUST) Nutritional Risk Assessment completed on admission 2. MUST Nutritional Risk Assessment reviewed at least every seven days 3. 100% of patients who require food/fluid charts have them completed correctly 4. 100% compliance with the Trust’s Nil By Mouth policy. Successes: • Building on work of Trust Nutrition Group and Nutrition Link Group • Multi disciplinary focus • Linking in with Trust Dementia project • ‘Hospital at Night’ link nurse involvement to promote the standards 24/7. Concerns: Improvements have been made. However the standards required remain unmet and work to further improve outcomes from this metric will be more targeted in the coming year. This will involve a complete review of some of the systems we currently have in place to manage and prevent malnutrition/dehydration and ensure we reliably deliver best practice nutritional care. James Paget University Hospitals NHS Foundation Trust Quality Account 2010/11 Page 38 of 62
Metric 9 – Executive Leadership Patient Safety Walk Rounds National Perspective: Executive Leadership Patient Safety Walk Rounds are a nationally and internationally recognised methodology for increasing engagement with frontline staff on issues that impact on their ability to provide care in a safe environment. Local Improvement Aim (CQUIN): 1. A minimum of 24 walk rounds to be performed during 2010/11 2. Up to three safety actions will result from each walk round. The target of 24 walk rounds has been significantly exceeded and the benefits are noticeable. In particular the presence of Executive and Non Executive Directors on the shop floor has made staff feel they are being given an opportunity to share their experiences regarding patient safety. Patient Safety team Metric 10 – Observations and the Deteriorating Patient National Context: Clinical deterioration can occur at any time in a patient’s illness but is more common following an emergency admission, during recovery from serious illness and following operations. Local Improvement Aim: 1. Increase compliance with observation policy to 100% by end December 2010 2. Increase compliance with Early Warning Score (EWS) escalation to 100% by end July 2010 The improvement aims for this metric have not been achieved in the timescales originally agreed. However, the aims and objectives of this work stream were reviewed part way through 2010 to establish if the targets we had set ourselves were realistic and achievable. It was agreed that the timescales should be extended and since that time good progress has been made with the vital sign and EWS observations elements of this metric. James Paget University Hospitals NHS Foundation Trust Quality Account 2010/11 Page 39 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 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 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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