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TRANSCRIPT
2015 - 2016 Quality Account
University HospitalsCoventry and Warwickshire
NHS Trust
Content
University HospitalsCoventry and Warwickshire
NHS Trust
UHCW 2015 - 2016 Quality Account
Section
1 AWelcomefromourChiefExecutiveOfficer Page3
2 IntroductiontoQuality Page4
2.1 QualityHighlights2015-2016 Page4-7
2.2 QualityImprovementPrioritiesfor2015-2016ProgressUpdate Page7-9
2.3 QualityImprovementPrioritiesfor2016-2017 Page10-14
2.4 StatementsbytheTrustBoard Page15-34
2.5 PerformanceagainsttheNHSOutcomesFramework Page35-42
3 OverviewofOrganisationalQuality Page43-77
4 Invitationtocommentandofferfeedback Page78
Annexes
StatementsfromPartnerAgencies Page79-80 CommentaryfromJointQualityAccountTaskGroup Page80-82 Director’sStatementofResponsibility Page83 ExternalAuditor’sLimitedAssuranceStatement Page84-86
Appendices CQUIN2015-2016 Page87
Glossary Page88-99
Section 1A Welcome from our Chief Executive Officer
Welcome to our Quality Account for 2015-2016. This report provides you with an overview of the quality of the services we provided to our patients during 2015-2016, and an outline of our priorities for the forthcoming year.
UniversityHospitalsCoventryandWarwickshire(UHCW)NHSTrusthassomeofthemostskilledandprofessionalstaffworkingintheNHS.Our9,600staffworkincrediblyhardtoprovideexcellentcareforourpatients,whocometoourhospitalsfromacrossCoventryandWar-wickshireandbeyond.AsChiefExecutiveOfficer,Iamproudtocelebratetheirachievementsoverthelastyear,aswellaslookingaheadtowherewehopetobeinMarch2017.
Thelastyearhasseenanumberofimportantdevelopmentstoimprovethequalityofcareweprovide.FollowingourinspectionbytheCareQualityCommission’s(CQC)ChiefInspectorofHospitalsTeaminMarch2015,wehaveimplementeda‘GettingtheBasicsRight’assuranceprogrammeacrosstheTrust.
InJuly2015,UHCWwasannouncedasoneofjustfiveTrustsinEnglandtoworkwiththeprestigiousVirginiaMasonInstitute,tofurtherimprovethequality,safetyandefficiencyofthecareweprovidetoourpatients.
Lastyear,ourtopthreeprioritieswerePatient Safety;ensuringeffectivehandoversbetweenstaff(continuingtheprogressmadein2014-15), Clinical Effectiveness;ensuringeffectiveEndofLifeCare,and Patient Experience;implementing‘AlwaysEvents’,i.e.thoseelementsofgoodcarethatallourpatientsshouldreceive.
Throughoutthisreportyouwillfindexamplesofourachievementsintheaboveareas.
Lookingforwardtoouryearahead,ourprioritiesfor2016-2017focuson:
• Patient Safety:Reducingandimprovingmedicationerrors;• Clinical Effectiveness:ImprovingcompliancewithCareBundles;packagesofinterventionsto befollowedforeverypatienttoimproveoutcomes,and;• Patient Experience:ImplementingtheCareContactTimeprojectacrosstheTrusttoincrease theamountoftimethatstaffspendwithpatients.
Overthenextyear,wewillcontinuetolistentotheviewsofourpatientsandstafftomakefurtherimprovementsaspartofourobjectivetodeliverexcellentpatientcareandexperience.ThroughourworkwiththeVirginiaMasonInstitute,wearealsolookingathowwecanidentify,celebrateandreplicateareasofoutstandingpracticeacrosstheTrust.
Theinformationanddatacontainedwithinthisreporthasbeensubjecttointernalreviewand,whereappropriate,externalverification.Therefore,tothebestofmyknowledge,theinformationcontainedwithinthisdocumentreflectsatrueandaccuratepictureoftheperformanceoftheTrust.
Iwouldliketothankallourstaff,volunteersandpatientsupportgroupsfortheirinputandsupportinhelpingustoprogressagainstourobjectivesduringtheyear.
Professor Andrew Hardy ChiefExecutiveOfficer
University HospitalsCoventry and Warwickshire
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UHCW 2015 - 2016 Quality Account
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Section 2Introduction to Quality
2.1 Introduction to the annual Quality Account
UHCWisonajourneytobecomeanationalandinternationalleaderinhealthcare.Thereareanumberofbuildingblocksthatsupportthisambition;thesearearticulatedwithinthevision,mission,values,aimsandobjectiveswhichareillustratedwithinthestrategicframeworkforQualitybelow:
AspartofthisUHCWhasqualityastheorganisingprincipleacrossallourservices,meaningthatpatientsafetyandharm-freecare,excellentclinicaloutcomesandhighqualitypatientexperienceiscentraltoallwedo.OurannualQualityAccountprovidesanopportunityforustotakestockofachievementsandprogresstodateandtolookforwardtotheyearahead.
2015-2016 Quality Highlights
OurPerfectWeekforPatients–BreakingFree
TheEmergencyCarePathwayatUHCWhasbeenchallengedformanyyears.TheEmergencyCareIntensiveSupportTeam,recommendatechniqueknownasthe‘PerfectWeek’to“resetthesystem”instrugglingorganisationsandhealtheconomies.Essentiallythisrequiresthewholehospitaltopauseandfocusonthekeyissuesimpactinguponpoorperformanceandtospendaweekfixingtheseissues.
TheEmergencyCareIntensiveSupportTeamsuggestedthatcommunicationisakeyissuefororganisationsattemptingtorun‘PerfectWeek’.TheTrustagreedacommunicationplanwhichbriefedtheorganisationaboutthe‘PerfectWeek’fromthepointofplanning.
TheCommunicationsPlanbeganwithemailandwrittenbriefings,butitquicklybecameap-parentthatthiswasnotsufficient.Projectleadsfoundface-to-facecommunicationthebestmethodtoengagestaffaboutthe‘PerfectWeek’andsoformalbriefingsessionswereorgan-isedaswellassocialevents(teaandcoffee/curry)and1:1meetings.Everyconversationwehadduringtheplanningperiodincludedreferencetothe‘PerfectWeek’.
Keyachievementsfollowingthe‘PerfectWeek’include:
• 120morepatientsweredischarged duringthePerfectWeek.• 20morepatientsweredischargedbefore 12noon each day compared to a poor performingweek.• 313 patientshadbeeninhospitalmore than14dayscomparedto430 for the weeksbefore.• 60patientswaitedmorethanfourhours intheEmergencyDepartmentduring PerfectWeekcomparedto584sixweeks previously.• Therewere16medicaloutliersi.e.dueto thelackofbedsinmedicalwards,many patientsareplacedinotherdepartments’ wards(usuallyinsurgicalwards).These patientsarecalled“medicaloutliers”.On abadweek,thisfigurestoodat160.
Thefollowingkeywork-streamsalsoderivedoutof‘PerfectWeek’andarebeingimplementedanddevelopedattheTrust:
• Reviewandintroduceweekendand eveningcoverforPhysiotherapy, OccupationalTherapy,Speechand LanguageTherapyandIntegrated Discharge.
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• Reviewandintroduceimproved administrativesupporttowardsat weekends.
• Reviewandstrengtheneveningand weekendcoverfrompartneragenciesin healthandsocialcare.
• Resolvetheoutlierissueonceandfor all,ensuringrobustmedicalcareforall patientsinthehospital.
• Introduceafocusseddailymulti-agency dischargeconferencecallsevendaysa weekwhichfocussesonproblem-solving aroundspecificpatients.
• ReviewtheHospitalEscalationPlan.• FocusonFREEDeverydayandreview thepublicationofrelevantmetricsto supportpractice.TheFREEDcampaign hasfivekeystepsallstaffareresponsible fortoensurepatientsreceivegoodcare:
Facilitateeffectivedischarge Rightperson,rightplace Earlyspecialistinput Eliminateunnecessarydiagnostics Dailyseniorreview
• Establishanannualprogrammeof themedPerfectWeeksatstrategicpoints acrosstheyear.
Virginia Mason
InJuly2015,UHCWwaschosenfollowingacompetitiveprocesstobenefitfromtheexpertiseoftheVirginiaMasonInstituteaspartofanewinitiativelaunchedbyHealthSecretaryJeremyHuntandtheNHSInstitute.
TheVirginiaMasonInstituteinSeattle,USAisworld-renownedfortransforminghealthcare.Theirmantraisthattheperfectpatientexperiencemeansthepatientcomesfirstaboveeverythingandeveryone.Itisexpertinteachingotherhealthcareorganisationshowtoimplementandmaintainapatient-centeredapproachthatwillhelptoincreasequality,safetyandefficiencyusingthesamemethodsthatmadethemsosuccessful.
ThefirstworkstreamtheTrustisfocusingonis‘OphthalmologyOutpatients:Fromreferraltothepatientintheroomwiththeclinician.’The
OphthalmologyTeaminOutpatientshasalreadytakenpartinaRapidProcessImprovementWorkshopwhichisafive-dayworkshopfocusedonaparticularprocessfromavaluestream,wherethosewhodotheworkareempoweredtoeliminatewaste.Thiswasverysuccessfulandidentifiedanumberofareaswithinthereferralprocesswhichcouldbeimproved.Thisworkshopalsoallowedtheteamtomakethenecessarychangeswhichultimatelywillleadtoimprovementstothepatientexperienceinthisarea.
Accreditation for its Lean Competency System
InSeptember2015,UHCWbecamethefirstNHSorganisationinthecountrytogainaprestigiousaccreditationforitsLeanCompetencySystem(LCS)fromCardiffBusinessSchool.
Leanisabusinessapproachthathelpsimprovement.DevelopedbyToyota,itaimstoimproveproductivitybyeliminatingwaste.Forexample,timecouldbesavedbysituatingequipmentclosertowhereitisneeded,ratherthanstafftravellingfurthertolookforit.
TheaccreditationallowstheTrusttoawardstaffanofficialLCSqualificationuponsuccessfulcompletionoflearningsessionsanddemonstrationofpracticalapplication.
LeantechniquesarealreadybeingusedinmanyareasofUniversityHospital,Coventry,andtheHospitalofSt.Cross,Rugby,toimprovecareforpatients.Theyincludeapre-operativeassessmentserviceatbothhospitalstocheckthatpatientsarefitforsurgery,andreorganisingthepharmacyworkspaceinUniversityHospitalsothatpatientsreadytoleavehospitalcangettheirprescriptionssooner.
Sign Up to Safety
ThisyeartheTrustwonfundingaspartofanationalsafetycampaign‘SignUptoSafety.’Itisathreeyearcampaignaimedatreducingavoidableharmtopatientsbyhalfandsaving6,000lives.TheTrustisinvestinginHumanFactorseducationforstaffwhoworkinTheatres,TraumaandOrthopaedicsandtheEmergencyDepartment.
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Humanfactorscanbedefinedasthosefactorsthatcaninfluencepeopleandtheirbehaviour;suchasenvironmental,organisationalandjobfactorsandindividualcharacteristicswhichinfluencebehaviouratwork.
TheTrustanticipatestheoutcomesfollowingfundingwillbethatitimprovespatientcare,re-ducesharmtopatientsandthelikelihoodofNeverEventsandtheywillprovideadditional‘humanfactors’traininganddevelopmentforstaff.
TheTrustwasoneofonly67successfulbidsoutof243bidsreceivedbytheNHSLitigationAuthority.MoredetailsaboutthiscampaignareoutlinedinPartThreeinthePatientSafetysection.
Our Brilliant Staff
2016
• TheTrust’sHospitalRadioteamhasbeen shortlistedforfourcategoriesinthe NationalHospitalRadioAwards.
• TimRobbinshasbeenawardeda WinstonChurchillMemorialFellowship whichwillentailsixweeksoftravelinthe USAtolearnfromtheirhealthcare systems(particularlythedigitalelements) andbringthatlearningbacktotheUK.
• HealthcareAssistantPharbinderAthwal wonaBritishJournalofMidwifery PracticeawardforMidwifeorPeer SupporterinImprovingBreastfeeding.
• MidwifeLyndseyPruewasshortlistedfor aTommy’sHealthcareHeroAward. Thesearegiventoamidwifewhohas providedexceptionalphysicalcareor emotionalsupporttoparentsindifficult times.
• ShortlistedforNHSEngland’sBest FriendsandFamilyTestInitiativeinany otherNHS-fundedservice–Maternity Services.
• ShortlistedforNHSEngland’sFriends andFamilyTestChampion(s)oftheYear- thePatientExperienceTeam.
• TwoteamsintheResearch,Development and Innovation Department have reached
thefinalsofthePharmaTimesNHS ClinicalResearchSiteoftheYear2016.
• InApriltheTommy’sCharityopenedthe UK’sfirstnationalresearchcentre dedicatedtoearlymiscarriage,UHCW isoneofthethreeNHSTrustsinvolved intheCentre,whichisthebiggestin Europe(inpartnershipwithImperial CollegeHealthcareTrust,Birmingham Women’sHospitalFoundationTrustand Birmingham,ImperialandWarwick Universities).
• TheDementiaTeamwerefinalistsfor theServiceInnovationTeamofthe YearAwardattheDementiaServices DevelopmentCentreUniversityofStirling InternationalDementiaAwards2015.
2015
• TheUHCWLungNursingTeamwonthe RoyCastleLungCancerTeamof theYear.
• MacmillanGynae-OncologyAdvanced NursePractitionerVikkiJoneswas awardedtheMacmillanHenryGarnett Award.
• MidwivesElizabethBaileyandAlison SearlewereshortlistedforaRoyal CollegeofMidwivesAwardinthe categoryofJohnson’sAwardforEvidence intoPracticefor“MindyourPsandQs: Protectedquiettimeinthehourafter birth.”
• ChiefNursingOfficerMarkRadfordwas recognisedasoneofthetopleadersin nursingintheNursingTimesInspirational Leaderslist2015whichrecognisedtop leadersinthenursingprofession.
• TherapistSueCrewe-Smithwasawarded aWinstonChurchillMemorialFellowship.
• CardiologyResearchRegistrarDoctor ChrisMcAloonwasawardedtheRoyal CollegeofPhysicians(RCP)andNational InstituteofHealthResearch(NIHR) ClinicalResearchNetworkClinical TraineesAwardinrecognitionofhis outstandingcontributiontoresearchinthe NHS.
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TheAwardacknowledgestheessential workofNHSphysiciansandtraineesin sustainingandbuildingclinicalresearch intheNHShealthservice,despite competingdemandsoncliniciantimeand resources.
• TheTogetherTowardsWorldClass organisationaldevelopmentprogamme wasshortlistedforanHealthService JournalAward2015intheStaff Engagementcategory.
• The2015PharmaTimesClinical Researchsiteoftheyearawardwaswon byUHCW’sResearch,Developmentand InnovationTeamforthesecondyearina row.
2.2 Quality Account Improvement Priorities 2015-16 A progress update
ThebelowdetailsprogressandachievementsagainsttheQualityImprovementPrioritiesfor2015-2016whichwereoriginallyoutlinedinthe2014-2015QualityAccount.
Priority 1 - Patient Safety: Ensuring effective handover between healthcare professionals
Rationale for Inclusion:
Accurate and timely handover of information aboutapatient,particularlywhenadmittedandtransferredbetweenteams,iskeyinensuringcareandtreatmentisefficient,safeandappropriate.
Achievements:
• AllJuniorDoctorshavebeengiven extensiveexposuretothehandovertool andprinciplesunderpinningitsuse, throughpresentationsand demonstrations.Additionally, presentationshavebeengivenatGrand Rounds,SpecialtyQualityandPatient Safetymeetings,ClinicalDirectors meetingsandattheChiefOfficer Groupmeeting.Emailcommunications havebeencirculated.
• WehavestartedworkonanewJunior DoctorInductionprocessforthesummer of2016,toensureallstaffhavethe
appropriateskillsettousecurrent informationtechnologysystems appropriatelyandeffectively,particularly e-handover.Thisworkcommencedin December2015andwearecurrently deliveringonetotwoweeklyclassroom teachingsessionsfor10JuniorDoctors for an hour at a time in the Clinical SciencesBuildingTrainingSuite,with themallloggedintoacomputer.Theaim istotrainall400JuniorDoctorsbefore progressingtootherstaffgroups.
• Ward22HospitalatNight(H@N)room hascontinuedtobethehubforoutof hoursfacetofacehandover,supported bytheuseofe-handoverandiPads.With newchangestoe-handover,thepatient bannerinClinicalResultsReporting System(CRRS)ande-discharge summary,afurtherupdatedlaunchtook placeinMarch2015.Thisintroduceda formalfacetofacehandovermeeting everymorningat8:30amintheseminar roomoffWard2.ThisinvolvesaJunior Doctorrepresentativefromallmedical wards,specialtiesandoutlierwardswho takeaformalhandoverreportfromthe H@Nteam.
• Rolloutofelectronichandoverofficially launchedwithiPadsforusebyoncall staffbetween5pmand9am.
• E-learningtrainingmaterialfor e-handover developed and implemented withrevisionofoperationalpolicy.
• Themobiledevicedeployment (WorkstationsonWheelsorWoWs) supportsembeddingusageofCRRS functionalityincludinge-handover.Over thelast6months,131(87%)ofWoWs havebeeninstalled.
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Priority 2 - Clinical Effectiveness: Ensuring effective End of Life Care Practices
Rationale for Inclusion:
AsystemwideapproachtoEndofLifeCareisrequiredtohelpstreamlineandco-ordinatelocalservicesforthebenefitofpatientsandtheirfamiliesandtoimprovecommunicationandefficiencyoflocalcaringprofessionals.
Achievements so far:
• Re-configurationoftheSupportiveand SpecialistPalliativeCareTeamsto theunifiedPalliativeCareTeamhas ledtobetterPalliativeMedicineand Nursingleadership.
• LeadershipfromtheChiefNursingOfficer astheChairmanfortheEndofLifeCare Committee(EOLC)hasledtowork disseminatingTrust-widebysubgroups workingonimprovingpatientexperience, bereavementservices,educationand training.
• VOICES(ViewsOfInformalCarers EvaluationSurvey)beingdevised electronicallybyLepidusandin-houseas hard copy.
• DeathCafétosupportbereavedstaff.A DeathCaféisanationalinitiativeand theyareforpeopletocometogether informallyanddiscussdeath.The objectiveis‘toincreaseawarenessof deathwithaviewtohelpingpeople makethemostoftheir(finite)lives.’
• Trainingneedsanalysisisbeingexplored onaTrustwideeducationprogramme forendoflifecarelookingate-learning optionsandworkingwiththeMedical EducationTeamtoestablisharobust formaleducationprogrammeforallstaff.
• TheDoveCampaignlaunchedin November2015toidentifydyingpatients ensuringrespectanddignityinthelast daysandhoursoflife.
• Sixcarerbedsarenowavailableand wereobtainedthroughcharitablefundsto supportrelativesofpatientswhoarein thelastdaysoflife.
• VolunteerCompanionServicehasbeen introducedwhichoffersacompanion tothedyingwithnosignificantotherto supportthepatientinthedyingphase.
• Collaborativeworkingwithpartnership organisations.Phase3QualityEndofLife CareforAll(QELCA)isfacilitatedby thePalliativeCareTeamstaffandhospice staffatCoventryandWarwickMyton Hospicesfacilitatingeducationaland practicallearning.
• QELCAtrainingdeliveredthisyearat CoventryandWarwickMytonHospiceto seniorwardnursesandTransform ProgrammeChampionsonWards 52,11,42and43.
• Qualityandgovernancereportingbeing achievedthroughtheEndofLife CommitteeandthePalliativeCareTeam monthlyQIPSmeetings.
• NationalEndofLifeCareClinicaland OrganisationalAuditcompletedbetween JulyandSeptember2015retrospective forMay2015.
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Priority 3 – Patient Experience Always Events: Implementing ‘Hello My Name Is’
Rationale for Inclusion:
The‘Hellomynameis’campaignwascreatedbyDrKateGranger,ayounghospitalconsultantfromYorkshirewhoworkedinelderlycare,toimprovethepatientexperiencenotonlyhereintheUK,butacrosstheworld.Katebecamefrustratedwiththenumberofstaffwhofailedtointroducethemselvestoherwhenshewasapatientin.Hercampaign,startedonthesocialmediaplatformTwitterandhasinspirednurses,doctors,therapists,receptionists,porters,domesticsandstaffinallroles.
Thecampaignissimple–remindingstafftogobacktobasicsandintroducethemselvestopatientsproperly.Katetalksaboutthisas“thefirstrungontheladdertoprovidingcompassionatecare”andseesitasthestartofmakingavitalhumanconnection,helpingpatientstorelax,andbuildingtrust.Feedbackfrompatientsacrossthecountryshowshowvitalthisistothem,sayingthatthesmallestthingsmakethebiggestdifference.
The#hellomynameiscampaignissomethingmanyareasoftheTrusthaveadopted.However,wehavenowexpandeditacrossbothourhospitalsitestoensurethatnomatterwhatdepartmentapatientgoesto,theywillgetafriendlyandattentiveservicefromallofourstaff.UHCWwantstaffintroducingthemselvestobean‘AlwaysEvent’somethingthatshouldhappenateveryinteractionapersonhaswithstaff.
Achievements so far:
• Asuccessfullaunchofthe #hellomynameiscampaignwithinthe TrustduringPatientExperience WeekinFebruary.Thislaunchsawover 85,000peopleinteractwiththecampaign overFacebookandTwitteraswellas over1000staffacrossbothsitesengage inpledgingsupport.
• Ashortvideohasbeenmadetousewith stafftohighlighttheimportanceof introductions.Thiscanbeviewedat www.uhcw.nhs.uk.
• Thecampaignteampresentedata UHCWGrandRoundwhichisamonthly meetingwherebyallstaffhavethe opportunitytoshareandlearnfromothers intheTrustonavarietyoftopics.The teamalsopresentedtoTrustBoardto overwhelmingsupportandpositivefeed back.
• TheTrusthasamendeditsonlineversion ofitsfeedbacksurveytogather informationastowhetherstaffintroduced themselves.
• Amulti-disciplinaryworkinggrouphas beenstartedtomaintainmomentumwith thecampaign.
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2.3 Quality Improvement Priorities for 2016-2017
Quality Priority 1 - Patient SafetyIncreasing the reporting of medication errors and learning from reports.
Why is it a priority?
RecommendationsbySirRobertFrancisQCandProfessorDonBerwickonpatientsafetyrecommendedtakingstepstomaximisethequalityandquantityofadverseincidentreportsfromhealthcareorganisations.
TheNationalPatientSafetyAgencyreportSafetyinDoses[2007]definedmedicationerroras“anyincidentwheretherehasbeenanerrorintheprocessofprescribing,dispensing,preparing,administering,monitoringorprovidingmedicinesadvice,regardlessofwhetheranyharmoccurredorwaspossible.”
Increasingreportingofmedicationerrorsenablestheorganisationtoanalyse,learnandthenreduceriskofpatientharm.Researchindicatesthatorganisationswithahighreportingratehaveagoodsafetycultureandbetterriskmanagementstrategies.ThePharmacyDepartment,workingwiththeQualityDepartment,willleadonaprojecttoincreaseoverallincidentreport-ingwhilstreducingthenumberofmoderateandseriousmedicationincidents.
Thekeydriversare:
• Reducingerrorsandharmtoourpatients.
• Understandingharmtoourpatients.
• Belowaveragereportingofmedication incidentslocally.
• Limitedcapabilitytomaximise organisationallearningfromthese incidents.
• MandatefromtheMedicinesand HealthcareproductsRegulatoryAgency. LookingatdataUHCWwerebelowtheaveragerateforreportingmedicinesrelatedincidents(per100admissions)whenrankedwithotherteachingtrusts.InUHCW0.68medicationincidentsarereportedper100admissions,
comparedtoarangefromNationalReportingandLearningSystemDataof0.46-1.75incidentsper100admissions.
Our Goal
PromotetheUHCWvalueofopennessinordertoincreasereportingandincreasethevalueofreportsbylearningwhereweneedtoimproveandmakingstepstoimprovepatientcare.Initiallywewillfocusonreducingharmfromomitteddosesofmedicinesasthisisourmostcommonlyreportedincident.
Our Starting Point – baseline
MedicationerrorsarethethirdmostcommonlyreportedClinicalAdverseEventwithintheTrust,withanincreaseofreportinginexcessof55%overthelast5years.Inorganisationswithagoodsafetyculturethepercentageofnoorlowharmincidentsreportedisexpectedtobehigh.AtUHCW,lowornoharmincidentshaveaccountedfor98%ofreportedmedicationerrorsforthelastfouryears(seetablepage11).
How will we achieve our goals?
• Promotereportingofmedicationerrorsto allstaffgroupsinvolvedinpatientcare.
• Co-ordinateeducationandtraining supporttoimprovethenumberand qualityofmedi-cationerrorincident reportsandsafemedicationpractices.
• Analyseincidentsreportedtoidentify trendsandthemesinordertoprioritise andaddressmedicationrisks.
• Communicaterisksidentifiedthroughthe Trustintranet,newslettersandposters.
• Auditomitteddosesofmedicines,looking atreasonsforomissionandthetypesof medicationsthatareomitted.
• Commencequalityimprovementprojects toreducethenumberofomitteddoses fromcriticalmedicines.
• Safetymessagessenttostafffromthe ChiefMedicalandQualityOfficer
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YearNumber of
medication errors reported
Increase on previous year - number (%)
Percentage No or low harm
2010 794 141(21.5%) 83%
2011 852 58(7.3%) 96%
2012 857 5(0.6%) 98%
2013 1089 232(27%) 98%
2014 1149 60(6%) 99%
2015 1789 640(55%) 98%
How will we monitor and report progress?
Monitorthenumberofmedicationincidentsreported,aimingtoseeamonthonmonthincrease,withatotalincreaseofatleast20%overthe year.
Monitorharmtopatients,bymonitoringthepercentageofNo/Lowharmincidentsaimingforthistobemaintainedatgreaterthan98%bytheend of the year.
Auditthefrequencyandnatureofomitteddosesinordertounderstandcontributingfactors.
Presentsuccessfulqualityimprovementprojectstoreduceomitteddoses.
ProgressagainstthesemeasureswillbemonitoredbytheMedicinesSafetyCommitteeeachquarterandreportedtothePatientSafetyCommittee.
Leads
TheprojectisbeingcollaborativelyledbyRebeccaMills(MedicinesSafetyOfficer)JanetteKnight(PharmacyGovernanceManager),MarkEaster(DirectorofPharmacy),andSharonFarthing(NursePracticeFacilitator).
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Quality Priority 2 - Clinical Effectiveness Improving Care Bundle Compliance
Why is it a priority?
ImprovedcompliancewithCareBundleswillleadtomoreeffectiveandsaferpatientcare.
ACareBundleisastructuredwayofimprovingtheprocessesofcareandpatientoutcomes:asmall,straightforwardsetofevidence-basedpractices—generallythreetofive—that,whenperformedcollectivelyandreliably,havebeenproventoimprovepatientoutcomes.TheInstituteofHealthImprovement(IHI)developedtheconceptof“Bundles”tohelphealthcareprovidersdeliverthebestpossiblecareforpatientsundergoingparticulartreatmentswithinherentrisks.
ThepowerofaCareBundlecomesfromthebodyofsciencebehinditandthemethodofexecution:withcompleteconsistency.It’snotthatthechangesinabundlearenew;they’rewellestablishedbestpractices,butthey’reoftennotperformeduniformly,makingtreatmentunreliable,attimesuniquetoanindividual.
ACareBundletiesthechangestogetherintoapackageofinterventionsthatpeopleknowmustbefollowedforeverypatient,everysingletime.
Our Goal
TheTrust’sgoalistoprovideimprovementsinpatientcarebyminimisingunwarrantedvariationinclinicalcareofacutelyillpatientsthroughincreasedcompliancewithclinicalCareBundles.In2016-2017wewillensurethatCareBundlesareimplementedforthehighriskgroupsandhighvolumeclinicalpathwaysincludingpneumonia,myocardialinfarction,heartfailure,acuterenalfailure,sepsisandstroke.
Our starting point – baseline
AnumberofspecialtygroupshaveusedCareBundlessincetheywereintroducedintoclinicalpracticeintheNHS.TheseincludeBundlesforcentralvenouslineinsertion,peripheralcannulacare,theventilatorCareBundleonGeneralCriticalCareUnitandtheSavingBabiesLivesCareBundleinNeonatology.TheSepsisSixBundleandtheAcuteKidneyInjuryPathwayare
thesubjectofCQUINS(CommissioningforQualityandInnovation)forallacuteadmissions.TherespiratoryandcardiologyservicesarecurrentlydevelopingCareBundlesforpneumoniaand heart failure.
How will we achieve our goals?
WewillestablishtheAcutelyIllPatientManagementCommittee(AIPMC)whichwillprovideleadershipanddirectiontobringtogethertheclinicalleadsofthemultipleworkstreamsandfacilitate development of further clinical Care Bundlesaswellasprovidingaforumtodevelopstrategiestoreduceepisodesof“failuretorescue.”ItisessentialtoensurethatallclinicianshaveanunderstandingofthebenefitsofCareBundlesandtheirbenefitforpatientsafety.ThecommitteewillalsolinktogethertheCQUINprojectsandworkbeingdoneinconjunctionwiththeSignuptoSafetyprogramme.
TherespectiveworkstreamswillbeexpectedtoreportprogresstotheAIPMConamonthlybasis.GrandRoundpresentations,multidisciplinaryundergraduateandpostgraduateteachingandwardbasedtrainingwillsupportthedisseminationoftheCareBundlesandpromotetheuptakeandcompletionofthespecificcarebundlecomponent.
How will we monitor and report progress?
OnceeachCareBundleisagreedbytherespectiveclinicalgrouptheCareBundleproformawillbeintroducedintoclinicalpractice.Theywillbeavailableinallclinicalareasandwillbecompletedandincludedinthepatient’smedicalrecord.TheprogressofeachCareBundlewillbemonitored.EachoftheCareBundleworkstreamswillbeexpectedtoreporttheirprogresstotheAIPMConamonthlybasis.TheAIPMCwillreporttothePatientSafetyCommitteeeverythreemonths.TheperformancewillalsobetrackedbytheSignuptoSafetyinitiative.
Leads
ChairsoftheAcutelyIllPatientManagementCommitteeandleadcliniciansforeachclinicalCareBundle.
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Quality Priority 3 - Patient ExperienceThe measurement of direct care using a multi-professional team approach (Care Contact Time)
Why is it a priority?
Theaimofmeasuringthedirectcaretimespentwithpatientsbyclinicalteamsistoachieveefficientandeffectivehighqualitycarethataddsvaluebybeingdeliveredatthepatientbedside.Deliveringcareatthebedsideplaysapivotalroleinpromotingpersoncentredcarefocusedonimprovingpatientexperienceandoutcomes.TheCareContacttoolisanationalinitiativewhichisbasedonLeanprinciplesandpartoftheSaferNursingCareTool.
UHCWisthefirstacuteTrusttohaveimplementedane-carecontacttoolwhichprovidesinstantreportingonthetimeeachclinicalandmulti-professionalgroupspendsdirectlywithpatientsandprovidesdatathatcanbeutilisedtoreduceandeliminatetimeandtasksthataddlittlevaluetotheprovisionofcare.
TheinitialworkundertakenwiththeNursingTeamsin2015,usingtheManchesterCareContactTimeModelgeneratedanumberoflocalwardbasedprojectstoimprovedirectcaretime.Thisincludesmedicinesmanagement,bedsidedocumentation,nurseperbayandhasinfluencedTrustwideinitiativessuchasvitalsignsobservationsandnighttimecaremanagement.However,therewasasubstantiallossofdatabecausetheTrustfollowednationalguidancewhichencouragedthatstaffrecorddataonpaper-basedclocks.Alsoonlydirectcaretimefornursingwascalculatedanddatadidnottakeintoaccountdirectcaretimebymedicalprofessionals.
TheelectronicclockandreportingsystemhasbeendevelopedincollaborationwiththeLeadNursesforPatientExperience,QualityandSafety,InformationTechnologyandarangeofmulti-professionalstaffincluding,nurses,midwives,doctorsandtherapists.
NationallytheManchesterCareContactTimeModelhasbeenadvocatedbyNHSEnglandasthepreferredmeasurementsystem,whichispaperbasedandrequiresadministrativesupporttocollect,collateandinputdata.
Thedevelopmentoftheelectronictoolsupportsaccuracyindatacollection,islesslabourintensive,enablestimetobemeasuredacrossclinicalteamsandgeneratestimelyreportsthatcanbeutilisedtoimproveefficiency,patientsafetyandexperienceoutcomes.TheimplementationteamhasundertakenapilotacrosstheTraumaandOrthopaedicClinicalGroupasphaseoneoftheTrustwiderollout.Toprogresstophase2(Trust-widedatacollection)thefollowingwillberequired:
• Adequateinformationtechnologysupport andresource
• E-Trainingpackage
• SystemsGatekeeper
• Supportofclinicalgroupleaders
• Timetodiscussreportfindingsand sharedlearningacrossgroupsand professions
• TimetoestablishPlanDoStudyAct (PDSA)cyclestoimprovedirectcaretime
Our Goal
Themaingoalistoimprovethetimespentwithpatientsbyutilisingmulti-professionalcarecontacttimefindingsforallclinicalgroupsandservices.Theelectronicsystemwillprovideaprocessbywhichinformationcanbeobtainedconsistentlyandaccurately,providingastandardisedtoolforthemeasurementofserviceimprovementacrosstheTrust.
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Task/Action By When
Firstnursingcarecontacttimerecordedacrossallinpatientadult,paediatricandmidwiferywards
April-September2015
DevelopmentofelectronicandApplication(App)reportingsystem September2015-January 2016
PilotconductedacrossTraumaandOrthopaedicwardstotestdatacollectionandreportingsystems
February2016
Evaluationofpilottobepresentedatrelevantcommittee April 2016
RolloutplanbyclinicalgrouptobedevelopedforTrustwiderollout May2016-September2016
ClinicalGroupstoestablishPlan,Do,Study,Act(PDSA)serviceimprovementprojectstoenhancemulti-professionaldirectpatientcare time
September2016-February2017
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How will we achieve our goals?
• Educateandraiseawarenessregarding thevalueandhowcarecontacttime multi-professionaltoolkitcanbeutilised toaddvaluetopatientoutcomes,safety and experience.
• Sufficientinformationtechnologyresource -correctnumberofhandhelddevices enablingallstafftohaveaccessto the app.
• Developauniversal,simple,online trainingmoduleaccessibletoallgroups.
• ShareprogressinregardtolocalPDSA projectsandevaluateoutcomes.
How will we monitor and report progress?
Evaluatethroughthelocalimprovementindirectcaretimewhichwillbemonitoredtwiceayear.
Leads: TheprojectisbeingcollaborativelyledbyJudithSmith-LeadNurseforQualityandSafety;DianeEltringham–LeadNurseProfessionalStandardsandPatientExperienceandKarlO’SullivanSmith-SeniorInformationTechnologyManager.
2.4 Statements of Assurance from the Board
2.4.1 Review of Services
During2015-2016UHCWprovidedand/orsubcontracted66relevanthealthservices*.UHCWhasreviewedallthedataavailableonthequalityofcarein66oftheserelevanthealthservices.Theincomegeneratedbytherelevanthealthservicesreviewedin2015-2016represents88%ofthetotalincomegeneratedfromtheprovisionofrelevanthealthservicesbyUHCWfor2015-2016.
*thisnumberrepresentsthenumberofservicesasdetailedintheTrust’sAcuteContract2015-2016.
2.4.2 Participation in Clinical Audits
During2015-201647nationalclinicalauditsand7nationalconfidentialenquiriescoveredrelevanthealthservicesthatUHCWprovides.DuringthatperiodUHCWparticipatedin100%ofnationalclinicalauditsand100%ofnationalconfidentialenquirieswhichtheTrustwaseligibletoparticipate in.
ThenationalclinicalauditsandnationalconfidentialenquiriesthatUHCWwaseligibletoparticipateinduring2015-2016arelistedinthetablebelow.ThenationalclinicalauditsandnationalconfidentialenquiriesthatUHCWparticipatedin,andforwhichdatacollectionwascompletedduring2015-2016areindicatedwithagreentick,alongsidethenumberofcasessubmittedtoeachauditorenquiryasapercentageofthenumberofregisteredcasesrequiredbythetermsofthatauditorenquiry.UHCWhasinvestigatedwhyparticipationwaslowerthanexpectedinsomeaudits,identifiedwithanasterisk(*).
Thereportsof37nationalclinicalauditsand93localauditswerereviewedbyUHCWin2015-2016andUHCWistakingthefollowingactionstoimprovethequalityofhealthcareprovided:
• Shareclinicalauditoutcomeswith relevantclinicalareas
• Undertakefollow-upauditstomeasure progress
• Providetrainingandsupportwhere requiredtoimprovecarestandardsor compliancewithbestpractice.
FurtherinformationontheactionstheTrusthasalreadytakeninresponsetonationalandlocalauditscanbefoundonpage20onwards.
For more information on National or Local Clinical Audit please contact Effectiveness and Compliance on 02476 968282.
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Eligible audits applicable to UHCW as published in the Department of
Health’s Quality Account List
Did UHCW Participate in 2015-2016?
Participation 2015-2016
AcuteMyocardialInfarctionandotherACS(MINAP) 100%
AdultCardiacSurgeryAudit(CABGandValvularSurgery) 100%
NationalBowelCancerAuditProgramme(NBOCAP) 100%
Cardiac Arrhythmia (CardiacRhythmManagementAudit) 100%
Adultcriticalcare(CaseMixProgramme)100%
NCEPODChildHealthClinicalOutcomeReviewProgramme-ChronicNeurodisability
Awaitingstartofdata collection
NCEPODChildHealthClinicalOutcomeReviewProgramme-YoungPeople’sMentalHealth
Awaitingstartofdata collection
CoronaryAngioplasty(AdultCardiacInterventionsAudit) 100%
NationalPaediatricDiabetesAudit(NDPA)100%
BTSEmergencyUseofOxygen100%
FallsandFragilityFracturesAuditProgramme-NationalHipFractureDatabase(NHFD)
100%
FallsandFragilityFracturesAuditProgramme-InpatientFalls
100%
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Eligible audits applicable to UHCW as published in the Department of
Health’s Quality Account List
Did UHCW articipate in 2015-2016?
Participation 2015-2016
InflammatoryBowelDisease(IBD)Programme 100%
TraumaAudit&ResearchNetwork(TARN)(MajorTraumaAudit)
100%
Maternal,NewbornandInfantClinicalOutcomeRe-viewProgramme(MBRRACE-UK)(previouslyCEMACH)
100%
NCEPODAcutePancreatitisStudy100%
NCEPODPhysicalandMentalHealthCareofMentalHealthPatientsinAcuteHospitals 100%
NCEPODSepsisStudy100%
NCEPODGastrointestinalHaemorrhageStudy100%
NCEPODNon-invasiveVentilationStudyData collection
not yet due
NationalCardiacArrestAudit(NCAA)100%
NationalComparativeAuditofBloodTransfusionProgramme-UseofBloodinHaematology
100%
NationalComparativeAuditofBloodTransfusionProgramme-AuditofPatientBloodManagementinScheduledSurgery
100%
NationalComparativeAuditofBloodTransfusionProgramme-AuditoftheuseofBloodinLowerGIBleeding
100%
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Eligible audits applicable to UHCW as published in the Department of
Health’s Quality Account List
Did UHCW articipate in 2015-2016?
Participation 2015-2016
NationalComplicatedDiverticulitisAudit(CAD) 100%
NationalDiabetesFootcareAudit(NDFA) 100%
NationalInpatientDiabetesAudit100%
NationalPregnancyinDiabetesAudit(NPID) 100%
NationalDiabetesAudit(NDA) 100%
NationalEmergencyLaparotomyAudit(NELA) 100%
NationalHeartFailureAudit100%
NationalJointRegistry(NJR) 100%
NationalLungCancerAudit(NLCA) 100%
NationalOphthalmologyAudit100%
NationalProstateCancerAudit100%
NationalVascularRegistry(NVR) 100%
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Eligible audits applicable to UHCW as published in the Department of
Health’s Quality Account List
Did UHCW articipate in 2015-2016?
Participation 2015-2016
NationalNeonatalAuditProgramme(NNAP) 100%
NationalOesophago-gastric(NAOGC)CancerAudit 100%
BTSPaediatricAsthma100%
RCEMProceduralSedationinAdults(careinemergencydepartments) 19%*
(Estimated)
SentinelStrokeNationalAuditProgramme(SSNAP) 100%
UKCysticFibrosisRegistry(Paediatriconly) 100%
NationalUKParkinson’sAudit100%
RCEMVitalSignsinChildren(careinemergencydepartments) 100%
RCEMVTERiskinLowerLimbImmobilisation(careinemergencydepartments)
100%
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Therewasonenationalclinicalauditthathadalowerthanexpectedparticipationrate,identifiedwithanasterisk(*)inthetableabove.UHCWhasinvestigatedthereasonswhythisoccurredasdescribedbelow:
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Audit Title Participation Rate Rationale for Low Participation Rate
NationalClinicalAuditofRheumatoidandEarlyInflammatoryArthritis
19% LowparticipationhasbeenacknowledgedandtheTrusthasrespondedtotheBritishSocietyofRheumatologytooutlineplanstoimproveparticipation.Discussionsaroundthefeasibilityofimplementingadedicatedearlyarthritiscliniccontinue.AnewclinicalnursespecialistisnowinpostandtheTrusthasagreedtofund2middlegradedoctorswhichwouldhelptoreducepatientwaitingtimes.Itishopedthatthiswillsubsequentlyimproveparticipationintheaudit.AposterhasbeencreatedinordertoremindRheumatologystafftorecruitallapplicablepatientsattheirfirstvisit,whichshouldhelptoincreaseourbaselineparticipation.ThereisaplantostartputtingthepostersupintheTrust’sRheumatologyOutpatientsclinicwhenthenextphaseoftheauditbegins.
Theparticipationrateof19%isonlyanestimateandisbasedupontheclinicalteamsanticipatingtheywouldseeapproximately2patientsperweek.Unfortunately,duetotheauditmethodology,itisdifficulttoidentifytheexactnumberofpatientsviaclinicalcodingforinclusionintheaudit.
Allofthe15patientssubmittedatbaselinealsohadatleastonefollow-upformcompleted,showingafollow-upcompletionrateof100%.
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Eligible audits applicable to UHCW as published in the Department of Health’s
Quality Account List
Reason for non-participation during 2015-2016
BTSAdultAsthma Auditdidnottakeplacein2015-2016.DuetocommenceSeptember2016
ChronicObstructivePulmonaryDisease(COPD) Auditdidnottakeplacein2015-2016.Duetocommenceearly2017
BTSNon-InvasiveVentilation-Adults Auditdidnottakeplacein2015-2016.Notcollectingdataduring2016-2017
BTSPaediatricPneumonia Auditdidnottakeplacein2015-2016.DuetocommenceinNovember2016
ThefollowingtabledetailsthenineauditsincludedintheQualityAccountlistpublishedbytheDepartmentofHealthinwhichUHCWdidnotparticipateduetoeligibility.
Ofthesenineaudits,infourUHCWdoesnotprovidetherelevantservice,intwotheTrustdoesnotperformtheprocedureandtheotherthreearenotapplicabletoAcuteTrusts.
ThefollowingnationalclinicalauditsareincludedontheQualityAccountlistfor2015-2016;howevertheTrustdidnotparticipateforthereasonsoutlinedbelow:
Audit Title Rationale for Non-participation
ChronicKidneyDiseaseinPrimaryCare Noteligible–notapplicabletoAcuteTrusts
CongenitalHeartDiseaseAudit(PaediatricCardiacSurgeryCHD)
Noteligible–procedurenotperformedatUHCW
Electivesurgery(NationalPROMSProgramme)
Noteligible–servicenotprovidedatUHCW
NationalAuditofInter-mediateCare Noteligible–servicenotprovidedatUHCW
NationalChronicObstructivePulmonaryRehabilitationWorkstream
Noteligible–servicenotprovidedatUHCW
NationalConfidentialInquiryintoSuicideandHomicideforPeoplewithMentalIllness(NCISH)
Noteligible–notapplicabletoAcuteTrusts
PulmonaryHypertensionAudit Noteligible–servicenotprovidedatUHCW
PaediatricIntensiveCareAuditNetwork(PICANet)
Noteligible–procedurenotperformed
PrescribingObservatoryforMentalHealth(POMH)
Noteligible–notapplicabletoAcuteTrusts
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ThefollowingtableoutlinesparticipationintheNationalClinicalAuditandPatientOutcomesProgramme(NCAPOP)from2010-2011topresentday.
Participation in the National Audit and Patient Outcomes Programme
2010 - 2011 100%
2011 - 2012 95%(non-participationin1audit)
2012-2013 98%(non-participationin1audit)
2013-2014 97%(non-participationin1audit)
2014-2015 98%(non-participationin1audit)
2015 - 2016 100%
Commentsonperformance UHCWisnowparticipatingintheNationalCardiacArrestAudit
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National Clinical Audits – Key Actions Taken in 2015-2016
ThefollowingarebriefsummariesofsomeofthekeyactionstheTrusthastakentoimprovethequalityofhealthcareasaresultofthereviewofnationalclinicalauditreports:
Audit Title Key Actions
RoyalCollegeofEmergencyMedicine(RCEM)ParacetamolOverdose
TheassessmentofmentalstateisnowpartofTrust’sEmergencyDepartmentdocumentation,allowingsimplerrecordingofcapacitytoconsent.
TheParacetamolOverdosetreatmentpathwaysummaryisnowreadilyavailableontheTrust’swebsite,toensurethesafeandtimelytreatmentofpatients,inlinewithnationalrecommendations.
TheTrust’sEmergencyDepartmentprovideseducationatstaffinductionandregularteachingsessionsforallnursingandmedicalstaffonthecorrecttreatmentofParacetamolOverdose,toensurethatpatientsreceivetheappropriatecareandtreatment.
BritishThoracicSociety(BTS)PaediatricAsthma
TheTrusthasupdatedthelocalasthmaguideline,whichcontainsasummaryondiagnosingasthmaandsignpoststothemostrecentBritishThoracicSociety(BTS)guidelineforin-depthguidance.Thisensuresthattreatmentisinlinewithnationalrecommendations.Allpatientsnowreceiveapersonalisedsymptom-basedwheezeactionplanaspartofthesalbutamolreducingregimeondischarge.
AdditionalAsthmaUKactionplansareprovidedtoasthmaticpatientsseenbythePaediatricRespiratoryClinicalNurseSpecialist(PRCNS)andtheseareavailabletoprintintheappendixofthenewasthmaguidelineforConsultants/otherhealthcareprofessionalstouse.Theplansclearlystipulateconcerningsymptomsandhowtorespond.Locallythegenericactionplanisidentifiedasa‘wheeze’actionplantocoverpatientswithbothasthmaandviralinducedwheeze.ThePRCNSidentifiespatientsathigherriskofrelapse/whohaveuncontrolledasthmaandtargetsthechildandfamilywithpersonalisedasthmaeducation.PatientscanalsobereferredtothePRCNSon‘inpatientinternalreferral’,andConsultantshaveaccesstothePRCNSforadvice.Thisensuresthateachpatientistreatedusinganindividualisedcareplan.
AllpatientsareassessedoninhalertechniqueusingaMeteredDoseInhalerandlargevolumespacer.Itistheresponsibilityoftheprescribertoteachinhalertechniqueifusinganyotherinhalerdevices,butthisisusuallyreservedforexceptionalcases.
ThereisanobjectivepathwaywithintheTrust’snewasthmaguidelineclearlystipulatingtreatmentaccordingtoseverity.LargepostershavebeencreatedfordisplayintheTrust’sPaediatricResuscitationDepartmentandtheChildren’sEmergencyDepartmentexhibitingthepathway.
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Audit Title Key Actions
BritishThoracicSociety(BTS)PaediatricAsthma
Thisensuresthatpatientsreceiveanaccuratemeasurementofseverityatthetimeofpresentationwhentheyattendwithanexacerbationoftheirsymptoms.
TheTrusthasimplementedadischargechecklistusedonthePaediatricwards.
Thechecklistaddressesdocumentationof:checkinginhalertechnique,supplyingadviceleaflets,supplyingthewheezeplanorasthmaactionplan,informingchild/parentof‘redflag’signs,andfollow-uparrangements.TheTrustisalsoworkingonaversionofthechecklisttouseintheChildren’sEmergencyDepartment.Thiswillensureconsistent,effectivetreatmentofpaediatricpatientswithasthma.
NationalPaediatricDiabetesAudit(NPDA)
Astructurededucationprogrammeforstaffandpatientsisinplaceandwillbereviewedanddevelopedoverthenext2years(itispartofthediabetesserviceworkprogrammefor2016-2018).
Apsychologyscreeningtoolhasbeenimplementedandisnowinusewhichhelpstoensurepatientsreceivetheappropriatecareand treatment.
SentinelStrokeNationalAuditProgramme(SSNAP)
Tworing-fencedbedsarenowavailableontheStrokeUnittoensurethatthereisspacetomeetpatientdemand.ThishasresultedinpatientsbeingadmittedmorequicklytotheStrokeUnitfromtheEmergencyDepartment.
TheStrokeSpecialistNurseandtheWardManagernowhaveaccesstotheTrust’sonlineEmergencyDepartmentsystem(ExtraMed),inordertosuccessfullyidentifypotentialStrokepatientsintheEmergencyDepartment.TheStroketeamarenowabletoensurethatallsuspectedStrokepatientsreceiveaswallowscreenwithin4hoursandaswallowassessmentwithin72hours.
AllseniorstrokenurseshavereceivedtrainingtorequestCTscansfornewpatientadmissions.Thishashelpedtoensurethatmorepatientsarescannedwithin1hourofarrivalathospital.
FollowingasuccessfulpilotofanEarlySupportedDischargeTeam(ESD),whichsupportspatientsinbeingdischargedfromhospitalearlier,theTrusthasnowimplementedthisonanongoingbasis.
TheTrusthasemployedanewPsychologyAssistant,whoisnowregularlyassessingandtreatingpatientsontheward,toensurethatStrokepatientsrequiringpsychologyinputarereceivingthis.
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Audit Title Key Actions
NationalJointRegistry(NJR) TheTrusthasputmeasuresinplaceforOrthopaedicSurgeonstouseasingletypeofprosthesisinpartialkneereplacementsurgerytoensureabetteroutcomeforpatients.
BritishThoracicSociety(BTS)AdultCommunityAcquirePneumonia
PneumoniapatientsingeneralwardsareidentifiedatwardroundsandtransferredtotheRespiratorywardswheretheycanreceiveappropriate care.
SingleantibioticpolicydevelopedforCommunityAcquiredPneumoniapatients,ensurestheappropriatecareandtreatmentisprovided.
TheTrusthasincreasedthenumberofrespiratorynurses,withfurtherplanstointroduceanAdvanceNursePractitionertoincreasethelevelofcareandsupportprovidedtopatients.
CapacityisbeingincreasedatRugbyStCrossforpost-dischargepulmonaryrehabilitationservicestoreducewaitingtimesforpatients.
Resultsofspirometrytests,measuringlungfunction,arenowavailableontheClinicalResultsReportingSystem(CRRS),makingthedataavailabletoallclinicalstaff.Thishelpstoassessandidentifyanumberofrespiratorycondi-tions,includingasthma,cysticfibrosisandChronicObstructivePulmonaryDisease.
NationalDiabetesAudit(NDA) InconjunctionwiththeClinicalCommissioningGroup(CCG),theTrust’sDiabetesEducationServicehasbeenrestructuredtoincludeinformationregardingType2DiabetesCare(excludingcomplexcases)whichwillbepredominantlyprovidedtopatientsinIntermediateClinics.ThisensurespatientsreceivetheappropriatecareandtreatmentasrecommendedbytheNationalInstituteofHealthandCareExcellence(NICE).
TheTrusthasimplementedadedicated‘youngadultclinic’,thepurposebeingtoensureyoungadultsdiagnosedwithdiabetesarefullysupportedandreceivevitalinformation,careandtreatmentfortheir condition.
Arevisedinpatientfootcarepathwayhasbeenimplemented;aimingtoimprovefootsurveillanceforinpatientswithDiabetes.
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Audit Title Key Actions
NationalDiabetesInpatientAudit
TheTrusthasworkedwithSouthWarwickshireNHSFoundationTrustandRugbySt.CrossHospitaltoimprovepatients’footcarebydevelopingapathwaychart,whichassessesfootcareduringandafteranyhospitalcare.
InorderforpatientswithDiabetestobeidentifiedearlier,consultant/specialistregistrarwardroundsaredoneeverymorning,MondaytoFriday.Thisaimstofacilitateearlyreviewandsafedischargeaswellasreviewthediabeticemergenciesearly.Inadditiontothis,aninpatientdiabetessteeringgrouphasbeenformedtomeetonceamonthtoencourageserviceimprovementsandencouragemultidisciplinaryteamworkingwithinthespecialty.
TheTrusthasincreasedspecialistinputintoinpatientdiabeteswhichwillincreasethelevelofcareandsupportprovidedtopatients.
AnInpatientfootpathwayhasbeenagreedwiththevascularteamandtissueviabilityteamwhichwasimplementedin2015.Thisenablesearlyidentificationofdiabeticfootproblemsallowingearlytreatmentandsafedischargeandavoidanceofamputations.
EducationwithintheTrusthasincreasedfortrainedstaffwherebyastudydayondiabetesisheldonceamonth.Thisallowsstafftocompleteonlinetrainingmodulessuchas‘SafeUseofInsulin’and‘Hypoglycaemia’whichresultsinimprovedcareforpatientswithdiabetesinthehospital,whichmakesupmorethan15%ofallpatients;overallimprovingoutcomes,reducinglengthofstayandimprovingpatientsatisfaction.
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Local Clinical Audits – Key Actions Taken in 2015-2016
ThefollowingarebriefsummariesofsomeofthekeyactionstheTrusthastakentoimprovethequalityofhealthcareasaresultofthereviewoflocalclinicalauditreports:
Audit Title Key Actions
Re-AuditofPretermCare LocalguidelinesforpretermcarehavebeenupdatedtoincludethenationalguidelinesforRetinopathyofPrematurity(ROP)screening,aneyeexaminationoftheretina,followingdiscussionwiththePaediatricOphthalmologists.ThisensuresthattheTrustisfollowingnationalrecommendationsforpretermcare.
AnAntenatalNeonatalCounsellingClinicisnowinplacetoensurethatmothersofpretermbabiesreceivedantenatalcounselling.
Audittomeasurecurrentpractice and diurnal variation in practiceagainstthrombolysisguidelines
AnInternationalNormalisedRatio(INR)bedsidemachinehasbeenacquiredinordertoreducelaboratorywaitingtimeforINRinwarfarinisedpatients.Staffhavebeentrainedontheuseofthemachine.Thisensuresthatthrombolysedpatientsonwarfarincanbemonitoredsooner.
Nursingstaffhavebeentrainedincannulationandvenepuncture,sotheycannowtakeamoreactiveroleintheassessmentofthrombolysedpatients.
AuditofMentalHealthActdocumentationinEmergencyDepartment
InformationonholdingpowershasbeenincorporatedintotheTrustinductionforjuniordoctors,toensurethatthereisaclearunderstanding.Thiswillensurethecorrectproceduresarefollowed.
MentalCapacityActdocumentationisnowbeingrecordedontheTrust’selectronicClinicalResultsReportingSystem(CRRS)intheEmergencyDepartment/ObservationsArea,andthisfunctionalityisbeingrolledouttothewiderTrust.ThiswillensureinformationregardingMentalCapacityforpatientsisdocumentedcorrectlyandthatpatientsaretreatedaccordingly.
ManagementofSuspectedNonAccidentalInjury(NAI)
Reportshavebeencompletedforanypaediatriccasesinwhichtherewassuspicionofnon-accidentalinjuryorharm,andthesereportshavebeendisseminatedamongstprofessionals.Thisensuresthatconcernsaroundchildsafeguardingarehandledappropriately.
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Audit Title Key Actions
Audit of the Outpatient ManagementofConstipation
Legandbackexaminationshavebeenroutinelyincorporatedintoclinicexamination,toensurethatpatientswithsuspectedconstipationreceiveeffectivetreatment,inlinewithnationalrecommendations.
LaminatedcopiesoftheBristolStoolCharthavebeenplacedinObservationfoldersonthewardsandpapercopiesofthecharthavebeenmadeavailableintheOut-patientsdepartment,toensurethatthisinformationisavailableforpatientstoview/takeaway.
Re-auditofPalliativeCareinParkinson’sPatients
‘Planningforyourfuture’leafletsarenowavailableintheTrust’sParkinson’sDisorderclinics.ThishashelpedtoinitiatediscussionsofAdvancedCarePlanningwithpatientsinclinic.
AsecondParkinson’sDiseaseNurseSpecialisthasbeenemployedbytheTrust,todevelopafollow-upclinicforpatientswithComplex/AdvancedCare.ThishashelpedtoensurethatAdvancedCarePlanningisdiscussedearlier.IthasalsoensuredthatpatientswithParkinson’sdiseaseareabletoavoidunwantedadmissionstohospitalatalaterstageofthedisease.
PaediatricdiabetesBestPracticeTariffaudit
AnewPointofCareTesting(POCT)deviceisnowinuse,facilitatingHbA1Cmeasurementinclinic.Thishelpswithmonitoringchildren’sbloodglucoselevelstoensurethecorrecttreatmentisprovided.
Apsychologyscreeningtoolhasbeenimplementedinordertoimprovepsychologyservicesforchildrenwithdiabetes.
AuditofSoffbanPlus ForallpatientswhorequiredcontinuousbloodpressuremonitoringwhilstinTheatre,OperatingDepartmentPractitioners/AnaesthetistsnowapplyathinlayerofSoffbanPlusbetweenthebloodpressurecuffandpatientsskintopreventtissuedamage.Thishasimprovedlevelsofsafetyandenhancesthepatientexperience.
Audit of the Dementia Care Bundle
Introductionofanewchecklisttoensurethattheneedsofpatientswithdementiaaremoreeasilyidentifiedandobserved.
Specialiseddementiaawarenesstrainingprovidedtoportersandsupportstafftoimprovepatientexperience.
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Audit Title Key Actions
AuditofTotalKneeReplacementalignmentinobesepatients
Raisingawarenesstopatientsoftheriskandfrequencyofproblemswiththealignmentofthebonesintheknee.
Recommendingfixingsupportstructuresontheinsideoftheboneasopposedtotheoutside,thereforeimprovingtheexperienceandoutcomesoftotalkneereplacementsonpatientswithaBMIofover35.
AuditofImplantcheckingduringorthopaedic procedure (Jointreplacement)
NewguidelinesdevelopedanddistributedtotheatrestaffacrosstheTrusttoreinforcetheimportanceofcheckingimplantlabelsbeforewoundclosureinsimpleandcomplexcases,andtoensurethattheleadorassistingsurgeonrecordstheimplantdetailsonthetheatrewhiteboard,inviewofallpresentinthetheatre.Thismulti-checkingapproachensurespatientsarefittedwiththecorrectimplantandensurespatientsafety.
Re-auditofdocumentationandreviewoffluidbalancechartsonrespiratorywards
ImportanceofaccuratedocumentationreinforcedwithnightnursingstaffandHealthCareAssistants,avoidingtheuseofambiguousterminologyinpatientnotes.
Desiredbalanceandfluidmanagementplansreviewedbybothseniorandjuniordoctorstoensurepatientsreceivetheappropriateamount.
Doweneedtoprovidecross-matchedbloodatRugbyforPrimaryHipReplacements?
Patientsarenowreviewedaheadofplannedoperationstochecktheymeetthecriteriaforcross-matchbloodtestingthusreducingthenumberoftestsrequiredandpotentialdelaystosurgery.
AuditofAcutePainManagementinPaediatricOrthopaedicPatients-Howareweperforming?
Increasededucationandawarenessprovidedtojuniordoctorsoninductiontoemphasisetheimportanceofpromptandaccurateanalgesicprescribingforallpaediatricpatientsadmittedwithafracturetoensureeffectivepainmanagement.
AuditofAcuteKidneyInjury AnAcuteKidneyInjury(AKI)alertsystemhasbeenimplementedintheTrust’selectronicClinicalResultsReportingSystem(CRRS).CRRScreatesanAKIflagwhichisanalertindicatingthatapatienthasabnormallevelsofcreatinine.ItadvisesclinicianstocontacttheRenalteamifappropriate.
TheRenalSpecialistRegistrarwillusetheinformationreportedonCRRStocreateadatabaseofinpatientswhohavereceivedanAKIalertandwillmonitorthis.ThealertisanextralevelofsafetytomakesureeverypatientwithpotentialAKIisidentifiedandensuringtheappropriatecareandtreatmentisprovided.
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Audit Title Key Actions
Compliancewiththestandardsforthediagnosisandmanagementoftherarebleedingdisorders(RBD)
TheTrusthasimplementedaprocesswherebypatientswhoreceivefactorreplacementtherapy,willhavetheirclinicalindicatedfactorlevelscheckedpriortoreceivingtreatment.Thisensuresaquickerdiagnosisandcommencementoftreatment.
Inpatientswherethereisnospecificcontraindication,tranexamicacidisofferedtoreducetheriskofbleedinginpatients.
Re-auditofcardiacarresttrolleyequipment
TheTrustensuredthatare-auditofadultandpaediatrictrolleysandgrabbagsandtheresuscitairesintheneonataldepartmentwasconductedtocomplywithUHCWstandards.Beforethiswasconducted,checklistswereamendedasaresultofthisauditwhichallowedbetterauditingofequipmentandcapturedthecorrectdata.Forthenon-compliantequipment,theResuscitationTeamreturnedtore-auditandensureallstockwasreplenished.
Re-auditofPhotodynamicTherapy(PDT)
PatientsaregiveninformationleafletspriortothemattendingforPhotodynamicTherapy(PDT);advisingthemofthediscomfortthetreatmentcancauseandprovidingadviceonwhatprecautionstotakepriortotreatmentincludingtheuseofanalgesia.
Re-AuditofSurgicalSafetyChecklist
TheSurgicalSafetyChecklisthasnowbeenincorporatedintotheTrust’selectronicTheatresystemwhichensurestherelevantsafetychecksforpatientsareundertakenbytheatrestaffduringandaftersurgicalprocedures.
AuditofComplianceagainstcommunication,educationandmonitoringofRheumatoidArthritispatientsfromatherapyperspective
Allpatientsnewlyreferredfortherapyarenowtriagedwithin24hoursandseenbyanOccupationalTherapistwithinonemonth.
TheOccupationalTherapistensuresthatpatientsareprovidedwitheducationalandself-managementadviceduringtheirfirstappointment after referral and are offered a place in the early arthritisgroupwhichprovidesongoingsupporttopatients.
UHCW 2015 - 2016 Quality AccountUHCW 2015 - 2016 Quality Account
2.4.3 Participation in Clinical Research
Researchisanintegralcomponentofprovidingworld-leadingexcellenceinclinicalcareandhasbeenlinkedtoimprovedpatientoutcomes.ItenablesUHCWtoleadinnovationanddevelopmentwhichenablesustoprovidethehighestqualitypatientcare.Itensuresthatwearealeaderratherthanafollowerinhealthcareprovisionandallowsustoattract,developandmaintainhighlyskilledandmotivatedstaff.WearecommittedtoestablishingourTrustasaninternationallyrecognisedcentreofexcellencethroughsupportingourstaff,workinginworldclassfacilitiesandconductingcutting-edgeresearchfocusedontheneedsofourpatients.
Thenumberofpatientsreceivingrelevanthealthservicesprovidedorsub-contractedbyUHCWin2015-2016thatwererecruitedduringthatperiodtoparticipateinresearchapprovedbyaresearchethicscommitteewas3885(proratatoJanuary2016asdatareportedtwomonthsinarrears,estimated4,500inyear).Whilethiswilllikelyrepresentareductionofrecruitmentonthepreviousyear(5146recruitedin2014-2015)ourcurrentportfolioconsistsofagreaterproportionofinterventionalandmorecomplextrials.Weaimtoexceed4,500patientsrecruitedtoNationalInstituteforHealthResearchPortfoliotrialsin2016-2017andincreasethenumberofpatientsrecruitedintocommercialtrials.
WeareoneoftheleadingresearchcentreswithintheWestMidlands,withaproventrackrecordofdeliveringhighqualityresearch.Wehavedevelopedourresearchbaseinrecentyears,movingfromapositionoflittleresearchactivitytobecomingahighlyresearchactiveuniversityhospital.Ourambitiouscommercialresearchstrategyhasresultedincontinualgrowthinincometoover£930kin2015-2016.
Ourexternalcollaborationwithacademicandindustrypartnerscontinuestoattractsignificantresearchincome.Thevalueofresearchgrantsawardedin2014-15was£6.3million(£8.4millionin2013-14).In2015-16,130researchgrantapplicationsweresubmittedtoexternalfunders.Currently,22%ofthesehavebeenfunded(totalvalue£3.9million)butthiswillriseastheoutcomeofapplicationsbecomesknown.Wehaveactivelyincreasedourcapacityandcapabilityinthesupportofhome-grownresearcherswithadedicatedstaffofferingcompre-hensiveguidanceandadviceoneverystepoftheresearch
pathway;fromdevelopingresearchideas,protocoldevelopment,grantapplication,trialmanagementanddeliverythroughtodataanalysisanddissemination.
Withmorethan350ongoingresearchprojectsledbystaffacrossawiderangeofspecialities,ourpatientsaregivenmanyopportunitiestotakepartinresearch.Patientinvolvementandrepresentationisdemonstratedthroughoutourresearchinfrastructure.Regulareventssuchasopendays,workexperienceopportunities,multi-mediacommunicationsandsocialmediaenableustoengagewithstaff,patientsandthepublic.OurResearch,DevelopmentandInnovationTeamwereawardedthePharmaTimesNHSClinicalResearchSiteoftheYearin2014and2015throughacompetitiveprocessjudgedbytheNationalInstituteforHealthResearch(NIHR)andAssociationofBritishPharmaceuticalIndustries.
InJuly2015weheldourinauguralResearch,DevelopmentandInnovationSummitwhichprovidedanopportunityforresearchactivestaffacrosstheTrustandourwiderpartnerstonetwork,collaborateandsharelearningandbestpractice.Buildingonthesuccessofthiseventweplan to hold a full-day event in July 2016 to coincidewiththelaunchoftheInnovationHubwhichisdetailedfurtherinSection3.
Ourcurrentmajorresearchthemesarereproductivehealth,traumaandorthopaedics,gastro-enterologyandcancer.Thesearecomplementedbyadditionalareasofclinicalresearchactivityandresearchactivitycontinuestoincrease.Thereareover100researchnurses,midwivesandalliedhealthprofessionalsassistingwithresearchprojectsandincreasingnumbersofstaffareundertakingresearch,clinicalacademicinternships,higherdegreesandPhDs.ThisyearhasseentheintroductionoftheInterdisciplinary(NonMedic)ClinicalAcademic(INCA)programmeincollaborationwithCoventryUniversitytofacilitateandsupportnurses,midwivesandalliedhealthprofessionalsdevelopessentialresearchskillsandtoencourageandnurturetheresearchersofthe future.
TheTrustprovidesfreeresearchtrainingforallstaffandoffersacomprehensivecompetencyframeworktoensurethatstaffarefullyequippedtodeliverhighquality,patientcentredcareandcontributetowardstorobustresearchoutcomes.
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ThisincreasinglevelofparticipationinclinicalresearchdemonstratesUHCW’scommitmenttoimprovingthequalityofcareweofferandtomakingourcontributiontowiderhealthimprovement.
Inthelastthreeyears,morethan500publicationshaveresultedfromourinvolvementinresearch,helpingtoimprovepatientoutcomesandexperienceacrosstheNHS.TheTrust’smission,Care-Achieve-Innovate,isexplicitinthatwewilldeliverthebestcareforourpatients,achieveexcellenceineducationandteachingandinnovatethroughresearchandlearning.Assuch,wehaveaclearstrategytodevelopresearchandinnovation.Thekeyareasfordeliveryareto‘instilandembedacultureofresearchandinnovation’and‘growinvestmentin,andrevenuefrom,researchandinnovation’.Bydeliveringonourresearchandinnovationstrategy,wealsocontributetothedeliveryoftheotherTruststrategicpriorities.InSection3.8ofthisQualityAccountyouwillfindmoredetailsofthewaysthatresearchcanbeusedtocreateimmediatebenefitsinpatientcare.
ForregularupdatesandinformationyoucanfollowUHCWresearchonTwitter:twitter.com/UHCWRDandI.
2.4.4 Goals agreed with Commissioners
Aproportionofourincomein2015-2016wasconditionaluponachievingqualityimprovementandinnovationgoalsagreedbetweenusandanypersonorbodiesthatweenteredintoacontract,agreementorarrangementwith,fortheprovisionofrelevanthealthservicesthroughthe
CommissioningforQualityandInnovationpayment(CQUIN)framework.Furtherdetailsoftheagreedgoalsfor2015-2016canbefoundinAppendix1ofthisQualityAccount.
2.4.5 Care Quality Commission
UniversityHospitalsCoventryandWarwickshireNHSTrust(UHCW)isgovernedbyaregulatoryframeworkthatrequireshealthcareproviderstoberegisteredwiththeCareQualityCommission(CQC)andthereforelicensedtoprovidehealthcareservices.TheTrust’scurrentregistrationstatusis‘registeredwithnoconditions’andtheCQChasnottakenenforcementactionagainstUHCWduring2015-2016.
TheCQChasastatutorydutytoassesstheperformanceofhealthcareorganisations,providingassurancetothepublicaboutthequalityofcarethroughasystemofmonitoring.CQCassessorsandinspectorsfrequentlyreviewallavailableinformationandintelligencetheyholdabouttrusts. FollowingtheCQCcomprehensiveinspectionwhichtookplaceintheTrustfrom10to13March2015,anactionplanwasdevelopedtoaddressthehighlevelspecificareasofimprovementidentifiedintheCQCreportthatwaspublishedinAugust2015.TheprogressagainsttheactionplanhasbeenmonitoredbytheChiefInspectorsofHospitalProgrammeBoardandhasbeenreportedtotheTrustDevelopmentAuthority(TDA)andtheTrustBoardonaregularbasis.Alloftheactionsintheactionplanarenowcomplete. Theoutcomeratingoftheoverallreviewresultedasfollows:
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Individualsiteratingsofeacharearesultedasfollows:
University Hospital
Onreview,theCQCdeemedOutpatientsandDiagnosticImaging‘inadequate’fortheSafedomain.ThiswasspecificallyinrelationtoservicesprovidedbyImagingservices.InresponsetheImagingDepartmentdevelopedaspecificactionplantoaddresstheissueshighlightedbytheinspectionprocess.ProgressagainstthisactionplanwasmonitoredbytheChiefInspectorofHospitalsProgrammeBoardandisnowreportedascomplete.
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During2015-2016theCQCmadeoneinspectionvisitandonethematicreviewtoUHCW.
TheCQCundertookamulti-agencyinspectionoftheCoventryhealtheconomyon11May2015,aspartofanationalreviewofhealthservicesforchildrenlookedafterandsafeguarding.TheTrusthasreceivedthereportwithnoratinginDecember2015andajointactionplan,ledbytheCoventryandRugbyClinicalCommissioningGrouphasbeensubmittedtotheCQC.
Inaddition,apilotUrgentandEmergencyThematicReviewtookplaceattheHospitalofStCrossintheRugbyUrgentCareCentreon23February2016.ThisreviewcoveredthegeographicalareaoftheSouthWarwickshireSystemResilienceGroupandareportwillbeissuedinduecoursebutwithnorating.
2.4.6 Data Quality
ThelastyearhasseenprominentdevelopmentsinDataQualityattheTrust;aDataQualityModelwasdevelopedthatconsistedoftheDataQualityStrategy,DataQualityPolicy,DataQualityStandards,andaDataQualityself-assessmenttool.ThishasbeenrolledouttothemajorsystemsintheTrust,wheretheobjectivehasbeentoengagewithInformationAssetOwners.ThisworkwillcontinuewithothersystemsandwillbereportedandmonitoredthroughtheInformationGovernanceCommittee.
ThePatientAdministrationSystemcontinuestobeapriorityfortheTrust,asanumberoftherequirementsintheInformationGovernanceToolkitencompassdataquality.Toensurethatwemeettherequiredattainmentlevels,specifictrainingandadvicetousersofthePatientAdministrationSystemwillbefocusedsothatinformationcapturedtosupporttheprovisionofpatientcareandnationaldatasubmissionsremainsaccurateandreliable.
TheTrustsubmittedrecordsduring2015-2016totheSecondaryUsesServiceforinclusionintheHospitalEpisodeStatisticswhichareincludedinthelatestpublisheddata.
Thepercentageofrecordsinthepublisheddata:
• whichincludedthepatient’s valid NHS numberwas:
- 99.4%foradmittedpatientcare; - 99.7%foroutpatientcare;and - 97.7%foraccident&emergency care:97.7%.
• whichincludedthepatient’s valid General Medical Practice codewas: - 100%overallinAdmittedpatient care,Outpatientcare,and Accident&Emergencycare.
2.4.7 Information Governance Toolkit
Version13oftheInformationGovernanceToolkithadanumberofchangesspecificallyaroundtheintegrationofCaldicott2intotheToolkit.UHCW’sInformationGovernanceToolkitassessmentfor2015-16wasanoverallscoreof81%andwasgradedgreenandsatisfactory.TheTrustimproveditsperformancefromthepreviousyearof78%andachievedLevelTwooraboveinallrequirements.Mandatoryinformationgovernancetrainingforallstaffstillremainsachallenge,buttheInformationGovernanceUnitcontinuestochampioninformationgovernanceacrosstheorganisation.
2.4.8 Clinical Coding Error Rate
UHCWwasnotsubjecttoaPaymentbyResultsclinicalcodingauditinthereportingperiod.TheTrustdidcommissionanexternalauditofarandomsampleofdiagnosisandtreatmentcodingandtheresultswere:
• PrimaryDiagnosesincorrect2.5%
• SecondaryDiagnosisincorrect4.9%
• PrimaryProceduresincorrect4.7%
• SecondaryProceduresincorrect3.8%
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2.5 Performance against NHS Outcomes Framework 2015-2016
At UHCW:
• TheTrustmonitorsmortalityratesusingthenationalHospitalStandardisedMortalityRatio (HSMR;providedbyDrFosterIntelligence)andSummaryLevelHospitalMortalityIndicator (SHMI;providedbytheHealthandSocialCareInformationCentre),whichmeasuremortality astowhetheritishigherorlowerthanthatwhichwouldhavebeenexpected.
• BoththeSHMIandHSMRarenotdefinitivemeasuresofqualityofcare.Theyactasawarning systemfordeviancefromthe‘norm’andcanprovideindicationforareastoinvestigate.They providetheTrustwith‘alerts’whentherehasbeensignificantlymoredeathsthanexpected. AllalertsreceivedfrombothmonitoringreportsarereviewedanddiscussedattheMortality ReviewCommittee.
• TheSHMIusesabenchmarkof1tomonitorperformance.Ifthevalueishigherthan1,thenit impliesthattherehavebeenmoredeathsthanexpected.Ifthevalueisbelow1thenthere havebeenfewerdeathsthanexpected.Analertwillonlybegeneratediftherehavebeen significantlymoreorfewerdeathsthanexpected.TheSHMIvalueforthemostrecentthree publicationsiswithinthe‘expected’mortalityrange.
• TheHSMRusesabenchmarkof100tomonitorperformance.Ifthevalueishigherthan100 thentherehavebeenmoredeathsthanexpected.IftheHSMRisbelow100,itmeansthat therearefewerdeathsthanexpected.Iftherearesignificantlymoredeathsorfewerdeaths thanexpected,amortalityalert(eithernegativeorpositive)willbecreated.
• ForJanuary2015toDecember2015theHSMRis103.26whichiswithinthe‘expected’ mortalityrange(thisisthelatestavailabledata).TheHSMRforDecember2015is79.95which isalowrelativeriskformortality(therehavebeensignificantlyfewerdeathsthanexpected). ThechartbelowshowstheTrust’smortalityperformancetrendover12months.Ithighlightsan improvementinmortalitydatafromSeptember2015.
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Related NHS Outcomes Domains 1 and 2
Indicator: Mortality Rates [source: HSCIC]
January 2014 –
December 2014
April 2014 – March 2015
July 2014 – June 2015
National Average
(July 2014 – June)
Lowest and Highest reported Trust (July 2014
– June 2015)
a) thevalueandbandingofthesummaryhospital-level mortalityindicator(“SHMI”)forthetrustforthereporting
period
1.038(within
expected)
1.039(within
expected)
1.054(within
expected)
1.00
0.661(lowerthan
expected)
1.209(higherthanexpected)
b) thepercentageofpatientdeathswithpalliativecare
coded for thereportingperiod 11.6% 12.5% 14% 26.1%
0.0%
52.9%
• UHCWhasbeenworkingtoimproveitsHSMRvalue.Investigationwasundertakenintothe diagnosisgroupswiththelargestnumberofdeathstoidentifyareasforimprovementacross allaspects–clinical,organisational,andcoding.Asaresultoftheseinvestigations,the followingareinprogress:
- EvidencebasedCareBundlesarebeingcreatedbyspecialtiesfordiagnosisgroups withalargemortalityrate.Acarebundleisasetofinterventionsthat,whenused together,significantlyimprovepatientoutcomes.Theyaimtoconsistentlydeliverthe bestpossiblecareforpatientsandhavebeenproventoimprovepatientoutcomes
- Pre-admissionpathwayswerealsoreviewedduringtheseinvestigationsandworkwith theCoventryandRugbyClinicalCommissioningGroupisinprogresstopromote adequatecommunitycaretoreduceavoidablehospitaladmissions.
- PalliativecareisimportantwithintheTrustasitfocusesonprovidingpatientswithrelief fromthesymptoms,pain,physicalstress,andmentalstressofaseriousillness. UHCWhasbeenoneofthelowestTrustsforrecordingpalliativecareforseveral years.Workhasbeenongoingduringtheyeartoincreasethenumberofpatients receivingpalliativecarebyourSpecialistPalliativeCareTeambyaccurately recordingtheiractivities.Thisincludestwicedailywardvisitstoprovideadditional supporttopatientsandnurses.Thishasresultedinanincreaseintherecordingof palliativecare.BetweenJanuary2014andDecember2014,thepalliativecarerate fordeceasedpatientsatUHCWwas8.78%.However,followingtheimprovements incapturingactivitywithintheSpecialistPalliativeCareTeamthisyear,thepalliative codingrateofdeceasedpatientshasincreasedto23.81%(January2015-December 2015).Thenationalaverageforpalliativecodingdur-ingthistimeis24.77% indicatingthatUHCWisnowreportingsimilarlytootherTrusts.Thishashadapositive impactontheTrust’sHSMR.
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• Additionally,allinpatientdeathsatUHCW(patientsaged18andabove)receiveamortality reviewcompletedbythespecialtyinchargeoftheircare.Thisistoprovideassurancethat patientsreceivedagoodqualityofcare–andinsituationswherecarecouldbeimproved, actionsandlearningaresharedacrosstheTrust.Currently,91%ofpatientshavereceiveda NationalConfidentialEnquiryintoPatientOutcomeandDeath(NCEPOD).Agradeatprimary review–thismeansthattherehasbeenagoodqualityofcare.Thisisanimprovementon previousper-formance.UHCWtakesprideinensuringthatallpotentialareasforlearningare highlightedandsharedamongsttheteamstopromotebettercareandreducepatientharm.
*PROMS Adjusted Health Gain Scores. Items marked with an asterisk are due to low numbers of patient records being submitted and therefore this information is suppressed on HSCIC. Full year 2015/16 information was not available from HSCIC when this account went to publication.
TheTrustconsidersthatthisdataisasdescribedforthefollowingreasons:Patientsareaskedtocompleteafeedbackformpost-operativelyfollowinganationallyagreedprotocol.
TheTrustintendstotakethefollowingactionstoimprovethisscoreandsothequalityofitsservices,bysharingfeedbackandliaisingwiththerelevantclinicalareastoensureinformationaboutthequestionnaireisgiventopatientsandpatientsareencouragedtoparticipate.
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Related NHS Outcomes Domain 3
Indicator :Patient reported outcome measures scores
(PROMS)[source: HSCIC]
2013/2014 2014/2015 Apr-Sep 2015Provisional
NationalAverage(Apr-Sep
2015Provisional)
Lowestand Highest
Reported TrustApril-September 2015 provisional
GroinHerniasurgery * 0.077 * 0.088 0.008– 0.135
VaricoseVeinsurgery * * * 0.104 0.037– 0.130
Hip replacementsurgery 0.449 0.454 0.520 0.454 0.359– 0.520
Knee Replacementsurgery
0.326 * 0.312 0.334 0.207– 0.412
**Indicates the information is not yet available on the HSCIC portal, it is due to be released in August 2016 + Indicates data is UHCW Data
TheTrustconsidersthatthisdataisasdescribedforthefollowingreasons:TheconsistencyandaccuracyofthedatacollectionhasbeenevaluatedbyinternalauditandismonitoredbytheTrustPerformanceManagementOffice.
TheTrustintendstotakethefollowingactionstoimprovethispercentage,andsothequalityofitsservices:bycontinuingtoimplementactionsaroundimprovingeffectiveandsafedischarge.
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Related NHS Outcomes Domain 3
Indicator: emergency readmissions to hospital [source: HSCIC, UHCW]
Year UHCW NHS England Average
lowest reported
Trust highest reported
Trust
Thepercentageofpatientsaged0to15readmittedtoahospitalwhichformspartoftheTrustwithin28daysofbeingdischargedfromahospitalwhichformspartofthetrustduringthereportingperiod
2013/14 7.87+ *
Not available
* Not
available
* Not
available
2014/15 7.33+ *
Not available
* Not
available
* Not
available
2015/16 7.54+ *
Not available
* Not
available
* Not
available thepercentageofpatientsaged16 or over readmitted to a hospitalwhichformspartoftheTrustwithin28daysofbeingdischargedfromahospitalwhichformspartofthetrustduringthereportingperiod
2013/14 7.76+ *
Not available
* Not
available
* Not
available
2014/15 7.76+ *
Not available
* Not
available
* Not
available
2015/16 8.09+ *
Not available
* Not
available
* Not
available
*The Trust’s responsiveness to the personal needs of its patients during 2015-2016 is not yet available on the HSCIC website.
Thepercentageofstaffemployedby,orundercontractto,thetrustduringthereportingperiodwhowouldrecommendthetrustasaproviderofcaretotheirfamilyorfriends:
**Thepercentageofstaffemployedby,orundercontractto,theTrustduringthereportingperiodwhowouldrecommendtheTrustasaproviderofcaretotheirfamilyorfriends:ThesefiguresarebasedontheresultsforUHCWfromtheNationalStaffSurvey.Eachyear850randomlyselectedstaffareabletotakepartinthesurvey.InApril2014theNationalStaffFriendsandFamilyTestwaslaunched,whichseesstaffbeingaskedwhethertheywouldrecommendtheTrustasaplacefortheirfriendsandfamilytoworkoraplaceforthemtobetreated.Wearerequiredtoaskallstaffeachyearthefriendsandfamilyquestions,howeveraspartofourcommitmenttolistenandrespondtostafffeedbackwehaveaskedallstaffineachquarterof2015-2016.InformationandtheresultsfromthissurveycanbefoundinSection3.11ofthisaccount.
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Related NHS Outcomes Domain 4
Indicator: A positive experience of care [source HSCIC] 2013/14 2014/15 2015/16
National Average 2015/16
Lowest and Highest
Reported Trust 2015/16
TheTrust’sresponsivenesstothepersonal needsof itspatientsduring thereportingperiod.
74.2% 75.5% * * *
Thepercentageofstaffemployedby,orundercontractto,theTrustduringthereportingperiod whowouldrecommend theTrustasa provider of care to their family orfriends.**
62% 70% 76% 69% HIGHEST 100% LOWEST44%
TheTrustconsidersthatthisdataisasdescribedforthefollowingreasons:theconsistencyandaccuracyofthedatacollectionhasbeenevaluatedbyinternalandexternalauditandismonitoredbytheTrustPerformancemanagementoffice.ThenationalVTEriskassessmenttooloriginatesfromNICEguidanceandstatesthatallpatientsshouldberiskassessedonadmissiontohospital.Patientsshouldbereassessedwithin24hoursofadmissionandwhenevertheclinicalsituationchanges.UHCW’saveragecomplianceacrosstheyearis96.2%ofpatientsreceivingaVTEriskassessmentonadmission.TheTrusthasincorporatedanumberofsystemcontrolswithinitsClinicalReportingandResultsSystem(CRRS)toenhancethequalityofcaretopatientsandthispromotescompletionoftheriskassessmentwithin12hours.Whilst,theTrustisconsciousthatitisnotclinicallyappropriatetocompleteaVTEassessmentwithinadefinedperiodoftimeforallpatients,whentakingintoconsiderationthenumberofpatientswhoseVTEassessmentwascompleted24hoursormoreafteradmission,theindicatorwouldchangeslightlyto92.6%.
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Related NHS Outcomes Domain 5
Indicator: avoiding harm [source HSCIC]
Year by quarters
UHCW National average
Trust with highest/lowest
score
The percentage ofpatientswho wereadmitted tohospitalandwhowere riskassessedforVenousThromboembolism(VTE) during thereporting period The indicator is expressed as a percentage of all adult in-patients that have received a VTE risk assessment upon admission to the Trust using the clinical criteria of the national VTE tool
2013/14 Q1 95.8%
95.5%
100%
78.8% Q2 95.9% 95.6% 100%
81.7% Q3 96.1% 95.8% 100%
74.1% Q4 96.2% 96.0% 100%
78.9% 2014/15
Q1 96.1%
96.1%
100% 87.2%
Q2 96.4% 96.1% 100% 86.4%
Q3 96.5% 95.9% 100% 81.2%
Q4 96.6% 96.0% 100% 79.2%
2015/16 Q1 96.6%
96.0%
100%
86.1% Q2
95.8% 95.9% 100% 75.0%
Q3 96.2% 95.5%
100% 61.5%
Q4 96.4% 95.5%
100% 78.1%
*National averages are not available from HSCIC until mid-July. It will then be available on the HSCIC website.
Pleasenotethatthe2015-16ratehasbeencalculatedusingCDifficilereportedcasesavailableontheHSCICandKH03beddaydata(38/382,843x100,000).
TheTrustconsidersthatthisdataisasdescribedforthefollowingreasons:ReportingofdataonC.difficileinfectionismandatory;dataqualityismonitoredthroughinfectioncontrolandsubjecttoauditandreportingtocommissioners.UHCWhassubmitteditsmandatoryreturnbutthishasnotyetbeenpublishednationally.
TheTrustintendstotakethefollowingactionstoimprovethispercentage:bycontinuingtoimplementitsinfectioncontrolandpreventionstrategy.
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Related NHS Outcomes Domain 5
Indicator: Reducing Infection [source HSCIC]
2013/14 2014/15 2015/16 National Average
Lowest to Highest Reported Trust
Therateper100,000beddaysofcasesofC.difficileinfection reportedwithintheTrustamongstpatientsaged2oroverduringthereportingperiod. The Trust is deemed responsible for a case where the sample was taken on the fourth day or later of an admission to that trust (where the day of admission is day one)
12.7 10.7 9.9 * *
**The patient safety indicator is expressed as a percentage of patient safety incidents reported to the National Reporting and Learning Service (NRLS) that have resulted in severe harm or death.
Apatientsafetyincidentisdefinedas‘anyunintendedorunexpectedincident(s)thatcouldordidleadtoharmforoneofmoreperson(s)receivingNHSfundedhealthcare’.
The‘degreeofharm’forpatientsafetyincidentsisdefinedasfollows:
• ‘severe’–thepatienthasbeenpermanentlyharmedasaresultoftheincident;
• ‘death’–theincidenthasdirectlyresultedinthedeathofthepatient.
TheTrustconsidersthatthisdataisasdescribedforthefollowingreasons:UHCWassessesdataqualitybeforesubmissiontoNHSEngland’sNationalReportingandLearningSystem(NRLS).TheNRLSmonitorsthedataandinformsUHCWofanyanomaliesorerrors.
TheTrustintendstotakethefollowingactionstoimprovethispercentage. • ContinuetoincreaseawarenessofincidentreportingthroughTrustinductionandad-hoc spot-checksonwardsanddepartments• Continuetoprovideimmediatefeedbacktoreporters• Improvefeedbacktostaffthroughavarietyofmedia,e.g.email,posters,newsletters,Grand Roundpresentations,webpages.• Ensurethatactionplanstoaddressincidentsarerealisticandachievableandhencecompleted withintheirdeadlines.
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Indicator: Incident reporting [source NRLS]
Apr 1
4 –
Sep
14
O
ct 1
4 –
Mar
15
Apr 1
5 –
Sep
15 National Median
(Acute non-specialist Trusts)
April 15-Sep 15
Lowest and Highest reported Trusts
April 15-Sep 15
The number of PatientSafety Incidents reportedwithin the Trust in thereportingperiod
5532 6141 6,047 4.125 Lowest- 1,559
Highest- 12,080
Rate of Patient SafetyIncidents reported withinthe Trust in the reportingperiod(per1000 beddays)
28.74 31.67 32.18 38.25 Lowest - 31.65
Highest- 61.32
The number of suchincidents that resulted insevereharmordeath
19 14 37 17 Lowest- 2
Highest- 89 **Percentage of suchPatient Safety Incidentsthat resulted in severeharm or death
0.3% 0.2% 0.6% 0.4% Lowest:- 0.1%
Highest- 2.9%
Section 3Overview of Organisational Quality
3.1 Patient Safety
Theaimofincidentreportingistocapturethemesandtrendsfromthenumerouslowlevelincidentsandresolvethem,toavoidthepotentialforaggregatedfailuresthatcancausepatientsahigherdegreeofharm.Ouronlineincidentreportingsystem(Datix)facilitatesearlydetectionofthesetrendsandalertsthecentralSafetyTeamtoanyseriousincidents,enablingescalationandswiftinvestigation.
ThelasttwelvemonthshaveseenanincreaseinthereportingofpatientsafetyincidentswithintheTrust.Thereportingofallincidentswhichimpactonapatient’scareissomethingwhichisencouraged,howeverminortheoutcome.Allreportedincidentsareinvestigatedaccordingtothetypeofincidentandtheirpotentialforharm.Seriousincidentsareinvestigatedusingrootcauseanalysismethodology.
Allofourstaffcanreportincidentsknowingthattheywillbesupportedthroughouttheprocessofinvestigationandinvolvedinmakingrecommendationsanddevelopingactionplans.TheprocessforincidentreportingistaughtatTrustinduction,whichisa3-daycoursewhichintroducesallstafftotheTrust’scorevaluesaspartofthewiderTogetherTowardsWorldClassprogramme.
Themajorityofpatientsinvolvedinasafetyincidentincurminorornoharm,whichisanindicationofanopenandlearningculture(refertobelowchart).Wesharetheoutcomesofinvestigationsandtrendanalysisacrosstheorganisationaswellaswithourcommissioners,otherlocalprovidersandwithNHSEngland.
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Serious Incidents
Seriousincidentsaredefinedasincidentswheretheconsequencesorpotentialforlearningissogreatthattheuseofadditionalresourcestocompileaninvestigationisappropriate.
Wereported182seriousincidentsin2015-2016.
AseriousincidentrequiringinvestigationisdefinedasanincidentthatoccurredinrelationtoNHS-fundedservicesandcareresultinginoneofthefollowing:
• Unexpectedoravoidabledeathofoneor morepatients,staff,visitorsormembers ofthepublic.
• Seriousharmtooneormorepatients, staff,visitorsormembersofthepublic orwheretheoutcomerequireslife- savingintervention,majorsurgical/ medicalintervention,permanentharmor willshortenlifeexpectancyorresultin prolongedpainorpsychologicalharm (thisincludesincidentsgradedunderthe NPSAdefinitionofsevereharm).
• Ascenariothatpreventsorthreatensto preventaproviderorganisation’s abilitytocontinuetodeliverhealthcare services,forexample,actualorpotential lossofpersonalandorganisational information,damagetoproperty, reputationortheenvironment,orIT failure.
• Allegationsofabuse.
• Adversemediacoverageorpublic concernabouttheorganisationorthe widerNHS.
ForAcuteTrusts2015-2016theNeverEventlistwas:
- WrongSiteSurgery
- WrongImplant/prosthesis
- Retainedforeignobjectpost-procedure
- Mis-selectionofastrongpotassium containingsolution
- Wrongrouteadministrationofmedication
- Intravenousadministrationofepidural medication
- OverdoseofInsulinduetoabbreviations or incorrect device
- Overdoseofmidazolamduringconscious sedation
- Overdoseofmethotrexatefornon-cancer treatment
- Fallsfromunrestrictedwindows
- Chestorneckentrapmentinbedrails
- TransfusionofABO-incompatibleblood componentsororgans
- Misplacednaso-ororo-gastrictubes
- Scaldingofpatients
ThisguidanceissetoutintheSeriousIncidentFrameworksetbyNHSEngland.
Over70%ofthesearemadeupofspecifictypesofincidentthatareautomaticallyreportedasSeriousIncidents,forexampleInfectionControlincidents(e.g.MRSAbacteraemia,CDifficile-associateddeathsandinfectionoutbreakssuchasNorovirus),pressureulcersandallNeverEvents.
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Chart illustrating serious incidents by type 2015-2016
WehaveaweeklySignificantIncidentGroupmeeting,whichisattendedbyseniorclinicalandnon-clinicalstaffaswellasacommissioningrepresentative,whoensurethatourprocessconformstothenationalSeriousIncidentFramework2015.Thegroupoverseestheinvestigationsandresultingactionplans,allofwhicharemonitoreduntilcompletion.
Asaresultofseriousincidentswehaveintroducedmanysafetyimprovements,examplesofwhichare:
• ReviewoftheTrust’sPatientTransferPolicy.
• Improvingthesafetyofcentrallineuseonthegeneralcriticalcareunit.
• Patient“callbells”nolongerusedonquieternight-timesettings.
• Introductionofanenhancedcareteamtoprovideonetoonecareforpatientswhorequire additionalinputduringtheirhospitaladmission.
• Anaide-memoirewasputinthemulti-birthroomtoremindstaffaboutspecific intrapartumcarerequirementsforwomenwithtwinpregnancy.
• WeeklysafetymessagesarecirculatedbytheChiefMedicalandChiefNursingOfficers.
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FurtherdetailsoftheworkundertakenareoutlinedintheQualityDepartmentAnnualReport2015-2016.
AleaguetableproducedbyMonitorandtheNHSTrustDevelopmentAuthorityinFebruary2016identifiedlevelsofopennessandtransparencywithinNHSTrustsandFoundationTrusts.TherankingsthatTrustsweremeasureonwere:
1– outstanding levelsofopennessand transparency
2– goodlevelsofopennessand transparency
3– significant concernsaboutopenness andtransparency
4– poor reporting culture
UHCWreceivedaratingas“good.”Theleaguetablewasdrawntogetherbyscoringprovidersbasedonthefairnessandeffectivenessofproceduresforreportingerrors;nearmissesandincidents;staffconfidenceandsecurityinreportingunsafeclinicalpractice;andthepercentageofstaffwhofeelabletocontributetowardsimprovementsattheirTrust.
Never Events
During2015-2016regrettablywereportedthree“NeverEvents”.Wehaverespondedtotheseincidentswithrobustinvestigationsandscrutinyofourprocessesandprocedures.
Allthreecasesweredeclaredas“wrongsitesurgery”,whichisdefinedbyNHSEnglandas:“asurgicalinterventionperformedonthewrongpatientorwrongsite(forexamplewrongknee,wrongeye,wronglimb,wrongtoothorwrongorgan);theincidentisdetectedatanytimeafterthestartoftheprocedure.”
Twocasesrelatedtoincorrectspinallevels(oneofwhichoccurredin2013butwasdetectedin2016followingimagingforfurthersurgery)andonecaserelatedtohandsurgery.
AllcasesoccurreddespiteuseoftheWorldHealthOrganisation’s(WHO)SaferSurgerychecklist.
Oneachoccasionwehavediscussedtheerrorwiththepatientinvolvedand/ortheirnextofkin
andofferedtosharetheresultsofourinvestigations.TheinvestigationswereeachledbyaseniorclinicianusingRootCauseAnalysis(RCA)methodology.RCAreportsarescrutinisedbyourSignificantIncidentGroup,whichhasarepresentativefromourcommissioners,toensurethatallaspectsareconsideredandthattheassociatedactionplansarerobust.Allactionsaremonitored until completion.
StaffinvolvedinaNeverEventarerequiredtodiscusstheincidentandactionstakenatameetingwiththeChiefExecutiveOfficerandtheRCAreportsaresharedwiththeTrustBoard.DetailsaboutNeverEventsarealsopublishedinthepublicTrustBoardpapersavailableontheTrustwebsiteatwww.uhcw.nhs.uk/about-us/trust-board.
WecontinuetotakeactivestepstotrytoeradicatetheoccurrenceofNeverEventsintheorganisation.Examplesofactionswehavetakenare:
• Conductedagapanalysisagainstthe 2015/16NeverEventslistandsupporting information.
• CommencedHumanFactorseducation withstaffwhoworkinoperatingtheatres.
• Setupamulti-disciplinaryTheatresafety team.
• RaisedawarenessofNeverEventsand sharedthelearningwithourstaff.
• Takenactionasrequiredbysafetyalerts andrecommendationsfromtheNational ReportingandLearningSystem(NRLS).
• MonitoredtheuseofWorldHealth Organisation(WHO)surgicalsafety checklistsandaddressedany shortcomingsimmediately.
• Reviewedandrevisedclinicalguidelines toimprovepatientsafety,basedon learningfromtheincidents.
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Duty of Candour
FollowingtheFrancisReportoftheMidStaffordshireNHSFoundationTrustPublicInquiryandaseriesofotherreviews,theDutyofCandourbecamepartofaregulatoryregistrationpackagewhichwasimplementedinOctober2014.
ClinicianshaveanethicalDutyofCandourtoinformpatientsaboutmistakesthatcauseseriousharmtotheirpatients.TheCareQualityCommission’s(CQC)Regulation20istoensurethatprovidersareopenandtransparentwithpeoplewhouseservicesandother‘relevantpersons’(peopleactinglawfullyontheirbehalf)ingeneralinrelationtocareandtreatment.Itsetsoutspecificrequirementsthatprovidersmustfollowwhenthingsgowrongwithcareandtreatment,includinginformingpeopleabouttheincident,providingreasonablesupport,providingtruthfulinformationandanapologywhenthingsgowrong.
InresponsetotheDutyofCandourthePatientSafetyTeamhasledontheproductionandpilotingofanewTrustpolicywhichisbasedonnational and international evidence.
Thepolicyincludesclearinformationforstaffonwhattheyshoulddowhentheyareinvolvedinaseriousincidentandthesupportavailabletothemtodealwiththeconsequencesofwhathappenedandhowtocommunicatewiththepatientsorserviceusers,theirfamiliesandcarers.
FollowinganincidenttowhichtheDutyofCandourapplies,thepatientinvolvedwillreceiveaverbalapologyandawritteninformationleafletwithacontactnameandnumberanddetailsofwhatwillhappennext.Followingtheinvestigationtheywillbegivenanopportunitytodiscussthefindingswithamemberoftheclinicalteam.
Sign up to Safety
UHCWjoinedthenationalSignuptoSafetyCampaignin2014,whichhastheambitionofmakingtheNHSthesafesthealthcaresystemintheworld.SignuptoSafety’sthreeyearobjectiveistoreduceavoidableharmby50%andsave6,000lives.
UHCWhassigneduptothecampaign’sfivepledges:
1. Wewillput‘Safety First’bycommittingto reduceavoidableharmbyhalf.2. Wewilllookto‘Continually Learn’ throughmakingourorganisationmore resilienttorisks,andactingonfeedback fromourpatientstomonitorhowsafeour servicesare.3. Wewillensure‘Honesty’ and transparencywithpeopleonourprogress intacklingpatientsafetyissues.4. Wewill‘Collaborate’withourpatient groupsandotherlocalpartnerson improvingpatientcare.5. Wewill‘Support’peopletounderstand whythingsgowrongandhowtoputthem right.
Aspartofthecampaign,in2015webidforaone-offdiscretionarypaymentbytheNHSLitigationAuthority.Ourbidwasoneofthe67successfulbidsoutofatotalof243,earningus£245,329whichisearmarkedfortheintroductionofHumanFactorsandforthedevelopmentofaninnovativeaudiosurgicalsafetychecklistforourTheatres.
Todatewehaveimplementedhumanfactorseducationandinnovationinanumberofways:
• Wehavecommencedselectionofthose staffwhowillbecomeourHumanFactors trainers.
• Wehavestartedtolookatstafftostaff “interactivity”,thatis,howstaff communicatewithoneanotherandhow thismightrelatetosafety.
• Theaudiosafetychecklisthasbeen pilotedintheatresoveroneweekandthe evaluationiscurrentlyinprogress.We willpossiblyneedtorepeatitforalonger period of time.
• WehavestartedtoaddHumanFactors educationintoouractionplansforserious incidents
• Weareworkingwithanationalcompany tolookathowtomakepatientbathrooms saferaswefoundoneofthereasonsthat patientswerefallingoverinbathrooms wasbecausethetoiletpaperdispensers werenoteasytoreach.
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3.2 Claims
TheTrustinthefinancialyear2015-2016reported101clinicalnegligenceclaimstotheNationalHealthServiceLitigationAgency(NHSLA),adecreaseof10claimsonthelastfinancialyear.In2015-16theNHSLA,onbehalfoftheTrust,settled46claims.FurtherdetailsontheTrust’sclaimshistorycanbeobtainedviatheNHSLA’swebsite:www.nhsla.com.
WecanconfirmthattheTrust’sclinicalnegligenceclaimshistoryiswithinthenationalaverageforAcuteTrustsprovidingamaternityservice.
TheTrustiscommittedtominimisingtheopportunityforhumanerrorinmedicineandwiththisaimhascommittedsubstantialresourcesinimplementingitsclinicalgovernanceframework.Clinicaladverseeventsareactivelyreportedandasappropriatelyinvestigated;withactionplansimplementedseekingtoavoidsimilarincidentsagain.
3.3 Dementia
AccordingtotheAlzheimer’sSociety,thereareover800,000peopleintheUKlivingwithdementiaandatanyonetimethisgroupoccupiesapproximately25%ofgeneralhospitalbeds.Itisestimatedthatifcurrenttrendscontinueandnoactionistaken,thenumberofpeoplewithdementiaintheUKisforecasttoincreaseto1,142,677by2025,anincreaseof40%overthenext12years.
Weaimtoensurethatweprovidehighquality,personalized,compassionatecareforthisvulnerablegroupofpatients,makingsuretheyareproperlysupportedandreassuredwhilsttheyareinhospitalandafterdischargewhentheyareinthecommunity.Wealsorecognisethatcarefulplanningforthefutureisrequiredtoensurethattherightcareandsupportisavailableforpatientswithdementiabothinhospitalandwithinthecommunity.
TherecentCareQualityCommissioninspectionfoundthattheTrusthaddemonstratedimprovementsindementiacareandoverallagoodexperienceforpatients.
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Graph of patients admitted to UHCW over the past 3 years with a diagnosis of dementia showing a steady increase in trend.
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What we set out to do
Promptly identify patients with dementia
TheTrustwantstomakesurepatientswhohaveormayhavedementiaareappropriatelyidentifiedonadmissiontohospitalsotheyreceivetherighttypeofcareandtreatment.Weknowthatitisimportantthatearlywarningsignsofdementiaareidentifiedtherefore;weaimtopromptlyscreen,assess,investigateandifnecessary,referpatientsovertheageof75ontoaspecialistwhentheyareadmittedtohospitalinanemergency.ThisformspartofthedementiaCQUINschemeandwehavecontinuallyachievedourtarget.Thegraphbelowshowsthatover90%ofpatientsarescreenedandreceivingsuitableinterventions:
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TheTrusthastakenactionstoimprovethisrateandtherebyincreasethequalityofourservice.Adashboardapplicationhelpstheteamtracktheirprogress.TheTrustcontinuestomeetthenationalstandardfordementiascreeningtoensureourpatientsreceivetheappropriatecare.
UHCWwanttoensurethatallstaffhavetheknowledge,confidenceandskillsrequired,andaccesstospecialistknowledgeandadvicesothatweareabletoprovidethemosteffectivecarepossibletoourpatientslivingwithdementia.DementiatrainingispartofthedementiaCommissioningforQualityandInnovation(CQUIN)paymentframeworkandwehaveconsistentlyachievedourtargetfortheCQUINsetbythelocalClinicalCommissioningGroup.
TheTrustiscommittedtocontinuallyembeddinggoodpracticewithregardstodementiacareandallstaff,whetherclinicalornon-clinical,areoffereddementiaawarenesstrainingtorecognizethesignsofdementiaandtogenerallyraiseawarenessoftheissuesaffectingpeoplewithdementiaandtheirfamiliestohelpthemprovidethemostappropriatecareforthisgroupofpatients.
During2015-2016(betweenApril2015andMarch2016),697UHCWstaffweretrainedondementia.Trainingisdeliveredthroughclassroomsessions;wardbasedonetooneexperientiallearningandane-learningmodule.Moreindepthdementiatrainingiscarriedoutinstand-alonesessionssuchastherecentworkshopon‘DealingwithChallengingBehaviour’organisedbytheDementiaTeam.
Staffarealsotrainedinvarioustechniquesformanagingpatientswithdementiasuchasthe‘M’Technique.The‘M’techniqueisasimplemethodofstructuredtouch.Eachmovementandsequenceisdoneinasetpatternatasetpressureandsetspeed,whichneverchange.TheMtechniqueisdifferentfrommassageandissuitablefortheveryfragile;thecriticallyill,activelydying,orwhenthegiverisnottrainedinmassage.The‘M’techniqueworksonskinreceptorswhichsendsignalstothebrainandhasbeendescribedas‘physicalhypnotherapy’anda‘spiritualdance’.StaffarealsotaughtthetheVERAtechnique.TheVERAtechniqueisahelpfulapproachandanaidtomemoryforstaffwhenworkingwithpatientsdiagnosedwithdementia.
VERAstandsfor:
V= Validate,acceptingthatthebehaviour exhibitedhasavaluetothepersonand isn’tjustasymptomofdementia.
E= Emotion,payingattentiontothe emotionalcontentofwhattheperson’s saying.
R= Reassure,canbeassimpleassaying‘it’ll beokay’andsmiling,holdingtheirhand.
A= Activity,peoplewithdementianeedtofeel occupied,active,seeifyoucanengage theminsomerelatedactivity.
Staffarealsoencouragedtoparticipateinanationallyrecognizedqualificationindementiaorganizedbythetrainingdepartment.WehaveinvestedintwoClinicalEducationLeadswhoworkcloselywithourstafftosupportwiththeirtraining.
Thetrainingmethodshavebeenimprovedtoallowmoreinteractionwithtraineesandprovidemorepracticallearningexperiencethroughwardbasedtraining.Wewillcontinuetofurtherdevelopoureducationalprogramwithafocusondevelopingstaffawarenessandunderstandingofeffectivecareindementiaandhopetoincreasethepercentageofstafftrainedinthecomingyear.
Promote dementia awareness across the Trust
Aswellasraisingawarenessofdementiathrougheducation,wehaveundertakensignificantworktowardsembeddingtheForgetMeNotCareBundleacrosstheorganization.ThisCareBundleprovidespromptsforstafftoensurethatcareisfocusedonfourkeydomains:communication,nutritionandhydration,asafeenvironmentandpersonalinformation.TherationaleforimplementingtheCareBundleistoprovidepersonalandindividualizedcaretodementiapatients.ArecentauditoftheCareBundleidentifiedareasofimprovementforstandardisationagainstfundamentalstandardsinthecareofpatientswithdementia.AfurtherauditofthecarebundleisongoingonsevenwardsinthehospitalwhichisduetocompleteinApril2016.
AllwardsanddepartmentshaveidentifiedDementiaChampionswhoreceiveadditionalregulartrainingandsupport.
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Theirroleistosupportpatientswithdementiaandstaffbypromotinggoodpracticeinthisareaandtheyalsoprovidefeedbacktothedementiateam.Weholdregulardementiachampionsforums.Workhastakenplacetoincreasethenumberofattendees,tomaintainmomentumandeffectchangeatwardlevel.
The‘GettingtoKnowMe’form,whichisakeyelementoftheforgetmenotcarebundleisadocumentwhereinformationrelevanttoeachpersonandtheirlikes/dislikesiswrittenbythepersonwithdementiaortheirrelativestohelpstaffprovidepersoncenteredcarerightfromtheonsetoftheircare.AllpatientswithdementiaaregivenaformfortheircarerstocompleteonadmissiontotheTrust.
Support Carers of patients with dementia
Werecognisethatcarersplayavitalroleinthecareofpatientswithdementiaandarecommittedtoimprovinghowweworkwithandsupportcarersofourpatientsandreducingtheriskofcarerbreakdown.
WehavesetupaCarersSupportGrouptoexplorebetterwaysofcommunicatingwithandsupportingcarers.Carersalsoreceivesignpostingtorelevantserviceswithinthetrustandinthecommunity.ViewsofcarersarefedbacktotheDementiaSteeringGrouptofacilitateanynecessaryimprovementstoservice.
Followingdiscussionwithwardstaffpatientnearestrelativeorprimarycarerareofferedflexiblevisitinghourstoenablethemvisitoutsidenormalvisitinghoursinordertoprovidesupportwithpersonalcare,provideassistanceatmealtimesifdesiredandbeactivelyinvolvedindiscussionsabouttheirlovedone’scare,ongoingtreatmentanddischarge.
AspartofthedementiaCQUINscheme,weestablishedaCarers’Surveywhichhasprovidedmuchwelcomedfeedbackonhowtoimproveservicesforourpatientswithdementia.Wehavetakenonboardfeedbackfromthesurveyandworkisongoingtoaddresssomeofthepointsraised.Wehaveimprovedinformationsharingwithcarersandnowprovidethemwithcarerinformationpacks.Wealsodisplayrelevantinformationoncarerinformationboardsprovidedonthewards.
BelowarekeyfindingsfromtheCarers’Survey(December2015toMarch2016):
- 90%ofcarerssaidtheywereprovided withtheGettingToKnowMeform.
- 90%ofcarerssaidtheyaskedhowmuch involvementtheywouldlikewiththeir relative’scare.
- 100%ofcarersfeltthattheenvironment meetstheneedsoftheirrelativesand wereofferedflexiblevisitingtimes.
- 100%ofcarersfeltthatstaffwere approachableandthattheywereableto askforinformationabouttheirrelative.
- 65%saidtheyhadsufficientinformation abouttheirrelative’sdischargeplans.
- 65%ofcarerswereofferedaninformation leafletfromtheirrelative’sward
- Overall,onascaleof1-10,anaverage scoreof9.0wasgivenforthecare receivedbypatientsandtheircarers.
What we hope to achieve this year
- Consistentcompliancewiththedementia CQUINtargets.
- Anincreaseinpercentageofstaff particularlynursingstaffandjunior doctorsindicatethattheyhavehad dementiatrainingandcanaccess dementiaspecialistknowledgeand advice.
- Continued evidence of dementia friendly environmentsthroughouttheTrust.
- ImprovedattendanceattheCarers’ SupportGroupsessions.
- Continuedpositivefeedbackfromcarers throughtheCarersSurvey.
- Establishedlinkswiththecarers associationtoimproveengagementwith carerswithinthecommunity.
- Furtherdevelopedlinkswithstakeholders todevelopamulti-agencyintegratedcare pathwayforpatientswithdementia.
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- Continually monitor the amount of time apatientspendsinhospitali.e.lengthof stay,readmissionsanddischarge destinationsinvolvingthosewith dementiatoensurepatientsare appropriatelyreferredontospecialist services.
- EvidencethattheCareBundleisused consistentlyacrosstheTrust.
- ConducttheNationalDementiaAuditin 2016.
How we will monitor progress
WewillmonitorprogressofourplannedimprovementsandmeasuresofsuccessthroughthemonthlyDementiaSteeringGroupwhichreportsprogresstotheTrustQualityGovernanceCommittee.Thiswillbeusedasaforumtosharelatestguidelinesandreviewfeedbackfromsurveysandauditsinordertodevelopactionplansforcontinuedimprovement.
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3.4 Infection Control
End of year performance against Department of Health (DH) Targets.
Clostridium difficile (C.diff)
UHCWendedtheyear2015-16*belowboththenationalandinternalstretchtargetssetforClostridiumdifficile.
ChartshowingreductioninC.diffnumbers
DHTarget InternalTarget Total cases Trustapportioned
42 40 38
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Methicillin-sensitive Staphylococcus aureus (MSSA)
TheTrustcontinuestoperformwellagainstnationaltargets.OurMSSAnumbersremainconsistentlylowandareinthebestperformingquartilenationally.
MRSA
UHCWdeclaredzeroMRSABacteraemiaattributedfor2015-2016.TheInfectionPreventionandControlTeamcontinuetoworkfurtheronaspectsofpracticetomaintainthis.
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Influenza and Norovirus
InfluenzalevelswerehighthisyearandstaffatUHCWmanagedthiswell,reducingpotentialharmtootherpatients.
Noroviruswasexperiencedatverylowlevels.UHCWhadnowardclosuresthisyearasagainstaffmanagedextremelywellandwesawonlyareaspartiallyclosedandverylimiteddisruptiontoservicedelivery.
WhenbenchmarkedagainstotherlargeacuteteachingTrustsUHCWperformswell,thetablebelowshowsTeachingHospitalComparisons–April-2015toMarch-2016:
TakenfromNationalMESSdatabase
Team innovation and research
UHCWInfectionPreventionandControlTeamhadfivepostersacceptedfortheInfectionPreventionSocietynationalconference.Onewasoverallwinnerandtwowererequestedtobesubmittedasarticlestoleadinghealthcarejournals.Oneotherposterwaschosentobeanoralpresentationattheconference.
DoctorCarolynDawson,PostDoctoralResearcherwasinvitedtoBraziltoattendtheprestigiousnovicehealthcareresearcherinternationalworkshop.Wecontinuetoworkwithotheragenciestoseeknovelsolutionstohealthcarerelatedissues.WehavebegunworkontheUrrghfactorresearchandtheWHOfivemomentsbehaviouralandeducationstudy.
The@uhcw_Inf_Contwitteraccountremainspopularwith2664followers.TheteamareinvolvedinteachingatBirminghamCity,andCoventryUniversities.
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3.5 Safeguarding Vulnerable Adults and Child Protection
TheSafeguardingTeamconsistsofaNamedNurseforChildProtection,aNamedNurseforSafeguardingVulnerableAdults,aSupportMidwifeandaSafeguardingAdministrator.Theteamisco-locatedandthisallowsforseamlesssafeguardingadviceandsupporttobeavailable.InMarch2016theSafeguardingTeamadvertisedaposttoincreasethecapacitytosupporttheAdultSafeguardingAgenda.Aposttoincreasetheteamcapacityinrelationtothechildren’sagendacommencedinMarch2016.
AdultSafeguardingTrainingatLevel1continuestobedeliveredviatheTrustinductionpackagethatallnewstaffarerequiredtoattend,withstaffrequiredtotakearefreshercourseeverythreeyears.Updatesareaccessedonline,orareavailableasbespokefacetofacesessionsuponrequest.Thereisnowane-LearningpackageforAdultSafeguardingTrainingatLevel2whichcanbeaccessedonlineviatheElectronicStaffRecord.
TheteamprovidesafulldayofSafeguardingTrainingonceamonthwhichhasevaluatedverypositively,andcoversthefollowingareas:
• Mentalhealthawareness• Mentalcapacity• DeprivationofLibertySafeguards(DoLS)• Theuseofrestraint• ThePREVENTAgenda• Domesticviolence
ThisparticularsessionisdeliveredatLevel3(childprotection).ThistraininghasbeenavailablesinceJanuary2015,andthereisamonthlyrollingprogrammeinplace.
TrainingcomplianceforLevel1(adults)hasrisenfrom85.29%inApril2015to90.22%inFebruary2016.TrainingcomplianceforLevel2(adults)hasrisenfrom86.14%inApril2015to92.94%inFebruary2016.Thismeetsthe90%compliancetargetsetforLevel1and2trainingwhichwassetbytheCoventryandRugbyClinicalCommissioningGroupthisyear.
PREVENT Training
PREVENTtrainingformspartoftheGovernment’sagendatopreventvulnerablepeoplebeingdrawnintoterrorism.The
GovernmenthasoutlinedadutythatallhealthworkerswillreceivePREVENTtraining.ThistrainingisbeingdeliveredbytheNamedNurseforSafeguardingAdults,whoisalsoaTraintheTrainerinPREVENT.ThereareplanstocreateaninternalpooloftrainersthatcanalsosupportwiththedeliveryofPREVENT.Atpresent42.56%ofstaffhavereceivedthistrainingandthenumberisincreasingsteadilymonthbymonth.ThetrainingisincludedintheSafeguardingTrainingDayandthereareplansforittobeincludedinthemandatorytrainingsuite.
RaisingawarenessofthehealthsectorcontributiontothePREVENTstrategyamongsthealthcareworkersiscrucial.TheNHSisoneofthebestplacedsectorstoidentifyindividualswhomaybegroomedinterroristactivity,with1.3millionpeopleemployedbytheNHSandafurther700,000privateandcharitablestaffdeliveringservicestoNHSpatients,wehave315,000patientcontactsperdayinEnglandalone.Staffmustbeabletorecognisesignsofradicalisationandbeconfidentinreferringindividualswhocanthenreceivesupport.
Child Protection
Level2ChildProtectiontrainingisalsodeliveredatTrustInduction.Updatesareavailableonline,orasbespokesessions,uponrequest.CompliancewithLevel2trainingattendancehasrisenfrom79.43%inFebruary2014to92.16%inJanuary2016.ThecohortofstaffrequiringLevel3childprotectioncompetenceshasbeenincreased.Thishasresultedinadecreaseinthecompliancefigures;however,atrainingstrategyisinplace,whichwilladdressthis.Priortothecohortbeingincreased,Level3compliancewasat94.42%.WorkingTogethertoSafeguardChildren(2015)andtheIntercollegiateDocument(2014)havebothbeenincor-poratedintorelevanttraining.
ForthosestaffthatrequireLevel3training,theyareencouragedandsupportedtoattendtrainingsessionsprovidedbytheCoventrySafeguardingChildrenBoard.Inaddition,UHCWdeliversLevel3trainingeventstowhichbothmulti-agencyandmulti-disciplinarydelegatesareinvited.
UHCWaverages47referralstochildren’ssocialcareeachmonth.Ofthesemorethanhalfresultinsomesocialcareactivityi.e.meetingsorassessment.Mostreferralstosocialcarearesubmittedbycommunitymidwives.
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Thisisinlinewithnationaldata.Regularauditsareundertakentoensurethatpracticeisinlinewithpolicy.ArecentSafeSleepAuditdemonstrat-edthereis100%compliance.Forthcomingauditsincludebothsingleagencyandmulti-agencyactivity.AUHCWFemaleGenitalMutilationAuditisdueinApril2016andaDomesticViolenceAuditisdueinMay2016.
BothNamedNursessupporttheirrespectiveSafeguardingBoardsubgroupsandremaincommittedtostrengtheningtheworkwithintheorganisation.Support,adviceandguidancearerequiredbystaffonadailybasisandparticipationinprofessionaldevelopmentwithstudentsisalsooffered.Learningeventsareorganisedfollowingseriouscasereviewsandsafeguardingincidentsandthisissharedwiththerelevantteamsanddepartments.Lessonslearntaredisseminatedtoallrelevantstaffandappropriatechangestopractice are introduced.
TherehasbeensignificantresourcecommittedtothecreationandsupportofthelocalMultiAgencySafeguardingHub(MASH)andtheChildSexualExploitation(CSE)agendaandmulti-agencyresponse.
3.6 Medical Revalidation
MedicalRevalidationisastatutoryrequirementbywhichlicenseddoctorsmustdemonstratetheyareup-to-dateandfittopractiseprovidinggreaterassurancetopatients,thepublic,employersandotherhealthcareprofessionals.
Itisbasedprimarilyontheoutcomeofannualappraisalthroughadoctor’sformallink(prescribedconnection)withanorganisation,knownasadesignatedbody.EachdesignatedbodyhasaResponsibleOfficer(RO)whoisresponsibleforensuringprocessesareinplacetosupportmedicalappraisalandrevalidationalongwithsubmittingrecommendationstotheGeneralMedicalCouncil(GMC).ForUHCWthisisChiefMedicalOfficer,ProfessorMeghanaPandit.Todateshehasmaderecommendationstorevalidate464oftheTrusts589prescribedconnections.
InApril2014NHSEngland(NHSE)introducedtheFrameworkforQualityAssurance(FQA)toprovideguidancewithregardstoqualityassessingtherevalidationandappraisalprocess.WiththistheTrustisobligatedtoprovideQuar-terlyAppraisalRates(QAR)toNHSE.TheTrust
mustprovideNHSEnglandwithassuranceofitsappraisalratesonaquarterlybasis.Percentagesreportedbelowfortheappraisalyear1stApril2015-31stMarch2016reflectsthosewhohavesuccessfullycompletedandthosewheretheROacceptsthatappraisalpostponementwasreasonable:
• Quarter1–86%• Quarter2–75%• Quarter3–81%• Quarter4–90%
Forthelastquarter(1stJanuary–31stMarch2016)217appraisalsdue,119doctorsdidnotholdanappraisalmeetinginthisperiod.14haveavalidreasonforpostponement(e.g.sickleave,maternity,etc.)53werestillwithinthe15monthwindowand8havesincelefttheTrust.Overall423appraisalswerecompletedthisyearmeaningcompliancewasat83%.
Achievementstostrengthenandstandardisetherevalidationandappraisalprocessmadeduringthisyearinclude:
• TheuseofMedicalPracticeInformation Transfer(MPIT)formwentliveinHuman Resources(HR)inAugust2015tomeet requirement1.1.5oftheCoreStandards laidoutintheFQA.
• Deliveryoffivein-houseappraiser top-uptrainingsessionstoretrain44 appraiserswhofirstcompletedacourse in2012,sincethereisaneedfor trainingtobeupdatedona3yearly basis.Thisalongwiththedeliveryof twonewmedicalappraiser trainingsessionshasmaintainedthe Trustsappraisertoappraiseratio. Therearecurrently96trainedappraisers intheTrust.
• NHSEIndependentVerificationVisit– RepresentativesfromNHSERegional MedicalDirectorate(Midlands&East) visitedtheTruston4thMarch2016to undertakeareviewofprocesses thatsupportMedicalRevalidation. Initialfeedbackwaspositivehoweverwe arestillawaitingformalfeedbackinthe formofareportandactionplan,which willbeimplementedintotheactionplanto TrustBoard.
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InadditiontoanythinghighlightedbytheNHSEVisitandtofurthercontinueprogresstheTrustsobjectivesfor2016/2017inrelationtomedicalappraisalandrevalidationareto:
• Ensureeducationalappraisalshavebeen undertakenbyallnamedEducationaland ClinicalSupervisorstofacilitateformal approvalwiththeGMC.
• Increaseappraisalrateswithbetter utilisationofRMSreportfunctions andsharingofinformationwithGroupsto ensuretimelycaptureofbreached appraisals.UHCWwillcontinuetowork toembedrevalidationacrossthe Trusttoensureitisviewedasatool bywhichdoctorscanreflectonand developtheirpractice,andthusdeliver ahigherqualityofcaretopatients. Goingforward,wewillcontinuetoassess ourselvesagainsttheFQAinorderto strengthenourprocessesfurther.
3.7 Equality, Diversity and Human Rights
Equality,DiversityandHumanRightsisvitaltoensuringthatourpatientsreceivethemostappropriateandrelevantservicesandtreatmenttomatchtheirneeds.Itisalsokeytoaworkforcethatisreflectiveofthecommunitiesthatitservesandabletorespondtothoseneeds.
AspertherequirementsoftheEqualityAct2010,allrelevantequalitydataispublishedannuallyontheTrust’swebsite,aswellasallpolicies,businesscasesandsignificantchangesintheTrustareassessedforimpactonprotectedcharacteristicgroups.
WenowhaveinplaceanumberofactivitiesandnewinitiativesthatnotonlyprogresstheEquality,DiversityandHumanRightsagendabutalsodemonstratesourabilitytobeexemplarsofbestpracticeandemployersofchoice.
Independent Advisory Group for Equality and Diversity (IAG)
TheIAGwassetupin2013andwearebothpleasedandencouragedbythecommitmentshowntothegroupbyitsmembers.Membershipofthegroupincludesrepresentationfrom:
• Healthwatch
• Coventry City Council
• HeartofEnglandCoventryCarer’sCentre
• TamarindCentre-BlackMentalHealth
• CoventryRefugeeandMigrantCentre
• Communityindividual(gay/lesbian community)
• Communityindividual(olderpeople)
• Grapevine(peoplewithphysical/sensory/ learningdisabilities)
• Patientrepresentative
• UHCWrepresentativesfrom: - PALS(PatientAdviceandLiaison Service) - Communications - Health Information Centre - ModernMatrons - WardManagers - Staffside - VolunteerServices - PatientExperience - FaithCentre
TheIAGhasfurtherstrengtheneditsinfluenceindevelopingpracticeandpoliciesthatpromoteEquality,DiversityandHumanRightsissuesforbothpatientsandstaff.
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Supporting Staff and Patients
TheEqualityandDiversityTeamandtheIAGhaveimplementedanddeliveredanumberoftrainingprogrammesandactivitiestodevelopknowledge,skillsandunderstanding.TheTeamhasworkedinpartnershipwithinternaldepartmentsandexternalagenciessupportingstafftobetterunderstandtheneedsofourpatientsandworkforce,makingrespectanddignitykeyelementsinallthattheydo.
Toachievethiswehave:
• Producedatrainingvideoinpartnership withtheVoluntaryServicesDepartment andPatientExperienceTeamtosupport staffwhenworkingwithblind/visually impairedanddeaf/hearingimpaired patients.
• Securedfundingtoprovideallwards witha‘Toolbox’containingresources thatwillenableblind/visuallyimpairedand deaf/hearingimpairedpatientstobe moreindependentandaccessimportant informationwhilststayinginhospital.
• DeliveredDignityatWorkTrainingtoover 300staff,furtherdevelopingtheir understandingofissuesthatcan negativelyimpactontheworking environment.
• Supportedseveraldepartmentsin developingtheirown‘StaffCharter’ settingouthowtheywillbehaveandtreat eachotherinlinewiththeTrust’svalues.
• ProvidedEqualityandDiversitytraining aspartoftheTrust’smandatorytraining programmeaswellotherbespoketraining programmes,suchasthementalhealth, mentalcapacityandrestraintday.
• Providedfeedbackregardingcultural menusforpatients.
• ConsultedwithCoventryRefugeeand MigrantCentretoidentifyspecificneeds/ issuesforrefugees,migrantsandasylum seekers.
• Organisedaseriesofactivitiesand eventsforNHSEquality,Diversity andHumanRightsWeekinMay2015.
ThisyearUHCWhasbeeninvolvedinthreekeyinitiativeswhichexemplifiesourcommitmenttomakingmeaningfulchangestoourpracticetoensuretrueengagementandaccessibilityformembersofourcommunityfromProtectedCharacteristicgroups.Theseinitiativesnotonlysupportourlocalagendabutalsoalignwithnationalaimstoaddressgapsandissuesastheyrelatetospecificgroups.
British Sign Language (BSL) Charter
OnThursday7May2015UHCWsigneduptotheBritishSignLanguageCharterataneventheldattheHenryFryCommunityCentre(CoventryDeafClub).Over100peopleattended,notonlyfromCoventryandthesurroundingareasbutfromotherpartsofthecountryincludingSheffieldandBristol.TheTrustwasthefirstpublicsectororganisationintheWestMidlandstocommittothecharterpledgingto:
• Ensureaccessfordeafpeopleto informationandservices.
• Consultwithourlocaldeafcommunityon aregularbasis.
AndtosupporttheBSLCharter,theE&DteaminconsultationwithCoventryDeafCommunityhasdeveloped a draft action plan.
(Fromlefttoright)MonicaMabbett(EqualityandDiversityAssistant),BarbaraHay(HeadofDiversity),AndyHardy(ChiefExecutiveOfficer),AndrewBlincow
(Coventry&WarwickshireAssociationfortheDeaf)LindaDay(Vice-ChairofBritishDeafAssociation),RobinAsh(BritishDeafAssociation)
TheChiefExecutiveOfficerandHeadofDiversitysignedonbehalfoftheTrust,theVice-ChairfortheBDAandarepresentativefromCoventryandWarwickshireAssociationoftheDeafsignedonbehalfoftheDeafcommunity.
TheChiefExecutiveOfficeralsotooktheopportunitytoengagewiththeDeafcommunitylisteningtotheirexperiencesandconsideringthepossiblesolutionsthatweresuggested.
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Changing Futures Together – Supported Internship Programme
UHCWhasworkedinpartnershipwithTheEmploymentSupportService(TESS),whichispartofCoventryCityCouncil’sEmploymentTeamtodevelopaSupportedInternshipProgrammeforyoungdisabledpeoplefromHerewardCollege.
ThisinitiativehasprovidedeightyoungpeoplewithlearningdisabilitiestheopportunitytocompleteworkplacementsinavarietyofdepartmentsandsettingsatUHCWduringtheninemonthprogramme.
TheInternsworkalongsidestaffandaresupportedbydedicatedJobCoaches/experiencedEmploymentAdvisors.Allinternsaretreatedinthesamewayasemployees,receivingafullinduction,occupationalhealthchecksandriskassessments.TheaimofSupportedInternshipistoenableInternstogainworkexperiencethroughon-the-jobtrainingandprovidethemwiththeskillsandknowledgerequiredforpaidemployment.Theyarealsoworkingtowardsanationallyrecognisedqualification.
TheInternstakeonvariousrolestosupportpatientcareeitheronthewards,administrationorfacilities.InstrivinginlinewiththeTogetherTowardsWorldClassorganisationaldevelopmentprogramme,thisprogrammestrengthensthesocialresponsibilitywehaveasoneofthelargestemployersinCoventryandWarwickshire.WorkforceRaceEqualityStandard(WRES)InApril2015theNHSEqualityandDiversityCouncil(EDC)introducedtheWREStoensureemployeesfromBMEbackgroundshaveequalaccesstocareeropportunitiesandreceivefairtreatmentintheworkplace.
UHCW’sWRESreportofSeptember2015identifiedanumberofareaswhereactionisre-quiredinordertoensurethatthesystemswe
haveinplacearerobustenoughtogatherthedatarequiredfortheWRESreportingtemplate.
AsmallworkinggrouphasworkedtogethertoensureajoinedupapproachandtodevelopaplanthatisbothachievableandprovidesrelevantandappropriateoutcomestomeettheneedsofourBMEstaff.
TheactionsidentifiedaredirectlyrelatedtotheWRESreportingtemplatebutalsosupporttheTrust’sTTWCprogrammeandtheTrust’sobjectivestobeanEmployerofChoiceandtoDeliverExcellentPatientCareandExperience.
3.8 Innovation to Improve Patient Care
Therearemanywaystotackleachallenge.TheUHCWInnovationTeamwascreatedtosupportstaffwiththeirideasforhowsomethingcanbedonedifferentlyandbetter.In2015-2016wecontinuedtoreceiveasteadyflowofstaffideaswith58ideasformallydisclosed.ApproximatelyhalfofthosehadIntellectualPropertywhichcouldpotentiallybeprotectedand/or exploited.
Examples of staff ideas:
Experience Innovation: Ideas for the way in which we interact, communicate and engage relevant audiences to enhance the delivery of our services.
TheTissueViabilityNurseswantedtodosomethingdifferentfor‘GlobalStopThePressureUlcerDay’inNovember2015.Wehelpedthemcreatea‘livinginstallation’usinglife-sizemock-upscenariosinthemainOutpatientswaitingarea.Thisformatwasfarmoreengagingthanjusthandingoutleaflets.
Product Innovation: Ideas for how new or existing devices and equipment could function and perform better to fill a clinical need.
Ashouldersurgeonhasdevelopedanideaforamodificationofthereverseshoulderimplantinanattempttoovercometheproblemofrestrictioninmotion.Havingfiledforapatent,wearenowincommercialisationnegotiationswiththemarketleaderinmusculoskeletalhealthcare.
Configuration Innovation: Ideas about creating superior processes, systems or networks by considering how they are best arranged or combined.
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Working with Radiology WorkingwithmembersoftheRadiologyDepartmenthelpedidentifyareasofhighestriskaswellaswhichactionswouldhavethehighestimpact,themajorityofwhichwereinformationtechnologyrelated.
Intellectual Property
Staffprovideanimportantsourceofideas,particularlyforsmall-scale,easy-to-implementinnovations.TheresponsibilitytoexploitIntellectualPropertywhichderivesfromstaffideaslieswiththeResearch,Development and Innovation Department.
During2015-16,wehaverevisedthe‘divisionofproceeds’elementoftheIntellectualPropertypolicytobemoreattractivetostaffintermsoftherevenuesharetheycouldreceiveiftheirideasturnintocommercialisedinnovation.
Innovation Hub
TheInnovationTeamhascreatedanaspirationalvisionofwhatanInnovationHubwithinUHCWwouldlooklike,includingwhowoulduseitandwhy,andwhatpartnershipsandout-comesitwouldaimtodeliver.WithcontinuedsupportfromChiefExecutiveOfficer,AndrewHardyasExecutiveSponsor,TrustBoardandChiefOfficers,implementationworkhasalreadybegunonmakingtheInnovationHubareality.AsoftlaunchisscheduledforJuly12016.
3.9 Patient Experience
TheTrust’srealtimefeedbacksystem,Impressions,hascontinuedtocapturefeedbackaboutitsservicefrompatients,relatives,carersandvisitors.Amongstthevarietyofquestions,thesurveyasksrespondentswhethertheyhadamainlygoodormainlybadimpressionoftheTrustanditsservices.Theresultsforthisquestionfor2015-2016areshownhere:
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TheTrustispleasedtonotethatthescoreswereconsistentlyinthe90%+range.Impressionsalsoasksrespondentstofeedbackintheirownwordsabouttheirexperiencesandsuggestionsforimprovements.Thesecomments/suggestionsaresenttorelevantmembersofstaffonadailybasisand,wherepossible/appropriate,actedupontodevelopservicesinlinewithwhatourpatientswant.
Friends and Family Test (FFT)
TheTrusthasimplementedtheFriendsandFamilyTest(FFT)inlinewithnationalguidanceandassuch,2015-2016hasbeenthefirstfullyeartoseeitusedthroughoutallitsservices.
PatientsrespondingtotheFriendsandFamilyTest,indicatedthehighestandlowestlevelsofsatisfactioninthefollowingelementsoftheTrust’sservices:
Highest:
• Staffrespecting[thepatient’s]privacyanddignity
• Stafftreating[thepatient]withkindnessandcompassion
• Feelingsafeinourcare
Lowest:
• Parking
• Thestandardoffoodanddrink
• Doingthingsontime
Inpatient and A&E National Comparison
ThefollowingtablesshowhowtheTrusthascomparednationallywithbothitsFFTrecommenderandresponseratesforbothInpatientsandA&E.Severalmeasureshavebeentakentoimproveresponseratesincluding:
• ThereinstatementoftheFFTImplementationGroupwithexpandedmembershiptoinclude broaderrepresentationfromstaffgroups.Itsprimaryremitistoensureresponseratesare maintained and improved.
• TheintroductionofFFTChampionsatawardanddepartmentallevelisbeingexplored.
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FFT Inpatient Experience Response Rate % by Month:
Month UHCW Figures National Figures ComparisonApr-15 25% 26% 1%↓May-15 24% 26% 2%↓Jun-15 29% 27% 2%↑Jul-15 26% 27% 1%↓Aug-15 24% 25% 1%↓Sep-15 26% 25% 1%↑Oct-15 25% 24% 1%↑Nov-15 27% 24% 3%↑Dec-15 23% 23% 0%↔Jan-16 26% 24% 2%↑Feb-16 28% 24% 4%↑Mar-16 24% 23% 1%↓
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FFT Inpatient Experience Recommender % by Month:
76%
78%
80%
82%
84%
86%
88%
90%
Rec
omm
ende
r %FFT A&E Experience Recommender % by Month
UHCWFigures NationalFigures
Month UHCW Figures National Figures ComparisonApr-15 91% 95% 4%↓May-15 90% 95% 5%↓Jun-15 90% 96% 6%↓Jul-15 91% 96% 5%↓Aug-15 91% 96% 5%↓Sep-15 92% 95% 3%↓Oct-15 91% 95% 4%↓Nov-15 90% 95% 5%↓Dec-15 90% 95% 5%↓Jan-16 89% 95% 6%↓Feb-16 92% 95% 3%↓Mar-16 89% 95% 6%↓
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FFT A&E Experience Response Rate % by Month:
0%2%4%6%8%10%12%14%16%
Res
pons
e R
ate
%FFT A&E Experience Response Rate % by Month
UHCWFigures NationalFigures
Month UHCW Figures National Figures ComparisonApr-15 13% 15% 2%↓May-15 13% 14% 1%↓Jun-15 14% 15% 1%↓Jul-15 15% 15% 0%↔Aug-15 14% 14% 0%↔Sep-15 13% 14% 1%↓Oct-15 14% 14% 0%↔Nov-15 13% 13% 0%↔Dec-15 14% 13% 1%↑Jan-16 14% 13% 1%↑Feb-16 14% 13% 1%↑Mar-16 13% 12% 1%↑
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FFT A&E Experience Response Rate % by Month:
76%
78%
80%
82%
84%
86%
88%
90%
Rec
omm
ende
r %FFT A&E Experience Recommender % by Month
UHCWFigures NationalFigures
Month UHCW Figures National Figures ComparisonApr-15 81% 88% 7%↓May-15 83% 88% 5%↓Jun-15 83% 88% 5%↓Jul-15 87% 88% 1%↓Aug-15 86% 88% 2%↓Sep-15 84% 88% 4%↓Oct-15 86% 87% 1%↓Nov-15 85% 87% 2%↓Dec-15 84% 87% 3%↓Jan-16 83% 86% 3%↓Feb-16 83% 85% 2%↓Mar-16 83% 84% 1%↓
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Maternity Friends and Family Test
Antenatal question:theTrustispleasedtonotethatfor10monthsitsrecommenderratewashigherthanthenationalaverage.
Birth question:theTrustispleasedtonotethatfor11monthsitsrecommenderratewashigherthanthenationalaverage.However,withtheexceptionofJune,JulyandAugust,itsresponseratewasbelowthisaverage.
Postnatal in hospital question:theTrustispleasedtonotethatfor10monthsitsrecommenderratewashigherthanthenationalaverage.
Postnatal in community question:theTrustispleasedtonotethatfor9monthsitsrecommenderratewashigherthanthenationalaverage.
Surveys undertaken as part of the national NHS Patient Survey Programme
Duringthe2015-2016,theresultsofthreenationalpatientsurveyswereundertaken/receivedaspartoftheCareQualityCommission’sNHSPatientSurveyProgramme:theannualInpatientSurvey,MaternityServicesSurveyandthefirstChildrenandYoungPeople’sSurvey.
WhilsttheTrustispleasedtonoteasignificantimprovementinthescoresinalargenumberofquestionsintheMaternityServicesSurvey,theresultsofitsInpatientSurveyremainmixed.TheTrustisalsodisappointedtonotethat,consistentwiththenationalpicture,theresponserateforwithitsfirstnationalChildrenandYoungPeople’sSurveyislow.
Analysisofallthesurveysundertakenduring2015-2016allowstheTrusttoconclude:
Patient,relativeandcarersatisfactionlevelsremaininghighparticularlywithstaffrespectingpatients’privacyanddignity,treatingpatientswithkindness,compassion,politenessandrespect.
Therecontinuestobehighlevelsofdissatisfactionwithparking,timeliness(e.g.waitingfortestresultsorTTOs–ToTakeOuts)andfoodanddrink.
You said we did in 2015-2016
InlinewiththeTrust’svisiontobecomeanationaland international leader in healthcare and our organisationaldevelopmentprogrammetoprovideaworldclassexperienceforourpatients,during2015-2016,theTrusthascontinuedtolistenandactupontheviewsofitspatients,relativesandcarers.Baseddirectlyonthisfeedback,areasanddepartmentshavecarriedoutthefollowinginthepast12months:
Hello My Name Is Campaign:ThenationalandinternationalHelloMyNameIscampaignwaslaunchedasaTrustwideAlwaysEventremindingallstafftoalwaysintroducethemselvestopatients.
Parking:AtUniversityHospital,onandoffsitedevelopmentshavecontinuedwiththecompletionoftheredesignoftheoff-sitepinchpointsincludingtheroundaboutatthejunctionattheAnstyRoad/HinckleyRoad/CliffordBridgeRoad,theredesignofonsiteroadsalongwiththere-routingoftraffic.
Food and Drink:WorkhascontinuedwithISS,ourPFIpartner,toimprovethemenuandthewayinwhichfoodorderingiscarriedoutacrosstheTrust.AmenureviewresultedinnewmenusbeingintroducedinApril2015withagreatermeal/snackchoiceandtheimplementationofasevenday menu cycle.
Increase in Birthing Partners:Inresponsetorequestsfromwomen,twobirthingpartnersarenowallowed.
WiFi access:WiFiaccessisnowavailableforpatientsattheHospitalofSt.Cross.
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Complaints
During2015-2016wereceived574formalcomplaints.
83%ofthe574complaintswererespondedtowithin25workingdaysofreceiptofthecomplaint.
40%ofthecomplaintsrespondedtoatthetimeofreportingwereupheld.Therearestillthree complaintsreceivedin2015-2016thatareyettobeanswered.
Parliamentary and Health Service Ombudsman (PHSO)
• Newrequestsreceivedin2015-2016–25
• ThePHSOdecided15complaintsin2015-2016–sevenpartiallyupheldandeightnotupheld.
Thetop5subjectsofcomplaint
ForfurtherinformationaboutcomplaintspleaseaccesstheComplaintsandPALSAnnualReportontheTrust’swebsite:www.uchw.nhs.uk.
Totalnumberofcomplaints
2011/12 2012/13 2013/14 2014/15 2015/16
UniversityHospitalCoventry
450 431 459 457 537
HospitalofSt.Cross,Rugby
44 42 26 21 36
Other 3 10 5 0 1 TOTALS 497 483 490 479 574 ReferredtothePHSO 25 23 16 14 25 Ratioofcomplaintstoactivity
911,206 914,700 966,763 900,392 997,149 0.05% 0.05% 0.05% 0.05% 0.06%
Allaspectsofclinicaltreatment 331
Communication/informationtopatients(writtenandoral) 107
Attitudeofstaff 58
Failuretofollowagreedprocedure 4
Admissions,dischargeandtransferarrangements 40
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3.10 PLACE (Patient Led Assessment of the Care Environment)
TheTrusthasagainachievedsatisfactoryresultscomparedtoother(PrivateFinanceInitiative)PFIhospitalsofsimilarsize:
Site Year Cleanliness Food - Overall
Food – Ward
Food- Organisation
Privacy Dignity and Wellbeing
Condition, Appearance and Maintenance
UniversityHospital
2014 98.17% 88.13% 89.96% 77.37% 97.74% 93.07%
2015 100.00% 95.24% N/A* N/A* 94.58% 97.45%
HospitalofStCross
2014 99.47% 86.19% 92.51% 76.53% 91.15% 96.12%
2015 100.00% 88.97% N/A* N/A* 92.75% 96.15%
NationalAverageAcute/Specialist
2014 97.26% 88.79% 89.1% 85.9% 87.73% 91.97%
NationalAverageAcute/Specialist
2015 97.57% 88.48% N/A* N/A* 86.02% 90.11%
*Duetochangesinscoringfor2015ascomparedto2014acomparisoncannotbedefined.TherearealsochangestothewaythePLACEauditswillbescoredin2016.
Thetableaboveshowsimprovementsinallareasacrossbothsiteswiththeexceptionofa3.16%reductionintheprivacyanddignityscoreattheUniversityHospital.Furtherworkwillbeundertakentobetterunderstandthedriversbehindtheseandappropriateactionundertakentoimprove.AcomparisonisalsoincludedtoshowthenationalaverageforAcute/SpecialistTrustsfor 2015
Althoughimprovementsweremadein2015-2016,aseriesofinitiativeswillbeadoptedacrosstheorganisationtoimprovePLACEauditscores,theseinclude:
• Cateringservices–theon-goingreview ofbothpatientandvisitorserviceswill continue.
• Regularfoodtastingsessionsare programmedforstaffandvisitorstotaste the patient menu food.
• Workcontinuestodevelopadecoration/ enhancedmaintenanceprogramto address:
- Publicspacesonatwiceyearlybasis- someareasfourtimesperyear,i.e.main entrancesandpublictoiletsdueto footfall. - EmergencyDepartmentbi-annually.- GeneralCriticalCareannually.- Ward50andtheRenalunitannually.- AshRenalunitannually.- OffsiteRenalUnitsannually.
UHCWworkedwithHealthwatchCoventrytoconsiderhowtostrengthenlayinvolvementinthePLACEassessmentprocessandensurethatmorelayassessorswereavailableforthenextroundtobalancetheassessmentteams.AworkshopwasrunbyLincolnDawkin,DirectorofEstatesandattendedbyHealthwatchvolunteers.ThisenabledvolunteerstobebriefedonthePLACEmethodology,howtorecordfindingsanddiscussionofhowbesttoorganisetheassessments.TheinputofVolunteerAssessorsisimperativewhencontributingtoimprovementstotheNHS.FollowingthissuccessfulworkshopthenumberofvolunteerPLACEAssessorsincreasedandnotificationhasbeenissuedforthe2016PLACEaudits.
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Site Access and Car Parking
Workhasbeenprogressingduring2015-2016withtheplannedon-siteimprovementstoaddressongoingcarparkingandcongestionissues.
PlanningpermissionwasgrantedinMay2013foraseriesofon-siteworks.Thefollowinghavebeencompleted:
• Anewtaxirank.
• Anewlargermainentrancepatientdrop offzone.
• Anupgradedbusinterchangefacilitythat willincreasecapacity.
• Modifiedroadandcarparkaccess layoutstoenablebettertrafficflow.
• Automatedcarparksignageindicating locationofavailablespaces.
Thereareafurthertwoelementswhicharebeingplannedtoincreasebothstaffandvisitorparkingandaredueforcompletionbytheendof2016.
Theseare:
• AnextensiontotheA&Edeckedcarpark.
• Anewraiseddecktoasectionofthecar parkbytheFacilitiesManagement(FM) Building.
Inconjunctionwiththeon-siteworks,asuccessfulapplicationwassubmittedtotheDepartmentofTransportwithCoventryCityCouncilfor£3.9moffundingtoaddressthepinchpointissuestojunctionsonroadsapproachingUniversityHospital.Theseworksarenowcompletedandconsistof:
• MajorenhancementstotheAnstyRoad/ CliffordBridgeRoadgyratoryjunction includingthemainhospitalsiteaccess.
• AdditionallanesattheAnstyRoad/Hall Lanecrossroadstoincreasevehicular capacityandrelievedelays,particularlyin WoodwayLane.
• Newpedestriancrossingfacilitiesatthe HinckleyRoad/BradeDriveroundabout.
3.11 Staff Experience
TheNHSStaffSurveyisundertakennationallybyallTrustsonanannualbasisandtakesplacebetweenthemonthsofOctoberandDecember.ThesurveyisusedtogaugethedegreeofstaffengagementandidentifytheeffectsofthefourstaffpledgeswithintheNHSConstitution.
Staff Pledges
ThefourstaffpledgescontainedintheNHSconstitutionare:
Staff Pledge 1:Toprovideallstaffwithclearrolesandresponsibilitiesandrewardingjobsforteamsandindividualsthatmakeadifferencetopatients,theirfamiliesandcarersandcommunities.
Staff Pledge 2:Toprovideallstaffwithpersonaldevelopment,accesstoappropriatetrainingfortheirjobsandlinemanagementsupporttoenablethemtofulfiltheirpotential.
Staff Pledge 3:Toprovidesupportandopportunitiesforstafftomaintaintheirhealth,well-beingandsafety.
Staff Pledge 4:Toengagestaffindecisionsthataffectthemandtheservicestheyprovide,individually,throughrepresentativeorganisationsandthroughlocalpartnershipworkingarrangements.Allstaffwillbeempoweredtoputforwardwaystodeliverbetterandsaferservicesforpatientsandtheirfamilies.
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2015 National Staff Survey
The2015NHSStaffSurveyinvolved297NHSorganisationsinEngland,withover741,000NHSstaffbeinginvitedtoparticipateusingaself-completionpostalquestionnairesurveyorelectronicallyviaemail.
Allfull-timeandpart-timestaffdirectlyemployedbyUHCWonSeptember1st2015wereeligibletoparticipateinthesurveythatwascarriedoutbetweenmid-Septemberand30thNovember2015.2015sawtheTrustutilisethenewlyintroducedoptionofelectronicsurveys,sodependingontheirstaffgroup,850randomlyselectedstaffweresenteitherapapercopyofthesurveyoralinktotheonlinesurveyviaemail.QualityHealth,ournationalstaffsurveyadministrator,sentthesurveysandemailsalongsidealetterfromourChiefExecutiveOfficerandremindercopiesofthesurveyandemails,forthosewhohadnotreturnedtheirsurveywithinafourweekperiod.
Response rate
TheTrust’sresponseratehasimprovedslightlythisyearto39%(332staff),anincreaseof2%from2014,althoughbelowthenationalaverageforAcuteTrust’swhichwas41%.ThenationalaverageforAcuteTrustshasslightlyfallenfrom42%in2014.
Engagement Score
Overallourengagementscore,measuredonascaleof1(poorlyengaged)to5(highlyengaged)calculatedusingtheresponsetoseveralofthesurveyquestions,standsat3.91.
Thisisanincreasefrom3.78in2014andisabovethenationalaverageforAcuteTrustswhichstandsat3.79.Onanationalscale,theoverallstaffengagementindicatorhasincreasedslightlyfrom3.70(2014)to3.79(2015).
Acute Sector Comparisons
Aswellasreceivingourresponsedirectly,ourresponsesarecomparedtootherAcuteTrustsinEngland.Fromthiswecanidentifytheareaswhereweperformmostandleastfavorably.
TheNationalStaffSurveyprovidesuswithabaselinesetofdataandanindicationofwhereactionsshouldbefocused.However,theresultsshouldalsobetreatedwithcaution,giventhesmallnumberofrespondentsincomparisontoourstaffbody.
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Top Five Ranking Areas
Thedriversforthisimprovementonthismetricincludeimprovementsinstafffeelingtheyhavetheabilitytocontributetowardsimprovementatwork,thenumbersofstaffrecommendingtheTrustasaplacetoworkorforfriendsandfamilytobetreated,andtheextenttowhichstafflookforwardtogoingtoworkandareenthusiasticabouttheirroles.
Key
Positivefinding,increaseinscoredcomparedto2014
Negativefinding,decreasedinscorecomparedto2014
Becauseof changes to the format of the survey questions this year, comparisonswith the2014scorearenotpossible
Area 2015 UHCW Percentage Score or Scale Summary Score
2015 Acute Average Score
Percentageofstaffagreeingthattheirrolemakes a difference to patients / serviceusers
93% 90%
Recognition and value of staff bymanagersandtheorganisation
3.60
3.42
Staff satisfaction with resourcing andsupport
3.51 3.30
Percentage of staff appraised in last 12months 93%
86%
Percentage of staff reporting errors, nearmisses or incidents witnessed in the lastmonth
94% 90%
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Bottom Four Ranking Scores
Where Staff Experience Has Improved
Thetablebelowhighlightsthefivekeyfindingswherestaffexperienceshaveimprovedattheorganisationsincethe2014survey.
Area 2015 UHCW Percentage Score
2015 Acute Average Score
Percentageofstaff /colleaguesreportingmostrecent experience of violence 41%
53%
Percentage of staff experiencing physicalviolencefrompatients,relativesorthepublicinthelast12months
16% 14%
Percentage of staff witnessing potentiallyharmful errors, nearmissesor incidents in thelastmonth
31% 31%
Percentage of staff experiencing harassment,bullyingorabusefrompatients,relativesorthepublicinthelast12months
28% 28%
Area 2015 UHCW Percentage Score or Scale Summary Score
2015 Acute Average Score
Staffmotivationatwork 4.03
3.89
Effectiveuseofpatient/serviceuserfeedback 3.76
3.51
Supportfromimmediatemanagers 3.82
3.66
Percentageof staff experiencingdiscriminationatworkinthelast12months 10%
15%
Staff recommendation of the organizationas aplacetoworkorreceivetreatment 3.90
3.76
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Where Staff Experience Has Deteriorated
ThetablebelowhighlightstheoneKeyFindingthathasdeterioratedattheTrustsincethe2014survey.
StafffeedbackalreadyformsthebasisofactionsbeingundertakenundertheTogetherTowardsWorldClassprogramme.Therefore,adecisionhasbeentakennottocompleteseparateactionsplansfromtheNationalStaffSurveyresults.
However,ourresultshaveidentifiedthatfocusneedstobegiventotheTrust’sresponsetonotonlythepercentageofstaff/colleaguesreportingviolence,butalsotostaffexperiencingphysicalviolenceandaggression.Todate,therearenospecificactionsundertheTogetherTowardsWorldClassprogrammethatwouldaddressthisareathereforeseparateactionswillbeledintheareabytheTrust’sSecurityManager,withareportbeingprovidedtoQualityGovernanceCommitteeinMarch2016.
Staff Friends and Family Test
Background
Undertakeneverythreemonths,theStaffFriendsandFamilyTestasksstafftogivetheirfeedbackonhowlikelytheyaretorecommendtheTrusttofriendsandfamilyforcareortreatmentandhowlikelytheyaretorecommendtheTrustasaplacetowork.
TheTrustisobligedtoaskallstafftheStaffFriendsandFamilyTestquestionsonanannualbasis,withtheopportunitytoundertakewithidentifiedsamplesintheremainingperiods.
Furthermoreaspartofourcommitmenttomovetowardsgainingcontinuousstafffeedbackwehaveprovidedallstaffwiththeopportunitytocompletethequestionsonaquarterlybasis,withtheexceptionofQuarter3(September–November2015)whereresultsweregatheredthroughtheNationalStaffSurvey.
Staff Friends and Family – Service/ Treatment Provider
2015-2016 Results - “How likely are you to recommend our Trust to friends and family if they needed care or treatment?”
Area 2015 UHCW Percentage Score
2015 Acute Average Score
Percentageofstaff /colleaguesreportingmostrecent experience of violence 41%
65%
Period Recommender Non-recommender Unsure
2015Qtr4(1371) 87% 4% 9%
2015 Qtr3(332) 76% 5% 18%
2015Qtr2(1655) 89% 3% 7%
2015Qtr1(288) 81% 7% 13%
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InQuarter3(throughtheNationalStaffSurvey)76%ofrespondentssaidtheywouldrecommendtheTrustasaplacetoreceivetreatment.WhilstthisisadecreasefromQuarter2(89%)weremainabovethenationalaverageof69%recommendingtheirTrust.
Staff Friends and Family – Workplace
2015-2016 Results – “How likely are you to recommend our Trust to friends and family as a place to work?”
InQuarter3(throughtheNationalStaffSurvey)68%ofsurveyrespondentssaidtheywouldrecommendtheTrustasaplacetoworkcomparedtoanationalaverage59%.
WhilstitisdisappointingtoseeareductioninthepercentageofrecommendersinQuarter3,itisimportanttonotethatthedifferentsurveymethodologiesusedacrossthequarters.Insummary,theNationalStaffSurveyisonlyreceivedbyarandomsampleof850staff,thereforerestrictingthoseinvolvedinrespondingtotheStaffFFTinQuarter3whilstinQuarter1andQuarter2allstaffhavehadtheopportunitytoparticipateprovidingawiderrepresentationofviews.TheresultsgainedinQuarter4throughStaffImpressionswillprovideanopportunitytofurtherreviewpatternsofrecommenders.
3.12 Performance against National Priorities 2015-2016
QualityandPatientSafetyIndicatorsgiveTrusts,Commissionersandthegeneralpublic,comparabledataonhowweareperforming.Becausetheindicatorsarestandardised,andhavetobemeasuredinspecificways,theyprovideanopportunityforperformancetobecomparedovertimeandacrosstheNHS.ThelocalindicatorsareagreedbytheTrustBoardandwhereappropriateagreedwithourCommissioners.ThebelowtableofindicatorsareoneswhereUHCWisrequiredtosubmitinformationnationally.
Period Recommender Non-recommender Unsure
2015Qtr4(1371) 71% 12% 16%
2015Qtr3(332) 68% 8% 24%
2015Qtr2(1655) 80% 8% 11%
2015Qtr1(288) 65% 17% 18%
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Indicators Target 2015/16
2015/16 2014/15 2013/14 Rating
CQCFundamentalStandards n/a Licensedwithout
conditions
Licensedwithout
conditions
Licensedwithout
conditionsMaximumtimeof18weeksfrom point of referral to treatmentinaggregate-patientsonaincompletepathway
92% 89.67% 88.10% 94.01%
Maximumtimeof18weeksfrom point of referral to treatmentinaggregate-admitted
90% 72.09% 75.13 91.84
Maximumtimeof18weeksfrom point of referral to treatmentinaggregate-non-admitted
95% 88.36% 94.41% 97.55%
A&E:maximumwaitingtimeoffourhoursfromarrivaltoadmission/transfer/discharge
95% 89.17% 90.37% 93.93%
Cancer:twoweekwaitfromreferraltodatefirstseen,comprising:allurgentreferrals(cancersuspected)
93% 96% 97.3% 94.41%
-forsymptomaticbreastpatients(cancernotinitiallysuspected)
93% 93% 98.8% 94.57%
Allcancers:31-daywaitfromdiagnosistofirsttreatment
96% 99.1% 99.3% 99.49%
Allcancers:31-daywaitforsecondorsubsequenttreatment,comprising:-surgery
94% 97% 98% 99.08%
-anticancerdrugtreatments 98% 100% 100% 100%
- radiotherapy 94% 96% 95.5% 95.80
Allcancers:62daywaitforfirsttreatmentfrom:-urgentGPreferralforsuspectedcancer
85% 82.7% 84.6% 85.01
-fromNHSCancerScreeningServicereferral
90% 93.7% 95.4% 95.92%
Performance against locally agreed priorities
*TheHSMRfigurefor2015/16isnotpublishedtotheTrustuntilJuly2016.
Indicators Target 2015/16
2015/16 2014/15 2013/14 Rating
NumbersofacquiredavoidablePressureUlcersIncidentreporting
Grade3:0Grade4:0
Grade3:21Grade4:0
Grade3:21Grade4:1
Grade3:16Grade4:0
Incidenceof‘NeverEvents’ 0 3 3 4
Hospitalstandardisedmortalityratio(HSMR)
100 * 109.18 104.84 Notyetrated
Delayedtransfersofcare 3.5% 6.67% 5.67% 4.37%
Breachesofthe28dayreadmissionguarantee
0 112 119 118
FriendsandFamilyTestinpatientrecommenders
89% 89.23% 90.82% n/a
FriendsandFamilyTestA&Erecommenders
85% 83.17% 81.9% n/a
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Indicators Target 2015/16
2015/16 2014/15 2013/14 Rating
ClostridiumDifficile-meetingtheClostridiumDifficileobjective
42 L38 41 47
Methicillin-resistantStaphylococcusAureus(MRSA)bacteraemia-meetingtheMRSAobjective
0 80 9 2
Certificationagainstcompliancewithrequiredaccesstohealthcareforpeoplewithlearningdisability
Green Green Green Green
Section 4An Invitation to comment and offer feedback
Your Views - Your Involvement
ThankyoufortakingthetimetoreadourannualQualityAccount.Wehopeyouhavefounditaninterestingandenjoyableread.IfyouwouldliketocommentonanyaspectofthisAccountorgiveusfeedbackonanyaspectofourservices,pleasewriteto:
Quality Department
UniversityHospitalsCoventryandWarwickshireNHSTrustCliffordBridgeRoadCoventryCV2 2DX
Youcanalsoshareyourviews:
• byvisitingourwebsitewww.uhcw.nhs.ukandcompletingtheImpressionsSurveyor
• byvisitingNHSChoiceswebsiteatwww.nhs.uk
Welookforwardtohearingyourcommentsandsuggestions.
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ANNEXES
Statements from Partners
NHS Coventry and Rugby Clinical Commissioning Group Commentary
NHSCoventryandRugbyClinicalCommissioningGroup(CCG)welcometheopportunitytocommentonUniversityHospitalsCoventryandWarwickshireNHSTrust’s2015/16QualityAccount.TheCCGbelievethattheQualityAccountfor2015/16meetstherequiredcontentassetoutinnationalguidanceandisagoodreflectionofthequalityofservicesprovidedbytheTrust.Whilstnotalldatafieldswerecompleteinthedraftaccount,theCCGhasreviewedtheinformationpresentedagainstdatasourcesavailabletotheCCGaspartofcontractingandperformanceandcanconfirmthemasaccurate.
TheTrusthasexperiencedanumberofchallengesthisyear,thefirstbeinginrelationtotheachievementofAccidentandEmergencyfourhourwaitstargetwhichisalsorecognisedasachallengeforthemajorityofacutetrustsnationally.ThiswillcontinuetobeoneofthebiggestchallengestheTrustwillhaveoverthenextyear.ItwillrequireeffectivepartnershipworkingwithcommunityprovidersandsocialcarethroughtheSystemTransformationPlantosupportachievementofthistarget.AsaCCG,wewillensurepatientsremainsafethroughcontinuedassurancevisitstotheTrust.
Nationally,achievementof62DayCancerwaitsisalsoachallenge.Locally,theTrusthasundertakensignificantworktostreamlinecancerpathwaysandreduceunnecessarydelays.Thishasbeguntoshowimprovementsandweareoptimisticthatthiswillhaveapositiveimpactonachievementofthistargetinthecomingyear.Nationally,achievementof62DayCancerwaitsisalsoachallenge.Locally,theTrusthasundertakensignificantworktostreamlinecancerpathwaysandreduceunnecessarydelays.Thishasbeguntoshowimprovementsandweareoptimisticthatthiswillhaveapositiveimpactonachievementofthistargetinthecomingyear. Patientfeedbackisanimportantpartofmonitoringandserviceimprovement.WearepleasedwithhowtheTrusthasmadesignificantprogresshandlingandrespondingtocomplaints.TheTrust’sstrengtheningoftheirPALSServicehasmadeasignificantdifference.However,theTrusthasfurtherworktodoinordertoensurelearningandfeedbackfromcomplaintsistranslatedintopractice.ThiswillbeapriorityfortheTrustin2016/17.
During2015/16theTruststrengthenedtheirSafeguardingTeamandisplanningtoincreasecapacityfurtherin2016/17.Thisisextremelypositiveandweareconfidentthiswillenablethemtoachievetheirtrainingtargets.However,wearedisappointedthatthePREVENTAgendahasnotprogressedaswewouldhavehoped,asthisisakeynationalpriority.
Whilsttheendofyearpositionisnotavailableattimeofwriting,evidencetodateindicatestheTrusthasprogressedwellagainsttheirnationalCQUINsforDementia,DeliriumandAcuteKidneyInjury(AKI)for2015/16.However,wearedisappointedthattheTrusthasnotprogressedalocalCQUINinrelationtocommunicatingwithpatientsandGeneralPractitionerspostdischarge.WeseethisasakeyimprovementareaandwillworkwiththeTrustthisyear,withtheaimofexploringimprovementstrategies.
TheTrusthasexcellentMaternityServices,whohavelistenedtofeedbackfrompatientsandrespondedbyimplementinginnovativepractices.TheyhavealsosharedagapanalysiscompletedagainsttherecommendationswithinthenationalBetterBirthsReport.Theirfocusfor2016/17willbetofurtherstrengthenMaternityServicesthrougheffectivemulti-professionalpartnershipworking. PatientSafetyremainsapriorityfortheCCG.WearedelightedthattheTrustwassuccessfulsecuringaplaceonanationalprojectbeingpilotedbytheDepartmentofHealthtoworkalongsidetheVirginiaMasonInstitute.TheCCGfullysupportstheinitialworkstreamsthathavebeenidentifiedbytheTrust.TheseincludeOphthalmology,TheatresandSeriousIncidentreporting.
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WebelievethiscomplimentstheTrust’sparticipationinthenationalSignuptoSafetycampaign.ThisshouldhaveasignificantpositiveimpactintermsofpatientsafetyandwewillfollowtheTrust’sprogresswithgreatinterest.Inconclusion,werecognisethattheTrusthasmadegoodprogressinanumberofareasandcanconfirmthatwefullysupporttheprioritiesidentifiedbytheTrustfor2016/17.
UHCW Comment:
UHCWwouldliketothankourCommissionersfortheirresponsetothe2015-16QualityAccount.WearecommittedtoworkingeffectivelywithourpartnersinthecommunityandsocialcaretostrivetoachievetheAccidentandEmergencyfourhourwaittarget.TheTrustisinagreementthatfurtherenhancementsneedtotakeplaceinrelationtohowlearningfromcomplaintsandconcernsleadstoimprovementsinpatientexperience.WecontinuetolookforwardtoworkingwiththeCCGonanumberofprojectsin2016-17andwelcometheircontinuedsupportinhelpingtorealiseourvisionofbecomingWorldClass.
Joint Quality Account Task Group Commentary
TheQualityAccountTaskGroupismadeupofHealthwatchCoventry,HealthwatchWarwickshire,CoventryCityCouncilScrutinyandWarwickshireCountyCouncilScrutiny.TheGroupmetwiththeTrustanddiscussprogressonlastyear’sprioritiesandtodiscusswhatshouldbeincludedasprioritiesthisyear.OverallthisdocumentisclearandeasytoreadwithintheconstraintsforthetemplateinformationTrusts’mustusewhenwritingaqualityaccount.
Theversionwereceivedtoprovideourcommentarywasnotcomplete–withnationaldatarelatedtoNHSoutcomesandotherdatawasnotavailable.Thisyearmoredatawasunavailabletousthanhaspreviouslybeenthecaseandthiswasproblematic.
However,weknowfromourongoingworkthatthisyearamajorchallengeforUHCWandthewiderhealthandsocialcaresystemhasbeentheflowthroughthehospitalfromA&E,toadmissionandthroughtodischarge.Thehospitalisoperatingataveryfulllevelofbedoccupancy.ThishasbeenimpactingonA&EwaitingtimesandtheTrust’sabilitytoachievethe4hourtargetwhichhasbeenmissedforanumberofconsecutivemonths.Therehavealsobeenissuesregardingmeetingcancerreferralwaitingtimetargetsandotheroutpatientreferraltargetsduringthecourseoftheyear,whichimpactsonpatientsnegatively.
EffectivejointworkandplansacrossNHSandsocialcareorganisationsareneededinordertoaddressissueswithpatientflow.
Thestatedproposaltointroduceweekendandeveningphysiotherapyiswelcome.Itshouldaidrecoveryandthedischargeprocess,althoughthereisnoindicationthatoutcomesaretobemeasured.
ItispleasingthatUHCWhavereversedpreviousincreasesincasesofMRSAandthefocusonOphthalmologyoutpatientsthroughtheTrust’sVirginiaMasonworkiswelcomeasthisreflectsfeedbackreceivedbyHealthwatch.
ThesectionoutliningresponsestotheCQCinspectionreportof2015wouldbenefitfrommoredetailaboutwhatactionstheTrusthastakentoaddressthepointshighlightedbytheCQCforexampleintheimagingdepartment.
Last year’s priorities
Priority1:Handover–ThisseemstobeworkinprogressacrosswhatisalargeTrust,whereconsistencyofuseofthetoolsdevelopedisimportant.
Priority2:EndofLifecare-FromtheinformationprovideditseemsthatalotofgoodworkhasbeendoneregardingEndofLifeCare.
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Priority3:Alwaysevents-DuringtheyeartherehasbeenachangeandfocusingoftheoriginalgoalsetlastyearofimplementingAlwaysEvents.TheHellomyNameIsinitiativeispositiveandchimeswithpatientfeedbackbutitisunclearhowextensivetheadoptionhasbeenacrosstheTrust.
Thereisanopportunitytoworkwithpatientsandrelativestoestablishabroadersetofpatientfocusedalwaysevents.
2016/17 Priorities
TheQualityAccountTaskGroupprovidedfeedbackonalonglistofpotentialqualityprioritiesandprovidedchallengeaboutsettingprioritieswhicharesufficientlychallenginganddonotreplicateexistingworkplansforexamplerelatedtotheTrust’sCQCinspectionin2015.Wefeelwehavebeenpartlysuccessfulinthis.
Priority1:IncreasingthereportingofmedicationerrorsTheinformationprovidedaboutthisgoalisclearandwellevidencedwithaclearmeasurementinplace.
Priority2:ImprovingcarebundlecomplianceThereismuchevidencetosupporttheimplementationofcarebundlesandanexpectationthatTrustswilldoso(hencetheCQUINtargetsalreadyinplace).Thereforeisseemsthatthispriorityistoacertainextentbusinessasusual.
Priority3:CareContactTimeTherecordingsystemdescribedise-basedandtheredoesnotseemtobeanelementofpatientfeedback.Thismakesthispriorityseemtobeabouttimeuseefficiencyratherthanpatientcontact.Whilstefficientandeffectivecareisimportantthisisapatientexperiencepriorityandthereforeshouldcapture an element of patient experience.
Other issues
Pressureulcersarethe1stand3rdhighestseriousincidentseventhoughtherehasbeenawidespreadpressureulcerpreventioncampaignoverlastcoupleofyears.Slipstripsandfallsrepresentthe2ndlargestnumberofseriousincidentsandthereforewouldbenefitfromdetailabouthowtheTrustwillworkonthis.
ItisgoodtoreaddetailsofworkrelatedtodementiaawarenessandthecommitmentfromtheTrusttoaddressingcareforpatientswhohavedementia.Thetrustissizeableandthereforethereisalargeongoingtaskoftrainingstaffwhichrequiresresourcing.
Carer’sofDementiapatientshaveasupportgroupaswellascompletingacarerssurvey.Thisideacouldbeextendedtothecarersofpatientsmoregenerally.
Communicationissueswithdeafpatients,peoplewithlearningdisabilityandpeoplewithEnglishasasecondlanguagehavebeenflaggedtoHealthwatch.Theworktodevelopresources,supportforstaffandsignuptotheBSLCharterarewelcomeandshouldbebuiltuponfurther.ThereisabigemphasisinthedocumentonFriendsandFamilyTestdataandlessinformationaboutotherTrustinitiativestogatherpatientexperienceortocarryoutdifferentlevelsofpatientengagementactivity.WewouldhavelikedtoseeacommitmenttodevelopingtheTrust’spatientengagementstrategywithinthisdocument.
TheTrustisclearlycarryingoutsignificantworkrelatedtoquality,howevermuchofthisisdrivenfrommanagementorotherinitiativesandthereisscopefordevelopingpatientinvolvementandengagementtodrivechangesandquality.ThiswillenabletheTrusttobeinabetterpositiontoinvolvepatientsandthepublicinthequalityaccountandsettingprioritiesforquality.
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Thecomplaintsdatawasnotavailabletousatthetimeofwriting.Fornextyearwewouldliketoseetheemphasisshifttoafocusonlearningfromcomplaints.
WelookforwardtocontinuingtoworkwiththeTrustinthecomingyear.
UHCW comment:
WewelcometheresponsefromtheJointQualityAccountTaskGroup.TheTrustagreesthateffectivejointworkingandplansacrossNHSandsocialcareorganisationsisrequiredtomeetthechallengesaroundpatientflowthroughthehospitalandUHCWarecommittedtothis.TheTrustwouldliketoworkfurtherwithHealthwatchinfurtherdevelopingourpatientinvolvementandengagementstrategyandwelookforwardtoworkingwiththeJointTaskGroupagainin2016-17.
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Statement of Directors’ Responsibilities in respect of the Quality Account
The directors are required under the Health Act 2009 to prepare a Quality Account each financial year. The Department of Health has issued guidance on the form and content of the Quality Accounts (which incorporates the legal requirements in the Health Act 2009 and the National Health Service (Quality Accounts) Regulations (as amended by the National Health Service (Quality Accounts) Amendment Regulations 2011 and the National Health Service (Quality accounts) Amendment Regulations)
InpreparingtheQualityAccount,directorsarerequiredtotakestepstosatisfythemselvesthat:
• theQualityAccountpresentsabalancedpictureoftheTrust’sperformanceovertheperiod covered;• theperformanceinformationreportedintheQualityAccountisreliableandaccurate;• thereareproperinternalcontrolsoverthecollectionandreportingofthemeasuresof performanceincludedintheQualityAccount,andthesecontrolsaresubjecttoreviewto confirmthattheyareworkingeffectivelyinpractice;• thedataunderpinningthemeasuresofperformancereportedintheQualityAccountisrobust andreliable,conformstospecifieddataqualitystandardsandprescribeddefinitions,andis subjecttoappropriatescrutinyandreview;and• theQualityAccounthasbeenpreparedinaccordancewithDepartmentofHealthguidance.
ThedirectorsconfirmtothebestoftheirknowledgeandbelieftheyhavecompliedwiththeaboverequirementsinpreparingtheQualityAccount.
ByorderoftheBoardNB: sign and date in any colour ink except black
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External Auditors
Independent Auditors’ Limited Assurance Report to the directors of University Hospitals Coventry and Warwickshire NHS Trust on the Annual Quality Account
WearerequiredtoperformanindependentassuranceengagementinrespectofUniversityHospitalsCoventryandWarwickshireNHSTrust’sQualityAccountfortheyearended31March2016(“TheQualityAccount”)andcertainperformanceindicatorscontainedthereinaspartofourwork.NHStrustsarerequiredbysection8oftheHealthAct2009topublishaQualityAccountwhichmustincludeprescribedinformationsetoutinTheNationalHealthService(QualityAccount)Regulations2010,theNationalHealthService(QualityAccount)AmendmentRegulations2011andtheNationalHealthService(QualityAccount)AmendmentRegulations2012(“theRegulations”).
Scope and subject matter
Theindicatorsfortheyearended31March2016subjecttolimitedassuranceconsistofthefollowingindicators:
• FriendsandFamilyPatientElementScore;and• Percentageofpatientsriskassessedforvenousthromboembolism.
Werefertothesetwoindicatorscollectivelyas“theindicators”.
Respective responsibilities of the Directors and the auditor
TheDirectorsarerequiredundertheHealthAct2009toprepareaQualityAccountforeachfinancialyear.TheDepartmentofHealthhasissuedguidanceontheformandcontentofannualQualityAccounts(whichincorporatesthelegalrequirementsintheHealthAct2009andtheRegulations).
InpreparingtheQualityAccount,theDirectorsarerequiredtotakestepstosatisfythemselvesthat: • theQualityAccountpresentsabalancedpictureofthetrust’sperformanceovertheperiod covered; • theperformanceinformationreportedintheQualityAccountisreliableandaccurate;• thereareproperinternalcontrolsoverthecollectionandreportingofthemeasuresof performanceincludedintheQualityAccount,andthesecontrolsaresubjecttoreviewto confirmthattheyareworkingeffectivelyinpractice;• thedataunderpinningthemeasuresofperformancereportedintheQualityAccountisrobust andreliable,conformstospecifieddataqualitystandardsandprescribeddefinitions,andis subjecttoappropriatescrutinyandreview;and• theQualityAccounthasbeenpreparedinaccordancewithDepartmentofHealthguidance.
TheDirectorsarerequiredtoconfirmcompliancewiththeserequirementsinastatementofdirectors’responsibilitieswithintheQualityAccount.
Ourresponsibilityistoformaconclusion,basedonlimitedassuranceprocedures,onwhetheranythinghascometoourattentionthatcausesustobelievethat:
• theQualityAccountisnotpreparedinallmaterialrespectsinlinewiththecriteriasetoutinthe Regulations;• theQualityAccountisnotconsistentinallmaterialrespectswiththesourcesspecifiedinthe NHSQualityAccountsAuditorGuidance(“theGuidance”);and• theindicatorsintheQualityAccountidentifiedashavingbeenthesubjectoflimitedassurance intheQualityAccountarenotreasonablystatedinallmaterialrespectsinaccordancewiththe RegulationsandthesixdimensionsofdataqualitysetoutintheGuidance.
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WereadtheQualityAccountandconcludewhetheritisconsistentwiththerequirementsoftheRegulationsandtoconsidertheimplicationsforourreportifwebecomeawareofanymaterialomissions. WereadtheotherinformationcontainedintheQualityAccountandconsiderwhetheritismateriallyinconsistentwith: • BoardminutesfortheperiodApril2015toJune2016;• papersrelatingtoqualityreportedtotheBoardovertheperiodApril2015toJune2016;• feedbackfromtheCommissionersdated25/05/2016;• feedbackfromLocalHealthwatchdated07/06/2016;• theTrust’scomplaintsreportpublishedunderregulation18oftheLocalAuthority,Social ServicesandNHSComplaints(England)Regulations2009,dated30/06/2016• feedbackfromothernamedstakeholder(s)involvedinthesignoffoftheQualityAccount;• thelatestnationalpatientsurveydatedFebruary2016;• thelatestnationalstaffsurveydatedFebruary2016;• theannualgovernancestatementdated01/06/2016;• theCareQualityCommission’sIntelligentMonitoringReportdatedMay2015.
Weconsidertheimplicationsforourreportifwebecomeawareofanyapparentmisstatementsormaterialinconsistencieswiththesedocuments(collectivelythe“documents”).Ourresponsibilitiesdonot extend to any other information.
Thisreport,includingtheconclusion,ismadesolelytotheBoardofDirectorsofUniversityHospitalsCoventryandWarwickshireNHSTrust. WepermitthedisclosureofthisreporttoenabletheBoardofDirectorstodemonstratethattheyhavedischargedtheirgovernanceresponsibilitiesbycommissioninganindependentassurancereportinconnectionwiththeindicators.Tothefullestextentpermissiblebylaw,wedonotacceptorassumeresponsibilitytoanyoneotherthantheBoardofDirectorsasabodyandUniversityHospitalsCoventryandWarwickshireNHSTrustforourworkorthisreportsavewheretermsareexpresslyagreedandwithourpriorconsentinwriting.
Assurance work performed
WeconductedthislimitedassuranceengagementunderthetermsoftheGuidance.Ourlimitedassuranceproceduresincluded:
• evaluatingthedesignandimplementationofthekeyprocessesandcontrolsformanagingand reportingtheindicators;• makingenquiriesofmanagement;• testingkeymanagementcontrols;• limitedtesting,onaselectivebasis,ofthedatausedtocalculatetheindicatorbackto supportingdocumentation;• comparingthecontentoftheQualityAccounttotherequirementsoftheRegulations;and• readingthedocuments.
Alimitedassuranceengagementisnarrowerinscopethanareasonableassuranceengagement.Thenature,timingandextentofproceduresforgatheringsufficientappropriateevidencearedeliberatelylimitedrelativetoareasonableassuranceengagement.
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Limitations
Non-financialperformanceinformationissubjecttomoreinherentlimitationsthanfinancialinformation,giventhecharacteristicsofthesubjectmatterandthemethodsusedfordeterminingsuchinformation.
Theabsenceofasignificantbodyofestablishedpracticeonwhichtodrawallowsfortheselectionofdifferentbutacceptablemeasurementtechniqueswhichcanresultinmateriallydifferentmeasurementsandcanimpactcomparability.Theprecisionofdifferentmeasurementtechniquesmayalsovary.Furthermore,thenatureandmethodsusedtodeterminesuchinformation,aswellasthemeasurementcriteriaandtheprecisionthereof,maychangeovertime.ItisimportanttoreadtheQualityAccountinthecontextofthecriteriasetoutintheRegulations. Thenature,formandcontentrequiredofQualityAccountsaredeterminedbytheDepartmentofHealth.Thismayresultintheomissionofinformationrelevanttootherusers,forexampleforthepurposeofcomparingtheresultsofdifferentNHSorganisations.
Inaddition,thescopeofourassuranceworkhasnotincludedgovernanceoverqualityornon-mandatedindicatorswhichhavebeendeterminedlocallybyUniversityHospitalsCoventryandWarwickshireNHSTrust.
Conclusion
Basedontheresultsofourprocedures,nothinghascometoourattentionthatcausesustobelievethat,fortheyearended31March2016:
• theQualityAccountisnotpreparedinallmaterialrespectsinlinewiththecriteriasetoutinthe Regulations;• theQualityAccountisnotconsistentinallmaterialrespectswiththesourcesspecifiedinthe Guidance;and• theindicatorsintheQualityAccountsubjecttolimitedassurancehavenotbeenreasonably statedinallmaterialrespectsinaccordancewiththeRegulationsandthesixdimensionsof dataqualitysetoutintheGuidance.
KPMGLLPOneSnowhillSnowHillQueenswayBirminghamB46GH 30June2016
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Appendices Appendix 1
CQUIN Schemes 2015-2016
TheCQUINframeworkwasintroducedinApril2009asaNationalFrameworkforlocallyagreedqualityimprovementschemes.Itenablescommissionerstorewardexcellencebylinkingaproportionofhealthcareprovider’sincometotheachievementoflocalqualityimprovementgoals.TheFrameworkaimstoembedqualitywithincommissioner-providerdiscussionsandtocreateacultureofcontinuousqualityimprovement,withstretchinggoalsagreedincontractsonanannualbasis.ForfurtherinformationonCQUINSchemesfor2016-17pleasecontactamemberoftheUHCWContractingTeamon02476968471.
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National/Local Theme Focus
National AcuteKidneyInjury Acute Kidney Injury diagnosis and treatment inhospital and planofcare tomonitorkidney failureafterpatientdischarge.
National SepsisScreening (a) All appropriate patients arriving via emergencydepartmentordirect emergency admissions tobescreenedforSepsis.
National
SepsisAntibioticAdministration(b)
Administration of intravenous antibiotics within 1hourforpatientsscreenedwhohaveseveresepsisorsepticshock.
National Dementia and Delirium – Find,Assess,Investigate,ReferandInform(FAIRI) (a)
Assess patients aged 75 years and over for DementiaorDeliriumwherethereisanepisodeofemergencyorunplannedcare.
National
Dementia and Delirium - StaffTraining (b) Ensure appropriate dementia training is available
toallstaff.
National
Dementia and Delirium - SupportingCarers (c)
Biannual survey to assess whether the carers ofpeople with dementia or delirium feel adequatelysupported.
Local
Reducing proportion of avoidableemergency admissions: Developing anintegratedGeneral Practitioner AssessmentUnitandEmergencyAmbulatoryCareclinic
Toensurepatientswithambulatorycareconditionsthat do notnormally requireadmission tohospitalreceivehighlyresponsiveurgentcareservices.
Local DevelopinganAcuteFrailtyUnittoimprovethemanagementoffrailelderlypatient
DevelopmentofanAcuteFrailtyUnittoensurefrail andelderlypatientsareassessedandcaredforinthemostclinicalappropriatesetting.
Local Improvingpsychologicalsupporttopatientswithcancer.
Increase psychological input into acute cancerservices with the appointment of a dedicatedpsychologist to improve psychological care in linewithnationalcancerstandards.
Local Improvingtheeffectiveness ofrehabilitationaftercriticalillness
Undertakeareviewofpatientsadmittedtocriticalcare who receive a rehabilitation assessment a)within 24 hours and b) at discharge from criticalcare and c) number of patients who have arehabilitation prescription on discharge. Actionplantoimprovetheeffectivenessofrehabilitation.
Local Facilitatingeffectivedischarge Toimprovethetimelinessofinpatientdischargeprocess.
Local CommunicatingwithpatientsandGPsafterdischarge
Toreviewthespecific type of clinical information to besharedwithpatientsandtheirGPpostdischarge,foranumberofclinicalpathways.
Appendix 2
Glossary
Acute Trust
ATrustisanNHSorganisationresponsibleforprovidingagroupofhealthcareservices.AnAcuteTrustprovideshospitalservices(butnotmentalhealthhospitalservices,whichareprovidedbyaMentalHealthTrust).
Advocacy
IndependentAdvocacyisavailabletopeoplewhowantsupportinmakingacomplaintaboutNHSservices.ContactdetailsareavailablefromyourlocalHealthwatch
Algorithm
Aspecificsetofinstructionsforfollowingaprocedureorsolvingaparticularproblem.
Appraisal
Theprocessbywhichamanagerorconsultantexaminesandevaluatesanemployee’sworkbehaviourbycomparingitwithpresetstandards,documentstheresultsofthecomparison,andusestheresultstoprovidefeedbacktotheemployeetoshowwhereimprovementsareneededandwhy.
Always Events
AlwaysEventsrefertoaspectsofthepatientexperiencethataresoimportanttopatientsandfamiliesthathealthcareprovidersmustperformthemconsistentlyforeverypatient,everytime.ThePickerInstituteleadsonthisnationalprogramme.
Audit Commission
TheAuditCommissionregulatesthepropercontrolofpublicfinancesbyLocalAuthoritiesandtheNHSinEnglandandWales.TheCommissionauditsNHSorganisationstoreviewthequalityoftheirfinancialsystems.Italsopublishesindependentreportswhichhighlightrisksandgoodpracticetoimprovethequalityoffinancialmanagementinthehealthservice.ItworkswiththeCareQualityCommissiontoproducenationalvalue-for-moneystudies.
BDA (British Deaf Association)
TheBDAisahighprofilenational“DeafPeople’sOrganisation”withastrongpresencethroughoutEngland,Scotland,WalesandNorthernIreland.
Benchmark
Astandardorsetofstandardsusedasapointofreferenceforevaluatingperformanceorlevelofquality.Benchmarkingisusedtocompareoneorganisationwithothers.
Board (of Trust)
TheroleoftheTrust’sBoardistotakecorporateresponsibilityfortheorganisation’sstrategiesandactions.TheChairandnon-executivedirectorsarelaypeopledrawnfromthelocalcommunityandareaccountabletotheSecretaryofState.TheChiefExecutiveOfficerisresponsibleforensuringthattheboardisproperlysupportedtogoverntheorganisationandtodeliveritsclinical,qualityandfinancialobjectives.
Board Round
Asimpleandeffectiveprocessuseddailyinwardstosupportthesafeandtimelydischargeofpatients,helpingtoaddresstherisksinherentinprolongedadmissions.
Breaking Free
TheBreakingFreecampaignwasintroducedtointroducetheperfectWeekinitiativetoimprovehospitalflow.Theperfectweekmethodologyisawayofresettingabrokensystemrelyingonamixtureofsocialmovementtheory,multiplerapidimprovementmethodologyandstrongleadershipandsupportmechanisms.Ithasbeendevelopedtohelpsolvepoorflowinhospitalsresultinginovercrowdinginemergencydepartments.Oneweekofintenseimprovementactivitycanimproveflowacrossthewholehospitalresultinginsafer,higherqualitycareanditcanthenbesustained.
British Sign Language
BritishSignLanguage(BSL)isthesignlanguageusedintheUnitedKingdom(UK),andisthefirstorpreferredlanguageofsomedeafpeopleintheUK.
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Care Act 2014
TheCareAct2014wascreatedtomakeprovisiontoreformthelawrelatingtocareandsup-portforadultsandthelawrelatingtosupportforcarers;tomakeprovisionaboutsafeguardingadultsfromabuseorneglect;tomakeprovisionaboutcarestandards;toestablishandmakeprovisionaboutHealthEducationEngland;toestablishandmakeprovisionabouttheHealthResearchAuthority;tomakeprovisionaboutintegratingcareandsupportwithhealthservices;andforconnectedpurposes.
Care Quality Commission
TheCareQualityCommission(CQC)istheindependentregulatorofhealthandsocialcareinEngland.Itregulateshealthandadultsocialcareservices,whetherprovidedbytheNHS,localauthorities,privatecompaniesorvoluntaryorganisations.Itmakesavailablereportsandinformationonallhealthcareproviders,andanyonecanusetheirwebsitetocommentonservices.Visitwww.cqc.org.uk
FromAugust2013theCQCbegantochangethewaythatitassessesthequalityofhospitalservices.Longerinspectionswithlargerteams(includingprofessionalsandpatients)evaluatequalityandcontributetothe‘Rating’;ultimatelyeveryhealthandsocialcareservicewillhavesucharating.
Care Quality Review Group
AmeetingheldmonthlybetweenUHCWandourCommissionerstodiscussclinicalqualityissuesatthehospital.
CiH (Chief Inspector of Hospitals)
CQCappointedProfessorSirMikeRichardsasthefirstChiefInspectorofHospitals,taskedwithimplementingtheCQC’snewwayofinspectinghospitals.Heisresponsibleforleadingtheinspectionserviceandassessingtheextenttowhichhospitalsaredeliveringqualitycare.
Clinical Audit
Clinicalauditmeasuresthequalityofcareandofservicesagainstagreedstandardsandsuggestsormakesimprovementswherenecessary.Ittellsuswhetherwearedoingwhatweshouldbedoing.InadditiontoinformationintheQualityAccount,theTrustpublishesmore
informationonclinicalauditwithintheQualityDepartment’sAnnualReportandontheTrust’swebsite:www.uhcw.nhs.uk
Clinical Coding
Clinicalcodingtranslatesthemedicalterminologywrittenbyclinicianstodescribeapatient’sdiagnosisandtreatmentintostandard,recognisedcodes.Theaccuracyofcodingisanindicatoroftheaccuracyofthepatienthealthrecords.Incorrectcodingcanhavepotentiallyseriousconsequencesforthecommissioningofhealthservices,aswellasmisleadingmanagersandcliniciansbyfalselyrepresentingtheprevalenceofparticularhealthproblems.TheTrustisassessedannuallyontheaccuracyofitscodingsystem.
CCG (Clinical Commissioning Group)
Since1April2013CCGshavebeenresponsibleforensuringadequatecareisavailablefortheirlocalpopulationbyassessingneedandpurchasingservices.Theycommissionservices(includingacutecare,primarycareandmentalhealthcare)forthewholeoftheirlocalpopulation,withaviewtoimprovinghealthandwell-being.CCGscommissionemergencyandurgentcare,includingambulanceandout-of-hoursservices.SeealsoCommissioning
C.diff (Clostridium Difficile)
AspeciesofGram-positivebacteriathatcausesseverediarrhoeaandotherintestinaldiseasewhencompetingbacteriainthegutflorahavebeenwipedoutbyantibiotics.
Commissioning
Commissioningistheprocessofensuringthathealthservicesmeettheneedsofthepopulation.Itisacomplexprocessthatincludesassessingtheneedsofthepopulation,procuringhealthcareservicesandensuringthatservicesaresafe,effective,patient-centredandofhighquality.NHSSpecialisedServicesisanationalorganisationresponsibleforthecommissioningofspecialisedservicesthathelptoimprovethelivesofchildrenandadultswithveryrareconditions.SeealsoClinical Commissioning Group.
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CQUIN (Commissioning for Quality and Innovation)
High Quality Care for All included a commitment tomakeaproportionofproviders’incomeconditionalonqualityandinnovation,throughtheCommissioningforQualityandInnovation(CQUIN)paymentframework.TheTrusthastomeetagreednationalandlocalperformancetargets;aproportionofourbudgetisonlyreleasedbyCommissionersiftheTrustcanshowthatithasmetthetargets.
CRRS (Clinical Results and Reporting System)
CRRSisanelectronicpatientrecordwherebypatients’clinicalresultsareuploadedandheld.
Dashboard
Avisualtoolthatgivescliniciansrelevantandtimelyinformationtheyneedtoinformthosedailydecisionsthatimprovequalityofpatientcare.Thetoolgivesclinicianseasyaccesstoawealthofdatathatiscapturedlocally,whenevertheyneedit.Italsoprovidesstraightforwardcomparisonsbetweenlocalandnationalperformanceforsomeactivities
Discharge
• Complexdischargeconcernspatients’ whohavecontinuinghealthcareneeds afterleavinghospitalandwhomayhave socialcareneedsrequiringspecialist equipmenttosupportthemina community environment.
• Simpledischargeconcernspatientsgoing homeortoresidentialcarewhoneed intermediatecareservices,renewedshort termpackagesofcareandaccessto rehabilitationfacilitatesinthecommunity.
DNA CPR (Do Not Attempt Cardio Pulmonary Resuscitation)
IfcardiacorrespiratoryarrestisanexpectedpartofthedyingprocessandCPRwillnotbesuccessful,makingandrecordinganadvancedecisionnottoattemptCPRwillhelptoensurethatthepatientdiesinadignifiedandpeacefulmanner.Itmayalsohelptoensurethatthepatient’slasthoursordaysarespentintheirpreferredplaceofcareby,forexample,avoidingemergencyadmissionfromacommunitysetting
tohospital.ThesemanagementplansarecalledDoNotAttemptCPR(DNACPR)orders,orDoNotAttemptResuscitationorAllowNaturalDeathdecisions.
Dr Foster
An independent provider of healthcare information intheUnitedKingdom;itmonitorsNHSperformanceandprovidesinformationonbehalfofthepublic.DrFosterIntelligenceisajoint-venturewiththeDepartmentofHealthandwaslaunchedinFebruary2006.Visitwww.drfoster-health.co.ukformoreinformation
Electronic Staff Record (ESR)
AstheworkforcesolutionfortheNHS,ESRsupportsthedeliveryofnationalworkforcepolicyandstrategybyprovidingHumanResourcesDirectorsandtheirteamswitharangeoftoolsthatfacilitateeffectiveworkforcemanagementandplanning;therebyenablingimprovedquality,efficiencyandassuranceofcomplianceagainstessentialworkforcestandards.
End of Life care
Itexplainswhatyoucanexpectfromendoflifecare,includingpalliativecaretocontrolpainandothersymptomsandtoofferpsychological,socialandspiritualsupport.
Equality Act 2010
Theactreplacedmanyseparatepiecesoflegislationconcernedwithdiscrimination.ItrequiresNHSTruststomeetvariousobligations,mostimportantlytoactinwaysthatdonotdiscriminateagainstanypatientoremployeeonthegroundsofninedefined‘specialcharacteristics’.Theninegroupsare:
• Age:Wherethisisreferredto,itrefers toapersonbelongingtoaparticularage (e.g.32yearolds)orrangeofages(e.g. 18-30yearolds).
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• Disability:Apersonhasadisabilityif s/hehasaphysicalormentalimpairment whichhasasubstantialandlong-term adverseeffectonthatperson’sabilityto carryoutnormalday-to-dayactivities.
• Gender reassignment:Theprocessof transitioningfromonegendertoanother.
• Marriage and civil partnership:The legallyorformallyrecognizedunionofa manorawoman(or,insome jurisdictions,twopeopleofthesamesex) aspartnersinarelationship
• Pregnancy and maternity:Pregnancy istheconditionofbeingpregnantor expectingababy.Maternityrefersto theperiodafterthebirth,andislinkedto maternity leave in the employment context.Inthenon-workcontext, protectionagainstmaternity discriminationisfor26weeksaftergiving birth,andthisincludestreatingawoman unfavourablybecausesheis breastfeeding.
• Race:Referstotheprotected characteristicofrace.Itreferstoagroup ofpeopledefinedbytheirrace,colour, andnationality(includingcitizenship) ethnicornationalorigins.
• Religion and belief:Religionhasthe meaningusuallygiventoitbutbelief includesreligiousandphilosophical beliefsincludinglackofbelief(e.g. Atheism).Generally,abeliefshouldaffect yourlifechoicesorthewayyouliveforit tobeincludedinthedefinition.
• Sex:thegenderofaperson(e.g.manor awoman)
• Sexual Orientation:Whetheraperson’s sexualattractionistowardstheirownsex, theoppositesexortobothsexes.
FFT (The Friends and Family Test)
Launchedon1April2012,theFFTispartofanationalinitiativerequiringthatpatientsareaskedwhethertheywouldrecommendthewardordepartmenttotheirfriendsandfamily.TheTrustalreadyhasanestablishedpatientexperience
feedbackprocess,butthisnationalrequirementasksthekeynationalquestiononwhichwewillbecomparedwithotherhospitalsacrosstheUK.
TheFriendsandFamilyTestquestionis:How likely are you to recommend our ward/Minor Injury Unit to friends and family if they needed similar care or treatment?Answersarechosenfromthefollowingoptions:Extremelylikely;Likely;Neitherlikelynorunlikely;Unlikely,ExtremelyUnlikelyorDon’tknow.
TheFriendsandFamilyTestgivespatientstheopportunitysharetheirviewsofthecareortreatmenttheyhavereceivedprovidinguswithvaluablefeedback.Weusethefeedback,alongsideotherinformation,toidentifyandtackleconcernsatanearlystage,improvethequalityofcareweprovide,andcelebrateoursuccesses.FormoreinformationontheFriendsandFamilyTest,pleasevisitwww.nhs.uk/friendsandfamily.FromApril2014,NHSEnglandintroducedtheStaffFriendsandFamilyTest(FFT)inallNHStrustsprovidingacute,community,ambulanceandmentalhealthservicesinEngland.NHSEngland’svisionforStaffFFTisthatallstaffshouldhavetheopportunitytofeedbacktheirviewsontheirorganisationatleastonceperyear.
General Medical Council
IndependentregulatorfordoctorsintheUK.Thepurposeistoprotect,promoteandmaintainthehealthandsafetyofthepublicbymakingsurethatdoctorsmeetourstandardsforgoodmedicalpractice.www.gmc-uk.org.
Getting Emergency Care Right
ThisprogrammewasdesignedbyUHCWtoimprovepatientflowacrossthehospitalandim-provethecareandqualityinourEmergencyDepartment.TohelpimplementthiscampaigntheFREEDmetricwasdeveloped;
• Facilitateeffectivedischarge.• Rightperson,rightplace.• Earlyspecialistinput.• Eliminateunnecessarydiagnostics.• Dailyseniorreview.
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Health Act
TheHealthAct2009receivedRoyalAssenton12November2009.ItisthelegislationthatunderpinsorganisationalarrangementsandresponsibilitieswithintheNHSinEngland
The Health and Social Care Information Centre
HSCICisadata,informationandtechnologyresourceforthehealthandsocialcaresystem.Itprovidessupporttoeveryonestrivingforbettercare,improvingservicesandthebestoutcomesforpatients.ItsupportsthedeliveryofITinfrastructure,informationsystemsandstandardshelpingtoensurethatclinicalandorganisationalinformationflowsefficientlyandsecurelythroughhealthandsocialcaresystems.Visitwww.hscic.gov.uk
Healthcare
Healthcareincludesallformsofhealthcareprovidedforindividuals,whetherrelatingtophysicalormentalhealth,andincludesotherproceduresthatarenotnecessarilyprovidedasaresultofamedicalconditionsuchascosmeticsurgery.
Health Education England
HealthEducationEnglandisresponsiblefortheeducation,trainingandpersonaldevelopmentofeverymemberofstaff,andrecruitingforvalues.
HRA (Health Research Authority)
TheHRApromotesandprotectstheinterestsofpatientsinhealthresearchandstreamlinestheregulationofresearch.
Healthwatch
HealthwatchistheconsumerchampionfortheNHSandsocialcareservices.LocalHealthwatchenableslocalpeopleandvoluntarygroupstoworkfortheimprovementofNHSandsocialcareservicesbycollectingtheexperiencesofthelocalcommunityandmakerecommendationstoserviceproviders.
High Quality Care for All
High Quality Care for All,publishedinJune2008,wasthefinalreportoftheNHSNextStageReview,ayear-longprocessledbyLordDarzi,arespectedandrenownedsurgeon,andaround2000frontlinestaff,whichinvolved60,000NHSstaff,patients,stakeholdersandmembersofthepublic.Itwasthisreportthatdescribedqualityashavingthreecomponents:PatientSafety,ClinicalEffectivenessandPatientExperience.
HSMR (Hospital Standardised Mortality Ratio)
TheHospitalStandardisedMortalityRatioistheratioofobserveddeathstoexpecteddeathsforagroupof56diagnosisgroupswhichrepresentapproximately80%ofinhospitaldeaths.Itisasubsetofallandrepresentsabout35%ofadmittedpatientactivity.HSMRisquotedasapercentageandisequalto100;thismeansthenumberofobserveddeathsequalsthatofexpected.Ifhigherthan100,thenthereisahigherreportedmortalityratio.
HSCIC (Health and Social Care Information Centre)
TheHSCICintheUKisanexecutivenon-departmentalpublicbodyoftheDepartmentofHealth.PreviouslyknownastheNHSInformationCentre,itproducesnationalcomparativedataforsecondaryuses,developedfromthelong-runningHospitalEpisodeStatisticswhichcanhelplocaldecisionmakerstoimprovethequalityandefficiencyoffrontlinecare.Itsprimaryaimistodrivetheuseofinformationtoimprovedecisionmakinganddeliverbettercarebyprovidingaccessible,highqualityandtimelyinformationtohelpfrontlinehealthandsocialcarestaffdeliverbettercare.
Human Factors
Humanfactorsencompassallthosefactorsthatcaninfluencepeopleandtheirbehaviour.Inaworkcontext,humanfactorsaretheenvironmental,organisationalandjobfactors,andindividualcharacteristicswhichinfluencebehaviouratwork.
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IAG (Independent Advisory Group)
TheIAGwassetupin2013andhasinfluencedthedevelopmentofpracticesandpoliciesthatpromoteEquality,DiversityandHumanRightsissuesforbothpatientsandstaff.
Information Governance Toolkit
TheIGToolkitisanonlinesystemwhichallowsNHSorganisationsandpartnerstoassessthemselvesagainstDepartmentofHealthInformationGovernancepoliciesandstandards.
Intellectual Property
Broaddescriptionforthesetofintangiblesownedandlegallyprotectedbyacompanyfromoutsideuseorimplementationwithoutconsent.Intellectualpropertycanconsistofpatents,tradesecrets,copyrightsandtrademarks,orsimplyideas.
Theconceptofintellectualpropertyrelatestothefactthatcertainproductsofhumanintel-lectshouldbeaffordedthesameprotectiverightsthatapplytophysicalproperty.
Intentional Rounding
Thisinvolvesreviewingallpatientsatsetintervalsforkeysafetyissuese.g.repositioning,toileting,food,fluidandpainmanagement;itsusehascontributedtothecontinuinglowlevelofavoidableharmsforpatientssuchaspressureulcersanddehydration.
ISS
ISSFacilityServicesmanagetherecruitmentofcleaning,patienthospitality,security,porteringandcateringstaffandprovidetheseservicesatUHCW.
IV (Intravenous)
Aprocedureinwhichahypodermicneedleinsertedintoaveinprovidesacontinuoussupplyofbloodplasma,nutrients,ormedicinedirectlytothebloodstream.
Key Performance Indicator (KPI)
Atypeofperformancemeasurement,KPIsarecommonlyusedbyanorganisationtoevaluateitssuccessorthesuccessofaparticularactivityinwhichitisengaged.
Lean
Simply“lean”,isasystematicmethodfortheeliminationofwaste.Leanalsotakesintoaccountwastecreatedthroughoverburdenandwastecreatedthroughunevennessinworkloads.
Major Trauma
Definedasmultiple,seriousinjuriesthatcouldresultindeathorseriousdisability,thesemightincludeseriousheadinjuries,severegunshotwoundsorroadtrafficaccidents.
Medical Revalidation
MedicalRevalidationisamechanismfordoctorspracticingintheUKtoprovetheirskillsareup-to-dateandtheyremainfittopracticemedicine.Itisintendedtoreassurepatients,employersandotherprofessionals,andtocontributetoimprovingpatientcareandsafety.
MEWS (Modified Early Warning System)
UtilisationoftheMEWSscoringsystemisnowtherecommendedassessmentofvitalsigns.Theaimofthesesystemsistoidentifypatientsatrisk/deterioratingstatuswhichtriggersanimmediateresponsethroughscoringpointsforabnormalphysiologicalvalues.
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MRSA and MSSA Bacteraemia
Staphylococcus aureusisabacteriumfoundontheskinandaproportion(upto30%)ofthehealthy population carry Staph. aureus in their noseorinothermoistpartsofthebody.
Commonly Staphylococcus aureuscausesinfectionssuchasboilsandinfectedskinwounds.Itcancausepneumonia,urinarytractinfectionsandbacteraemiabothinthecommunityandinhospitalpractice.
SometypesofStaph. aureushavebecomeresistanttovariousantibiotics.TheseareknownasmethicillinresistantStaph.aureusorMRSA.ThosetypesthatarenotresistanttocertainantibioticsareknownasmethicillinsensitiveStaph. aureusorMSSA.
‘M’ Technique
The‘M’techniqueisasimplemethodofstructuredtouch.Eachmovementandsequenceisdoneinasetpatternatasetpressureandsetspeed,whichneverchange.TheMtechniqueisdifferentfrommassageandissuitablefortheveryfragile;thecriticallyill,activelydying,orwhenthegiverisnottrainedinmassage.The‘M’techniqueworksonskinreceptorswhichsendsignalstothebrainandhasbeendescribedas‘physicalhypnotherapy’anda‘spiritualdance’.
NPSA (National Patient Safety Agency)
TheNationalPatientSafetyAgencywasanarm’s-lengthbodyoftheDepartmentofHealth,responsibleforpromotingpatientsafetywherevertheNHSprovidescare.ItsrolehasbeentransferredtotheNHSCommissioningBoardSpecialHealthAuthority.ThisensuresthatpatientsafetyisattheheartoftheNHSandbuildsonthelearningandexperiencedevelopedbytheNPSA,drivingpatientsafetyimprovement.
National Patient Surveys
TheNationalPatientSurveyProgramme,coordinatedbytheCareQualityCommission,gathersfeedbackfrompatientsondifferentaspectsoftheirexperienceofrecentlyreceivedcare,acrossavarietyofservices/settings.
National Research Ethics Service
TheNationalResearchEthicsServiceispartoftheNationalPatientSafetyAgency.Itprovidesarobustethicalreviewofclinicaltrialstoprotectthesafety,dignityandwellbeingofresearchparticipantsaswellasensurethroughthedeliveryofaprofessionalservicethatitisalsoabletopromoteandfacilitateethicalresearchwithintheNHS.
NCEPOD (National Confidential Enquiry into Patient Outcome and Death)
Confidentialenquirieshelpmaintainandimprovestandardsofmedicalandsurgicalcareforthebenefitofthepublic.Usinganonymiseddatafromconfidentialsurveysandresearch,theyreviewtheclinicalmanagementofpatients,publishingreportsandmakingrecommendationsforimprovement.Byrespectingconfidentiality,theymaximisethecomplianceofmedicalandsurgicalstaffinsharinginformationonclinicaloutcomes.
Never Event
NeverEventsareserious,oftenpreventablepatientsafetyincidentsthatshouldnotoccurifavailablepreventativemeasureshavebeenimplemented.NHSEnglandpublishesafulllistofNeverEventseachquarter.
NHS Choices
AwebsiteforthepubliccontainingextensiveinformationabouttheNHSanditsservices;gotowww.nhs.uk.
NHS England
NHSEnglandisanexecutivenon-departmentalpublicbodyoftheDepartmentofHealth.NHSEnglandoverseesthebudget,planning,deliveryandday-to-dayoperationofthecommissioningsideoftheNHSinEnglandassetoutintheHealthandSocialCareAct2012.
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NHS Next Stage Review
AreviewledbyLordDarzi.Thiswasprimarilyalocallyledprocess,withclinicalvisionspublishedbyeachregionoftheNHSinMay2008andanationalenablingreport,High Quality Care for All,publishedinJune2008.
NICE - National Institute for Health and Care Excellence
NICEisanindependentorganisationresponsibleforprovidingnationalguidanceonpromotinggoodhealthandpreventingandtreatingillhealth.Cliniciansaregenerallyexpectedtofollowguidanceunlesstheyhavegoodcause.
Parliamentary and Health Service Ombudsman (PHSO)
TheroleofPHSOistoinvestigatecomplaintsofindividualsthathavebeentreatedunfairlyorhavereceivedpoorservicefromgovernmentdepartmentsandotherpublicorganisationsandtheNHSinEngland.
Patient and Advice Liaison Service (PALS)
ThePatientAdviceandLiaisonService(PALS)offersconfidentialadvice,supportandinformationonhealth-relatedmatters.Theyprovideapointofcontactforpatients,theirfamiliesandtheircarers.
Pathway
Atoolusedbyallhealthcareprofessionalsintreatingpatients,inwhichthedifferenttasksinvolvedinthepatient’scarearedefined.Apathwaywillclarifystaffrolesandresponsibilities,andwhatfactorsshouldbeconsideredindeterminingwhenandhowpatientsmovetothenextstageofcareandtreatment.Healthcarecanbemoreeffectiveandefficientwhenwell-designedandpatient-centredpathwaysareused.
Patient flow
Atermusedtodescribehowefficientlyhospitalsuseresources.Ideallypatientsareadmitted,treatedanddischargedintheshortestpossibletimeconsistentwithsafepracticeandbestavailabletreatment.Disruptiontopatientflowmayresultindelayatanypoint,fromarrivalatA+Etodischarge,causingconcernordistresstopatientsandcarers.Delayincreasestheriskofharmtopatients.
Patient-led assessments of the care environ-ment (PLACE)
Anewsystemforassessingthequalityofthepatientenvironment,replacingtheoldPatientEnvironmentActionTeam(PEAT)inspections.Theassessmentswillapplytohospitals,hospicesanddaytreatmentcentresprovidingNHSfundedcare.Theywilllookathowtheenvironmentsupportspatientprivacyanddignity,themeetingofdietaryneeds,cleanlinessandgeneralbuildingmaintenance.
ResultsfromtheAnnualassessmentsarereportedpubliclytohelpdriveimprovementsinthecareenvironment;theywillshowhowwearedoinglocallyandbycomparisonwithotherTrustsacrossEngland.Formoreinformationvisitwww.england.nhs.uk/ourwork/qual-clin-lead/place
Periodic reviews
PeriodicandthematicreviewsarereviewsofhealthservicescarriedoutbytheCareQualityCommission(CQC).Theterm‘review’referstoanassessmentofthequalityofaserviceortheimpactofarangeofcommissionedservices,usingtheinformationthattheCQCholdsaboutthem,includingtheviewsofpeoplewhousethoseservices.
PDSA (Plan, Do, Study, Act)
ThePDSACycleisasystematicseriesofstepsforgainingvaluablelearningandknowledgeforthe continual improvement of a product or process.ThecyclebeginswiththePlanstep.Thisinvolvesidentifyingagoalorpurpose,formulatingatheory,definingsuccessmetricsandputtingaplanintoaction.TheseactivitiesarefollowedbytheDostep,inwhichthecomponentsoftheplanareimplemented,suchasmakingaproduct.NextcomestheStudystep,whereoutcomesaremonitoredtotestthevalidityoftheplanforsignsofprogressandsuccess,orproblemsandareasforimprovement.TheActstepclosesthecycle,integratingthelearninggeneratedbytheentireprocess,whichcanbeusedtoadjustthegoal,changemethodsorevenreformulateatheoryaltogether.
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Thesefourstepsarerepeatedoverandoveraspartofanever-endingcycleofcontinualimprovement.
Pressure Ulcer
Alsosometimesknownasbedsoresorpressuresores,theyareatypeofinjurythataffectsareasoftheskinandunderlyingtissue.Theyarecausedwhentheaffectedareaofskinisplacedundertoomuchpressure.Pressureulcerscanrangeinseverityfrompatchesofdiscolouredskintoopenwoundsthatexposetheunderlyingboneormuscle.
Avoidable pressure ulcer:Thepersonreceivingcaredevelopedapressureulcerandtheproviderofcaredidnotdooneofthefollowing:evaluatetheperson’sclinicalconditionandpressureulcerriskfactors;planandimplementinterventionsthatareconsistentwiththeperson’sneedsandgoals,andrecognisedstandardsofpractice;monitorandevaluatetheimpactoftheinterventions;orrevisetheinterventionsasappropriate.
Unavoidable pressure ulcer:meansthattheindividualdevelopedapressureulcereventhoughtheindividual’sconditionandpressureulcerriskhadbeenevaluated;goalsandrecognisedstandardsofpracticethatareconsistentwithindividualneedshasbeenimplemented.Theimpactoftheseinterventionshadbeenmonitored,evaluatedandrecorded;andtheapproacheshadrevisedasappropriate.
Inherited pressure ulcer:ApatientisadmittedtotheTrustwithpressuredamageandthisisidentifiedorbecomesapparentwithin72hoursofadmission
Acquired pressure ulcer:thepatientdevelopsapressureulcerwhilstahospitalinpatientafterthefirst72hoursofadmission.
Grade 1 pressure ulcer:Theskinatthispointisredandontheapplicationoffingertippressuretheskinremainsred.
Grade 2 pressure ulcer:thesuperficiallayeroftheskinisdamaged.Itpresentsasablister,abrasionorshallowcraterandanyofthesecanhaveblue/purple/blackdiscoloration.
Grade 3 pressure ulcer:fullthicknessskinlossinvolvingdamageornecrosistosubcutaneous
tissue.
Grade 4 pressure ulcer:fullthicknessskinlosswithextensivedestructionextendingtounderlyingstructures;i.e.bone,muscle,tendon,orjointcapsule.
Prescribed Connection
Alicenseddoctorwithaformalconnection(e.g.contractofemployment)totheorganisationforthepurposesofregularappraisalandsupportingthemintheprocessofrevalidation.
Primary Care TrustswerereplacedbyClinical Commissioning Groups (CCGs) from 1 April 2013(seeCCGentry).
Protected Characteristics Groups:seeEquality Act
QIPS (Quality Improvement Patient Safety) meetings
TheQualityImprovementPatientSafetymeetingsarewherepatientsafety,clinicalauditandpatientexperienceissues,includingcomplaintsaresharedanddiscussedwithspecialties,sothatlessonscanbelearned.
RAG Rate
Trafficlightsystemisusedasacodingsystemforgoodorbadperformance-usuallyknownasa‘RAGrating’.Forexampleinrelationtotheworkloadperformance,redwouldmeaninadequate,amberwouldmeanreasonable,andgreenwouldmeanideal.ThelettersR,AandGareusedinadditiontoswatchesofcolour.
Registration – licence to provide health services
FromApril2009,everyNHSTrustthatprovideshealthcaredirectlytopatientsmustberegisteredwiththeCareQualityCommission(CQC).UHCWislicensedtoprovidehealthcareserviceswithoutconditions
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Research
ClinicalresearchandclinicaltrialsareaneverydaypartoftheNHS.Thepeoplewhodoresearcharemostlythesamedoctorsandotherhealthprofessionalswhotreatpeople.Aclinicaltrialisaparticulartypeofresearchthattestsonetreatmentagainstanother.Itmayinvolvepeopleingoodhealthaswellasthoseundergoingtreatment.ResearchandTrialshelpclinicalstafflearnthebestwaysoftreatingpatients,butcanalsobeusefulinshowingwhatworkslesswell,ornot at all.
RCA (Root Cause Analysis)
EverydayamillionpeoplearetreatedsafelyandsuccessfullyintheNHS.However,whenincidentsthatresultinharmtopatients(orthatare‘nearmisses’)dohappen,itisimportantthatlessonsarelearnedtopreventthesameincidentoccurringagain.RootCauseAnalysisinvestigationisanestablishedwayofdoingthis.
RootCauseAnalysisidentifieshowandwhyincidentshappen.Ateamapproachisusuallytakenandinvolvesteammemberswiththerelevantknowledgeand/orexpertiseaswellasmembersofstaffwhowereinvolvedintheincident.TheaimofanyinvestigationistolearnfromtheeventandtomakerecommendationstotheTrust.
Safeguarding
Toprotectanadultorchildfromharmordamagewithanappropriatemeasure.
Safer Nursing Care Tool
IsatoolkitwhichhasbeendesignedbytheChiefNursesofUniversityCollegeLondonHospitalsandSheffieldTeachingHospitalstohelphospitalssetappropriatenursestaffinglevelsandthishasbeenendorsedbytheNationalInstituteforHealthandCareExcellence(NICE).
Secondary Uses Service
TheSecondaryUsesServiceisdesignedtoprovideanonymouspatient-baseddataforpurposesotherthandirectclinicalcaresuchashealthcareplanning,commissioning,publichealth,clinicalauditandgovernance,benchmarking,performanceimprovement,medicalresearchandnationalpolicy
development.TheTrustcanusethisinformationtocompareperformancewithothersimilarTrusts.
SIRI (Serious Incident Requiring Investigation)
AseriousincidentrequiringinvestigationisdefinedasanincidentthatoccurredinrelationtoNHS-fundedservicesandcareresultinginoneofthefollowing:
• Unexpectedoravoidabledeathofoneor morepatients,staff,visitorsormembers ofthepublic;
• Seriousharmtooneormorepatients, staff,visitorsormembersofthepublic orwheretheoutcomerequireslife- savingintervention,majorsurgical/ medicalintervention,per-manentharmor willshortenlifeexpectancyorresultin prolongedpainorpsychologicalharm (thisincludesincidentsgradedunderthe NPSAdefinitionofsevereharm);
• Ascenariothatpreventsorthreatensto preventaproviderorganisation’sabilityto continuetodeliverhealthcareservices, forexample,actualorpotentiallossof person-al/organisationalinformation, damagetoproperty,reputationorthe environment,orITfailure;
• Allegationsofabuse;
• Adversemediacoverageorpublic concernabouttheorganisationorthe widerNHS;
• ForAcuteTrusts2015-2016theNever Eventlistwas:
- WrongSiteSurgery- WrongImplant/prosthesis- Retainedforeignobjectpost-procedure- Mis-selectionofastrongpotassium containingsolution- Wrongrouteadministrationofmedication- Intravenousadministrationofepidural medication- OverdoseofInsulinduetoabbreviations or incorrect device
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- Overdoseofmethotrexatefornon-cancer treatment - Fallsfromunrestrictedwindows- Chestorneckentrapmentinbedrails- TransfusionofABO-incompatibleblood componentsororgans- Misplacednaso-ororo-gastrictubes- Scaldingofpatients
ThisguidanceissetoutintheSeriousIncidentFrameworksetbyNHSEngland.
Sign Up to Safety Campaign
SignuptoSafetyisanationalinitiativetohelpNHSorganisationsandtheirstaffachievetheirpatientsafetyaspirationsandcarefortheirpatientsinthesafestwaypossible.AttheheartofSignuptoSafetyisthephilosophyoflocallyled,self-directedsafetyimprovement.
Special Review
AspecialreviewisconductedbytheCareQualityCommission(CQC).Specialreviewsandstudiesareprojectsthatlookatthemesinhealthandsocialcare.Theyfocusonservices,pathwaysofcareorgroupsofpeople.AreviewwillusuallyresultinassessmentsbytheCQCoflocalhealthandsocialcareorganisations.Astudywillusuallyresultinnational-levelfindingsbasedontheCQC’sresearch.
Summary Hospital Mortality Indicators (SHMI)
TheSHMI,liketheHSMR,isaratiooftheobservednumberofdeathstotheexpectednumberofdeaths.However,thisisonlyappliedtonon-specialistacuteproviders.Thecalculationisthetotalnumberofpatientadmissionstothehospitalwhichresultedinadeatheitherinhospitalorwithin30dayspostdischarge.Likeallmortalityindicators,theSHMIshowswhetherthenumberofdeathslinkedtoaparticularhospitalismoreorlessthanexpected,andwhetherthatdifferenceisstatisticallysignificant.
Trauma Audit and Research Network (TARN)
TheTARNmainaimistocollectandanalyseclinicalandepidemiological(thesciencethatstudiesthepatterns,causes,andeffectsofhealthanddiseaseconditionsindefinedpopulations)dataandtherebytoprovideastatisticalbasetosupportclinicalaudittoaidthedevelopment
oftraumaservicesandtoinformtheresearchagenda.
Teaching Trusts
Ahospitalthatisaffiliatedtoamedicalschoolandprovidesthestudentswithteachingandsupervisedpracticalexperience;UHCWhasclosetieswiththeUniversityofWarwickMedicalSchool.
Tissue Viability
TheTissueViabilityServiceatUHCWprovidesaspecialistservicetopatientswithawidevarietyofcomplexwoundsincludingpressureulcerpreventionandmanagement,managementoflegulceration,managementoftraumaticinjuriesandcomplexnon-healingwounds.
Transform Programme
“Transformingendoflifecareinacutehospitals:RoutetoSuccess.”
Thisistheimplementationofkeyenablers:AdvancecareplanningAMBERcarebundle,rapiddischargeforpatientsintheterminalstagesoftheirdisease,careinthelastdaysoflifeEPaCCS(ElectronicPalliativeCareCo-ordinationSystem),supportingthecollaborativede-velopmentandimplementationofaclinicalelectronicregisterofpatientsapproachingtheendoflifeacrossdifferentcaresettings.
VERA approachA helpful approach and an aid to memory for staffwhenworkingwithpatientsdiagnosedwithdementiaisVERA(mustbeassociatedwithVeraLynnandthe1940’s)–thisstandsfor:
V=Validate,acceptingthatthebehaviourexhibitedhasavaluetothepersonandisn’tjustasymptomofdementia.E=Emotion,payingattentiontotheemotionalcontentofwhattheperson’ssaying.R=Reassure,canbeassimpleassaying‘it’llbeokay’andsmiling,holdingtheirhand.A=Activity,peoplewithdementianeedtofeeloccupied,active,seeifyoucanengagetheminsomerelatedactivity.
University HospitalsCoventry and Warwickshire
NHS Trust
UHCW 2015 - 2016 Quality Account
Page98
Virginia Mason Institute
TheVirginiaMasonInstituteinSeattleisworld-renownfortransforminghealthcare.Theirmantraisthattheperfectpatientexperiencemeansthepatientcomesfirst-aboveeverythingandeveryone.Theyareexpertsinteachingotherhealthcareorganisationshowtoimplementandmaintainapatient-centredapproachthatwillhelptoincreasequality,safetyandefficiencyusingthesamemethodsthatmadethemsosuccessful.A“valuestream”isaspecificprojecti.e.theOphthalmologyOutpatientsprojectwhichfollowstheVirginiaMasonInstituteimprovementprocess.ARapidProcessImprovementWorkshop(RPIW)ranbyVirginiaMasonInstituteandtheTrustisafive-dayworkshopfocusedonaparticularprocessfromavaluestream(i.e.patientreferraltotheOphthalmologyOutpatientclinic)wherethosewhodotheworkareempoweredtoeliminatewastei.e.inefficienciesintheservice.
WHO (World Health Organisation)
TheWorldHealthOrganisation(WHO)isaspecialisedagencyoftheUnitedNations(UN)thatisconcernedwithinternationalpublichealth.
University HospitalsCoventry and Warwickshire
NHS Trust
UHCW 2015 - 2016 Quality Account
Page99
UniversityHospitalCliffordBridgeRoad
Coventry CV2 2DX
HospitalofStCrossBarbyRoad
RugbyCV225PX
www.uhcw.nhs.uk
02476964000
June 2016
University HospitalsCoventry and Warwickshire
NHS Trust
UHCW 2015 - 2016 Quality Account