quality account 2009-10

Norfolk and Norwich University HospitalsNHS Foundation Trust

Quality Account 2009 - 2010

QUALITY ACCOUNT 2009/10

Part One - Foreword Our Quality Account, for the financial year 2009/10, serves to underline our commitment and ambition to deliver excellent care for all our patients and is driven by our vision: “To provide every patient with the care we want for those we love the most”. This Quality Account is just one step on a journey to achieving our vision. The publication of this report marks neither the beginning nor the end of our ambition. Success will mean that we have fostered a culture of learning, of preventing harm, and of delivering an excellent experience for our patients, their carers and families. That will not be achieved in a year but must be a continual goal for all of us. Our staff deserve congratulations for the significant achievements made over the past year, particularly in relation to continued reductions in hospital-acquired infections. Our clinical teams have risen to the challenge of improving patient safety and clinical quality whilst balancing the increasing demands on our services. We are learning from best practice nationally and internationally in our pursuit of clinical excellence for our patients. It will be imperative that our culture is one where improvement is constantly sought and reflective practice is encouraged. In Part Three of this report we have set out in more detail what we are already doing to improve the quality of care and in Part Two what we will do in the year ahead to further improve quality and safety. We have developed close links with our Governors, the Norfolk Local Involvement Network, our commissioners and many other patient and public stakeholder groups. They have played a part in the development of this report and will continue to be central to our efforts to further improve our high quality services. To the best of my knowledge the information provided in this Quality Account is accurate. Anna Dugdale Chief Executive 28 May 2010

Glossary 18 Week Target – Maximum waiting time target in England for non-urgent NHS treatment #NOF - Fractured neck of femur i.e. broken hip ACS - Acute coronary syndrome Acute Medical Unit – Rapid assessment and diagnosis unit for emergency patients AMI - Acute myocardial infarction i.e. heart attack Analgesia – a drug that provides pain relief Bacteraemia – infection resulting from presence of bacteria in the blood BCIS - British Cardiovascular Intervention Society C diff - Clostridium difficile, a bacterium that can cause infection CEC - Clinical Effectiveness Committee CEMACH - Confidential Enquiry Maternal and Child Health CKD - Chronic Kidney Disease Clinical Audit – process of reviewing clinical processes to improve them Clinical Governance – describes processes that maintain and improve quality of patient care Coding – internationally agreed system of analysing clinical notes and assigning clinical classification codes Chlamydia – a common sexually transmitted infection CQC - Care Quality Commission, regulator for all healthcare providers and the authority that registers hospitals CQUINS - Commissioning for Quality Improvement Schemes, quality improvements that carry financial rewards in the NHS Crude mortality – the actual number of deaths CT scan - Computed Tomography scanning combines special x-ray equipment with computers to produce images of the inside of the body. DAHNO - Data for Head and Neck Oncology Data Quality – Process of assessing how accurately the information and data we gather is held Delayed Transfer of Care – Term for patients who are medically fit to leave a hospital but are waiting for social care or primary care services Dementia - Loss of cognitive ability (memory, language, problem-solving) in a previously-unimpaired person, beyond that expected of normal aging) Discharge Planning – Process of planning the care needs of patients in order to facilitate their timely discharge from hospital Dr Foster – Company that has developed Hospital Standardised Mortality Rate comparisons across the NHS EWS - Early Warning Score, a checklist process used to identify rapidly deteriorating patients EUS - Endoscopic Ultrasound, use of endoscopy (insertion of a probe into a hollow organ) combined with ultrasound to get images of the internal organs HSMR - Hospital Standardised Mortality Rate is an indicator of healthcare quality that measures whether the death rate at a hospital is higher or lower than could be expected ICNARC CMP - Intensive Care National Audit and Research Centre Case Mix Programme GPs - General Practitioners i.e. family doctors GTT - Global Trigger Tool, use of "triggers," or clues, to identify adverse events to measure the overall level of harm in healthcare LINks - Local Involvement Networks aim to give citizens a stronger voice in how their health and social care services are delivered. Liverpool Care Pathway - a model of best practice that aims to improve care of the dying in their last hours/days of life MDT - Multi-disciplinary Team, composed of doctors, nurses, therapists and other health professionals MINAP - Myocardial Infarction Audit Project MRSA - Methicillin Resistant Staphyloccus aureus, a strain of bacterium that is resistant to one type of antibiotic NBOCAP - National Bowel Cancer Audit Programme NCE - National Confidential Enquiries carry out research into patient care in order to identify ways of improving the quality. Neonates – Medical term for babies in the first 28 days of life NHFD - National Hip Fracture Database NJR - National Joint Registry

NLCA - National Lung Cancer Audit NNAP - National Neonatal Audit Programme NVD - National Vascular Database Palliative Care – Form of medical care that concentrates on reducing the severity of disease symptoms to prevent and relieve suffering PPCI - Primary Percutaneous Coronary Intervention is a treatment for heart attack patients which unblocks an artery by opening a small balloon PROMs - Patient Reported Outcome Measures, where patients fill in questionnaires before and after their treatment reporting on the quality of care Paediatric – The branch of medicine for the care of infants, children and young people up to the age of 16. PEAT - Patient Environment Action Team, assessment process that ensures improvements in areas such as hospital cleanliness, food and infection control. Perinatal - Defines the period occurring around the time of birth (five months before and one month after). Perioperative – Defines the duration of a patient's surgical procedure, including admission, surgery, and recovery RCP - Royal College of Physicians Serco – company that provides support services including catering, cleaning and engineering to the Norfolk and Norwich University Hospital STEMI - ST segment elevation myocardial infarction - occurs when a coronary artery is blocked by a blood clot. Stroke - The rapidly developing loss of brain function due to a blocked or burst blood vessel in the brain TARN - Trauma Audit and Research Network Thrombolysis - The breakdown of blood clots through use of clot-busting drugs Tissue Viability – term to describe all aspects of skin and soft tissue wounds including acute surgical wounds, pressure ulcers and leg ulcers VSSGBI - Vascular Surgical Society of Great Britain and Ireland VTE - Venous Thromboembolism - a condition in which a blood clot (thrombus) forms in a vein.

Part Two This section describes our priorities for quality improvement in the coming year and provides the required statements of assurance with regard to services, clinical audit, research, clinical quality goals, Care Quality Commission (CQC) registration and data quality. a) Priorities for Improvement 2010/11 We have made important progress during 2009/10 towards embedding quality and safety at the heart of our clinical services. We intend to continue to build on this progress during 2010/11 and we have identified the following six strategic quality priorities to further this aim. Many of the schemes listed here also form part of our Commissioning for Quality Improvement (CQUIN) programme, agreed with NHS Norfolk, our local lead commissioner. The strategic priorities have been divided into three categories: Clinical Effectiveness, Patient Safety and Patient Experience.

Clinical Effectiveness – Priorities

Key actions

Targets / measures 2010/11

Decrease our crude mortality, and decrease our Hospital Standardised Mortality Rate (HSMR) to less than 100.

We will continue to review our HSMR data through the clinical governance and divisional performance structures. We will continue our ground-breaking monthly review of crude mortality via the Mortality Committee, chaired by the Associate Medical Director of Patient Safety. We will report crude mortality, avoidable deaths and HSMR publicly via our monthly Quality Dashboard. We will continue our monthly case note review using the Global Trigger Tool to identify incidents which caused actual or potential harm and we will develop systems and processes to prevent them being repeated. We will expand and enhance our use of Early Warning Scores for very sick patients to detect and protect those acutely deteriorating patients.

We are aiming for an average HSMR during 2010/11 of 100 or less, and this is reflected in our agreed CQUIN scheme.

We aim to have no hospital acquired grade 3 or 4 pressure sores.

We have recently established a dedicated tissue viability team who are available to provide specialist advice and care to patients at risk of a high grade pressure ulcer, or who are admitted with an ulcer, across the hospital. We will continue to audit the prevalence of such ulcers and expand our educational programme to ensure the highest standards of tissue and wound care across our hospitals.

We aim to have zero hospital acquired grade 3 and 4 pressure sores.

Patient Safety - Priorities

Key actions Targets / measures 2010/11

We aim to reduce the incidence of prescribing errors.

We will be focusing on two key areas; transcription errors and improving prescribing practice with reference to our prescribing policy. We will be focusing particularly on staff working in our Acute Medical Units, as this is the key point of entry for most emergency patients. We are developing Direct Observation of Procedural Skills (DOPS) to be included in junior doctors’ competencies in prescribing practice to ensure all medical staff in the emergency admission areas are complying with best practice. We will be aiming to increase the number of prescriptions which are cross-checked by a pharmacist within 48 hours of the patient being admitted to hospital as part of our CQUIN schemes.

We will aim to reduce the incidence of non-intentional non-prescribing on admission by 33 per cent.

We aim to achieve the 10 Commissioning for Quality Improvement (CQUIN) quality schemes agreed with NHS Norfolk for 2010/11.

Our 10 CQUIN schemes are to: - implement venous thromboembolism

risk assessment for all appropriate patients

- improve in-patient experience - reduce our HSMR and increase the

use of the Early Warning Score - improve discharge planning and

provide timely patient information on discharge

- implement a dementia pathway and improve the use of the Liverpool Care Pathway in palliative care,

- increase referrals to smoking cessation services and increase the number of patients being screened for chlamydia

Target achievement levels for each scheme are defined in the CQUIN schedule. Both the schemes themselves and the targets will be reviewed annually.

- complete medicines reconciliation and decrease medication errors,

- implement paediatric clinical pathways to avoid admission to hospital

- redesign the colorectal cancer pathway and reduce hospital stays for these patients post-operatively and

- implement a seamless pathway across primary, community and acute care for patients with learning disabilities.

We aim to reduce both the number of patient falls and the harm caused by those falls.

- Falls Steering group meets monthly - Norfolk and Norwich Improving

Patient Safety (NNIPs) project is introducing “7 simple steps” monitoring tool; new falls advice leaflet to families/carers; continuing to improve medical staff patient assessment skills.

We aim to have a five per cent reduction in in-patient falls in 2010/11.

Patient Experience - Priorities

Key actions Targets / measures 2010/11

We aim to ensure an excellent patient experience for everyone using our services.

We will continue to extend our well-established programme of patient experience reviews. We will continue to use our “real time” electronic patient experience tracker and act on the findings. We display the results of these surveys publicly on wards and in out-patient areas. We will continue to act on the findings of surveys of our care, for example, the Care Quality Commission surveys.

We aim to complete a patient experience project in every significant specialty. We aim to maintain patient experience personal recommendation scores at >95 per cent We will review and address any survey issues when published.

These strategic priorities are devolved down through our organisation to divisional and clinical specialty level, where appropriate. In addition, clinical teams also have their own, locally determined, quality and governance standards. These are being incorporated into Divisional and specialty performance dashboards, allowing for regular, ongoing monitoring at all levels. During 2010/11 we will continue to develop these measures and dashboards to ensure quality is visible from ward to Board, and to the general public. Please see Appendix B for our overall Clinical Quality and Safety Dashboard.

b) Statements of Assurance Review of Services During 2009/10 we provided and/or sub-contracted 32 NHS services. Through our clinical governance structure, we have reviewed the data available on the quality of care in all of these NHS services. The income generated by the NHS services reviewed in 2009/10 represents 87 per cent of the total income generated from the provision of NHS services by us for 2009/10. Participation in Clinical Audits During 2009/10, 39 national clinical audits and seven national confidential enquiries covered NHS services that we provide. During that period we participated in 79 per cent of national clinical audits and 100 per cent of national confidential enquiries of the national clinical audits, and national confidential enquiries which we were eligible to participate in.

The national clinical audits and national confidential enquiries that we were eligible to participate in, and for which data collection was completed during 2009/10 are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry.

National Clinical Audits we were eligible

to participate in Participation

Yes (Y) or No (N)

Required sample number

Actual sample number

Percent

VSSGBI VSD/NVD National Vascular Database - 2009 report

Y Around 200

225 112.5

Continuous: all patients with no planned end date

NNAP: neonatal care N NDA: National Diabetes Audit - Inpatients 2009 Y 10 104 1040 ICNARC CMPD: adult critical care units N National Elective Surgery Patient Reported Outcome Measures (PROMs) -elective surgical treatment (hip and knee replacement, hernia repair and varicose surgery)

Y 2272 1951 86

CEMACH: perinatal mortality N National Joint Registry/Joint Review Program i.e. hip and knee joint replacement implants and surgery (6th Annual report).

Y 1392 1324 95

Renal Registry: renal replacement therapy Y All Patients on RTT

266

NLCA: lung cancer Y To be confirmed

To be confirmed

NBOCAP: bowel cancer Y To be confirmed

To be confirmed

DAHNO: head and neck cancer 6TH Annual Report

Y No target number required

All patients with Head & Neck Cancer

100



Y or N Required sample number


Percent

Myocardial Ischaemia National Audit Project MINAP (inc ambulance care): AMI & other ACS Discharge medication for ACS +ve patients (Aspirin, Ace, B blocker, Statin and Clopidogrel) - quarterly & annual reports

Y N/A 1357

Heart Failure Audit Y continuous 51 Pulmonary Hypertension Audit N NHFD: hip fracture Y continuous 561 TARN: severe trauma Y To be

confirmed To be

confirmed

NHS Blood & Transplant: potential donor audit Y No required or expected number - all Critical

Care Deaths are examined.

116

Adult cardiac interventions BCIS (PCI) monthly / quarterly reports data

Y 1024 1024 100

UK Carotid Interventions Audit Carotid Endarterectomy Round 2

Y To be confirmed

To be confirmed

Intermittent samples of patients, with samples recruited according to time period or sample size

National Kidney Care Audit National Audit of Vascular Access in CKD Stage 5

Y Continuous AH all

patients on RTT

266

National Audit of Dementia: dementia care Y 40 40 100 National Comparative Audit of Blood Transfusion Audit of the use of red cells in neonates & children

Y To be confirmed

To be confirmed

National Comparative Audit of Blood Transfusion - Audit of the Use of Fresh, Frozen Plasma

Y 40 40 100

British Thoracic Society Paediatric Pneumonia Y 6 20 British Thoracic Society Adult Asthma N British Thoracic Society Emergency Oxygen N British Thoracic Society Paediatric Asthma Y 65 65 100 British Thoracic Society 2009 Pilot Pleural procedures audit

N

Pain in children – College of Emergency Medicine

Y 60 60 100

Management of patients admitted with acute asthma – College of Emergency Medicine

Y Est 30-40 Min 15

Awaiting information

Fractured neck of femur – College of Emergency Medicine

Y N/A 50

Management of patients presenting with paracetamol overdose - College of Emergency Medicine

Y N/A 54

One-off; all patients with no plan to repeat patient recruitment in the future.

National Mastectomy and Breast Reconstruction Audit

Y No target number required

301

National Oesophago-gastric Cancer Audit Y To be confirmed

To be confirmed

RCP Continence Care Audit N Asthma in children (severe and moderate) 2009/2010 round

Y 65 65 100



Y or N Required sample number


Percent

Other National Audits National Audit on Major Complications of Airway Management in the UK

Y To be confirmed

70+

Perinatal, Paediatric and Young people with HIV -baseline audit as part of a review of CHINN arrangements

Y 6 6 100

UK CF Registry (cystic fibrosis database) Y 39 39 100

National Confidential Enquiries

Participation

Y or N

Required

sample no

Actual

sample no

Percent

Adding Insult To Injury - Report on care of patients who died in hospital with a primary diagnosis of Acute Kidney Injury (AKI).

Y 4-5 cases 5 100

Caring to the End? – Report on the process of care of patients who died within four days of admission to hospital.

Y Unknown Awaiting update

Peri-operative care study - Data Collection for study March 2010 to March 2011 (Report not yet published)

Y Data collection underway

Ongoing

Review of cosmetic surgery facilities - March 2009 to August 2009 Organisation questionnaire sent out from August 2009 (Report not yet published)

Y Summary due April

2010

To be confirmed

Children undergoing surgery - Data Collection for study - 1st April 2008 to 31st March 2010 (Report not yet published)

Y Any eligible patients

0 - there were no

paediatric surgery- specific

deaths in that year.

Emergency and Elective surgery in the elderly - October 2008 to December 2009 (Report not yet published)


Parenteral Nutrition - Data Collection for study - January 2009 to December 2009 Organisation questionnaire - April 2009. A Mixed Bag (Report not yet published)


The reports of six national clinical audits were reviewed by us in 2009/10 and we intend to take the following actions to improve the quality of healthcare provided.

Title Recommendation/Actions

National Audit of Oesophago - gastric Cancer 2nd Annual Report

1. O-G cancer services should strive to improve awareness of the disease among their population, local GPs and hospital clinicians. National initiatives such as the recent O-G cancer awareness week should be supported by all trusts and networks. 2. Cancer Networks should examine their referral guidelines and pathways, in order to reduce the proportion of referrals after emergency admission and attempt to reduce the delays experienced by patients referred non urgently. 3. O-G cancer services should ensure that all patients undergo a CT-scan plus an EUS (if oesophageal / upper junctional tumour) or a staging laparoscopy (if gastric / lower junctional tumour) before undergoing curative treatment and should improve the monitoring of their use.

4. All patients should be discussed with the specialist MDT to reduce the observed variation in the proportion of patients selected for curative treatment and palliative oncology. 5. All patients with stage II or III adenocarcinoma who are physiologically fit enough should be offered neoadjuvant chemotherapy or entered into appropriate national trials of such treatment, irrespective of tumour site. 6. Surgeons should monitor their pathology outcomes in order to ensure an adequate lymph node yield is obtained in every patient. 7. Minimally invasive surgery should continue to be introduced cautiously following the guidance published by the Association of Upper Gastro-Intestinal Surgeons. Early indications are that this approach is safe and may reduce the incidence of postoperative respiratory complications. 8. Cancer Networks should improve access to brachytherapy, because it improves symptom control in patients with a prognosis longer than three months. 9. Dilatation alone should not be performed as it is ineffective in controlling symptoms and much better alternatives are available. 10. NHS trusts should concentrate on improving the data completeness of their submissions, in particular those data items essential for examining treatment processes (such as staging investigations) and outcomes (such as resection margin status).

National Comparative Audit of Blood Transfusion - Audit of the Use of Group O RhD Negative Red Cells 2008

Taken from CEC minutes for August 2009 - 'Dr Gill Turner submitted a summary comparing NNUH practice against the report recommendations and an action plan. We are complying with most of the recommendations but Dr Turner has identified any actions required in the plan. The only outstanding item on the action plan is the review of the neonatal guideline which is in progress.'

National Comparative Audit of Blood Transfusion - Audit of the Use of Fresh, Frozen Plasma

Taken from April 2009 CEC minutes - 'The final report has been published and Dr Gil Turner submitted a paper to the CEC comparing present practice with the recommendations. Dr Turner concluded that we had performed well and that, with over 95% of the recommendations already in place and actions to address the remaining 5% either in progress or almost completed, there is no need to compile an action plan. The department aims to continue to educate staff re FFP usage and is planning a re-audit of PPC in the future.'

National Joint Registry/Joint Review Program i.e. hip and knee joint replacement implants and surgery (6th Annual report)

• Clinical feedback section of NJR website introduced to Consultant staff at February 2010 Governance meeting. All Consultants requested to sign – on with NJR, to enable access and data sharing. • Consultant staff aware of implant issues raised in report - Highlighted metal on metal implant tissue reactions noted in 2009 • Ankle replacements added as a joint replacement 01/04/2010 – data will be collected

National Vascular Database - 2009 report

There were no recommendations. • At present incomplete data submission is now a national requirement • Consultant time constraints main limiting factor • Need to identify possible sources of support

Fractured neck of femur 2009/2010

IV paracetamol has now been introduced specifically for patients with a fractured neck of femur. This should increase the percentage of patients given analgesia receiving analgesia within 20 minutes. A repeat audit will be performed in 2010.

The reports of more then 400 local clinical audits were reviewed in 2009/10 and we have action plans to improve the quality of healthcare provided.

Research The number of patients receiving NHS services provided or sub-contracted by us in 2009/10, that were recruited during that period to participate in research approved by a research ethics committee, was 4,900.

Our increasing level of participation in clinical research demonstrates our commitment to improving the quality of care we offer and to making our contribution to wider health improvement.

We were involved in conducting 272 clinical research studies. We used national systems to manage the studies in proportion to risk. 59 per cent of the studies were established and managed under national model agreements and five per cent involved use of a Research Passport. In 2009/10 the National Institute for Health Research (NIHR) supported 54 per cent of these studies through its research networks.

We have also strengthened relationships with the University of East Anglia and other Institutes on the Norwich Research Park. Two high-profile clinical Chairs have been appointed and a further increase in clinical academic appointments has been agreed.

We have actively cooperated with other institutions across the county and together we were successful in our application to be designated as a Health Innovation and Education Cluster (HIEC).

The Norfolk and Waveney Health Innovation and Education Cluster (HIEC), will combine its skills and experience to accelerate the coordination of health and social care for older people, in mental health, acute services, long-term conditions and end of life care.

The Norfolk and Waveney (HIEC), comprises a core membership: Norfolk Community Health and Care, NHS Norfolk, Norfolk County Council, NHS Great Yarmouth and Waveney, Norfolk and Norwich University Hospitals NHS Foundation Trust, the University of East Anglia, Norfolk and Waveney Mental Health NHS Foundation Trust, City College Norwich and James Paget University Hospitals NHS Foundation Trust. Also on board are organisations from outside the public sector, including Archant, the publisher of regional and local newspapers.

Clinical quality goals agreed with NHS Norfolk A proportion of our income in 2009/10 was conditional on achieving quality improvement and innovation goals agreed between us and any person or body with whom entered into a contract, agreement or arrangement for the provision of NHS services, through the Commissioning for Quality and Innovation (CQUINS) payment framework. There were over 30 goals identified in CQUINS covering the following areas: cardiology, maternity, orthopaedics, stroke and PROMS.

The monetary total for the amount of income in 2009/10 that was conditional upon achieving quality improvement was £1.5 million and the monetary total for the associate payment in 2009/10 was £1.5 million. Full details of the agreed goals for 2009/10 are available on request from the Medical Director, Mr Krishna Sethia. The identified CQUIN schemes for 2010/11 largely reflect our strategic quality priorities, together with nationally mandated quality improvement initiatives, and work to be undertaken with our local NHS and Social Care partners to improve clinical pathways for our patients. Registration and the Care Quality Commission We are required to register with the Care Quality Commission (CQC) and our current registration status is: registered with no conditions attached. The Care Quality Commission has not taken enforcement action against us during 2009/10. We are subject to periodic reviews by the CQC and the last review was held on 21 October 2009 in relation to the Hygiene Code. The CQC’s assessment in relation to the Hygiene Code was that we fully met all 15 infection prevention and control standards. We have not participated in any special reviews or investigations by the Care Quality Commission during the reporting period. Quality of data We submitted records during 2009/10 to the Secondary Uses Service for inclusion in the Hospital Episode Statistics which are included in the latest published data. The percentage of records in the published data:

which included the patient’s valid NHS number (using month 10 data) was:

• 99.3 per cent for admitted patient care • 99.6 per cent for out-patient care • 94.2 per cent for accident and emergency care

which included the patient’s valid General Medical Practice Code was:

• 100 per cent for admitted patient care • 100 per cent for out-patient care • 100 per cent for accident and emergency care.

Our score for 2009/10 for Information Quality and Records Management assessed using the Information Governance Toolkit was 87 per cent. We were subject to the Payment by Results clinical coding audit during the reporting period by the Audit Commission. The results of the coding audit should not be extrapolated further than the actual sample audited. The error rates reported

in the latest published audit for that period for diagnoses and treatments coding (clinical coding) were:

• Primary Diagnosis Incorrect 4 per cent • Secondary Diagnosis Incorrect 3.7 per cent • Primary Procedures Incorrect 3.6 per cent • Secondary Procedures Incorrect 2 per cent.

Part Three This section describes our quality performance in 2009/10, including safety development and service innovations a) Ensuring we have a culture of safety and quality The vision is: “To provide every patient with the care we want for those we love the most.” Our vision is to deliver the best standards of care that we can for our patients. In order to help us do this we have continued to focus on best clinical practice nationally and internationally. Our Board is committed to maintaining patient safety and quality of care at the top of its agenda. During 2009/10 we have made important progress in this regard in a number of key areas, including patient safety, changing our clinical governance structures, infection prevention and control, and achieving a number of service innovations all designed to improve quality. To support a growing culture of quality and safety across our hospitals we have identified three strands to the delivery of our quality agenda:

1. Investing in and developing our people, our learning and our governance

structures 2. Reviewing all the available information we have about our outcomes and

innovating to make improvements 3. Establishing tools to measure what our quality indicators are, to monitor and

report them at all levels Investing in our people and learning We have invested in establishing an Associate Medical Director of Patient Safety who is a senior clinical leader, with a clear remit to improve patient safety using all available national and international tools. The Associate Medical Director of Patient Safety has established a Patient Safety Committee and a Mortality Committee, both of which report to the Clinical Governance Committee, which in turn reports to the Board. These initiatives have strengthened our clinical governance structure and played a valuable role in providing improved and more extensive clinical governance data. The work of the Mortality Committee in particular, which involves Consultant review of all hospital deaths and identifying learning from those deaths, is providing powerful intelligence to support the ongoing development of Hospital Standardised Mortality Ratios (HSMR) as reliable quality indicators.

We have invested in both new staff and new facilities to deliver high quality care for all and the Board closely monitors staff-related factors such as appraisal performance and staff morale. We have seen our national staff satisfaction survey results improve significantly in 2009/10. The 2009 Care Quality Commission national staff survey reported that we were in the top four ranking scores for: • Percentage of staff agreeing they have an interesting job • Staff intention to remain in their job • Percentage of staff stating we provided equal opportunities for career

promotion or progression • Percentage of staff not experiencing discrimination at work in the last 12

months We were also in the best 20 per cent nationally for:

• Staff who reported feeling valued by their work colleagues (79 per cent) • Staff who agreed they had an interesting job (83 per cent) • Scoring 3.67 (maximum possible score of 5) for support from immediate

managers

Better than average

• 90 per cent of our staff agreed that their role makes a difference to patients or service users

• We scored of 3.4 (maximum possible score of 5) for quality of job design • 79 per cent of staff reported receiving job-relevant training, learning or

development in last 12 months • 77 per cent of staff said they had been appraised in last 12 months • We scored 3.58 (maximum possible score of 5) for staff recommendation of

our hospitals as a place to receive treatment

Worse than average

• 28 per cent of staff reported they did not have well structured appraisals • Higher than average numbers of staff (40 per cent) reported witnessing

potentially harmful errors • Lower than average numbers of staff (93 per cent) said they had reported an

adverse incident • Only 23 per cent of staff said that engagement with senior management was

good

Staff engagement is a priority and a new Staff Engagement Group is developing a Valuing our Staff action plan to address areas for improvement for our colleagues.

During the year we have updated our Team Brief process, developed an Ask the Staff suggestion scheme, and continued to provide a wide range of workplace well-being groups such as pilates and tai chi, poetry reading and writing, yoga, weaving and a book club. A Staff Awards scheme has also been launched to recognise excellence and has proved popular. More frequent briefing sessions by senior managers are held for staff and an internal staff survey is also being developed by our Human Resources team.

Ensuring our patient safety processes are right – our Clinical Governance Structure During 2009/10 we have strengthened our Clinical Governance structure – the arrangement of groups and committees which ensures that clinical performance and risk data is routinely considered and issues are addressed throughout the organisation.

Clinical Governance Committee

Patient Safety Mortality & Morbidity Clinical Incident Team Global Trigger Tool Team Infection Control Radiological protection Resuscitation Blood Transfusion Falls

Drugs and Therapeutics Thrombosis and Thromboprophylaxis

Clinical Effectiveness New Procedures Clinical Guidelines Clinical Information Review

Complaints and Clinical Incidents

Health & Safety

Divisions

Clinical outcomes Risk Audit Patient experience

There are four clinical divisions within our hospitals: Medicine and Emergency Care, Surgery, Women’s and Children’s Services and Clinical Support. The divisions have now also changed their Clinical Governance reporting process. They appear regularly before the Clinical Governance Committee, where they formally report their data on their local risks and mitigation, clinical and non-clinical incidents and resulting actions, infection prevention and control initiatives, clinical outcome measures, local audits, and key local quality and safety initiatives. Making patient safety the priority Under the leadership of the Associate Medical Director of Patient Safety we have enrolled in the “Patient Safety First Campaign” and the national “Leading in Patient Safety Programme” (LIPS). We are submitting monthly data to the Patient Safety First campaign including crude mortality data, cardiac arrest call, Global Trigger Tool, central line and ventilator acquired infections and the World Health Organization surgical checklist. We have involved 65 clinical staff in the establishment of 15 local improvement programmes, called the Norfolk and Norwich Improving Patient Safety (NNIPs). Amongst other issues they focus on are:

• Safe transfer/handover of patients • Pathology sample mislabelling • Medication errors

Reducing deaths One of our main aims is to reduce both our crude mortality rate and hospital standardised mortality rates (HSMR) and we peer review all deaths each month to identify any areas of learning. This process of peer review is achieved by the Mortality Committee and involves Consultant review of all hospital deaths within our hospitals and identifying learning from those deaths. The Mortality Committee reports to the Clinical Governance Board. Increasing incident reporting We are rolling out an electronic incident reporting system to all clinical areas. We expect this will increase reports of clinical incidents and near misses by 40 per cent compared to the former paper-based system. Missed medication doses During 2009/10 a focused study into missed doses of medication was undertaken on our respiratory ward, Hethel. It highlighted the need to educate staff on the potential significant impact of patients missing a dose, especially for higher risk drugs.

Patient Safety Walkrounds We have also introduced patient safety walkrounds. These are led by the Chief Executive and Medical Director and are designed to allow all grades of staff within clinical and supporting teams the opportunity to voice concerns about patient safety and promote an open and fair culture. Lessons and actions undertaken from walkrounds are published on our Intranet. b) Innovations and Outcomes – Our story so far Patient Safety Preventing and controlling infection We have continued to have low numbers of patients acquiring Methicillin Resistant Staphylococcus aureus bacteraemias (MRSA) and Clostridium difficile (C diff) whilst in our care. Ongoing hand hygiene and uniform policy audits in all clinical areas, coupled with regular and intensive audit of key clinical processes such as catheter care, line insertion and maintenance, have all continued to contribute to strong performance. We will continue with this audit regime on an ongoing basis. During 2009/10 we were invited to become a field test site for qualitative research being undertaken by the NHS Institute for Innovation and Improvement regarding infection prevention and control and communications with patients and public. Clinical staff and communications staff have been involved in sharing their best practice with other hospitals nationally and the project is due to conclude shortly. Three year performance - reducing hospital-acquired MRSA infection (bacteraemia) Over the past three years we have reduced the number of patients with hospital-acquired MRSA bloodstream infection by 62 per cent and this compares well against a national reduction of 59 per cent over a similar period. (Source: Health Protection Agency, MRSA, Oct-Dec 2007 – Oct-Dec 2009).

0

5

10

15

20

25

2007/08 2008/09 2009/10

Hospital-acquired MRSA (bacteraemia)

Three year performance - reducing hospital-acquired Clostridium difficile Over the past three years we have reduced the number of patients with Clostridium difficile by 73 per cent and this compares well against a national reduction of 58 per cent over a similar period (Source: Health Protection Agency, CDI, Oct-Dec 2007 – Oct-Dec 2009).

Hospital-acquired C difficile

0

50

100

150

200

250

300

350

2007/08 2008/09 2009/10

How we compared on infection with other hospitals in the East of England (April 2009 – February 2010) – C difficile

Source: NHS East of England

Preventing pressure sores During the year we have established a dedicated tissue viability team for the first time, staffed by two senior nurses. The service will improve the quality of care received by patients, who are admitted with a pressure ulcer, and will try to ensure that no patients acquire a serious pressure ulcer during their stay in hospital.

The senior nurses also work to improve the quality and accuracy of the weekly register of patients with pressure ulcers and compare this data with clinical incident data relating to pressure sores from our incident reporting system. They are working with all ward teams to improve knowledge and skills for the diagnosis and ongoing treatment of pressure ulcers, including the use of specialist dressings where required.

The team also plans to work with other similar teams across the East of England region, aiming to standardise the reporting and monitoring of pressure sores, allowing more accurate comparisons to be made and learning to be achieved across the region.

Sheila Ginty, Tissue Viability Team Leader and Staff Governor, said: “We are delighted to have introduced a dedicated team to help patients get the best treatment, and ensure that staff are able to prevent future problems wherever possible. We are confident that by really focusing on incident reporting and staff training, we can make a real difference to the quality of patient care.”

Clinical Effectiveness Hospital Standardised Mortality Ratio We were disappointed that we have not been able to reduce our Hospital Standardised Mortality Rate (HSMR) to below 90 in spite of the improvements in patient safety we have made during the year. This has prompted extensive work with Dr Foster Intelligence, the Associate Medical Director of Patient Safety, the Medical Director and the coding department. We are continuing to improve the accuracy of our coding and we are also comparing the results of our crude mortality audit with our Dr Foster HSMR reports. As part of this work we have recently resubmitted coding data to Dr Foster to ensure that our HSMR calculation is as accurate as possible.

Heart Attack Centre – Primary Percutaneous Coronary Intervention (PPCI) The newly introduced Primary Percutaneous Coronary Intervention (PPCI) service for the management of acute heart attack has proved highly successful, and 82 per cent of patients were treated within 150 minutes, against a target of 75 per cent. In terms of outcomes the evidence is that PPCI, also known as primary angioplasty, reduces deaths from heart attacks by up to 50 per cent. We are continuing to work with colleagues in the East of England Ambulance Service NHS Trust to increase the speed at which patients arrive at the hospital and can access treatment.

Balloons save lives For 51 year–old Paul Blyth, the primary angioplasty service at the Norfolk and Norwich University Hospital proved a real lifesaver after he had a heart attack at work. Mr Blyth was working at a garage in Framlingham, Suffolk, when he fell ill in November 2009.

His colleagues called 999 and paramedics attended him and realised he needed to get to a heart attack centre. The air ambulance was called in and airlifted him to the PPCI team in Norwich within 15 minutes.

Mr Blyth remained awake both during his flight in the air ambulance and during his procedure. He said: “I think it was more serious than I thought at the time, it was about 40 minutes from the time I took off in the helicopter to the operation being finished. I’m just so grateful to everyone who helped me. I have nothing but praise for them and they provided a fantastic service.”

Enablement means better care and happier staff During 2009/10 we have also focused on multi-disciplinary working to improve care for patients and also to improve the working lives of staff. This work was done in our large and very busy Medicine for the Elderly (MFE) department.

Improved patient experience and staff morale Medicine for the Elderly operational manager Jo Walmsley explained: “An initial pilot project was introduced to one of the Medicine for the Elderly wards, Elsing. This was to increase the multidisciplinary staffing available to patients on that ward and ensure that the patients received ongoing rehabilitation while still in hospital, rather than having to wait for a rehabilitation bed to become available in the community.”

The findings of the pilot were that patients really benefited in terms of confidence and function: fewer patients actually required ongoing rehabilitation in the community when they were ready to be discharged and, very interestingly, staff morale increased enormously, with staff sickness rates halving in the process.

Because of the clear benefits to both patients and staff the Enablement model was then rolled out to the three other acute MFE wards in the hospital during 2009/10, with some variation to make it suitable for the different patient groups on those wards. The staff in each ward said how they wanted the Enablement model on their own ward, and the same benefits for patient care and staff morale have been seen. Jo commented: “The atmosphere on the wards has really changed and become much more positive. We say to patients: “We are just keeping you moving because you will be well enough to go home soon,” and that positive focus has benefits for everyone.” The wards have now found that gentle group exercise sessions are also beneficial and popular with patients and these will be introduced to all the Elderly care wards during 2010/11.

Patient Experience Listening to and learning from patients During the last year we extended the use of a real time electronic patient experience tracking survey system across all clinical areas and now capture the experience of more than 1,000 patients every month. The results are displayed in public areas and are used to identify areas for improvement and recognise outstanding performance. In addition to the monthly patient experience tracker, we have continued with our in-depth Patient Experience Project.

Listening and Learning – Patient Experience Project Our patient experience projects are qualitative, in-depth reviews of clinical services undertaken with both patients and staff. Focus groups and video interviews are conducted with patients and data gathered to present a 360-degree view of each service.

Rebecca Perry, Project Lead said: ‘The commitment from the staff and the involvement of patients, including speaking directly to staff and patients about their experiences, contributing to a patient experience DVD and completing patient questionnaires, has given us a superb mechanism to use across other specialty areas within our hospitals.“ During 2009/10 the Patient Experience Project was extended to cover Urology, Stroke, Renal services and Medicine for the Elderly, and in April 2010 Dermatology and Rheumatology services will also take part. Each service sets its own improvement criteria, based on what the patient in each service tell us. Below is a list of some of the ways the project has helped to improve the experience for our patients. • Thank you cards provided for patients attending A&E to give feedback to

staff • Providing more information for patients to help reduce their anxieties. • Increased communication with patients e.g. the stroke team is developing

a questionnaire on admission to obtain information on patient likes/ dislikes

• Providing more support for patients at mealtimes to ensure patients are fed before the food goes cold

• Lowering tables at mealtimes to make independent feeding easier for stroke patients

• Providing a better service for urology patients when they phone with queries

• Reducing the turnaround time for electronic discharge letters from the wards to benefit patients and GPs

Food for Thought Patients’ views of the quality of food have not historically been as positive as we would like, and we are making constant efforts to improve. Diet and nutrition for our patients are taken very seriously both by us and by our catering provider, Serco.

A Nutrition Action Group meets regularly to set the overall priorities in this area. Working alongside this is our Nutrition on the Wards group (NOW), whose members include nurses, dietitians, speech and language therapists, our LINk partners and a public Governor. The group also works very closely with Serco.

A number of important initiatives were introduced during the year, including working with Serco to revise their patient survey and comment cards, an important source of information for both Serco and the Trust.

In response to feedback from the PEAT (Patient Environment Action Team) visit, Serco have now redesigned some of the food trolleys so that every ward now has a trolley serving soup, jacket potatoes and a salad bar; this is proving to be extremely popular with patients. Serco have also redesigned the breakfast trolleys, incorporating a proper warm toast rack, so that soggy toast is now a thing of the past.

The Speech and Language Therapy team, working with Serco, has introduced a picture menu this, which has made communication about food choices much easier for many patients. A new food chart has also been introduced, ensuring that food intake is reported consistently.

Nutrition on the Wards (NOW) Senior nurse Sian Watkins said: “All the wards take part in a food and nutrition assessment every year, covering areas including screening tools to identity malnourished patients, the patient’s environment, assistance with eating, obtaining food and the presentation of food. Each ward develops an individual action plan in response to this assessment.

“One issue highlighted was that sometimes more patients needed assistance with feeding than the nurses could cope with. To help address this problem, in 2009, 16 volunteers were selected and formally trained by us to be able to feed patients. This initiative has proved very popular with patients and volunteers alike.

“For 2010/11 a key development is the introduction of colour contrasting equipment – plates and cutlery. There is evidence that patients with dementia suffer from an altered visual perception, with the result that pale food presented on a pale plate is very hard to see. We want to be able to start serving food for these patients on different coloured plates, using specially adapted cutlery.

“In addition, there is some evidence that having fresh finger food available also acts as an appetite stimulant – we are still exploring the practicalities of this in the ward environment, but we hope to offer this during 2010/11.”

Performance against quality priorities in 2009/10

We identified a number of quality priorities for 2009/10, and these were set out in our Quality Report of 2008/09. A summary of our performance in these areas, compared to our targets, is as follows:

Patient Safety 2009/10 target 2009/10 performance

Prescribing Errors MRSA C diff Central Line/Surgical Site infections

Data collection 27 cases 220 cases Data collection

Audit = transcription error rate of 33 per cent. This will now be tackled during 2010/11 20 cases (eight hospital acquired) (target achieved) 134 cases (89 hospital acquired) (target achieved) Data collection complete

Clinical

Effectiveness 2009/10 target 2009/10

performance Decrease Mortality (HSMR and crude) PPCI/STEMI ≤150 mins Stroke thrombolysis ≤3hours

<90 HSMR 75 per cent 8 per cent

97.4 (target not achieved) 82 per cent (target achieved) 6.35 per cent (target not achieved)

Patient Experience 2009/10 target 2009/10 performance Overall quality of care Food Patient experience project

To be among the top 20% of Trusts nationally for overall quality of care To be among the top 40% of Trusts nationally for food Roll out to three departments

Target achieved Target achieved Rolled out to four departments

Reviewing last year’s priorities Prescribing and Infection Safety Audits Patient safety audits on prescribing errors and wider data collection on sources of infection (in addition to MRSA and C Diff) were both initiated. The prescribing audit data collection period is now complete and action will be taken on this issue in 2010/11. Data collection is still ongoing regarding infection control and action plans in this area will be implemented during 2010/11. Heart Attack Centre – Primary Percutaneous Coronary Intervention (PPCI) The newly introduced Primary Percutaneous Coronary Intervention (PPCI) service for the management of acute heart attack has proved highly successful and exceeded the target of treating 75 per cent of people within 150 minutes. We continue to work with ambulance colleagues to increase the speed at which patients can arrive and access treatment. Stroke Thrombolysis During the past year stroke services provided in central Norfolk have been completely reorganised. The opening in January 2010 of a new stroke rehabilitation unit at the Norwich Community Hospital enabled the further development of an acute stroke unit at the Norfolk and Norwich University Hospital. Investment by NHS Norfolk in therapy, nursing and medical staff has ensured that the service and facilities are now in place to provide significantly improved stroke care. Performance is being measured against a number of areas and the timeliness of treatments and service to stroke patients has improved significantly since the opening of the new stroke unit. We did not achieve the thrombolysis target for 2009/10 and this remains one of our key areas for focus in the year ahead, and an extensive quality dashboard for stroke services is being closely monitored as we strive to continue to improve the stroke service. What our patients say The Care Quality Commission (CQC) in-patient survey for 2009 confirms that we maintained a top 20 per cent performance nationally for overall quality of care and that patient experience of hospital food has improved on 2008 levels, rising to the top 40 per cent.

Performance against national core standards During 2009/10 we generally performed well against the national standards. The Board of Directors, with the support of the Council of Governors, undertook to eliminate the backlog of patients waiting more than 18 weeks. This resulted in an expected dip in performance against the 18 week target as patients who have waited the longest are treated first.

Target Target 09/10 QTR1 QTR2 QTR3 QTR4

Full Year 2009/10

C Difficile 220 16 21 29 23 89 MRSA Year on Year reduction 27 7 4 6 3 20 4 hours in A&E - 98% achievement 98% 99.2% 98.9% 98.2% 98.5% 98.7% 2 week cancer referral 93% 89.9% 91.4% 93.8% 96.2%* 92.7%* Maximum waiting time of 31 days diagnosis to treatment for all cancers 96% 97.3% 96.2% 97.6% 98.1%* 97.2%* Maximum waiting time of 31 days for subsequent treatments for all cancers - Anti Cancer Drugs

98% 98.5% 100% 99.6% 99.0%* 99.3%*

Maximum waiting time of 31 days for subsequent treatments for all cancers - Surgery

94% 89.7% 86.7% 89.0% 94.2%* 90.2%*

Maximum waiting time of 62 days for referral to treatment for all cancers - GP Referral

85% 81.4% 73.8% 74.0% 85.0%* 78.4%*

Maximum waiting time of 62 days for referral to treatment for all cancers - Screening

90% 92.7% 89.0% 79.1% 84.9%* 86.3%*

For admitted patients, maximum time of 18 weeks from point of referral to treatment**

90% 92.1% 92.6% 91.6% 83.8% 90.3%

For non-admitted patients, maximum time of 18 weeks from point of referral to treatment**

95% 97.6% 97.8% 97.9% 98.6% 98.0%

Thrombolysis within 60 mins of call 68% N.B. Does not apply due to de minimus ruleScreening all elective in-patients for MRSA - 83.4% 85.0% 91.7% - Any core standard All met met met met met

c) Measuring and Monitoring safety and quality We have made good progress in embedding safety and quality measures and monitoring across the organisation. The Board has a monthly clinical quality dashboard that sets out the clinical priorities and indicators and forms the basis of discussion at the Board meeting and also at our Council of Governors meetings which are held in public. The monthly Clinical Quality Dashboard that goes to the Board is also relayed to all members of our staff through our Team Brief and has also been published publicly on our website since late 2009. We have four clinical divisions which each have their own clinical dashboard and clinicians and managers are working to develop specialty level clinical data and measures.

Appendix B Clinical Quality Dashboard

Annex - Statements from key stakeholders Council of Governors The Governors of the Norfolk and Norwich University Hospitals NHS Foundation Trust have received its draft Quality Account for 2009/10. Consistent with advice received from ‘Monitor’ in relation to the duties and responsibilities of Trust Governors, we wish to make the following comments: We have had the opportunity to examine the Account, to contribute to its development and to discuss relevant items arising from it with the Executive Directors. The Governors endorse the emphasis and focus within the Trust on patient safety and the quality of care. They applaud the transparency with which the Trust has openly disclosed and publicly discussed important safety and quality information during the year. We believe that the quality and safety priorities that have been set by the Trust for 2010/11 are entirely appropriate and reflect what we believe to be the priorities of the Trust’s members. NHS Norfolk NHS Norfolk is happy to verify that the information captured within this Quality Account is accurate and consistent with information made available to NHS Norfolk, either through performance data, or through our joint clinical quality and patient safety meetings. We are looking forward to working collaboratively with the Trust, in the coming year, to continue improving services for patients through priorities identified in this year’s Quality Account. Norfolk Local Involvement Network Norfolk Local Involvement Network (LINk) welcomes the importance that the Trust places on a good working relationship between the two organisations. ‘The Liverpool Care Pathway in palliative care’ (p7) LINk raised concern with the Chief Executive about the lack of funding for a Macmillan Nurse to continue promoting the Liverpool Care Pathway within the hospital. In response, the Chief Executive is currently looking at how existing capacity within the team can be used to carry this valuable work. Electronic patient experience tracker (p7) While this is useful to give an overall picture of patient experience, it should not be exclusively relied upon to provide details about the patient experience. We suggest that the questions be kept constantly under review to ensure that it captures patient experiences in different areas.

2009 Adverse incident reporting (p19) NNUH has introduced a programme of awareness amongst staff about reporting adverse incidents. This may be the reason for the high level reported in 2009 which may also include incidents not related to patient safety. We are pleased that staff are reporting incidents and look forward to seeing the performance in this area improve next year. ‘Improved patient experience and staff morale’ (p26) Based on a visit to the Medicine for the Elderly wards, LINk can attest that the pilot project for the Medicine for the Elderly project was a success for patients and staff. We are pleased that the enablement pilot is being rolled out to other wards, with the LINk being involved in the steering and operational meetings. Patient Experience Project (p27/28) LINk welcomes the initiative and look forward to an objective analysis of the outcomes. ‘Nutrition on Wards’(NOW) (p28/29) LINk has taken part in the PEAT inspections and is part of the NOW committee. Members can attest that the hospital is continually working to improve the provision and presentation of food and that many good ideas are followed through. NOW is looking at training more volunteers to assist people who require help with feeding. Maternity Maternity services and NICU appear to be short of staff (a reflection of national shortages in experienced midwives). LINk hopes that the Trust will minimise the number of transfers to other maternity units and ensure that patient safety remains the top priority. Electronic discharge letters completed within 48 hours of discharge Not mentioned, but we are aware that this is still a challenging target to achieve. Hospital discharge NNUH has improved its management of hospital discharge by working closely with NHS Norfolk, Adult Social Services and other NHS Trusts. This has led to an increase in capacity at NNUH, improved access to intermediate care beds. improved communication and a reduction in delayed discharges. We hope that a tighter and more robust policy will reduce the need to cancel operations to cope with high demand. However we remain concerned that patients and families are not being involved early on about their hospital discharge; and that there is no robust means of tracking whether discharge protocol is being followed.

Norfolk Health Overview and Scrutiny Committee The Norfolk Health and Overview Scrutiny Committee has taken the view that it is more appropriate for Norfolk’s Local Involvement Network to consider the Quality Report and comment accordingly and the committee has therefore decided not to comment.

Norfolk and Norwich University Hospitals NHS Foundation TrustColney LaneNorwich NR4 7UYTel: 01603 286286Fax: 01603 287211

website: www.nnuh.nhs.ukemail: [email protected]

This report is also available upon request in various formats and languages. Contact Communications on 01603 289821