quality report 2014
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2013-14
The Hillingdon HospitalsNHS Foundation Trust
quality report
Improving your local hospitals – our report to you
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-14 01
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contentsAbout the Trust’s Quality Report 4
Executive summary 4
Part 1 Statement from the Chief Executive 6
Part 2 Review of quality priorities for improvement 8
Key quality achievements for 2013-14 8
2.1 Looking back… 9
Quality priorities for improvement 2013-14 – How did we do? 9
2.2 Performance against Core Quality Indicators 2013-14 16
2.3 Looking forward… 20
Our new Clinical Quality Strategy 20
Quality priorities for improvement in 2014-15 20
Patient Safety Collaborative Programme 27
2.4 Formal statements of assurance from the Board 27
Provision of NHS Services 27
Participation in clinical audit 28
Participation in research 33
Lessons learned from Serious Incidents 34
Goals agreed with our commissioners 35
Care Quality Commission registration 35
Data quality 37
Information governance toolkit 37
Clinical coding error rate 37
Part 3 Other key quality improvements we have made in 2013-14 38
Annex one 49
Part 4 Statements from our stakeholders 49
4.1 Statement from Hillingdon Clinical Commissioning Group (CCG) 49
4.2 Statement from our local Healthwatch (formerly LINks) 50
4.3 Statement from External Services Scrutiny Committee 51
4.4 The Hillingdon Hospitals NHS Foundation Trust response
to the consultation 53
4.5 Independent Auditor’s Report 55
Annex two 57
4.6 Statement of Directors’ responsibilities in respect of
the Quality Report 57
Glossary 58
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-1401
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About the Trust’s Quality Report
What is the Quality Report?This is produced for the public by NHS healthcare
providers about the quality of services they deliver.
All NHS providers strive to achieve high quality
care for all their patients, and the Quality Report
provides the Trust an opportunity to demonstrate
its commitment to quality improvement and show
what progress we have made in 2013-14. The
Quality Report is a mandated document which is
laid before Parliament before being made available
on the NHS Choices website and our own website –
(www.thh.nhs.uk).
What is included in the Quality Report?The Quality Report is a statutory document that
contains specific mandatory statements and
sections. There are also three areas that are
mandated by the Department of Health (DH)
which give us a framework in which to focus our
quality improvement programme. These are patient
safety, patient experience and clinical effectiveness.
The Trust undertook extensive consultation and
engagement in developing this report to ensure that
the quality improvement priorities reflect those of
our patients, our staff and our partners and
the wider public.
Part 2 of the report highlights the Trust’s quality
priorities and includes:
• The areas identified for improvement in 2013-14
• What the priority was
• How we performed against the targets
• And what this means for our patients.
There is also a section in Part 2 on the quality
priorities that have been identified for improvement
projects in 2014-15.
There is a useful glossary at the back of the report
which lists the abbreviations and terms included in
the document.
Executive summaryThis Executive Summary provides a very brief
overview of the information in this year’s report.
The Quality Report is a summary of our performance
during 2013-14 in relation to our quality priorities
and national requirements. The detail of our key
quality achievements and improvements are outlined
in the main body of the report. Overall the Trust has
performed very well across a wide range of core
quality indicators during this past year which has
resulted in us achieving green status for governance
in Monitor’s risk rating system. Particular successes
include the reduction in the Trust’s mortality rate, the
reduction in Health Care Associated Infections and
achieving Level 2 status in our recent NHS Litigation
Authority risk management standards assessments
for acute general and maternity care.
To demonstrate progress against our quality priorities
during 2013-14 we have included information that
shows how clinical teams have changed the way
they deliver care in order to improve the quality of
services for patients in our hospitals. Even though
our five priorities for 2013-14 have not been fully
achieved, some elements of the improvement work
have been fully realised and targets met. Some
examples of our achievements in the five priority
areas are listed below. Finally we have set out our
quality priorities for 2014-15 and the targets we
aim to achieve.
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-14 01
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Quality Priorities for Improvement 2013-14 – How did we do?
Quality priority How did we do?
The First Contact Project – Improving the Outpatient Experience
Reduced call abandonment rate (target <10%) 12% – improved by 16% from 2012-13
Reduced ‘Did Not Attend’ rates for outpatient appointments (target 8%)
Reduced by 0.6% to 9.1%
Improving People’s Experience of Leaving Hospital / Improving Inpatient Care
Achieve average Length of Stay to 3.5 days Reduced from 4 to 3.6 days
Earlier therapy and specialist review for >400 patients 463 patients via our ‘Home Safe’ project
Improving Emergency Care
Reduction of Hospital Standardised Mortality Ratio (HSMR) to London average
Achieved lower than national average, but remains slightly above London average
Improved response rate for A&E in the Friends and Family Test 19.4% – against a national target of 15%
CQUINS (Commissioning for Quality and Innovation)
Electronic requesting for radiology and pathology 100% achievement
Improving the experience of both patients and staff (measured using the ‘Friends & Family’ Test)
100% achievement
Embedding our culture and values framework – CARES
Staff completing their Personal Development Review (PDR) Achieved 84% against a target of 90%
Improved result in Compassionate Care question as part of the local patient experience survey
Achieved 96% against a target of 85%
Quality Priorities for Improvement in 2014-15 – What do we aim to do?
• Continuing to Improve the Outpatient
Experience
• Continuing with the Improving Inpatient
Care Project
• Improving patient safety in Emergency and
Maternity Care
• Introducing and embedding patient care
bundles/pathways
• Improve responsiveness to patient need.
During 2013-14 the Trust has published a new
Clinical Quality Strategy to support its delivery of
high quality care over the next three years. The
purpose of the new Strategy is to provide a structure
for delivering quality governance to ensure ongoing
improvement in the quality and safety of patient
care. The quality priorities outlined in this year’s
Quality Report reflect the clinical quality priorities
outlined in our Strategy.
The mandated statements/sections within this
Quality Report include information on our
participation in national audits and our research
activity during 2013-14. In addition, information is
provided on our registration as a healthcare provider
with the Care Quality Commission (CQC) and the
result of our unannounced visit during 2013.
This Quality Report and the priorities for 2014-
15 are presented as a result of consultation and
engagement with our Foundation Trust members,
our Governors, our staff, Healthwatch and our
Commissioners.
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-1401
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This Quality Report provides the Trust an opportunity
to demonstrate our commitment to delivering
high quality care to all. It outlines our quality
improvement work and the progress we have
made in 2013-14. I am extremely proud of our
achievements and of the ongoing commitment
from our staff in striving to continue to improve the
care and services that we deliver. I know that what
patients want is reassurance that they can trust their
local hospital to provide reliable, high standards
of care 24 hours a day, seven days a week. This
Quality Report confirms our commitment to you
to achieve this and ensures that we always put our
patients at the forefront of service development
and improvement. In this report you will read of the
extensive quality improvement work that has been
taking place across our hospitals to support this
ethos and the elements of clinical care and service
delivery that we aim to further improve to provide
the safe and high quality care that our patients
expect and deserve.
Within North West London the ‘Shaping a Healthier
Future’* (SaHF) programme outlines a five year
strategy which places the Hillingdon Hospital site as
one of the five major hospitals for providing a full
range of 24/7 emergency care in the region. The
programme is based on implementing the London
Health Programme (LHP) quality standards for
emergency care across all the major hospitals and in
all specialties that take part in the provision of this
service. The Trust has undertaken a self-assessment
on its current position against these standards and
key actions are being driven forward as part of our
clinical quality strategy. The SaHF programme also
places an emphasis on the provision of a wider
range of out-of-hours primary and urgent care, and
we are working closely with our GP commissioners
and other providers to ensure that across the
healthcare community patient care is provided
in the right place at the right time.
During 2013-14 there has been an increased
focus on how we measure and monitor quality at
the Trust. The Trust has considered
and made reference to key NHS
investigations and reviews,
and in particular the Francis
Inquiry into the failings at Mid
Staffordshire NHS Foundation
Trust where the standard of
services put patients at risk. Not
only was this a salutary reminder
that things can go wrong when
quality is not put at the heart of what we do but
it has also served to focus us all on continuously
striving to provide the safest possible care. Our
new Clinical Quality Strategy outlines the learning
and recommendations from the Francis Report
and other key quality reviews; these underpin our
key aims and objectives for quality improvement.
In addition we have reviewed our current quality
performance alongside national and regional quality
data and referenced local feedback from both staff
and patients in informing our new Strategy. We
have also undertaken a thorough review of our
governance structures and processes in relation to
delivering a robust quality management system
in accordance with Monitor’s Quality Governance
Framework.
We have performed very well on our quality
performance during 2013-14 across a wide range of
indicators which has resulted in us achieving green
status for governance with regard to Monitor’s risk
rating system. Under the Care Quality Commission’s
new Intelligent Monitoring System of acute trusts
(where trusts are assessed against 188 different
indicators) we have been assessed as being in
Part 1Statement from the Chief Executive
* http://www.healthiernorthwestlondon.nhs.uk/
INCREASED FOCUS
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-14 01
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view and to highlight the areas that we know we
need to focus on to make our services even more
safe and of a higher quality.
In developing our quality priorities for 2014-15
we have made reference to national best practice
and reviewed our current quality performance in
line with local, regional and national performance.
The report is the result of consultation with a wide
group of stakeholders, including our Governors,
Commissioners, People in Partnership and our local
Healthwatch.
I hope that this Quality Report provides you with a
clear picture of how important improvement and
safety are to us at The Hillingdon Hospitals NHS
Foundation Trust.
I confirm that to the best of my knowledge the
information in this document is accurate.
Yours sincerely
Shane DegarisChief Executive
The Hillingdon Hospitals NHS Foundation Trust
28th May 2014
the lowest level of risk category (band 6) for two
consecutive assessment periods. We have also
achieved Level 2 status in our recent NHS Litigation
Authority (NHSLA) and the Clinical Negligence
Scheme for Trusts (CNST) maternity assessments.
This demonstrates the Trust has robust risk
management processes in place which have been
checked for compliance and that staff see it as one
of their concerns to keep patients safe. In addition,
the Trust was Highly Commended in the 2013 Dr
Foster Hospital Guide awards for the improvement
in its performance for weekend emergency HSMR
(Hospital Standardised Mortality Ratio). This is
recognition of the good work that has been done to
not only improve weekend mortality but importantly
to maintain overall performance.
We have received over 15,800 patient responses
to the Friends and Family Test (FFT) during 2013-14
with the majority of patents recommending our
wards and emergency department to family and
friends. Where problems were highlighted we have
looked to address these. An example of this is our
Comfort at Night programme, recognised as a very
positive outcome on action taken as a result of
feedback from the FFT.
Despite a very positive quality performance record
for 2013-14, we are not complacent. Weaknesses
in our systems are dealt with promptly and openly
to ensure that better and safer systems of care can
be developed. The aim of this report is not only to
report on our achievements and the improvements
we have made in the last year but to give a balanced
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-1401
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In this part of the report we tell you about the quality of our services and how we have performed in the areas
identified for improvement in 2013-14. These areas are called our quality priorities and they fall into the three
areas of quality as mandated by the Department of Health (DH): patient safety, patient experience and clinical
effectiveness, and we are required to have a minimum of one priority in each area.
Firstly, the information below provides an overview of some of our key quality achievements in 2013-14.
These are important indicators for the public and our key stakeholders to provide assurance on the quality
of care and services that are delivered at the Trust:
Part 2Review of Quality Priorities for Improvement
*There are four NHSLA/CNST Levels: 0, 1, 2 and 3 being the highest level – higher levels indicate a reliable, robust and embedded risk management system across an organisation.
Key Quality Achievements during 2013-14
Achieved Level 2 accreditation for NHS Litigation Authority standards*
Dr Foster Good Hospital Guide – Highly Commended for improvement on weekend mortality
Achieved Level 2 accreditation for Clinical Negligence Scheme for Trusts (CNST) for Maternity standards*
Monitor – the Trust is rated green (no Evident concerns) for its performance on quality
Care Quality Commission – achieved Band 6 (lowest level of risk) in two consecutive assessments
Trust ranks among the best in London for patients on the fractured hip pathway
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-14 01
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insight about the challenges patients face when
booking outpatient appointments. The group have
reviewed the quality targets concerning reducing
the call abandonment rate, answering calls in 60
seconds and call resolution. Times that patients are
more likely to contact the Outpatient Appointment
Centre (OAC) were suggested and a system has
been introduced which enables an increase in staff
to cover high call volumes. The opening times of the
OAC were discussed and it was felt these offered
patients choice and good accessibility.
For improving the target of where patients do
not attend their appointment it was agreed
that patients should have an option to cancel
their appointment without being transferred
to a call agent. Following introduction of this
streamlined cancellation service during the latter
part of 2013-14 the DNA rate has fallen below
the target of 8%. Furthermore in February
2014 work commenced to pilot an enhanced
reminder service to one specialty and the impact
is currently being tracked. Evaluation of this pilot
will report on-going work in 2014. Also, following
feedback from patients, the text message format
was changed to include the specialty of the
appointment.
In addition, an Electronic Document Transfer
system (EDT) is being introduced which supports
the delivery of clinical documentation securely
between secondary and primary care in real
time. The EDT Hub will be used to send clinical
correspondence such as attendance notifications
and outpatient letters from Q2 onwards.
LOOKING BACK jPart 2.1 Quality priorities for improvement 2013-14 – How did we do?
PRIORITY 1
The First Contact Project – Improving the outpatient experience
We said: We would continue with the First Contact Project
(improving the outpatient experience) to further
embed the way patients are contacted and
reminded about their appointments. The Call
Management System (CMS) which was introduced
in 2012 needed further development during 2013-
14 to ensure we were getting our messages right
for patients. We also wanted to further centralise
bookings of new and follow-up outpatient
appointments across the Trust, having only partially
achieved our plans during 2012-13.
How did we do?
We have been successful in significantly reducing
the call abandonment rate to just 12% and realising
improvement across the other key indicators. It has
been recognised that the targets that were set for
2013-14 for this project were very ambitious and
based on performance in the private sector. During
2013-14 a working group has been meeting to
further facilitate this service development and add
Annual Quality Report Projects KPI Dashboard 2013-14
2011-2012 2012-2013 2013-14 2013-14Target
Reduced call abandonment rate N/A 28% 12% <10%
No of telephone calls answered within 60 seconds
N/A N/A 75% 95%
Resolution of queries in the first contact with patients
N/A N/A 55% >90%
Reduced DNA rates for outpatient appointments
9.8% 9.7% 9.1% 8%
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-1401
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and to reduce any unnecessary lengths of stay in
hospital, as well as reducing readmissions. We said
we would improve the discharge process by better
co-ordination of teams and closer working together
with doctors, nurses, pharmacists and therapists
when reviewing a patient’s needs before they
leave hospital.
How did we do? The specific goals we set for the project and the
performance are outlined below.
The Improving Inpatient Care Programme has
continued to evolve and has been focussed on a
number of key services that either avoid hospital
admissions or reduce length of stay by ensuring
comprehensive consultant-led assessment at an
early stage in the patient’s pathway. Last year we
also said that we would implement new electronic
whiteboards to provide reminders of all patients’
next steps for all teams who work on the wards. A
new electronic white board system has now been
implemented, with full roll out to every ward now
completed. This has improved communication
between all staff on the wards, improved the daily
handover and now the staff can clearly see what
each patient is waiting for, and act promptly to
ensure minimal delays.
The ambulatory care service that has previously
focussed on seeing and treating patients presenting
with deep vein thrombosis has now expanded to
include conditions such as community acquired
pneumonia, kidney infections and pulmonary
embolus. On average when compared with the
What does this mean for our patients?The outpatient pathway has been a key area of
focus for the Trust over the past few years in really
driving forward improvement around the patient
experience and that the systems we have in place
become much more efficient. The local outpatient
experience survey demonstrates that patients are
generally satisfied with the experience within the
outpatient department with an overall satisfaction
score of 87% across a range of indicators. We have
heard through our local Healthwatch however
that there are a number of elements in relation to
the outpatient pathway that need to continue to
improve, particularly in relation to the number of
appointment letters that a patient may receive and
the resolution of enquiries to the OAC. This is why
our improvement work will continue as a priority
into 2014-15 as identified by our FT members, our
local Healthwatch and our staff.
PRIORITY 2
Improving people’s experience of leaving hospital/improving inpatient care
We said:We would continue with the Leaving Hospital
Project to further improve the patient journey
through the hospital thereby decreasing length
of stay and to ensure an improved experience for
patients leading up to and including discharge
from hospital. We advised that we had reviewed
our goals and priorities and re-launched the project
as ‘Improving Inpatient Care’. Our aims were to
enhance early assessments for elderly people
Annual Quality Report Projects KPI Dashboard 2013-14
2012-2013 2013-14 2013-14Target
Reduce average length of hospital stay (LoS) by 12%, achieving average LoS to 3.5 days (national upper quartile level)
4 3.6 – Trust overall3.5 – elective
inpatients
3.5
Percentage of discharges leaving hospital before midday 29% 23.6% 40%
Earlier therapy and specialist review (numbers of patients via ‘Home Safe’ project)
N/A 463 400
Reduction in avoidable readmissions by 230 cases 3401 20 fewer 3171
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-14 01
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organised resulting in discharges happening much
later in the day. New initiatives to be explored in
the forthcoming year include opening a medication
dispensary on the new acute medical unit. This is
expected to reduce the time that patients wait for
their medications resulting in an increased number
of earlier discharges per day.
Reducing readmission rates is a key priority for the
Trust in achieving high quality care. Despite aiming
to reduce readmissions our current workstreams
have not had significant impact in 2013-14.
Readmissions to hospital within 28 days in 2012-
13 was 105.2 and in 2013-14 it reduced to 102.9
slightly above the national average of 100 (this
data is sourced from Dr Foster and is a standardised
measure that looks at case-mix, identifying whether
we have more or less or the same readmissions as
would be expected).
A recent audit that was undertaken in partnership
with Hillingdon CCG has revealed that there are
opportunities to improve the existing workstreams
to improve communication and documentation
across primary and secondary interfaces and also
to support increased empowerment of patients to
manage their own condition more effectively. The
audit findings also suggested there is an opportunity
to work with local nursing homes to provide their
staff with advice and guidance on management of
common conditions where admission to hospital
could perhaps be avoided. This work will be driven
forward in 2014-15 as part of our clinical quality
strategy and action plan.
PRIORITY 3
Improving emergency care
We said:We would improve emergency care by aiming
to achieve key elements of the London Health
Programme Emergency Care Standards. We advised
that nationally there is evidence to show that there
are significant differences in the mortality rates for
patients admitted as an emergency during the week
compared with patients admitted as an emergency
previous year the service now treats an additional
200 patients per month.
The ‘Home Safe’ team has evolved from the acute
care of the elderly service that was previously piloted
in the emergency assessment ward and is working
proactively with community services and Age UK to
provide expert clinical review. The level of specialist
input facilitates high quality patient discharge for the
care of the elderly group. The ‘Home Safe’ team, led
by a consultant geriatrician provide a high quality
multidisciplinary care team review and provide
individualised plans of care that may include referral
to a variety of services both in and out of hospital.
Overall, length of stay has continued to reduce
within the division of Medicine (by 0.7 days for
2013-14) and since the formal introduction of
‘Home Safe’ in January 2014, the average length of
stay for care of the elderly has fallen from 14 days
to 11.5 days for two consecutive months. From
November 2013 until end of March 2014 the ‘Home
Safe’ team screened 463 patients and assessed 189
patients. 118 of these patients were able to be sent
home at an earlier stage with 58 receiving additional
support from a range of services.
What does this mean for our patients?
Reducing the length of stay in hospital for our
patients means that they spend less unnecessary
time in hospital. The ‘Home Safe’ project ensures
there is a multidisciplinary approach to planning
for discharge as soon as the patient is admitted.
Going forward there are plans to expand the service
to be able to offer ‘Home Safe’ discharge from
our specialty wards. This will mean that patients
who have undergone surgery or who have had an
extended length of stay in hospital will also be able
to benefit from this innovative new service.
Although length of stay has achieved the target
during 2013-14 we have not been able to improve
further on patients leaving hospital before midday.
Our local Healthwatch have advised us that they
continue to receive this feedback and that this
is a real concern for our patients, often waiting
for medication or for community services to be
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Reduction of HSMR to London average During 2013-14 trust weekday and weekend
mortality rates have reduced based on bench-
marking data available from Dr Foster (historically
re-based annually). The overall Hospital Standardised
Mortality Ratio (HSMR) is currently lower (84.1) than
the national average for weekdays (up until February
2014) with statistical significance. HSMR is also
lower than the national average at the weekends
(98.2) however for 2013-14 it remains slightly
above the London average. The Trust is tracking
the HSMR at specialty level within clinical divisions
and is carrying out regular reviews of all deaths
in hospital.
Participation of attending A&E patients in the Friends and Family Test We advised that we wanted to improve the
participation in the Friends and Family Test in the
Accident and Emergency Department because
participation had been 8% for 2012-13 against
a target of 15%. There has been significant
improvement in this area where the trust now has
the second highest response rate of all emergency
departments in London. Our overall response rate
for 2013-14 is 19.4% against the national target of
15%. The Friends and Family Test reports a net-
promoter score whereby the patient would either
highly recommend or recommend the emergency
department to their friends and family. The vast
majority of comments are extremely positive (see
page 127) and very importantly actions have been
taken where there have been recommendations
for improvement.
What does this mean for our patients?We are committed to ensuring that the care we
deliver to patients who are admitted as an emergency
is of the highest quality in relation to patient safety,
patient experience and clinical effectiveness. We have
been commended by Dr Foster for our reduction in
HSMR for weekend mortality; this means that our
patients are receiving improved care throughout the
week. We will continue to focus on this improvement
work during 2014-15 in relation to implementing the
London Quality Standards.
at the weekend and that nationally, and in London,
reduced service provision at weekends has been
associated with a higher mortality rate.
We stated that as a Trust we are committed to
achieving these quality standards and that we had
already invested in additional senior doctor time,
out of hours Monday to Friday and also at the
weekends. Notably we had provided consultant
ward rounds twice a day on our medical
Emergency Assessment Unit (EAU).
The focus of work for 2013-14 was to ensure that
there was a senior doctor (consultant level) review
within 12 hours of a patient being admitted to
the hospital and that we would aim to reduce
the measure of mortality known as the Hospital
Standardised Mortality Ratio to the London average
and reduce the variation between weekday and
weekend mortality. We also stated that we would
improve participation of attending patients in the
Friends and Family Test so that we could better
gauge the patient’s experience of emergency care.
How did we do?Consultant review within 12 hours of decision to admitThe trust has made
further investments in our
Emergency Department
and EAU resulting in
increased consultant cover
seven days per week. The rapid assessment service is
now well embedded in the department and means
that all emergency admissions benefit from an
initial review by a senior doctor. The January audit
showed that 64% of patients were reviewed by a
consultant within 12 hours once admitted to the
EAU against a target of 90%. Additional investment
in the consultant body in 2014-15 will enable further
expansion of ambulatory care pathways and will
ensure that the vast majority of patients are seen by
a consultant within 12 hours of admission. This will
be a key focus in 2014-15 as part of the London
Quality Standards recommendations and our local
action plan.
HOW DID WE
DO?
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PRIORITY 4
CQUINS (Commissioning for Quality and Innovation)
The key aim of the Commissioning for Quality
and Innovation (CQUIN) framework is to secure
improvements in quality of services and better
outcomes for patients, whilst also maintaining
strong financial management. In 2013-14 there
were ten Acute CQUIN schemes agreed, six of
which were locally derived by Hillingdon Clinical
Commissioning Group. In 2013-14 we have
achieved 78.6% of our acute CQUIN target
demonstrating a material improvement on
2012-13 in which we achieved 73%.
CQUIN Targets for 2013-14 Achievement Commentary
National Schemes
Improving the experience of both patients and staff (measured using the ‘Friends & Family’ Test)
100% achievement
Promoting ‘harm free’ care for patients (as measured by the Patient Safety Thermometer)
Partial achievement
The Trust had a challenging target of 50% reduction in pressure ulcers (as measured by the Patient Safety Thermometer) for 2013-14 and started the year lower than the national average. The Trust achieved an overall year-end reduction of 37% but continues to see significant variation in the number of community acquired pressure ulcers and so will need to continue to work with community colleagues to best support and reduce these for 2014-15.
Improving services for patients with dementia
Partial achievement
As part of the 2013-14 dementia CQUIN the Trust was required to provide complete monthly carers’ surveys, implement staff training and to find, assess, investigate and refer 90% of elderly patients admitted through emergency methods. The Trust has achieved both the training and carers surveys but despite significant improvement of 70%, has been unable to achieve the 90% target.
Preventing blood clots 100% achievement
How did we do?See table below.
What does this mean for our patients?The CQUIN framework supports improvements in
the quality of services and aims to provide better
outcomes for patients. It enables commissioners
to reward excellence, by linking a proportion of
healthcare providers’ income to the achievement
of local quality improvement goals. Having fully
and partially achieved nine out of the ten CQUINS
for 2013-14 will mean that the quality of our
services and the care that we deliver to
our patients has improved.
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-1401
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CQUIN Targets for 2013-14 Achievement Commentary
Local & Regional Schemes
‘Home Safe’ (enables patients to be safely discharged sooner from hospital)
100% achievement
Consultant assessments within 12 hours of emergency admission
Not achieved The Trust had a target of consultant assessments within 12 hours of emergency admission however this has proved particularly difficult to achieve with performance of between 50 and 60%.
Electronic requesting for radiology and pathology
100% achievement
Improving Colorectal services Partial achievement
This included reducing wait times for colonoscopies, comprehensive post-operative assessment by a geriatric specialist, and GP education. The Trust was successful in all but the GP education element where a small take up by GP practices made the face to face element particularly challenging.
Improving communications between GPs and hospital consultants
Partial achievement
The Trust achieved its target to develop referral pathways with local GPs but did not fully achieve the target to provide an advice line service for GPs calling with condition-specific queries. 80% of calls from GPs were connected but the small volume of calls in some specialties meant that it was difficult to achieve the target of 92.5%. This CQUIN continues to have focus with roll out to additional specialties.
Reducing the length of time patients wait for treatment in A&E
Partial achievement
A&E Rapid Access and Triage was a success within the first three quarters, however the Trust was not able to sustain reduced waits over the winter months leading to partial achievement of the CQUIN of 75%.
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-14 01
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pressures during winter resulted in staff not being
able to be released to attend training, therefore a
decision was made to postpone sessions and re-start
them in April 2014.
Learning from complaints – improving behaviour and attitude We said that we would ensure that all complaints
were addressed using the CARES framework and
that we would make the framework an integral part
of the investigation process to identify behavioural
and attitudinal issues as well as the technical aspects
so that we can learn from them. There have been
significant changes in our Complaints Management
Unit team during this year; this has meant that
the focus has been on ensuring that complaints
are investigated thoroughly and within the agreed
timescale. Many of our senior sisters and matrons
now successfully use the CARES framework when
investigating and sharing the complaint with their
teams. In this way they can bring the CARES values
to ‘life’ encouraging individuals to evaluate whether
they have demonstrated the expected attitude and
behaviour.
Our key targets also included improvement in
the communication, involvement, information
and compassionate care questions in our local
satisfaction survey:
Performance Indicator
Performance 2013-14
Target for 2013-14
Communication, involvement and information – using the cluster of questions in the inpatient survey
89% Improve baseline
(88%) result by 2%
Compassionate Care – ‘overall were you treated with kindness and understanding while you were in the hospital’?
96% Achieve 85%
PRIORITY 5
Embedding our culture and values framework – CARES
We said:Our goal was to deliver the best possible experience
to our patients and to our staff. We felt we could
make real improvement in this area through
embedding our culture and values framework, CARES
(Communication, Attitude, Responsibility, Equity
and Safety). Formally launched in May 2012 CARES
provides clear core values supported by a framework
that sets out the standard in terms of attitude and
behaviours we expect from our staff. This supports
our staff to deliver care with compassion as well as
ensuring it is safe and effective.
How did we do?
Performance Indicator
Performance 2013-14
Target for 2013-14
Staff completing their Personal Development Review (PDR)
84% 90%
Staff completing the Customer Care Training
50% 33%
Whilst the target was not achieved for staff
completing their PDR, this is a good return given the
extension of the Talent Management (TM) process
to around 500 staff – significantly more than the
previous year. The TM process incorporates a more
detailed review for each individual and as a result
requires much more time for both preparation and
conversations with staff members.
The Customer Care Training was introduced to raise
awareness of our CARES values to all of our staff
so that they could understand the impact of their
behaviours on patients and their colleagues. We
have not achieved our target because additional
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-1401
16
sources and is presented in line with the detailed
Monitor guidance.
Data InconsistenciesA number of indicators are showing changes to
2012-13 data that was published in last year’s
Quality Report. There are several reasons for
this as follows:
1. The statutory timescale within which the
Quality Report is published is very tight. Not all
of the latest data was available at the time of
publication last year and so the Trust has taken
the opportunity to update 2012-13 indicators
with full year updates which are now available
2. National Indicators based on statistical methods
by definition require re-basing (e.g. standardised
readmissions, HSMR, SHMI)
3. Data quality or data completeness issues may
have affected last year’s indicators. If these have
been identified then they have been rectified in
this year’s report.
What does this mean for our patients?Improvement in the patient experience indicators
outlined above demonstrate that the measures we
have put in place this year such as staff receiving
feedback on CARES as part of their personal
development review and the delivery of an extensive
programme of customer care training has had a
positive impact on staff attitude and behaviours. We
will continue to deliver on improving staff attitude
and behaviour in line with our CARES values in the
forthcoming year; some of these workstreams are
outlined in Priority 5 for 2014-15.
Part 2.2 Performance against Core Quality Indicators 2013-14
In this part of the report the Trust is required
to report against a core set of national quality
indicators to provide an overview of performance in
2013-14. The following page provides information
which has been obtained from the recommended
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-14 01
17
2012
-13
Perfo
rman
ce20
13-1
4 Ta
rget
2013
-14
Perfo
rman
ceLo
ndon
Tru
stsNa
tiona
lBe
nchm
ark
Sour
ceBe
nchm
ark
Perio
dLo
wes
t Per
form
ing
Trust
High
est P
erfo
rmin
g Tru
st
1: S
umm
ary H
ospi
tal-L
evel
M
orta
lity (
SHM
I)0.
9 (A
s Ex
pect
ed)
As E
xpec
ted
or Lo
wer
Than
Ex
pect
ed
0.89
(As
Expe
cted
)n/
an/
aHS
CIC
Oct-2
012
to
Sep-
2013
WYE
VAL
LEY
NHS T
RUST
, 1.
1859
Band
1 (H
ighe
r tha
n Ex
pect
ed)
The W
hitti
ngto
n Ho
spita
l NHS
Trus
t0.
6301
Band
3 (L
ower
Than
Exp
ecte
d)
2: th
e pe
rcen
tage
of p
atien
t dea
ths w
ith
pallia
tive
care
code
d at
dia
gnos
is19
.80%
n/a
23.0
%23
.6%
20.9
%HS
CIC
Oct-2
012
to
Sep-
2013
T AUN
TON
AND
SOM
ERSE
T NH
S FO
UNDA
TION
TRUS
T 0%
EAST
AND
NOR
TH H
ERTF
ORDS
HIRE
NHS
TRUS
T44
.9%
3: E
mer
genc
y rea
dmiss
ions
to h
ospi
tal w
ithin
28
day
s of d
ischa
rge
from
hos
pita
l: chi
ldre
n of
ag
es 0
-15
[Sta
ndar
dise
d] (C
rude
)
[9.1
1%]
(5.6
0%)
n/a
[8.2
8%]
(6.2
8%)
[7.8
1%]
[10.
01%
][H
SCIC
][P
AS]
2011
-12
[Sta
ndar
dise
d]20
13-1
4 [C
rude
]
THE
ROYA
L WOL
VERH
AMPT
ON
HOSP
ITALS
NHS
TRUS
T 14
.94%
AINT
REE
UNIV
ERSI
TY H
OSPI
TALS
NHS
FOU
NDAT
ION
TRUS
T (P
lus 5
0 ot
her T
rusts
)0%
4: E
mer
genc
y rea
dmiss
ions
to h
ospi
tal w
ithin
28
day
s of d
ischa
rge
from
hos
pita
l: Adu
lts o
f ag
es 1
6+ [S
tand
ardi
sed]
(Cru
de)
[11.
88%
](7
.55%
)n/
a[1
2.11
%]
(7.6
2%)
[12.
17%
][1
1.45
%]
[HSC
IC]
[PAS
]20
11-1
2 [S
tand
ardi
sed]
2013
-14
[Cru
de]
SHEF
FIELD
CHI
LDRE
NS N
HS
FOUN
DATI
ON TR
UST
17.1
5%
QUEE
N EL
IZAB
ETH
HOSP
ITAL N
HS TR
UST
(Plu
s 45
othe
r Tru
sts)
0%
5: C
lostr
idiu
m d
iffici
le23
case
s(1
8.0
Case
s pe
r 100
,000
be
dday
s)
14 C
ases
(A
bsol
ute)
12 C
ases
(8.5
Cas
es
per 1
00,0
00
bedd
ays)
17.0
Ca
ses p
er
100,
000
bedd
ays
17.3
Cas
es
per 1
00,0
00
bedd
ays
PHE
2012
-13
North
Tees
& H
artle
pool
had
61
Trust
ap
ortio
ned
Case
s (30
.8 ca
ses p
er 1
00,0
00
bedd
ays)
Follo
win
g Tru
sts h
ad Z
ero
Case
s of C
diff
in 2
012/
2013
,Al
der H
ey C
hild
ren’
s, Bi
rmin
gham
Wom
en’s,
Liver
pool
Wom
en’s,
Moo
rfield
s Eye
Hos
pita
l,Qu
een
Vict
oria
Hos
pita
l
6: V
enou
s Thr
ombo
emol
ism (V
TE)
91.9
%95
.0%
95.2
%95
.5%
95.7
%NH
S En
glan
dAp
r-201
3 to
Feb
2014
(Nat
iona
l/Lo
ndon
)Oc
t-201
3 to
De
c-20
13 (L
owes
t/Hi
ghes
t Per
form
ers)
77.7
% -
NORT
H CU
MBR
IA
UNIV
ERSI
TY H
OSPI
TALS
NHS
TRUS
T
100.
0% -
BRID
GEW
ATER
COM
MUN
ITY
HEAL
THCA
RE N
HS
TRUS
T; QU
EEN
VICT
ORIA
HOS
PITA
L NHS
FOU
NDAT
ION
TR
UST;
ROYA
L NAT
IONA
L HOS
PITA
L FOR
RHE
UMAT
IC
DISE
ASES
NHS
FOU
NDAT
ION
TRUS
T; SO
UTH
ESSE
X PA
RTNE
RSHI
P UN
IVER
SITY
NHS
FOU
NDAT
ION
TRUS
T
7: P
ROM
S (H
ealth
Gai
n), G
roin
Her
nia,
EQ-
5D
Inde
x/VA
S0.
119/
-0.0
750.
1/4.
471
n/a
0.08
6/-0
.874
HSCI
CAp
r-201
3 to
De
c-20
13-0
.033
BMI -
F AW
KHAM
MAN
OR H
OSPI
TAL
-0.0
29GU
Y’S A
ND S
T THO
MAS
’ NHS
FO
UNDA
TION
TRUS
T
0.39
9NU
FFIE
LD H
EALT
H, IP
SWIC
H HO
SPITA
L0.
24DA
RTFO
RD A
ND G
RAVE
SHAM
NHS
TRUS
T
8: P
ROM
S (H
ealth
Gai
n), H
ip R
epla
cem
ent,
EQ-5
D In
dex/
VAS
0.39
6/12
.992
0.46
7/11
.239
n/a
0.43
9/11
.663
HSCI
CAp
r-201
3 to
De
c-20
130.
179
HOM
ERTO
N UN
IVER
SITY
HOS
PITA
L NH
S FO
UNDA
TION
TRUS
T
0.64
1BM
I - TH
REE
SHIR
ES H
OSPI
TAL
0.63
4EA
ST A
ND N
ORTH
HER
TFOR
DSHI
RE N
HS TR
UST
9: P
ROM
S (H
ealth
Gai
n), K
nee
Repl
acem
ent,
EQ-5
D In
dex/
VAS
0.26
7/4.
827
0.32
4/2.
691
n/a
0.33
/5.8
HSCI
CAp
r-201
3 to
De
c-20
130.
028
SPIR
E LE
EDS
HOSP
IT AL
0.20
2W
ALSA
LL H
EALT
HCAR
E NH
S TRU
ST
0.57
3BM
I - TH
E CL
EMEN
TINE
CHU
RCHI
LL H
OSPI
TAL
0.48
7NO
RTH
TEES
AND
HAR
TLEP
OOL N
HS F
OUND
ATIO
NTR
UST
10: F
riend
s and
Fam
ily Te
st qu
estio
n 12
d –
‘If
a fri
end
or re
lativ
e ne
eded
trea
tmen
t I w
ould
be
hap
py w
ith th
e sta
ndar
d of
care
pro
vided
by
this
orga
nisa
tion’
59%
(46%
ag
ree
13%
stro
ngly
agre
e)
n/a
62%
(46%
agr
ee16
% st
rong
ly ag
ree)
67%
n/a
Pick
er In
stitu
te20
13M
id Yo
rksh
ire H
ospi
tals
NHS T
rust
and
North
Cum
bria
Uni
versi
ty
Hosp
itals
NHS T
rust
(33%
agr
ee 7
% st
rong
ly ag
ree)
Salfo
rd R
oyal
NHS
FT
89%
(42%
agr
ee47
% st
rong
ly ag
ree)
11: T
rust’
s res
pons
ivene
ss to
per
sona
l nee
ds
of o
ur p
atien
ts65
%n/
a66
.4%
n/a
n/a
n/a
n/a
n/a
n/a
12: [
a] Th
e nu
mbe
r, and
whe
re a
vaila
ble,
rate
of
pat
ient s
afet
y inc
iden
ts re
porte
d w
ithin
the
perio
d, a
nd;
[b] t
he n
umbe
r and
per
cent
age
of su
ch
patie
nt sa
fety
incid
ents
that
resu
lted
in se
vere
ha
rm o
r dea
th
4758
, 8.0
%38
, 0.8
%n/
a52
42, 8
.9%
56, 1
.1%
1256
9,
7.0%
138,
1.1
%
1332
07,
7.4%
893,
0.7
%
NRLS
Apr-2
013
to
Sep-
2013
Base
d on
[a] W
ALSA
LL H
EALT
HCAR
E NH
S TRU
ST(4
888,
14.
49%
)Ba
sed
on [b
] BAS
ILDON
AND
TH
URRO
CK U
NIVE
RSIT
YHO
SPITA
LS N
HS F
OUND
ATIO
N
TRUS
T (1
06, 3
.1%
)
Base
d on
[a] W
RIGH
TING
TON,
WIG
AN A
ND LE
IGH
NHS
FOUN
DATI
ON TR
UST
(153
9, 3
.54%
)Ba
sed
on [b
] THE
ROT
HERH
AM N
HS F
OUND
ATIO
NTR
UST
(0, 0
%)
13: S
elf ce
rtific
atio
n ag
ains
t com
plia
nce
with
re
quire
men
ts re
gard
ing
acce
ss to
hea
lthca
re
for p
eopl
e w
ith a
lear
ning
disa
bilit
y
Fully
Com
plia
ntFu
llyCo
mpl
iant
Fully
Com
plia
ntn/
an/
an/
an/
an/
an/
a
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-1401
18
Indicator 5: The Trust successfully achieved a significant
reduction in Clostridium difficile (C. diff) this year
and reported 12 cases, a 48% reduction from
the previous year’s total of 23. This was achieved
through a number of focused activities across the
organisation as outlined on page 122. The Trust
intends to take the following actions to improve on
this indicator and so the quality of its services:
• Undertaking further work on antimicrobial
prescribing including monitoring compliance to
policy by specialty. This will be reflected in audits
undertaken by clinical teams in the next year.
Indicator 6:The Trust has shown an improvement over the last
three years. This was a CQUIN for 2013-14 and
there was 100% achievement in relation to the
CQUIN requirements; this has supported the Trust in
achieving this target. The Trust intends to take the
following actions to maintain the performance on
this indicator and so the quality of its services:
• Monthly monitoring of VTE performance via
the Patient Safety Thermometer
• To continue with Root Cause Analysis
investigation of hospital acquired VTEs.
Indicator 7:The Trust has significantly better outcomes reported
for Groin Hernia repair with the pre-operative
participation rate being well above the national
average however the drive on post-operative
responses needs significant attention. The Trust
intends to take the following actions to improve on
this indicator and so the quality of its services:
• Promotion of the importance of the patient
responding to the survey
• Improve data collection, submission and
response rates through governance forums with
clinical leadership driving this forward to ensure
we achieve compliance.
Indicator 8 and 9: For the Knee replacement PROMs performance the
most recent figures available for comparisons of
national data indicate we are only marginally below
the national average score. The Trust intends to take
Supporting Information about the indicators required in accordance with the Quality Account regulations The Hillingdon Hospitals NHS Foundation
Trust considers that this data is as described
for the following reasons:
Indicator 1:National reporting shows the Trust to be within the
‘As Expected’ range and that it has had a stable
ratio over the past three years. The Trust intends to
take the following actions to further improve on
this indicator and so the quality of its services:
• Improve the variation between weekdays
and weekends by implementing the London
Quality Standards
• Examine any specialty outliers.
Indicator 2: During the last year there has been a marked increase in
our palliative care coding towards the national average.
This is in line with rates of palliative care coding
having increased nationally. Dr Foster has reported
that it is unclear as to whether this is as a result of
increased number of patients receiving palliative care
or improvements to the clinical coding processes for
these patients or whether there have been changes to
the way trusts interpret the guidance around coding
of palliative care. It is noted that there is also significant
variation in coding rates across trusts. The Trust intends
to take the following actions to maintain performance
on this indicator and so the quality of its services:
• Monitor performance and ensure that reporting
systems are robust and efficient through audit.
Indicators 3 and 4: The Trust is aware from a variety of data sources that
the figures are higher than expected for the +16 age
group. The Improving Inpatient Care initiative has
been working to reduce this rate during 2013-14 as
outlined on pages 90 and 91. The trust intends to
take the following actions to further improve on
this indicator and so the quality of its services:
• Continuing with the Improving Inpatient Care
project as a Quality Priority for 2014-15 as
outlined on page 103 and 104
• Develop improved integrated care pathways.
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-14 01
19
intentional rounding principles and taking action on
feedback provided through the Friends and Family
Test have supported staff in responding to patient
needs in a much more timely and proactive way.
Embedding our CARES values has also supported
staff in demonstrating the right behaviours when
responding to patients’ needs. The Trust intends
to take the following actions to improve on this
indicator and so the quality of its services:
• Delivering on priority 5 for 2014-15
outlined on pages 106.
Indicator 12: Following the publication of the Francis Report and
several reviews that followed, such as Berwick and
Keogh, the Trust has supported a safety culture
where staff feel able to report incidents. Staff have
been encouraged to be open and honest so that we
can learn from when things go wrong in order to
improve the quality of care we provide. Our reporting
rate to the National Reporting and Learning Service
has increased from 6.6 (1 April 2012 – 30 September
2012) to 8.33 (1 April 2013 – 30 September 2013).
The increase in incident reporting will also result
in an increase in those incidents that resulted in
severe harm or death. The Trust intends to take the
following actions to improve on this indicator and
so the quality of its services:
• Continue to raise awareness of the importance
of incident reporting
• Ensure there is thorough investigation of all
severe/death reported incidents to support
learning and changes in practice.
Definitions of the two mandated indicators for substantive sample testing by the Trust’s auditors are:1. Percentage of patients receiving first definitive
treatment for cancer within 62 days of an
urgent GP referral for suspected cancer.
2. C. difficile.
the following actions to improve on this indicator
and so the quality of its services:
• Since the Professor Briggs report ‘Getting it Right
First Time’ (2012), we have pulled together a
detailed action plan. An Orthopaedic consultant
has been nominated as the clinical lead and on
reviewing the Trust’s results it was considered
that a deep dive into the make-up of the
PROM score which comprises of participation
rate, health gain and patient satisfaction was
required. In all aspects Hip surgery results
performed better than the national average
however performance on the Knee PROM
was below national average in the patient
satisfaction element.
• The review on post-operative outcomes for
the Knee PROM showed that our scoring for
participation rate is above national average
however we had a dramatic drop in our EQ-5D
responses for Mobility, Self-Care, Usual Activity
and Anxiety. The ‘Pain’ element however has
seen the biggest improvements year on year
within knee surgery. We are actively encouraging
all patients to attend our joint school to ensure
their expectations of recovery are discussed
at length.
Indicator 10: This indicator has improved on the previous year by
3% although further work is required to ensure we
are in line with the London trusts’ average. The Trust
intends to take the following actions to improve on
this indicator and so the quality of its services:
• More in-depth scrutiny of the results is taking
place, enabling targeted support, action
planning and interventions within the Divisions
and Departments, to improve advocacy
• Our first Staff Friends and Family Test will run
from 19th May which will support us receiving
immediate feedback from staff on this element.
Indicator 11: We have improved our performance in relation
to this indicator during this past year and seen
significant improvement in many areas covered in the
national patient survey and local patient surveys in
relation this element of care. Our implementation of
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-1401
20
Key principles that support our strategy and
which have been key recommendations from
national investigations include:
• Always putting the patient first
• Clearly understood fundamental standards
of care and measures of compliance
• Openness, transparency and candour
throughout our organisation
• Improved support for compassionate and
committed nursing
• Strong and patient centred leadership
• Accurate, useful and relevant information.
The Strategy will help to ensure that the ethos
of a clinically-led, quality and patient-focused
organisation is strengthened and that the Trust
Board is provided with robust and detailed
information on quality so that it can be assured that
the clinical quality agenda is being appropriately
identified, assessed, addressed and monitored.
The clinical priorities outlined in the Strategy reflect
the quality priorities outlined in this year’s Quality
Report.The full Clinical Quality Strategy is available
via our website at: http://www.thh.nhs.uk/
patients/safety/index.php.
Quality priorities for improvement in 2014-15
In this part of the report, we tell you about the
areas for improvement in the next year in relation
to the quality of our services and how we intend
to assess them. We call these our quality priorities
and they fall into three areas: patient safety, patient
experience and patient outcomes.
In arriving at these priorities, agreed by the Trust
Board, there was a process of engagement with our
foundation trust members, our governors, our staff,
Healthwatch and our commissioners. In addition,
the Trust triangulated data from several sources to
identify themes and recurring trends. Over the last
year there has been more active engagement with
our local Healthwatch including incorporating their
members on several of our Trust working groups.
LOOKING fOrwArd fPart 2.3 Our new Clinical Quality Strategy
The Trust has published a new Clinical Quality
Strategy (2013-2016) to support its delivery of
high quality care over the next three years. The
purpose of the new Strategy is to help the Trust
achieve its vision ‘To put compassionate care, safety
and quality at the heart of everything we do’. The
Strategy provides a structure for delivering quality
governance to ensure ongoing improvement in the
quality and safety of patient care. It builds on the
local and national context of service change that so
critically affects quality of care for all its patients and
ensures that the trust’s approach and commitment
to high quality care is clearly defined.
The Strategy also outlines the responsibilities of
its staff and is supported by the Trust’s culture
and values framework, CARES (Communication,
Attitude, Responsibility, Equity and Safety) which
embraces a culture that empowers staff to report
incidents and raise concerns about quality in an
open, blame-free working environment. The
Strategy will ensure that clinical quality governance
and risk management are integrated into the Trust’s
culture and everyday management practice and that
all members of staff are clear on their role and the
drive to continually improve the quality of care.
In building its Strategy the Trust has considered the
local and regional health economy and national
contexts and has made reference to key NHS
investigations, such as the Francis Report and the
Berwick and Keogh reviews. The Trust has also
reviewed its current position in relation to key
quality and performance data alongside other
acute providers in order to focus its priorities and
to be in line with local, regional and national best
performance. The priorities focus on those areas
which are the most important based on a balance
of greatest impact on patient care, national
profile and public profile, as well as those where
performance is below expected.
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-14 01
21
Quality Report 2013-14 Consultation
Respondent Category Quality Priority Topic 2014-15
Patient Safety
Staff • Implementing the Emergency and Maternity Care Standards
• Reduction in weekend mortality
• Improve pathways/bundles of care to provide reliable care
• Achieving reduction in patient harms. such as falls/pressure ulcers, associated with the Patient Safety Thermometer
• Improve staff / patient ratios
• Improving staff feedback mechanisms in relation to incidents
Healthwatch • Better support for patients discharged from Accident and Emergency
• Ensure proactive care ward rounds are happening as expected particularly in relation to continence care in inpatient areas and A&E
Governors and FT members
• Better support for patients discharged from Accident and Emergency
GP Commissioners • Implementing the Emergency and Maternity Care Standards – especially senior clinician review 7 days a week
Patient Experience
Staff • Improve responsiveness to need
• Improve learning from patient feedback
• Review of complaints management
• Improve staff / patient ratios
• Continuing with improving the outpatient experience
• Continuing with the improving inpatient care project (includes leaving hospital) – reduce length of stay
Healthwatch • Improvements in the outpatient appointment system/call management system – continuing with improving the outpatient experience
• Improvement in the management of letters for outpatient appointments
• Improve medical engagement/staff attitude – further work on CARES
• Look at other ways of getting patient feedback
• Display information on patient experience feedback on information boards on each ward/department
• Improve the participation in the Friends and Family Test in some areas
• Ensure new pathways of care include metrics on the patient experience
This has proved valuable in being able to hear on an
ongoing basis the feedback it receives from people it
engages with.
During the consultation period there was a strong
opinion from our stakeholders that we should
continue with some of our projects started in the
previous year/s where further outcomes needed
to be achieved to fulfil their potential. Hence
the projects relating to an improved outpatient
experience and improving inpatient care with
effective discharge are being retained.
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Respondent Category Quality Priority Topic 2014-15
Governors & FT members • Improvements in the outpatient appointment system – continuing with improving the outpatient experience
• Improve medical engagement/staff attitude – further work on CARES culture and values
• Look at other ways of getting patient feedback
• Improvements in hospital patient transport
• Improving the hospital grounds
GP Commissioners • Achieving the A&E target
Patient Outcomes
Staff • Improving admissions avoidance/ambulatory care pathway
• Implementing the Emergency and Maternity Care Standards
• Reducing number of readmissions
• Improving diagnostic reporting times
• Drive forward early supported discharge work streams
• Improve Dementia indicator – FAIR assessment
Healthwatch • Better support for patients discharged from Accident and Emergency
• Improvement in improving inpatient care workstream to ensure actions are being progressed as planned
• Understanding outcomes for patients with regard to early supported discharge schemes
Governors and FT members
• Better and quicker access for tests
GP Commissioners • Consultant access for GPs
• Achieving the A&E target
The Board considered all of the suggestions put forward and the priorities below have been recommended for
inclusion in the Quality Report for 2014-15. These have been identified as falling under the three domains of
safety, clinical effectiveness and patient experience as follows:
No. Priority Safety Clinical Effectiveness
Patient Experience
1 First Contact – Continuing to Improve the Outpatient Experience
2 Continuing with the Improving Inpatient Care Project
3 Improving patient safety In Emergency and Maternity Care
4 Introducing and embedding patient care bundles/pathways
5 Improve responsiveness to patient need
Further information on these priorities and what we will be measuring in 2014-15 can be found on the
following pages.
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Our aims for 2014-15: The performance targets we will use to measure the
impact of the changes and new initiatives are:
Percentage of clinics cancelled with six weeks’ notice Performance for 2013-14 shows that 2.3% of clinics
were cancelled with less than six weeks’ notice
(average of 115 clinics per month). The target for
2014-15 is set at 1.5% (75 clinics per month); this
will provide some tolerance for unexpected leave/
urgent reasons.
Clinic UtilisationIn 2013-14 new information software was designed
to enable managers and clinicians to have better
visibility about the activity in their outpatient services.
This information will assist in planning capacity to
meet the referral demand. The data for 2013-14
shows that 85.6% of outpatient slots were utilised.
The target for 2014-15 is set at 90%. This will provide
some flexibility to manage changes in demand.
Local outpatient experience survey The aim is to achieve an overall satisfaction target
of 88%. Patient experience will be monitored via a
local survey on a quarterly basis. Patients are asked
six questions covering staff attitude, communication
about waiting times, respect and dignity and overall
satisfaction. This target will enable monitoring of
experience which is implicit across the different
development areas. Current performance against
the existing questions averages 87%.
PRIORITY 2
Continuing with the Improving Inpatient Care Project
Why is this one of our priorities? Reducing the length of stay for inpatients has been
a priority service improvement goal for a number
of years. We know that the longer patients are in
hospital, the more risks there are to the patient, and
fundamentally, we know people do not want to
be in hospital. We want to remove all unnecessary
waits and support our patients to return to their
PRIORITY 1
Accessible and Responsive Services – Continuing to improve the outpatient experience
Why is this one of our priorities?The Trust’s outpatient productivity scheme has
highlighted areas in appointment management
(listed below) that would benefit from further service
redesign. In addition, our patients are telling us
that they continue to experience some difficulties
with the booking of their appointments and
communication with the hospital.
• The introduction of information software that
assists in planning outpatient capacity to meet
the referral demand.
• Management of appointment cancellations will
move from the Patient Administration System
(PAS) team to the outpatient appointment
centre (OAC). This will ensure greater scrutiny
of appointment cancellations and challenge to
specialities.
• Correspondence about appointments will
be centralised to improve the accuracy and
consistency of information given to patients.
How are we doing so far?Although we have made many improvements in
the last few years we recognise that there are still
concerns from patients about their experience of
the outpatient pathway. We have changed the way
patients are contacted and are reminded about their
outpatient appointments. We have reduced the
call abandonment rate when patients are making
calls to the OAC and very recently our DNA rate
has reduced (please see Priority 1 for 2013-14).
Continuing with this priority has come from a
number of sources, including the public membership
focus group and from our local Healthwatch.
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Cellulitis, Pyelonephritis and Pulmonary Embolism.
An important part of developing this service further
will be to gauge the patient’s experience of this
type of service so that we can be assured that it is
effectively meeting the needs of our patients.
Early supported discharge workstreamThe aim of this workstream will be to assess in
excess of 300 patients on the ‘Home Safe’ pathway
over a three-month period and to provide a
comprehensive geriatric assessment for patients
requiring multidisciplinary team input. In addition
we wish to expand the service from the EAU to
incorporate patients who have had an inpatient
stay on one of the specialty wards.
Specific targets include:
• Achieve a reduction in our length of stay of three
days for patients over the age of 65 years old
who are eligible for the ‘Home Safe’ programme
• Division of Medicine to monitor the patient
experience of the ‘Home Safe’ pathway as a
key metric.
Leaving Hospital Improvement Project, including discharge from A&E
• To aim to discharge =/>25% of our patients
from the inpatient wards before midday
• We aim to achieve a target of 72% of patients
leaving hospital with a positive experience
through the use of the ‘Leaving Hospital’
questionnaire.
PRIORITY 3
Improving patient safety in Emergency and Maternity Care
Why is this one of our priorities?There is national and London data to show that
there are significant differences in the mortality
rates for patients admitted as an emergency during
the week compared with patients admitted as
an emergency at the weekend. Reduced service
provision at weekends has been associated with this
higher mortality rate. In response to the data, the
London Quality Standards (LQS) were developed
homes safely and be supported in the community
as soon as clinically appropriate. The need for
improvement in this area has been identified from
a variety of sources including information from our
local Healthwatch referencing patient feedback of
lengthy delays on the day of discharge, priorities
within our new Clinical Quality Strategy and the
aim to work with our local health and social care
partners in delivering integrated care pathways and
more care in the community. In addition, Dr Foster
Intelligence data shows the trust to be an outlier in
relation to its readmission rate.
How are we doing so far?Following the successful introduction of our
‘Home Safe’ project we want to make sure that
the principles adopted for this project are shared
in order to examine additional opportunities for
early supported discharge schemes. We have
implemented our leaving hospital principles
across all of our wards and we have reviewed our
goals and priorities. The overall objective of this
programme of work is to ensure we provide an
improved experience to all inpatients by improving
the patient journey, timeliness of interventions and
thereby decreasing their overall length of stay. Our
performance for this past year is outlined under
Priority 2 in the priorities for 2013-14.
Our aims for 2014-15 are:
Reducing readmissionsThe rate of readmissions will be tracked per
specialty and will be benchmarked against national
figures for readmission rates. Specialties that are
currently showing high rates of readmissions will
be scrutinised to identify different pathways of
care. The aim is to reduce readmissions in relevant
specialties by 1%-2%.
Ambulatory care pathway The aim is to see > 200 patients per month with
the expectation that 80% – 90% of patients would
be suitable to be treated via ambulatory pathways
of care. The aim of developing this service further
is to increase capacity and treat a broader range
of conditions to include Deep Vein Thrombosis,
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Our aims for 2014-15 are:
• Seven day working for Emergency Care with
earlier senior decision-making seven days a week:
– Achieve consultant physician presence at
weekends in Medicine 12hrs/day
– Patients seen by a consultant within
12 hours within Medicine, Surgery,
Paediatrics and Gynaecology
• Access to multi-professional assessment and
radiological diagnostics and reporting within
specified timeframes.
PRIORITY 4
Introducing and embedding patient care bundles/pathways
Why is this one of our priorities?Care bundles/pathways are tools that include a
collection of healthcare interventions and that can be
used to manage the quality of care that is delivered
by standardising care processes. It has been shown
that their implementation reduces variability in
clinical practice and improves patient outcomes in
the acute care setting. They promote more organised
and efficient patient care based on evidence-based
practice, whereby locally agreed standards help a
patient with a specific condition or diagnosis receive
a consistently high standard of care.
How we are doing so far?The Trust has demonstrated good progress in
this area in order to support high quality care
introducing care bundles and improved clinical
care pathways for a variety of diagnoses and care
interventions. However there is more work to be
done to ensure the well-recognised care bundles/
pathways are truly embedded and that where there
are gaps in consistency of approach to best practice
for particular diagnoses that these are addressed.
Our aims for 2014-15 are:
• Implement the Acute Kidney Injury (AKI)
Pathway, in line with a London wide AKI
pathway and show some improvement
• Sepsis Care Bundle to achieve =/> 70%
compliance
to try and describe what good care should look
like and to ensure that there was a well-recognised
minimum quality of care that patients attending
an emergency department or admitted as an
emergency should expect to receive in every acute
hospital in London. Similarly, the maternity services’
quality standards represent the minimum quality
of care women who give birth should expect to
receive. As part of the Shaping a Healthier Future
(SaHF) programme there is proposed expansion of
our maternity facilities to allow for an anticipated
increase in births taking the total number to 6,000
each year. This expansion in facilities will enable the
Trust to make improvements in the models of care
offered and to support the LQS, in particular by
providing a dedicated midwifery-led unit to provide
additional choice for women.
At the end of 2013 London’s hospitals were asked
to self-assess their progress towards meeting the
standards and provide information on action taken
in acute medicine and emergency general surgery
services throughout 2012-13. The results from our
self-assessment highlight our progress towards
meeting the LQS, as well as the need to continue
on the journey of improvement and investment.
In addition, feedback from our staff and our
commissioners highlights the need for us to drive
forward this improvement work in 2013-14.
How are we doing so far?We have already invested in additional senior doctor
time, out of hours Monday to Friday and at the
weekends. Notably we have provided consultant
ward rounds twice a day on our medical EAU. This
has ensured that our patients continue to receive
care from our most senior doctors irrespective of the
day of the week. We have found some elements
of this work challenging however the Trust is fully
committed to implementing the standards in a
phased approach over the forthcoming years.
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timescale for conclusion. In 2014-15 we aim to
undertake a complaints review in line with the
recommendations from Designing Good Together
(DGT): Transforming Hospital Complaint Handling
(2013) and develop a local action plan.
The Trust has always carried out an annual ward
staffing review but the outcomes of these reviews
have not generally been reported to the Trust Board.
In addition, professional judgement has been the
main approach used to inform the review. New
guidance from the National Quality Board has set
out a more robust approach to ensure that we have
the right skills, in the right place at the right time. To
improve ‘Care at the Bedside’ we will implement a
quarterly cycle of acuity and dependency assessment
with quarterly reports received by the Nursing and
Midwifery Assembly and a bi-annual paper to the
Trust Board setting out the outcome of a review of
staffing levels and skill mix.
Our CARES (Communication, Attitude, Responsibility,
Equity and Safety) values and associated behavioural
framework were launched in May 2012. To
raise awareness of the values and to help staff
to understand their application a customer care
programme was procured. The programme was
developed using patient complaints, feedback from
staff and incidents to ensure the scenarios included
local issues that staff could relate to. The programme
was introduced in June 2013 and so far 1,087 staff
members have completed the programme. We
will continue to deliver Customer Care training to
our staff and we will aim to incorporate the CARES
behaviours as a weighted element of performance
related pay progression and for this to be fully
implemented by 2015-16. We will reward staff who
demonstrate the expected behaviours through the
staff awards event, giving recognition to staff that
do a good job. We will also introduce the Staff FFT
questions to measure staff engagement levels as an
indicator of their attitude towards the organisation.
Our aims for 2014-15:
• Improvement in baseline compassionate care
indicator (baseline to be established calculated
from Q1 result)
• FAIR assessment completed for >90% of
elderly patients per quarter
• To achieve a 20% reduction in falls
without harm
• Catheter Care Bundle to achieve =/> 95%
compliance
• Improvement against the NHS Safety
Thermometer with focus on pressure sores –
to realise a 25% reduction, from a baseline of
3.2% to a final value of 2.4%.
PRIORITY 5
Improve responsiveness to patient need
Why is this one of our priorities?Patient experience is a recognised element of high-
quality care and understanding and improving how
patients experience their care is key to delivering
high-quality services. Using a variety of different
approaches and seeking feedback from different
pathways will help staff to gain greater insight
into our patients’ perspective of their care. Key
stakeholders (our staff, our Governors, Healthwatch)
advise us that we need to ensure that there is focus
on improving the patient experience further and
that our services, and how they are delivered, are
truly responsive to individual patient needs.
How we are doing so far?The Trust participates in the annual national patient
survey programme and in addition a number of
local patient surveys have also been developed
and implemented. The Friends and Family Test has
also been fully rolled out to inpatient areas, the
emergency department and maternity. This will be
rolled out to outpatients and day care settings in
2014-15.
During 2013 our Complaints Management Unit
went through an unsettled period with a change in
management and support staff. With a substantive
team now in place a number of changes have
already taken place which include more robust
processes for managing open complaints aiming
to always contact the complainant by telephone to
discuss their concerns and agreeing an appropriate
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improvement and patient safety work and will look
to the collaborative for support and structure. The
Director of Nursing and Patient Experience has been
appointed as the trust director with responsibility
to oversee medication error incident reporting and
learning and the Terms of Reference for a multi-
professional group to drive forward this work are
being drawn up.
NHS England has advised that there is unlikely to
be significant additional funding available through
this programme to purchase additional capacity for
improvement activity. Healthcare organisations will
be expected to undertake quality improvement as
part of their usual business.
Part 2.4 Formal statements of assurance from the Board
Information for our regulatorsOur regulators need to understand how we are
working to improve quality so the following two
pages are specific messages they have asked us
to provide:
Provision of NHS ServicesDuring 2013-14 The Hillingdon Hospitals NHS
Foundation Trust provided medicine, surgery, clinical
support services and women’s and children’s NHS
services. The Hillingdon Hospitals NHS Foundation
Trust has reviewed all the data available to them
on the quality of care in all of these relevant health
services. The income generated by these relevant
health services reviewed in 2013-14 represents 100%
of the total income generated from the provision of
the relevant health services by the Hillingdon Hospitals
NHS Foundation Trust for 2013-14.
• 50% of additional staff (from 2013-14) to
receive customer care training
• Friends and Family Test – Q4 response rates
>20% A&E / >30% Inpatients
• Friends and Family Test – March 2015 response
rate >40%
• Improvement in the net promoter score of FFT
for inpatient and A&E surveys.
Our quality priorities will be monitored by the
individual clinical and management teams, through
their divisional performance reviews and quarterly
through reports to the Board or Board Committee
and the results will be reported in the 2014-15
Trust Annual Report.
Patient Safety Collaborative Programme
The Berwick Review which was commissioned
following the Mid Staffordshire Hospitals enquiry
and the publication of the Francis Report includes
recommendations to ensure a robust nationwide
system for patient safety. The challenge is for our
whole healthcare system to systematically support
and foster a culture of continual learning and
improvement that supports staff to provide the
safe care they all want to, ensuring patients are at
the centre of care. NHS England’s Patient Safety
Domain and NHS Improving Quality have therefore
introduced the Patient Safety Collaborative
Programme with the formation of 15 Patient Safety
Collaboratives (PSCs), enabled to create and nurture
sustainable local continual learning environments.
This fundamental focus on continual learning
systems will encourage the kind of organisation
and system-wide patient safety culture that can
deliver definitive improvements in specific patient
safety issues and build local capability and energy
for change.
One of the core clinical priorities is ‘Medication
Errors’ – the prescribing, dispensing and
administration of medicines is a huge area where
error and poor process has the potential to affect
large numbers of patients, making this a priority
area for reducing harm. The Trust will ensure
that it actively participates in this key piece of
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Audit Participated Cases submitted
Acute Myocardial Infarction Yes 100%
Adult Critical Care Case Mix Programme No N/A. Decision to not participate in this audit by clinical leads; to be reviewed in 2014-15.
National Bowel Cancer Audit Programme Yes 100%
National Chronic Obstructive Pulmonary Disease Audit Programme
Yes Data submission in progress
National Adult Diabetes Audit, includes National Diabetes Inpatient Audit (NADIA)
Partial Participation in NADIA only – 35 patients included in the audit. The trust is reviewing National Adult Diabetes Audit requirements with a view to participate fully in the future.
National Paediatric Diabetes Audit (Royal College of Paediatric and Child Health)
Yes 100%
Elective Surgery (National Patient Reported Outcome Measures (PROMS) Programme)
Yes Percentages unavailable, numbers are:Hip replacements – 255Knee replacements – 297Groin hernia – 138Varicose veins – 10
Emergency Use of Oxygen (British Thoracic Society) No N/A. Non participation was as a result of local clinical decision. Trust is reviewing requirements with a view to participate in 2014-15.
Epilepsy 12 Audit (Royal College of Paediatrics and Child Health) National Childhood Epilepsy Audit
Yes 100%
Falls and Fragility Fractures Audit Programme including National Hip Fracture Database
Yes 100%
Head and Neck Oncology (Data for Head and Neck Oncologists)
Yes 100%
Heart Failure Audit Yes Expected 75%
Participation in clinical audit
National auditsDuring 2013-14, 29 national clinical audits and
three national confidential enquiries covered
NHS services that The Hillingdon Hospitals NHS
Foundation Trust provides.
During that period The Hillingdon Hospitals NHS
Foundation Trust participated in 86% of national
clinical audits and 100% of national confidential
enquiries for which it was eligible to participate in.
The national clinical audits and national confidential
enquiries that The Hillingdon Hospital NHS
Foundation Trust was eligible to participate in during
2013-14 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.
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Audit Participated Cases submitted
Inflammatory Bowel Disease Yes 100% for the inpatient audit. Trust not currently participating in Biologic Therapy Audit, following recruitment of Biologic’s Co-ordinator it is expected we will participate going forward.
National Lung Cancer Audit Yes 100%
Moderate or severe asthma in children (College of Emergency Medicine)
Yes 100%
National Audit of Seizures in Hospitals Yes 100%
National Cardiac Arrest Audit Yes 100% in hospital cardiac arrests. The trust needs to extend this to ensure we include pre-hospital cardiac arrests – this has been put in place from January 2014.
National Comparative Audit of Blood Transfusion – Audit of the use of Anti-D
Yes 100%
National Emergency Laparotomy Audit (NELA) Yes Data submission in progress
National Joint Registry Yes Hillingdon: 62%
Mount Vernon Treatment Centre: 92%
National Neonatal Audit Programme Yes 100%
National Oesophago-gastric Cancer Audit Yes 100%
Paediatric Asthma (British Thoracic Society) Yes 100%
Paediatric Bronchiectasis (British Thoracic Society) Yes 100%
Paracetamol overdose (College of Emergency Medicine)
Yes 100%
Rheumatoid and early inflammatory arthritis No N/A. Non participation is as a result of local review/decision and is being added to the risk register.
Sentinel Stroke National Audit Programme Yes 100%
Severe Sepsis and Septic Shock (College of Emergency Medicine)
Yes 64%
Trauma Audit & Research Network Yes 22.9%
Clinical Outcome Review Programmes
Maternal, New-born and Infant Clinical Outcome Review Programme (MBRRACE-UK)
Yes 100%
Lower Limb Amputation (National Confidential Enquiry into Patient Outcome and Death (NCEPOD)
Yes Data submission in progress
Subarachnoid Haemorrhage (NCEPOD) Yes 100%
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Taking actionsThe reports of 12 national clinical audits were reviewed by the provider in 2013-14 and The Hillingdon Hospitals
NHS Foundation Trust intends to take the following actions to improve the quality of healthcare provided.
Audit Actions
National Comparative Audit of Blood Transfusion – Blood Sample Labelling and Collection
Frequency of training for staff on blood transfusion has been reduced from annually to every two years and this is now in line with recommendations from the Medicine and Healthcare Products Regulatory Agency and National Patient Safety Agency. This will result in the Trust being better able to train all relevant staff within the new extended time period. Also training sessions have been increased in frequency and this has resulted in 78% of relevant staff now trained.
The trust Blood Transfusion Policy has been updated and now has zero tolerance for incorrect labelling. A process is being implemented where the Transfusion Practitioner receives a weekly report from the Pathology Lab on the number of incorrectly labelled samples, the areas and the member of staff responsible. This will be investigated and staff reminded of the correct protocol and the importance of ensuring all information is completed and correct.
National Lung Cancer Audit A spirometer is to be purchased in order to improve our figures regarding measurement of respiratory function. Spirometry is an important part of the patient assessment for curative treatments such as surgery and radical radiotherapy and is also a key indicator in the National Lung Cancer Audit data fields.
National Oesophago-gastric Cancer Audit
Treatment for Oesophago-gastric cancer patients is part of a pathway within the London Cancer Alliance (LCA). The trust works closely with the specialist centres involved and follows the LCA guidelines as part of its action plan in response to the audit.
National Cardiac Arrest Audit (NCAA)
The trust joined NCAA in July 2013. We have received our first report and have reviewed our practice within this. As we continue to receive the quarterly reports an action plan identifying any required improvements will be developed. We recently identified that we had not submitted all required patients for the first quarter, as we did not include pre-hospital cardiac arrests; we have now amended this and submit all required patients.
National Diabetes In-patient Audit
As a result of the audit a programme of hypoglycaemia training is now in place – approximately 70% of staff have undertaken this. In addition, a pilot has taken place using a revised hypoglycaemia proforma, which has proven successful for use in the Trust.
Falls and Fragility Fractures Audit Programme including National Hip Fracture Database (NHFD)
Overall, the trust performed well in this audit. One area for improvement was collection of follow up data once the patient has been discharged from hospital. A process has now been put in place where we are working with Hillingdon Community Rehabilitation Team to capture available follow up information and provide this back to the Trust for submission to NHFD.
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Audit Actions
National Neonatal Audit Programme
Neonatal Unit notes have been modified with a prompt for senior consultation with parents within 24 hours. Year on year the percentage of parents seen by senior staff within 24 hours is increasing – we do try to ensure that parents are spoken to as soon as possible after admission.
The division is continuing to focus on improving breast feeding rates for all babies of all gestations. ‘Hot on Cold Babies’ is currently being promoted to prevent hypothermia in the new-born.
Sentinel Stroke National Audit Programme
As part of implementation of recommendations from this audit, the trust intends to review the Early Supported Discharge pathway and potential implementation.
College of Emergency Medicine Renal Colic
After reviewing the results of the renal colic audit we identified issues regarding note keeping especially when it came to recording pain scores and adequate analgesia. To improve practice, on induction days junior doctors are educated by one of our consultants on the importance of adequate record keeping and the necessity to record and re-evaluate pain scores. The Accident and Emergency (A&E) Department Matron also has regular sessions with the nursing team during handovers and sisters’ meetings reminding the nurses about the importance of pain score documentation and reassessment. An A&E Registrar and a Radiology consultant are in the process of developing a renal colic pathway which will include a pain relief protocol. Once the pathway is ready a separate A&E renal colic pathway for patients over 65 years of age, which will include instructions regarding the exclusion of Abdominal Aortic Aneurysm, will be developed.
College of Emergency Medicine Fractured Neck of Femur
This audit identified issues regarding the recording of pain scores and adequate analgesia. The education that takes place in Accident and Emergency (A&E) will cover patients with a Fracture Neck of Femur. One of the A&E consultants has also written to all staff reminding them of the importance of recording and re-assessing pain scores.
Alcohol Related Liver Disease: Measuring the Units (NCEPOD)
Some work has already been put in place for this group of patients including: an update to our nursing assessment booklet which now includes an alcohol assessment – this was put in place from July 2013; an Alcohol and Liver Disease study day took place on 28th March 2014, to further educate and support Nurses and Allied Healthcare Professionals.
The trust is currently working with Central North West London Foundation Trust on the further implementation of the recommendations within this NCEPOD report. CNWL have employed an Alcohol Nurse Specialist who is helping to support patients with alcohol-related admissions to engage with community alcohol services.
Subarachnoid Haemorrhage: Managing the Flow (NCEPOD)
As a result of the recommendations within this NCEPOD report the trust is in the process of reviewing and updating relevant clinical guidelines.
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Local audits The reports of 81 local clinical audits were reviewed by the provider in 2013-14 and examples of The Hillingdon
Hospitals NHS Foundation Trust actions to improve the quality of healthcare provided:
Clinical Record Keeping Standards Audit
During 2013-14 the trust reviewed and updated our clinical record keeping standards and have agreed that audit against these will take place every six months. To improve record keeping standards stamps are being provided to help to clearly identify who wrote in the patient record, their designation and their bleep number. A small project group has been developed to improve standards within the division of Medicine – a teaching session to all foundation year doctors has been organised and posters are being produced promoting the trust record keeping standards.
Re-audit of Staff Survey of Caring for Vulnerable Patients including those with a Learning Difficulty
We have continued to drive improvements through Safeguarding Adults/Learning Disability training, specifically raising awareness to use pictorial easy read information, Patient Administration System alert and Patient Passport. It is highlighted, within training, that all information is available on dedicated Safeguarding Intranet pages.
Preventing Surgical Site Infection re-audit
We are in the process of purchasing ‘additional’ thermometers and evaluating evidence on new patient warming systems.
Do Not Actively Resuscitate (DNAR) re-audit
To make sure we involve patients/families in the DNAR decision-making process we are in the process of producing a leaflet. This will help to inform them of the DNAR process and what discussions/decision will take place.
WHO Surgical Safety Checklist Audit
To raise continued awareness on the use of the WHO surgical safety checklist posters are displayed in Theatres. A teaching session in March 2014 at the theatre/anaesthetic departmental meeting included WHO, Consent and Sedation. One of our anaesthetic consultants is producing a presentation for e-induction and will include this in local induction packs for all staff (doctors/nurses/other theatre staff).
WHO Surgical Safety Checklist and SWAB Count in Maternity
To reinforce the requirements for use of the WHO Checklist and SWAB count processes, standard risk management training, in Maternity, has been changed to include this. Future plan is for 2 Maternity theatre staff to attend a full theatre training course to enhance their knowledge and skills to disseminate within the service.
Safe Sedation A teaching session took place in March 2014 at the theatre/anaesthetic departmental meeting which included WHO, Consent and Sedation. The WHO checklist has been revised to include safe sedation elements.
Paediatric Casualty Card Audit in Minor Injuries Unit (MIU)
A stamp has been purchased and is in use to provide proof that copies of all paediatric notes are sent to the Paediatric Liaison Health Visitor. Awareness has been raised and any necessary further training provided to ensure GP registration is checked electronically, this is then documented in children’s notes – re-audit has shown 100% compliance.
Supporting Carers of People with Dementia
To improve information provided to carers, dementia resource folders are being distributed to all wards within the hospital. The folders include information such as, leaflets on different types of dementia and local contacts to go to for support.
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Mortality Audit Process An initial mortality audit took place and was reported on in September 2013. Actions include the process where a list of National Early Warning Score (NEWS) calls is handed out at Medical hand-back meeting on Monday mornings so that patients who have needed urgent review out of hours are prioritised for review, by the appropriate teams. A further action includes nursing progress notes being recorded on the same progress sheets as medical entries. This will help medical staff to better monitor events relating to patients. In October 2013 the Trust introduced an ongoing Mortality audit to help to ensure we consistently provide high quality care for all patients who die in hospital. The first full report was presented to our Quality and Risk Committee in April 2014.
Participation in research
Commitment to research as a driver for improving the quality of care and patient experience The number of patients receiving relevant NHS
health services provided by The Hillingdon
Hospitals NHS Foundation Trust in 2013-14 that
were recruited during that period to participate in
research approved by a research ethics committee
was 650.
The Hillingdon Hospitals NHS Foundation Trust has
a good track record for research for a hospital of its
size. We are continuing with our strategy to broaden
our research portfolio and this has enabled us to
offer a greater number of patients, from different
clinical areas the opportunity to participate in
research. This year we invested in a research nurse to
support our Cardiologists and Diabetes consultants
as a means of increasing commercially funded and
portfolio-adopted research activity in these areas.
This post is now fully funded by the commercial
income it generates.
Participation in clinical research demonstrates the
trust‘s commitment to improving the quality of care
we offer and to making our contribution to wider
health improvement. This allows our clinical staff to
stay abreast of the latest treatment possibilities while
active participation in research allows our patients
access to new treatments that they would otherwise
not have. With this in mind we aim to offer our
patients the opportunity to participate in a wide
range of clinical research projects. These studies are
both funded by the pharmaceutical industry and
by the Department of Health via the North West
London Comprehensive Research Network (CLRN).
We received £464,284 in 2013-14 from the CLRN
for this work.
The money generated from this research activity
funds research nurses and data managers to
support the clinicians in this work. The majority
of our studies are National Institute for Health
Research (NIHR) portfolio-adopted multi-centre
studies where we are acting as a recruiting site on
behalf of the lead centre. Our research portfolio is
a balance of observational and treatment studies
across many clinical areas in the Trust including
Cancer, Stroke, Haematology, Paediatrics and many
of the General Medicine and Surgical Specialties.
This year we plan to become more research active
in Ophthalmology, Obstetrics and Rheumatology.
We also support PhD and Masters Students from
the local universities giving them access to our
patients and staff for their projects.
During 2013-14 we had 63 open or follow-up
studies. We recruited 639 patients into 40 NIHR
Portfolio Studies, supported the repatriation of
ten patients recruited into treatment studies at
other hospitals and supported six Masters or PhD
student studies.
All of our research activity is scrutinised for quality
and compliance to the standards expected by the
Research Governance Framework. In addition we
work to comply with the Department of Health
NIHR objectives.
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-1401
34
Lessons learned from Serious IncidentsDuring 2013-14, the trust reported ten ‘Serious Incidents’ and two ‘Never Events’ where panel investigations were
conducted. Protecting patients from avoidable harm is something to which there is universal agreement and the
Trust has clearly defined processes and procedures to follow to help avoid these events occurring. Lessons learnt as
a result of the Serious Incidents include:
Area Division Summary
1:1 observation of patients with increased observation need
All divisions Review of the trust’s ‘Specialling’ Policy on the 1:1 supervision of patients
Nursing documentation All divisions A patient specific risk assessment form, an individual patient care plan outlining level of observation and a behavioural monitoring chart included in the revised specialling policy
Availability of specialist nursing staff
All divisions Recruitment of Registered Mental Health Nurses to the nurse bank
Specialist training for nursing staff
Medicine Introduction of mental health training for nursing staff in A&E and the Emergency Admissions Unit (EAU)
Specialist psychiatric input Medicine Work with CNWL on raising awareness and availability of the psychiatric liaison service
Safety in A&E and EAU Medicine Environmental health and safety risk assessments completed
Managing Sepsis All divisions New sepsis care bundle created and launched. Full audit and review of the ‘Bundle’ undertaken
Managing the Deteriorating Patient
All divisions Reinforcing the ‘Patient At Risk’ policy – discussed at staff meetings and information provided within departments
Mortality Reviews All divisions Implementation of a robust mortality review process
Record Keeping All divisions Best practice training and medical notes audit programme
Specialist Referral Pathways and Processes
All divisions Review of referral pathways and processes to ensure these are robust and gaps are identified
Escalating Concerns - medical management of a patient
All divisions Importance of early escalation to highest level reinforced with staff where medical management issues cannot be resolved
Neurosurgical pathway to tertiary centre
Medicine Involvement of tertiary centre to resolve issues associated with neurosurgical referral process and pathway
Clinical management/pathway for patients requiring limb amputation for non-vascular/trauma reasons
Surgery Decisions on consultant responsibility, operation arrangements and availability of vascular services as part of North West London vascular network agreements
Clinical handover of care from the Intensive Care Unit
Surgery Agreed protocol for handing-back the care of an ITU patient to the parent team communicated to consultants
Review of CT scans C & CSS Reinforced to all consultant radiologists that the review of CT scans should take place in multi-plane views
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-14 01
35
Further details of the agreed goals for 2013-2014
and for the following 12 month period are available
electronically at: www.thh.nhs.uk.
Care Quality Commission registration The Hillingdon Hospitals NHS Foundation Trust is
required to register with the Care Quality Commission
and its current registration status is that it is registered
without conditions. The CQC paid an unannounced
visit in October 2013 as part of their planned review
of the Trust. The report issued from this visit stated
the Trust was not fully compliant with the Essential
Standards of Quality and Safety; one moderate
staffing concern was raised and two minor concerns
regarding cleanliness and infection control, and safety
and suitability of premises. The Trust set out an action
plan to close the gaps in compliance and awaits
further CQC inspection to review its compliance level.
An action plan was submitted to the CQC and further
updates on progress have been provided.
Area Division Summary
Discussion of emergency gastrointestinal cases
Surgery Patients with an emergency acute gastrointestinal problem are discussed in an appropriate forum (x-ray/MDT meeting) regardless of the primary specialty of the admitting team
Care of the seriously ill woman in Maternity
Maternity Training completed by all staff on the recognition of the seriously ill woman, including the completion of the Maternity Early Warning System (MEWS) chart and the escalation procedures
Mentoring of student midwives
Maternity Ensuring the mentoring of students is to Nursing and Midwifery Council standards – mandatory training incorporates the responsibilities of the mentor
WHO Maternity surgical safety checklist
Maternity WHO Maternity surgical safety checklist reviewed and strengthened and documentation standard improved
Maternity theatre processes Maternity Review of Maternity Theatre processes including pre, intra and post-operative procedure
Midwifery staff training in surgical competencies
Maternity Clarity on training, responsibilities and accountability in relation to surgical/operative procedures
Review of surgical swabs Maternity Review of surgical swabs in maternity theatres/labour rooms
Patient advocacy All divisions Importance of patient advocacy in decision-making where mental capacity may be affected or a patient is vulnerable
Review of Safeguarding Policy
All divisions To ensure there is clarity on the importance of escalation and 2nd/3rd opinions in relation to mental capacity assessments
Goals agreed with our commissioners (CQUINs) A proportion of The Hillingdon Hospitals NHS
Foundation Trust’s income in 2013-14 was
conditional on achieving quality improvement and
innovation goals agreed between The Hillingdon
Hospitals NHS Foundation Trust and any person
or body we entered into a contract, agreement
or arrangement with for the provision of relevant
health services, through the Commissioning for
Quality and Innovation payment framework.
Total CQUIN income for 2013-14, is expected to be
£2,943,523 for National and Local schemes, and
£234,314 (91% of potential available income) for
Specialised Commissioning which includes 100%
achievement of drugs QIPP at 1.1% of contract
value. In the previous year (2012-13) total income
for National and Local schemes was £2,719,136
(73% of potential available income) and £78,858
(100% of potential available income) for Specialised
Commissioning.
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-1401
36
right time is now in place; acuity and dependency is
reviewed using accredited tools and this information
used when agreeing staffing establishment and
skill mix; ward leaders have been appointed on
each extra capacity ward along with a small team
of substantive staff. This forms a core team of
experienced nurses with additional nurses
recruited from the nurse bank as
required. Staff are encouraged to
escalate and report all occasions
when staffing levels fall below the
established profile using the trust
incident system.
Moving forward, the trust’s processes
for CQC compliance will be internally
assessed using both the established desk-top style
review of outcomes, and a revised peer review
process which will be based on different levels
of review and frequency from daily ward based
checks to monthly Executive/Non-Executive led
Observations of Care ward visits and external peer
review from another NHS trust.
The Hillingdon Hospitals NHS Foundation Trust
has not participated in any special reviews or
investigations by the CQC during the reporting
The actions taken include – for cleanliness and
infection control: cleaners and cleaning supervisors
have been reminded of the standards required and
performance will be monitored through regular
cleaning audits. The Waste Manager has ensured
wards are reminded not to overfill clinical waste
bins – monitored as part of the monthly audit
process; a revised curtain changing template has
been devised; increased auditing around cleaning
medical equipment, checking protective covers
on equipment, inspections around catheters and
wound drains are carried out fortnightly. For safety
and suitability of premises – all estates staff have
been reminded of the safety standards required;
the improved maintenance requirements have
been carried out; regular environment audits occur
e.g. PLACE (Patient-Led Assessment of the Care
Environment) and mini PLACE, actions that arise
from these are monitored by the PLACE group
which includes estates and nursing staff.
For staffing: the staffing level and skill mix on
each ward is being reviewed against best practice
guidance and where required staffing mix realigned
to reflect these recommendations. A bi-annual
establishment review to ensure that the right people
with the right skills are in the right place at the
MOVING FORWARD
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-14 01
37
period. The Care Quality Commission has not taken
enforcement action against the Hillingdon Hospitals
NHS Foundation Trust during 2013-14.
Data qualityThe Hillingdon Hospitals NHS Foundation Trust
submitted records during April – January for
2013-14 to the Secondary Uses Service (SUS) for
inclusion in the Hospital Episode Statistics (HES)
which are included in the latest published data. The
percentage of records in the published data which
included the patient’s valid NHS number was:
• 98.5% for admitted patient care
• 99.8% for outpatients care
• 96.7% for accident and emergency care.
The percentage records in the published data
which included the patient’s valid General Medical
Practitioner Code was:
• 100% for admitted patient care
• 100% for outpatient care
• 100% for accident and emergency care.
These figures are based on the SUS DQ Dashboard
released by the HSCIC covering the period Apr-
2013 to Jan-2014. The Hillingdon Hospitals
NHS Foundation Trust will be taking forward the
following actions to improve data quality:
• The Trust will continue its Integration Engine
programme to link disparate clinical systems
across the Trust, enhancing the quality of
electronic patient information
• The Trust will continue to review and action
data quality issues at its data quality meetings
• Daily data quality reports are published on the
Trust’s web based management information
system for action and rectification.
Information governance toolkitThe Hillingdon Hospitals NHS Foundation Trust’s
Information Governance Assessment Report overall
score for 2013-14 was 81%. This is termed as
unsatisfactory as one of 43 requirements relevant
to the Trust remains at level 1; all the other scores
are at level 2 or 3. The level 1 score relates to the
fact that currently 70% of staff have undertaken
their information governance training rather than
the required 95% annually. An action plan is in
place to drive compliance to the required level going
forward which includes a revised approach to the
annual refresher training and improved performance
management of non-compliance.
Clinical coding error rate THHFT was not subject to the Payment by Results
Clinical Coding Audit during 2013-14 by the
Audit Commission.
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-1401
38
Trust’s performance on the 62 day cancer waiting
time however reduced by 3.2%; this pathway
relates to patients we treat here who breach but
also patients we refer to tertiary specialist centres
that then go on to breach the 62 day pathway. In
2013-14 we saw an increase in shared breaches, up
from 19 to 46 – the Trust has to accept half of each
of those breaches even though the patient did not
breach the pathway whilst at our hospital. In 2012-
13 we accounted for 306 pathways with 11 full
breaches and 19 shared breaches. In 2013-14 there
were 338.5 pathways with ten full breaches and
46 shared.
Extensive re-modelling has been undertaken with
other providers to ensure that the care of patients on
complex pathways is properly co-ordinated between
organisations. This means that patients can have
their procedure booked at another hospital while
they are still undergoing investigations at this Trust.
Indicators 8-10 – Referral to treatment waiting timesAll 18 week targets for both admitted and non-
admitted patients were achieved and exceeded.
The Trust consistently achieves this target and has
been one of the strongest performers in London
for the past three years. The Trust’s continued high
performance means that other organisations have
been in contact requesting support with delivering
their elective 18 week activity. In the last year the
Trust supported two organisations in undertaking
elective work.
Indicator 12 – Accident and Emergency (A&E) waiting times
In this part of the report we have included other
key quality indicators which have been selected
by the Board in consultation with stakeholders.
They represent those indicators that are of national
importance that patients will want to know about
and they include targets used by Monitor as part of
Monitor’s Risk Assurance Framework. The indicator
set includes patient experience, patient safety
and clinical effectiveness indicators. The indicators
covered in this year’s report are consistent with those
from last year’s Quality Report. Narrative has been
provided on some of these indicators to outline
our performance.
Details are in the Table on page 39.
Indicator 2 – Readmissions to hospital within 28 days Despite several initiatives undertaken by the Trust,
the Clinical Commissioning Group, Social Services
and Intermediate Care, in 2014 there has been little
change in the performance over the previous year.
This continues to be a priority area in 2014-15.
Indicator 3 – Non-clinically justified single sex accommodation breach There was one mixed sex breach during 2013-14.
This occurred when a patient was deemed fit to
be discharged from the Intensive Therapy Unit but
there was no suitable step down bed available
within six hours.
Indicators 4-7 – Cancer performance The Trust successfully achieved all of the cancer
access targets for the second year in a row. The
Part 3 Other key quality information and improvements we have made in 2013-14
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-14 01
39
2012
-13
Perfo
rman
ce20
13-1
4 Ta
rget
2013
-14
Perfo
rman
ceLo
ndon
Trus
tsNa
tiona
lBe
nchm
ark
Sour
ceBe
nchm
ark
Perio
d
1: In
Hos
pita
l Sta
ndar
dise
d M
orta
lity R
atio
96.7
(89.
6 - 1
04.2
)<1
0087
.6 (8
0.6
- 95.
1)81
.8 (8
0.6
- 83
.0)
100
Dr Fo
ster
Apr-2
013
to Fe
b-20
14
2: R
eadm
issio
ns to
hos
pita
l with
in 2
8 da
ys10
5.2
(102
.2 -
108.
2)<1
0010
2.9
(99.
3 -
106.
7)95
.8 (9
5.2-
96
.4)
100
Dr Fo
ster
Apr-2
013
to N
ov-2
013
3: N
on cl
inica
lly ju
stifi
ed si
ngle
sex
acco
mm
odat
ion
brea
ch, r
ate
per 1
,000
fini
shed
cons
ulta
nt e
piso
des
0.05
%0.
0%0.
02%
0.50
%0.
20%
NHS
Engl
and
Apr-2
013
to Fe
b-20
14
4: C
ance
r: Tw
o w
eek
wai
t fro
m G
P re
ferra
l to
seei
ng a
spec
ialis
t (su
spec
ted
canc
er)/(
brea
st sy
mpt
oms)
97.9
%98
.0%
93.0
%93
.0%
97.9
%94
.7%
95.0
%95
.3%
95.6
%95
.5%
NHS
Engl
and
Apr-2
013
to D
ec-2
013
5: C
ance
r: 31
day
max
imum
wai
t fro
m d
iagn
osis
to fi
rst t
reat
men
t 99
.2%
96.0
%99
.3%
97.9
%98
.3%
NHS
Engl
and
Apr-2
013
to D
ec-2
013
6: C
ance
r: 31
day
max
imum
wai
t fro
m d
iagn
osis
to su
bseq
uent
trea
tmen
t, dr
ug o
r sur
gery
100.
0%10
0.0%
98.0
%94
.0%
100.
0%10
0.0%
99.7
%95
.8%
99.8
%97
.0%
NHS
Engl
and
Apr-2
013
to D
ec-2
013
7: C
ance
r: 62
-day
max
imum
wai
t fro
m re
ferra
l by G
P/sc
reen
ing
serv
ice/c
onsu
ltant
upg
rade
to tr
eatm
ent
93.5
%93
.9%
98.6
%
85.0
%90
.0%
85.0
%
90.3
%97
.8%
96.9
%
82.9
%93
.1%
92.2
%
85.8
%94
.5%
92.1
%
NHS
Engl
and
Apr-2
013
to D
ec-2
013
8: R
efer
ral t
o tre
atm
ent w
aitin
g tim
es -
adm
itted
97.4
%90
.0%
97.1
%90
.2%
91.4
%UN
IFY2
Apr-2
013
to Fe
b-20
14
9: R
efer
ral t
o tre
atm
ent w
aitin
g tim
es -
non
adm
itted
98.8
%95
.0%
98.6
%96
.8%
96.9
%UN
IFY2
Apr-2
013
to Fe
b-20
14
10: R
efer
ral t
o tre
atm
ent w
aitin
g tim
es -
Inco
mpl
ete
97.3
%92
.0%
97.4
%92
.8%
94.1
%UN
IFY2
Apr-2
013
to Fe
b-20
14
11: F
ract
ured
nec
k of
fem
ur e
mer
genc
y pat
ient
s in
thea
tre w
ithin
36
hour
s88
.4%
90%
92.4
%n/
an/
aLo
cal I
ndica
tor
n/a
12: T
otal
tim
e in
A&E
: 4 h
ours
or l
ess (
All T
ypes
/ Typ
e 1)
96.7
%94
.6%
95.0
%96
.0%
92.1
%95
.5%
92.6
%95
.7%
93.5
%UN
IFY2
100.
0%
13: N
umbe
r of l
ast m
inut
e el
ectiv
e op
erat
ions
canc
elle
d fo
r non
clin
ical r
easo
ns0.
61%
0.8%
0.85
%0.
83%
0.79
%NH
S En
glan
dAp
r-201
3 to
Dec
-201
3
14: P
erce
ntag
e of
pat
ient
s not
trea
ted
with
in 2
8 da
ys o
f hav
ing
oper
atio
n ca
ncel
led
for n
on-c
linica
l rea
sons
6.0%
0%0.
0%4.
3%5.
1%NH
S En
glan
dAp
r-201
3 to
Dec
-201
3
15: P
erce
ntag
e of
wom
en in
the
rele
vant
PCT
pop
ulat
ion
who
hav
e se
en a
mid
wife
or a
mat
erni
ty h
ealth
care
pr
ofes
siona
l, fo
r hea
lth a
nd so
cial c
are
asse
ssm
ent o
f nee
ds, r
isks a
nd ch
oice
s by 1
2 w
eeks
and
6 d
ays o
f pr
egna
ncy
80.4
%95
%83
.1%
77.0
%86
.1%
NHS
Engl
and
Jan-
2013
to M
ar-2
013
16: P
erce
ntag
e of
wom
en in
the
rele
vant
PCT
pop
ulat
ion
who
hav
e se
en a
mid
wife
or a
mat
erni
ty h
ealth
care
pr
ofes
siona
l, fo
r hea
lth a
nd so
cial c
are
asse
ssm
ent o
f nee
ds, r
isks a
nd ch
oice
s by 1
2 w
eeks
and
6 d
ays o
f pr
egna
ncy (
exclu
ding
late
Ref
erra
ls)
93.2
%95
%97
.2%
n/a
n/a
Loca
l Ind
icato
rn/
a
17: S
troke
pat
ient
s: Pe
rcen
tage
of P
atie
nts t
hat h
ave
spen
t at l
east
90%
of t
heir
time
on th
e st
roke
uni
t99
.6%
80%
97.3
%94
.3%
84.8
%NH
S En
glan
d20
12/2
013
18: S
troke
pat
ient
s: Pe
rcen
tage
of h
igh
risk
Tran
sient
Isch
aem
ic At
tack
(TIA
)/min
i stro
ke p
atie
nts w
ho a
re
treat
ed w
ithin
24
hour
s10
0%75
%10
0%81
.2%
74.0
%NH
S En
glan
d20
12/2
013
19: M
etici
llin-R
esist
ant S
taph
yloco
ccus
Aur
eusis
(MRS
A)1
case
s (0.
8 Ca
ses p
er
100,
000
bedd
ays)
01
Case
(0.7
Cas
es
per 1
00,0
00
bedd
ays)
1.7
Case
s pe
r 100
,000
be
dday
s
1.2
Case
s pe
r 100
,000
be
dday
s
PHE
2012
/201
3
20: I
npat
ient
Exp
erie
nce
Prog
ram
me
(loca
l sur
vey r
esul
ts)
88%
88%
91%
n/a
n/a
n/a
n/a
21: O
utpa
tient
Exp
erie
nce
Prog
ram
me
(loca
l sur
vey r
esul
ts)
87%
88%
87%
n/a
n/a
n/a
n/a
22: M
ater
nity
Exp
erie
nce
Prog
ram
me
(Loc
al su
rvey
resu
lts)
86%
87%
86%
n/a
n/a
n/a
n/a
23: I
ndep
ende
nt a
sses
smen
t of c
lean
lines
s of h
ospi
tal*
- Ver
y Hig
h Ri
sk a
reas
- Hig
h ris
k ar
eas
87%
95%
92%
94%
95%
n/a
n/a
n/a
n/a
24: P
erce
ntag
e of
com
plai
nts r
espo
nded
to w
ithin
agr
eed
times
cale
74.5
%90
%73
.6%
n/a
n/a
n/a
n/a
Defin
ition
s for
the
indi
cato
rs a
re in
clude
d in
Mon
itor’s
‘Risk
Ass
essm
ent F
ram
ewor
k’ (a
vaila
ble
on h
ttp://
ww
w.m
onito
r.gov
.uk/
raf).
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-1401
40
Indicator 15 – Percentage of women who have seen a midwife or maternity healthcare professional within 12 weeks and six days of pregnancyThere is now an identified lead within the Clinical
Commissioning Group to work on this project.
This work includes proactive public engagement
through dissemination of information in public
venues such as children’s centres and public libraries
as well as potentially working with local shops that
sell pregnancy tests, offering leaflets with relevant
information around when and how to book to
encourage early engagement. This is an ongoing
piece of work which includes public health and the
Trust supporting the process.
Indicator 21 & 22 – Outpatient and Maternity local patient experience surveys There has been detailed examination of the key
issues identified by our patients when attending the
outpatients department during this past year. As a
result improvement actions have been implemented
across the various specialties. The department is now
piloting the FFT which will allow for more immediate
feedback from patients. As a result the local patient
experience survey has changed and reporting on this
will take place on a quarterly basis.
The Maternity Unit has continued to ensure that it
learns from women’s feedback on their experience
of maternity care. Engagement activities during
the year have included meeting with the Afghan
Women’s Group to better understand their needs
and their expectations of Maternity Services. Staff
have also been involved in presenting patient
stories at the Experience and Engagement Group.
Through the Maternity Services Liaison Committee
staff are receiving direct feedback of women’s
experience through the ‘Walk the Patch’ initiative.
For the forthcoming year the staff hope to engage
with the Travelling Community to understand their
experiences and expectations as well as being
involved in further future public engagement events.
The maternity unit has now been incorporated in to
the Friends and Family Test initiative.
The Trust achieved the target for 95% (all types)
of patients to have a total time in A&E of less than
four hours, with a mean performance throughout
the year of 96%. Initial performance was affected
by a challenging start to the year (April and May)
when the Trust did not meet the required standards.
An extensive review was undertaken and a number
of measures were introduced which improved
performance.
Additional winter funds were made available to the
A&E department for the final quarter of the year.
Extra medical, nursing and phlebotomy staff were
recruited. In addition, on site senior managerial
support was provided over the weekend. This had a
significant positive impact on performance, and the
Trust achieved 96.8% in quarter four.
The number of acutely unwell patients continued to
increase throughout the year. Between April 2013
and February 2014, 1,777 ‘blue light’ ambulances
attended the trust compared to 1,633 for the
same period last year. This represents an 8.8%
increase (144 attendances). Blue light ambulances
convey the sickest patients to the hospital who
require admission to the A&E resuscitation unit and
intensive support. It takes on average seven hours
to stabilise patients before they can be transferred
to another location in the hospital. On average 4.8
patients per day are treated in the resuscitation unit.
Despite the increase in the number of blue light
conveyances, non-elective (unplanned / emergency)
admissions are slightly down on the previous year.
During 2012-13 there were 23,672 non-elective
admissions compared to 23,442 for 2013-14. This
is equates to an average decrease of 4 admissions
per week.
Indicator 13 – Number of last minute elective operations cancelled for non-clinical reasons The total number of operations cancelled on the
day for non-clinical reasons was 203. The majority
of these cancellations were due to short notice
surgeon/anaesthetist illness.
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-14 01
41
• Continue to review improvement work at the
Safeguarding Committee, including action plans
based on patient and carer feedback, and work
collaboratively with the Community Learning
Disability Team.
Patient SafetyDuring 2013-14 we have undertaken targeted work
to reduce patient harms and we have achieved the
following improvements to ensure that we keep our
patients safe:
Indicator 23 – Independent assessment of cleanliness of hospitalThe monthly cleaning audits, local patient
satisfaction surveys and the Friends and Family Test
feedback has all indicated a significant improvement
in cleaning services during 2013-14. The cleaning
audits taking place during the latter part of the year
have been showing an average score of 95% each
month, which is in line with the standards expected
in the National Standards of Cleanliness in the NHS.
Indicator 24 – Percentage of complaints responded to within agreed timescalesIn 2013-14 the number of complaints due for
response was 405, compared to 503 in 2012-13;
this represents a reduction of 19%. The response
rate was 73.6% which means that 298 of the 405
complaints were answered within the timescale
agreed with the complainant.
It is important to note that the Complaints
Management Unit went through a period of
significant change this year, with the long term
Complaints Manager leaving, followed by the
two Complaints Administrators. Following a
new permanent appointment to the Complaints
Manager post in December 2013, enhanced
processes were established and new ways of
working introduced. An analysis of the performance
for the first three quarters of the year identified that
the complaints team was working on a ‘just in time’
basis. This meant that there was limited time to get
the response letters approved or to get additional
information if the reply was not complete. The new
Complaints Manager has implemented a number of
control measures in order to enhance performance
and support the divisions in meeting their deadlines.
The focus of these measures is twofold – timeliness
and quality of response. Performance improved in
March 2014 to 90.6%.
Indicator 25 The Tust continues to fully comply with the
requirements regarding access to healthcare for
people with a learning disability. The Trust intends to
take the following actions to maintain performance
on this indicator and so the quality of its services:
*Please note that the percentage shown is the overall percentage of harm free care, as measured by the Patient Safety Thermometer (PST), includes patients admitted into the Trust with pre-existing pressure ulcers, ‘old’ urinary tract infections (UTIs) in patients with catheters. Old UTIs are defined as those where treatment had started outside of the Trust and old VTE (defined as those where treatment for the VTE started outside of the Trust).
48% reduction in Clostridium difficile infections
94.5% of patients have received harm free care as measured by the PST*
National average is 93.1%
15.7% reduction in patient falls
38% reduction in patient falls resulting in a fracture
37% reduction in pressure ulcers as measured by the PST
Venous Thromboembolism (VTE) assessment compliance – 95.2%
Reducing patient harms – improving safety
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-1401
42
0
5
10
15
20
25
30
35
40
2013
-14
2012
-13
2011
-12
2010
-11
2009
-10
2008
-09
2007
-08
2006
-07
2005
-06
2004
-05
2003
-04
24
30
24
38
30
17
10
4 41 1
for 2013-14. Whilst this is over NHS England’s zero
tolerance approach with a zero target, it is well
within the limit set by Monitor.
The one attributed case was complex with multiple
admissions across two acute trusts over a five month
period. Under the new MRSA infection review
system the case ultimately lies with the organisation
that has the most learning opportunities, and for
this case it was the acute sector across two trusts.
Due to the constraints of the new process only one
acute trust can be recorded and this is the one
where the blood culture was taken.
Clostridium difficile2013-14 was a challenge for the Trust as our
C. diff objective target reduced to 14 cases from
24 the previous year. Having finished the previous
year (2012-13) under the objective – with 23 cases
– achieving a reduction of nine further cases in one
year required a significant amount of attention. It
was therefore a major achievement to complete the
year reporting only 12 cases. This is a 48% reduction
in 12 months and a substantial accomplishment.
The trust had learnt through detailed investigation
in 2012-13 that for the previous 23 cases some
samples should not have been included for
testing. This was either due to the patient taking
laxatives or samples not taken early enough when
admitted with diarrhoea. Ongoing work from 2012-
A key part of ensuring a safety culture throughout
the organisation is to engage with staff – this is an
important part of our new clinical quality strategy.
Listening and learning from the multi-disciplinary
team is a key part of creating a strong culture of
openness and candour. As part of widening the
scope of engagement, the Medical and Nurse
Directors have scheduled meetings with junior
doctors, student nurses and therapists to gain a
granular understanding of how our organisation
can improve both patients and staff experience. In
2013-14 the Trust Board received feedback from
our junior doctors on how we could make further
improvements in our safety culture.
Through triangulating the themes that we have
amassed via complaints, feedback and surveys this
presents opportunities to conduct deep dives into
our services for patients. The Trust has just approved
for 2014, the implementation of Schwartz rounds
which will include executive leadership and enhance
ward to board feedback and action.
Infection Control Prevention and Control
MRSAThe Trust has sustained performance for a second
year reporting only one MRSA bloodstream infection
MRSA bloodstream infections
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-14 01
43
feedback enables our staff to gain a real insight into
the patient’s experience of care. We use a number
of different approaches, all of which provide us
with information about what we are doing well
and where we need to improve. These include:
• National and local surveys
• PALS concerns
• Compliments/Complaints
• Friends and Family Test
• Observations of Care.
What our patients have told us in our local surveys for inpatient care:
13 has therefore focused on staff understanding
when samples should be sent and clear
involvement with the clinical team.
A key development for this year has been a new
‘Bristol Stool Chart’. This new chart now includes
easy identification of those patients with a history of
bowel surgery or chronic bowel condition as well as
clear information on laxatives and their effectiveness.
Using this new chart is now standard practice across
the organisation and this has really supported clinical
decision making.
Work has also been ongoing on antimicrobial
prescribing and this year the organisation further
engaged senior colleagues with a ‘Start Smart Then
Focus’ action plan based on the Department of
Health guidelines. Antimicrobial performance was
also reviewed with a move from focusing on just
‘restricted’ antibiotics but to all other antibiotics and
the compliance to policy by specialty. This will be
reflected in audits undertaken by clinical teams in the
next year.
Patient Experience – Listening to our patientsWe aim to be a listening and learning organisation.
We want concerns that are raised by patients to be
understood, shared and responded to. Listening to
158
76
24 2325
12
0
20
40
60
80
100
120
140
160
2013-142012-132011-122010-112009-102008-09
Source: Local inpatient survey 2013-14 year end results
96% of our inpatients were treated with kindness and understanding
89% for communication, involvement and information
93% for our responsiveness to patient needs
Clostridium difficile toxin positive
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-1401
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• Overall, experience was very poor…very good
(score 1 very poor to 10 very good)
• Saw or was given information about how to
complain.
There were no significant deteriorations from last
year’s survey however our scores were lower in
seven questions:
• Privacy when being examined / treated in A&E
• Involved in decisions about care or treatment
• Anaesthetist explained how he/she would
anaesthetise and control pain
• Involved in decisions about discharge
• Given enough notice about discharge
• Told about medication side effects when
going home
• Given written and printed information
about medicines.
The Trust was worse than most other trusts
in only two questions:
• Privacy when being examined / treated in A&E
• Cleanliness of the room or ward.
National Patient SurveyA survey of inpatients is part of the annual
mandatory survey programme for acute trusts;
this assists organisations to find out about the
experience of patients when receiving care and
treatment at their hospitals. Between September
2013 and January 2014, a questionnaire was sent to
850 recent inpatients at each trust. Responses were
received from 344 patients that had been inpatients
in July 2013 at the Hillingdon Hospitals.
Based on the patients’ responses to the survey
the Trust scored ‘About the Same’ as most other
trusts that took part in the survey for all of the
key grouped sections of the survey. The Trust has
improved in 48 questions from the 2012 survey, and
has seen significantly higher scores (improvement) in
the following areas:
• Admission date changed by the hospital
• Feeling threatened whilst in hospital by other
patients or visitors
• Response to the call bell
• Hospital staff discussing adaptations required at
home after discharge
How we have responded to patient experience feedback
• Breakdown in communication about discharge plans
• We’ve revised discharge planning documentation
Complaint
• ‘I don’t always know what the uniforms mean’
• We’re creating uniform posters and information for the intranet to describe uniforms and roles
Observations of Care
• ‘It’s too bright and noisy at night’
• Comfort at Night campaign
• We’ve implemented a standard for lights out at night
Friends and Family Test
Listening and Improving
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-14 01
45
Historically, there has been a small year on year
improvement in the question about cleanliness of
the ward. It is disappointing that the result this year
still places us in a position that is worse than most
other trusts. However, following cleaning services
moving ‘in house’ there was a comprehensive review
of cleaning schedules and frequencies across all areas
of the Trust, with many areas having an increase in
cleaning input hours. This took shape from mid-
August 2013 and was refined through September
and October onwards which unfortunately was
after the sample period for this survey.
The monthly cleaning audits, local patient
satisfaction surveys and the Friends and Family Test
feedback has all indicated a significant improvement
in cleaning services since that time. The cleaning
audits taking place have been showing an average
score of 95% each month, which is in line with the
standards expected in the National Standards of
Cleanliness in the NHS.
The Board and the Trust’s Experience and
Engagement Group will be driving forward the
improvements that we expect to see in all areas that
are reflected in the National Patient Survey.
DETRACTORS PASSIVE
NET PROMOTER SCORE =% PROMOTERS – % DETRACTORS
PROMOTERS
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-1401
46
November 2012Inpatients and A&E
Department
September 2013Maternity
May 2014Several Outpatients
and Day care settings
Friends and Family TestThe Friends and Family Test (FFT) provides a simple
way of gathering feedback about patient experience
to drive improvement. It is a simple standardised
question which asks patients to consider their recent
experience in the hospital and rate how likely they
would be to recommend that particular ward,
service or department to a friend or family member
if they required similar care or treatment.
The patient can choose from six responses ranging
from ‘extremely likely’ to ‘extremely unlikely’,
with a ‘don’t know’ option for those who remain
undecided. Most importantly we also ask patients
a further question: what was good about your
care, and what could be improved. The comments
received help us to gain an insight into the
experience and understand what really matters
to patients and identify areas for improvement.
To calculate the results we use a Net Promoter Score.
The idea is simple: if you like using a certain product
or doing business with a particular company you like
to share this experience From the answers given three
groups of people can be distinguished. These are:
• Promoters – people who have had an
experience which they would definitely
recommend to others
• Detractors – people who would probably
not recommend you based on their experience,
or couldn’t say
• Passive – people who may recommend you
but not strongly.
This gives a score of between -100 and +100,
with +100 being the best possible result.
The FFT has been implemented using a phased
approach. This is illustrated below.
During 2013-14 over 15,800 patients completed
an FFT survey.
Our March 2014 scores are set out below:
• The inpatient score was 71, this is based
on 557 responses
• The A&E score was 62, this is based on
419 responses
• The maternity score was 67, this is based
on 231 responses.
The overall Trust score for March 2014 was 67.
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-14 01
47
How do our FFT results compare with others?Our response rates are considerably higher
for both inpatient areas and A&E.
We do much better than the national and London
average in relation to fewer ‘extremely unlikely’ /
‘unlikely’ scores for both inpatient areas and A&E.
We have a higher number of ‘extremely likely’ / ‘likely’
responses for A&E however it is slightly lower than
national and London average for inpatient areas.
We do much better than the national and London
average in relation to fewer ‘extremely unlikely’ /
‘unlikely’ scores for both inpatient areas and A&E.
Response rates
Positive responses (extremely likely/likely)
Negative responses (extremely unlikely/unlikely)
0%National London THHFT
National London THHFT
National London THHFT
10%
20%
30%
40%
50%
13%
87.3%
5.9%
29.1%
93.7%
1.7%
15.2%
88%
5.6%
31.3%
92.7%
2.1%
19.4%
88.7%
2.6%
42.8%
91.2%
1.5%
84%
86%
88%
90%
92%
94%
96%
0%
1%
2%
3%
4%
5%
6%
7%
Responserate AE
Responserate IP
Extremelylikely/likelyAE
Extremelylikely/likelyIP
Extremelyunlikely/unlikely AE
Extremelyunlikely/unlikely IP
0%National London THHFT
National London THHFT
National London THHFT
10%
20%
30%
40%
50%
13%
87.3%
5.9%
29.1%
93.7%
1.7%
15.2%
88%
5.6%
31.3%
92.7%
2.1%
19.4%
88.7%
2.6%
42.8%
91.2%
1.5%
84%
86%
88%
90%
92%
94%
96%
0%
1%
2%
3%
4%
5%
6%
7%
Responserate AE
Responserate IP
Extremelylikely/likelyAE
Extremelylikely/likelyIP
Extremelyunlikely/unlikely AE
Extremelyunlikely/unlikely IP
0%National London THHFT
National London THHFT
National London THHFT
10%
20%
30%
40%
50%
13%
87.3%
5.9%
29.1%
93.7%
1.7%
15.2%
88%
5.6%
31.3%
92.7%
2.1%
19.4%
88.7%
2.6%
42.8%
91.2%
1.5%
84%
86%
88%
90%
92%
94%
96%
0%
1%
2%
3%
4%
5%
6%
7%
Responserate AE
Responserate IP
Extremelylikely/likelyAE
Extremelylikely/likelyIP
Extremelyunlikely/unlikely AE
Extremelyunlikely/unlikely IP
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-1401
48
Friends and Family Test
What patients have told us is good about their care
What patients have told us could be improved
“The midwives were polite and reassuring, if I had any worries or
concerns they helped me through them”
“The only thing that could be improved is the slamming of the
treatment room door, which shakes the whole
ward. When you are trying to get off to sleep
it is annoying”
“It would be helpful if patients could be
introduced to contacts when they come to the
bedside”
“My partner had to wait for an hour before being
told where I had been moved to, after he was asked to leave whilst I was being examined”
“Smiling, welcoming faces that are caring and provide
personal care by listening and knowing the patient rather
than treating me like a robot”
“Everything was perfect, the treatment and the
information given by the doctor. I felt that I am in
safe hands”
ActionOur estates team have checked the
door and made some adjustments to reduce the noise
ActionWe are going to support a national
campaign locally by encouraging our staff to start every contact with a patient by
introducing themselves by name and role
ActionStaff have been reminded of the
importance of keeping family members informed in these circumstances
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-14 01
49
We acknowledge the progress made to date on specific
goals for 2013-14 and the areas of underperformance
but would like to emphasise that these still remain areas
of focus and priority in the forthcoming year. In particular
the consultant review within 12 hours of decision to
wait, the reduction of HSMR to London average and
continuing to embed the culture and values framework.
We would like to commend the work being undertaken
in relation to the reduction in HSMR for weekend
mortality and look forward to seeing a continuation of
this improvement work during 2014-15 in relation to
implementing the London Quality Standards.
We acknowledge 100% participation in the National
Clinical Audit Programme and the commitment to
research as a driver for improving the quality of care
and patient experience.
We also recognise some of the challenges the Trust faces
with the fabric and estate and how this impacts on the
quality of our care for patients and how Estates have
been working hard to address some of these issues.
We are very happy to work collaboratively with you to
help shape how we move the quality agenda forward
both from a commissioner and provider perspective.
Given the publication of the Francis Inquiry and
subsequent Berwick, Keogh and Cavendish reports
clearly our agendas will continue to evolve further
as we embed the recommendations.
Overall we welcome the vision described within the
Quality Account, agree on the priority areas and will
continue to work with the Trust to continually improve
the quality of services provided to patients.
We look forward to receiving the final version
which will include an easy read format.
Yours sincerely,
Dr Ian GoodmanChair Hillingdon CCG
16th May 2014
Annex 1 Statements from our stakeholders
Statement from Hillingdon Clinical Commissioning Group (CCG)
The Hillingdon Clinical Commissioning Group
welcomes the opportunity to provide this statement
on The Hillingdon Hospitals NHS Foundation
Trust Quality Accounts. We confirm that we have
reviewed the information contained within the
Account and checked this against data sources
where this is available to us as part of existing
contract/performance monitoring discussions and
is accurate in relation to the services provided.
This Quality Account has been reviewed within
Hillingdon Clinical Commissioning Group and by
colleagues in the Brent Harrow Hillingdon (BHH)
Federation of Clinical Commissioning Groups
and NHS North West London Commissioning
Support Unit.
We have reviewed the content of the Quality
Account and confirm that this complies with the
prescribed information, form and content as set out
by the Department of Health. We believe that the
Account represents a fair and robust summary of
the overview of the quality of care at the Trust for
the services covered in the report.
We have taken particular account of the identified
priorities for improvement for the Trust and how this
work will enable real focus on improving the quality
and safety of health services for our local population.
We agree with the priorities for improvement and
particularly welcome a focus on improving patient
safety in Emergency and Maternity care, embedding
patient care bundles and pathways and an improved
responsiveness to patient need.
We are pleased to see the development of a new
Clinical Strategy and look forward to reviewing how
this is being embedded in the coming year. We
welcome the focus within this Strategy on the Trust’s
approach to safety and compassion in care.
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-1401
50
were perhaps overly ambitious and this has
been taken into account in our assessment
of this year’s performance.
The Trust should be congratulated on those priorities
where it has clearly shown improvement this year.
We are particularly delighted to see the joint work
with Age UK and community services, which has led
to a reduced length of stay for elderly patients.
Whilst there is some reference to 12-13 versus
13-14 performance in the Quality Report, this is
mainly in relation to national CQUINs, or other
national targets rather than the local targets. As
the quality account reporting process is now well
established and previous data is available, we feel it
would be helpful for the general public to now see
performance over time which would demonstrate
continuous improvement. This would be specifically
useful where the priorities are part of a long term
programme, such as the First Contact project which
has been a priority for the last 3 years. We would
suggest this could be achieved by publishing a table
outlining 11-12, 12-13 and 13-14 performance,
with 14-15 targets. This would give a clear and
easily understood view of performance over time,
and would demonstrate continuity, consistency
and where progress has been made.
We support the Trust in their choice of 2014-15
quality priorities and thank them for taking into
account the views of Healthwatch and the wider
public membership. Having previously indicated that
last year we questioned the ambitiousness of some
of the targets and the affect this would have on
patient expectation, this year we feel the opposite
has happened. Some set targets seem easily
obtainable, such as discharging at least 1 patient
from each acute inpatient ward area before 12pm.
We would like to see realistic targets set that are
neither easily achieved, nor totally unattainable.
Healthwatch Hillingdon look forward to continuing
the relationship we have with the Trust and working
with them, through a joint commitment, to focus
on the monitoring and improving of quality. We are
especially pleased about two initiatives agreed with
Statement from our local HealthWatch
IntroductionHealthwatch Hillingdon wishes to thank the Trust for
the opportunity to comment on the Trust’s Quality
Report for the year 2013-14.
Healthwatch Hillingdon has a close working
partnership with the Trust. We welcome their
continued commitment to engage with us and the
value the Trust places upon our relationship. We
meet regularly with The Chief Executive Officer, the
Chair and Director of Nursing of the Trust, are lead
assessors for the Patient Led Assessment of the Care
Environment, and Healthwatch representatives sit on
a number of important groups to monitor patient
experience and quality.
Through our work we have witnessed and
acknowledge the Trust’s commitment to improve the
quality of the services they provide and their desire
to have a positive impact upon the experiences of
their patients.
Quality ReportIn the main, Healthwatch Hillingdon found this year’s
Quality Report, well set out, logical and easy to read.
It is an honest and balanced assessment of the Trust’s
performance on the quality of their services.
We are again pleased that the Trust has been candid
in its reporting, acknowledging that although
there are many areas in which they have shown
improvement, they have recognised where targets
have not been met and have committed to making
further improvements through their 2014-15
priorities. We are however uncomfortable with
the use of the label “partially achieved”. This term
does not give a clear indication to the public of
achievement and although the Trust has been frank
in giving a full explanation where targets were not
fully achieved, it was felt that for some targets,
“not achieved” would be a fairer reflection of
accomplishment. We would however acknowledge
that in our response to last year’s quality report we
did indicate that some of the targets set by The Trust
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-14 01
51
for its work to improve weekend emergency
HSMR (Hospital Standardised Mortality Ratio) from
2011-12 to 2012-13 whilst also maintaining overall
performance.
Although it is understood that the format
and content of the Quality Report is largely
predetermined, the Committee believes that it
would benefit from a simpler configuration to
ensure that it is more easily read and understood.
For example, the data contained within the report
which illustrates what the Trust has achieved in
comparison to its targets (and supported by a
commentary) is not set out as simply as
it could be.
The Trust’s five Quality Priorities during
2013-14 were:
1. The First Contact Project – improving the
outpatient experience
2. Improving people’s experience of leaving
hospital / improving inpatient care
3. Improving emergency care
4. CQUINS (Commissioning for Quality and
Innovation)
5. Embedding out culture and values
framework – CARES
the Trust for 2014, which will see us work together
to look at the quality of mealtime provision, through
the Patient Assessment of the Care Environment
programme and quarterly scheduled meetings,
which will review the progress of quality priorities
and take an overview of quality through the
evaluation and comparison of patient experience,
complaints, and friends and family data.
Graham HawkesChief Executive Officer
Healthwatch Hillingdon
9th May 2014
Statement from External Services Scrutiny Committee
Response on behalf of the External Services Scrutiny Committee at the London Borough of HillingdonThe External Services Scrutiny Committee
welcomes the opportunity to comment on the
Trust’s 2013-14 Quality Report and acknowledges
the Trust’s commitment to attend its meetings
when requested. The Committee is particularly
pleased to note that the Trust has been highly
commended in the Dr Foster Hospital Guide 2013
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-1401
52
It is noted that the Trust has developed five key
areas for improvement in 2014-15 on which the
following draft Quality Priorities for 2014-15
have been based:
1. Continuing to improve the outpatient experience
2. Continuing with the improving inpatient care
project
3. Improving patient safety in emergency and
maternity care
4. Introducing and embedding patient care
bundles / pathways
5. Improve responsiveness to patient needs
Looking forward, improvements to the outpatient
and inpatient experiences have been deemed
important enough to again be included in this year’s
priorities. The Committee welcomes this move and
looks forward to seeing improvements over the next
year. Overall, the Committee is pleased with the
continued progress that the Trust has made over the
last year but notes that there are a number of areas
where further improvements still need to be made.
We look forward to being updated on the progress
of the implementation of priorities outlined in the
Quality Report over the course of 2014-15 and
the impact that the Clinical Quality Strategy has
in supporting the delivery of high quality care.
Although the Committee recognises the amount of
work that has been undertaken by the Trust over
the last year with regard to achieving its Quality
Priority targets, it is disappointing to note that none
of them had been achieved in full (all five priorities
had resulted in ‘partial achievement’ overall).
However, the Trust’s achievements with regard to
the reduction of mortality rates and Health Care
Associated Infections should be celebrated.
Insofar as The First Contact Project is concerned,
it is noted that the Call Management System that
was introduced in June 2012 has needed further
development over the last year. However, the
Committee is disappointed to note that the call
abandonment rate for outpatient appointment
queries was 12% (missing the target of 10%).
Furthermore, only 75% of calls were answered
within 1 minute (the target was 95%) and just
90% were answered within 2 minutes. As such, the
Committee is reassured to note that improvements
to the outpatient experience will continue to be a
priority for the Trust over the next year and we look
forward to seeing significant improvements.
The Committee is pleased to note that, following
an audit and the identification of work stream
improvements, work will continue during
2014-2015 to reduce the number of avoidable
readmissions. Despite aiming to reduce readmissions
over the last three years, these have remained
fairly static: 7.5% in 2011-12; 7.8%
in 2012-13; and 7.6% in 2013-14.
We would like to congratulate the Trust on
achieving a 19.8% response rate for the Friends
and Family Test (FFT) within the A&E Department
between April 2013 and February 2014 (the target
was 15%) – this is a vast improvement on the
8% response rate in 2011-12. It is noted that FFT
will be rolled out to Outpatients and Day Care
settings during 2014-15 and it is hoped that a good
response rate will be achieved in these areas.
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-14 01
53
within the report; this also allows patients to see
our performance over time on some of our local
indicators, where this information is available. It is
hoped that this will also address a concern raised
from the External Services Scrutiny Committee on
presentation of the information and readability.
Our commissioners and the External Services
Scrutiny Committee have recognised and
commended our work to improve weekend
emergency HSMR (Hospital Standardised Mortality
Ratio) whilst also maintaining overall performance,
and our commitment to deliver improvements
in Maternity and Emergency Care in relation to
the London Quality Standards. It has also been
acknowledged that there is a firm commitment
once again this year to continue to improve the
patient’s experience of care, having made good
improvements on this in 2013-14 in the National
Patient Survey, the Friends and Family Test and
our local patient experience surveys.
Our stakeholders have recognised that we have
presented an honest and robust summary of
the overview of quality of care at the Trust,
acknowledging, alongside our achievements, that
some targets have not been met and that we
are committed to making further improvements
in 2014-15. This was taken as feedback from
Healthwatch in last year’s report. This year we
have been very thorough in our assessment of our
current position in relation to the priorities we have
set and have endeavoured to set realistic goals
that are both achievable but also stretching. Our
local Healthwatch rightly noted that a target of
discharging one patient per ward before midday as
part of the Improving Inpatient Care Project did not
appear very ambitious – this has been amended in
the report to ensure the percentage of patients that
we aim to discharge by midday as part of our overall
patient discharges per day is clear.
We look forward to continuing our very positive
working relationships with our key stakeholders to
support the delivery of improved quality of care and
patient experience, and in particular working with
Healthwatch on the Patient Led Assessment of the
The Hillingdon Hospitals NHS Foundation Trust response to the consultation
The Hillingdon Hospital NHS Foundation Trust
thanks all its stakeholders for their comments
about the 2013-14 Quality Report.
The Trust is pleased that our key stakeholders
recognise the trust’s commitment to improve the
quality of the care and services that we provide
and to work closely with them in achieving further
improvement. The Trust enjoys a good working
relationship with both Healthwatch and with the
Hillingdon Clinical Commissioning Group and it
looks forward to further collaborative working to
help shape the quality agenda and the delivery of
safe, high quality care.
The Trust is also pleased that its key stakeholders are
in agreement with its quality priorities for 2014-15,
recognising where we have made good progress
in quality improvement across a range of quality
indicators and also where further work needs to be
driven forward to realise the expected outcomes
that we wish to achieve. The Trust has taken
comments on board as part of the consultation for
the Quality Report and as such these are aligned
with our partners’ views on where we need to
focus our efforts. These are recognised by our
key stakeholders and it is very positive that both
Healthwatch and our local commissioners wish to
continue to work closely with us on projects such
as the ‘Accessible and Response Services project –
continuing to improve the outpatient experience’
and more generally on the monitoring and
improving of quality.
The trust acknowledges the feedback from
Healthwatch on the categorisation of achievement
for the quality priorities for 2013-14 (achieved;
partially achieved and not achieved) and as such
has reviewed the presentation, so that it is not
confusing to our patients and the public as to how
we have performed. To help understand the Trust’s
position information has now also been included
in simple tables to reduce some of the narrative
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-1401
54
even more robust and inclusive approach for next
year – our aim will be to host a large stakeholder
event earlier on in the process so that we can ensure
wide engagement and have the opportunity of
following up on the outputs from the event in a
planned and timely way.
Care Environment and a quarterly review of quality data
so that progress of the quality priorities can be reviewed
and an overview of quality provided.
We are keen to learn from our consultation exercise on
the Quality Report for this year so that we can have an
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-14 01
55
We refer to these national priority indicators
collectively as the ‘indicators’.
Respective responsibilities of the directors and auditorsThe directors are responsible for the content and
the preparation of the quality report in accordance
with the criteria set out in the NHS Foundation Trust
Annual Reporting Manual issued by Monitor.
Our responsibility is to form a conclusion, based
on limited assurance procedures, on whether
anything has come to our attention that causes
us to believe that:
• the quality report is not prepared in all material
respects in line with the criteria set out in the
NHS Foundation Trust Annual Reporting Manual;
• the quality report is not consistent in all material
respects with the sources specified in the
Detailed Guidance for External Assurance on
Quality Reports; and
• the indicators in the quality report identified as
having been the subject of limited assurance in
the quality report are not reasonably stated in
all material respects in accordance with the NHS
Foundation Trust Annual Reporting Manual and
the six dimensions of data quality set out in the
Detailed Guidance for External Assurance on
Quality Reports.
We read the quality report and consider whether
it addresses the content requirements of the NHS
Foundation Trust Annual Reporting Manual, and
consider the implications for our report if we
become aware of any material omissions.
We read the other information contained in the
quality report and consider whether it is materially
inconsistent with:
• board minutes for the period April 2013 to 27
May 2014;
• papers relating to quality reported to the board
over the period April 2013 to 23 May 2014;
• feedback from the Commissioners;
• the 2013 national staff survey;
• Care Quality Commission quality and risk
profiles;
Independent Auditor’s Report to the Council of Governors of The Hillingdon Hospitals NHS Foundation Trust on the Quality Report
We have been engaged by the Council of Governors
of The Hillingdon Hospitals NHS Foundation Trust to
perform an independent assurance engagement in
respect of The Hillingdon Hospitals NHS Foundation
Trust’s Quality Report for the year ended 31st March
2014 (the ‘Quality Report’) and certain performance
indicators contained therein.
This report, including the conclusion, has been
prepared solely for the Council of Governors of The
Hillingdon Hospitals NHS Foundation Trust as a body,
to assist the Council of Governors in reporting The
Hillingdon Hospitals NHS Foundation Trust’s quality
agenda, performance and activities. We permit the
disclosure of this report within the Annual Report
for the year ended 31st March 2014, to enable the
Council of Governors to demonstrate they have
discharged their governance responsibilities by
commissioning an independent assurance report in
connection with the indicators. To the fullest extent
permitted by law, we do not accept or assume
responsibility to anyone other than the Council of
Governors as a body and The Hillingdon Hospitals
NHS Foundation Trust for our work or this report,
except where terms are expressly agreed and with
our prior consent in writing.
Scope and subject matterThe indicators for the year ended 31st March 2014
subject to limited assurance consist of the national
priority indicators as mandated by Monitor:
• Number of clostridium difficile infections
reported; and
• Maximum 31 day cancer waiting time from
Decision to Treat a Cancer diagnosed patient to
the beginning of treatment (first day definitive
treatment).
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-1401
56
LimitationsNon-financial performance information is subject to
more inherent limitations than financial information,
given the characteristics of the subject matter and
the methods used for determining such information.
The absence of a significant body of established
practice on which to draw allows for the selection
of different, but acceptable measurement
techniques which can result in materially different
measurements and can affect comparability. The
precision of different measurement techniques may
also vary. Furthermore, the nature and methods
used to determine such information, as well as the
measurement criteria and the precision of these
criteria, may change over time. It is important to
read the quality report in the context of the
criteria set out in the NHS Foundation Trust
Annual Reporting Manual.
The scope of our assurance work has not included
governance over quality or non-mandated indicators
which have been determined locally by The
Hillingdon Hospitals NHS Foundation Trust.
ConclusionBased on the results of our procedures, nothing has
come to our attention that causes us to believe that,
for the year ended 31 March 2014:
• the quality report is not prepared in all material
respects in line with the criteria set out in the
NHS Foundation Trust Annual Reporting Manual;
• the quality report is not consistent in all material
respects with the sources specified in the
Detailed Guidance for External Assurance on
Quality Reports; and
• the indicators in the quality report subject to
limited assurance have not been reasonably stated
in all material respects in accordance with the
NHS Foundation Trust Annual Reporting Manual.
Deloitte LLPChartered Accountants
St Albans
29th May 2014
• Care Quality Commission intelligent monitoring;
• the Head of Internal Audit’s annual opinion
over the trust’s control environment dated
27 May 2014; and
• any other information included in our review.
We consider the implications for our report if we
become aware of any apparent misstatements or
material inconsistencies with those documents
(collectively the ‘documents’). Our responsibilities
do not extend to any other information.
We are in compliance with the applicable
independence and competency requirements of
the Institute of Chartered Accountants in England
and Wales (ICAEW) Code of Ethics. Our team
comprised assurance practitioners and relevant
subject matter experts.
Assurance work performedWe conducted this limited assurance engagement
in accordance with International Standard
on Assurance Engagements 3000 (Revised) –
‘Assurance Engagements other than Audits or
Reviews of Historical Financial Information’ issued by
the International Auditing and Assurance Standards
Board (‘ISAE 3000’). Our limited assurance
procedures included:
• Evaluating the design and implementation of the
key processes and controls for managing and
reporting the indicators.
• Making enquiries of management.
• Testing key management controls.
• Limited testing, on a selective basis, of the
data used to calculate the indicator back to
supporting documentation.
• Comparing the content requirements of the NHS
Foundation Trust Annual Reporting Manual to
the categories reported in the quality report.
• Reading the documents.
A limited assurance engagement is smaller in
scope than a reasonable assurance engagement.
The nature, timing and extent of procedures
for gathering sufficient appropriate evidence
are deliberately limited relative to a reasonable
assurance engagement.
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-14 01
57
– The Head of Internal Audit’s annual opinion
over the Trust’s control environment dated
April 2014
– CQC Quality and Risk Profiles dated from 1
April 2013 to 31 March 2014.
• The Quality Report presents a balanced picture
of the NHS Foundation Trust’s performance over
the period covered;
• The performance information reported in the
Quality Report is reliable and accurate;
• There are proper internal controls over the
collection and reporting of the measures of
performance included in the Quality Report, and
these controls are subject to review to confirm
that they are working effectively in practice;
• The data underpinning the measures of
performance reported in the Quality Report is
robust and reliable, conforms to specified data
quality standards and prescribed definitions, is
subject to appropriate scrutiny and review; and
• The Quality Report has been prepared in
accordance with Monitor’s annual reporting
guidance (which incorporates the Quality
Accounts Regulations) as well as the standards
to support data quality for the preparation of the
Quality Report (available at www.monitor.gov.
uk/annualreportingmanual).
The Directors confirm to the best of their knowledge
and belief they have complied with the above
requirement in preparing the Quality Report.
By order of the Board
Shane DeGarisChief Executive
28th May 2014
James ReidInterim Chair
28th May 2014
Annex 2 Statement of Directors’ responsibilities in respect of the Quality Report
The Directors are required under the Health Act
2009 and the National Health Service (Quality
Accounts) Regulations 2010 as amended to prepare
Quality Accounts for each financial year.
Monitor has issued guidance to NHS Foundation
Trust Boards on the form and content of Annual
Quality Reports (which incorporate the above legal
requirements) and on the arrangements that NHS
Foundation Trust Boards should put in place to
support the data quality for the preparation of the
Quality Report.
In preparing the Quality Report, Directors are
required to take steps to satisfy themselves that:
• The content of the Quality Report meets the
requirements set out in the NHS Foundation
Trust Annual Reporting Manual 2013-14;
• The content of the Quality Report is not
inconsistent with internal and external sources of
information including:
– Board minutes and papers for the period
April 2013 to May 2014
– Papers relating to quality reported to the
Board over the period April 2013 to
May 2014
– Feedback from the Commissioners dated
16th May 2014
– Feedback from the Governors dated
28th April 2014
– Feedback from Healthwatch dated 9th May
2014
– The Trust’s Complaints Report published
under Regulation 18 of the Local Authority
Social Services and NHS Complaints
Regulations 2009, dated 28th May 2014
– The latest national patient survey published
8th April 2014
– The latest national staff survey 25th February
2014
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-1401
58
Glossary
A
Ambulatory Care Pathway Allows patients who are safe to go home be managed promptly as
outpatients, without the need for admission to hospital, following an
agreed plan of care for certain conditions.
B
Berwick Review Commissioned following the Mid Staffordshire Hospitals enquiry and
publication of the Francis Report. The review includes recommendations to
ensure a robust nationwide system for patient safety.
C
Call Management System (CMS) A database, administration, and reporting application designed for complex
contact centre operations with high call volume.
Care Pathway Anticipated care placed in an appropriate time frame which is written and
agreed by a multidisciplinary team.
Care Quality Commission (CQC) The independent regulator of health and social care in England.
www.cqc.org.uk
Care Quality Commission (CQC)
Intelligent Monitoring System
A form of monitoring to give CQC inspectors a clear picture of the areas of
care that need to be followed up within an NHS acute trust. Together with
local information from partners and the public, this monitoring helps the
CQC to decide when, where and what to inspect. 160 acute NHS trusts are
grouped into six priority bands for inspection based on the likelihood that
people may not be receiving safe, effective, high quality care. Band 1 is the
highest priority trusts and band 6 the lowest.
Cellulitis Cellulitis is an infection of the skin and the tissues just below the skin
surface. Any area of the skin can be affected but the leg is the most
common site.
Clinical audit A quality improvement process that seeks to improve patient care and
outcomes by measuring the quality of care and services against agreed
standards and making improvements where necessary.
Clinical Negligence Scheme for
Trusts (CNST) – Maternity
Administered by the NHS Litigation Authority (NHSLA), provides an
indemnity to members / their employees in respect of clinical negligence
claims. Trusts are assessed on their level of risk management against
detailed standards.
Clostridium Difficile infection A type of infection that occurs in the bowel that can be fatal. There is a
national indicator to measure the number of C. Difficile infections that
occur in hospital.
Comfort at Night campaign This campaign supports reducing disturbances at night and includes
increasing staff awareness of the issue and changing staff attitude ensuring
that essential nursing and midwifery standards are applied.
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-14 01
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Commissioning for Quality and
Innovation (CQUIN)
A payment framework enabling commissioners to reward quality by linking
a proportion of the trust’s income to the achievement of local quality
improvement goals.
Community Acquired
Pneumonia
Inflammatory condition of the lung usually caused by infection and acquired
from normal social contact (that is, in the community) as opposed to being
acquired during hospitalisation.
D
Department of Health (DH) The government department that provides strategic leadership to the NHS
and social care organisations in England. www.dh.gov.uk
Dr Foster An organisation that provides healthcare information enabling healthcare
organisations to benchmark and monitor performance against key
indicators of quality and efficiency.
E
Eighteen (18) week wait A national target to ensure that no patient waits more than 18 weeks from
GP referral to treatment. It is designed to improve patients’ experience of
the NHS, delivering quality care without unnecessary delays.
Electronic Document Records
System
This helps the trust to manage clinical records in electronic format making
records management more efficient and ensuring patient records are more
accessible to clinicians.
F
FAIR assessment for dementia Find, Assess, Investigate and Refer (FAIR) - The identification of patients
with dementia and other causes of cognitive impairment that prompts
appropriate referral and follow up after they leave hospital and ensures that
hospitals deliver high quality care to people with dementia and support
their carers.
Foundation Trust (FT) NHS foundation trusts were created to devolve decision making from
central government to local organisations and communities. They still
provide and develop health care according to core NHS principles - free
care, based on need and not ability to pay.
Friends and Family Test (FFT) An opportunity for patients to provide feedback on the care and treatment
they receive. Introduced in 2013 the survey asks patients whether they
would recommend hospital wards, A&E departments and maternity services
to their friends and family if they needed similar care or treatment.
G
‘Getting it right first time’ (GIRFT) The ‘Getting it right first time’ (GIRFT) report published by Professor Briggs
in late 2012, considered the current state of England’s orthopaedic surgery
provision and suggested that changes can be made to improve pathways of
care, patient experience, and outcomes with significant cost savings.
Governors The Hillingdon Hospitals NHS Foundation Trust has a Council of Governors.
Governors are central to the local accountability of our foundation trust and
helps ensure the trust board takes account of members and stakeholders
views when making important decisions.
The Hillingdon Hospitals NHS Foundation Trust Quality Report 2013-1401
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GP Commissioners GP Commissioners are responsible for ensuring adequate services are
available for their local population by assessing needs and purchasing
services.
H
Health and Social Care
Information centre (HSCIC)
The HSCIC is an Executive Non Departmental Public Body (ENDPB) set up
in April 2013. It collects, analyses and presents national health and social
care data helping health and care organisations to assess their performance
compared to other organisations.
Healthwatch (formerly LINk) Healthwatch is a new independent consumer champion that gathers and
represents the views of the public about health and social care services in
England. http://www.healthwatch.co.uk
Hospital Episode Statistics (HES) The national statistical data warehouse for the NHS in England. ‘HES’
is the data source for a wide range of healthcare analysis for the NHS,
government and many other organisations.
Hospital Standardised Mortality
Ratio (HSMR)
A national indicator that compares the actual number of deaths against
the expected number of deaths in each hospital and then compares Trusts
against a national average.
I
Indicator A measure that determines whether the goal or an element of the goal has
been achieved.
Inpatient A patient who is admitted to a ward and staying in the hospital.
Inpatient Survey An annual, national survey of the experiences of patients who have stayed
in hospital. All NHS trusts are required to participate.
K
Keogh Review A review of the quality of care and treatment provided by those NHS
trusts and NHS foundation trusts that were persistent outliers on mortality
indicators. A total of 14 hospital trusts were investigated as part of this
review.
L
Local Clinical Audit A type of quality improvement project involving individual healthcare
professionals evaluating aspects of care that they themselves have selected
as being important to them and/or their team.
London Health Programme
Standards
Programme to improve the quality and safety of acute emergency and
maternity services based on achieving key standards of practice.
M
Monitor The independent regulator of NHS foundation trusts.
http://www.monitor.gov.uk
Multidisciplinary team meeting
(MDT)
A meeting involving healthcare professionals with different areas of
expertise to discuss and plan the care and treatment of specific patients.
Meticillin-resistant
staphylococcus aureus (MRSA)
A type of infection that can be fatal. There is a national indicator to
measure the number of MRSA infections that occur in hospitals.
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N
National Clinical Audit A clinical audit that engages healthcare professionals across England and
Wales in the systematic evaluation of their clinical practice against standards
and to support and encourage improvement and deliver better outcomes in
the quality of treatment and care.
The priorities for national audits are set centrally by the Department of
Health and all NHS trusts are expected to participate in the national audit
programme.
National Reporting and Learning
System (NRLS)
The National Reporting and Learning System (NRLS) is a central database
of patient safety incident reports submitted from health care organisations.
Since the NRLS was set up in 2003, over four million incident reports have
been submitted. All information submitted is analysed to identify hazards,
risks and opportunities to continuously improve the safety of patient care.
Never events Never events are serious, largely preventable patient safety incidents
that should not occur if the available preventative measures have been
implemented. Trusts are required to report nationally if a never event occurs.
NHS Litigation Authority (NHSLA) Established to indemnify NHS trusts in respect of both clinical negligence
and non-clinical risks. It manages both claims and litigation and has
established risk management programmes against which NHS trusts are
assessed.
NHS number A 12 digit number that is unique to an individual, and can be used to track
NHS patients between organisations and different areas of the country. Use
of the NHS number should ensure continuity of care.
O
Operating Framework An NHS-wide document outlining the business and planning arrangements
for the NHS. It describes the national priorities, system levers and enablers
needed to build strong foundations whilst keeping tight financial control.
Outpatient A patient who goes to a hospital and is seen by a doctor or nurse in a clinic,
but is not admitted to a ward and is not staying in this hospital.
Overview and Scrutiny
Committee (OSC)
OSC looks at the work of NHS trusts and acts as a ‘critical friend’ by
suggesting ways that health-related services might be improved. It also
looks at the way the health service interacts with social care services, the
voluntary sector, independent providers and other Council services to jointly
provide better health services to meet the diverse needs of the area.
P
PAS – Patient Administration
System
The system used across the trust to electronically record patient information
e.g. contact details, appointment, admissions.
Pressure ulcers Sores that develop from sustained pressure on a particular point of the
body. Pressure ulcers are more common in patients than in people who are
fit and well, as patients are often not able to move about as normal.
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Priorities for improvement There is a national requirement for trusts to select three to five priorities
for quality improvement each year. This must reflect the three key areas of
patient safety, patient experience and patient outcomes.
PROMs (Patient Reported
Outcome Measures)
PROMs collect information on the effectiveness of care delivered to NHS
patients as perceived by the patients themselves. Hospitals providing four
key elective surgeries invite patients to complete questionnaires before and
after their surgery The PROMs programme covers four common elective
surgical procedures: groin hernia operations, hip replacements, knee
replacements and varicose vein operations.
Pulmonary Embolism (PE) A blood clot in the lung.
Pyelonephritis A kidney infection that can cause an unpleasant illness which is sometimes
serious.
R
Re-admissions A national indicator. Assesses the number of patients who have to go back
to hospital within 30 days of discharge from hospital.
Root Cause Analysis (RCA) A method of problem solving that looks deeper into problems to identify
the root causes and find out why they’re happening.
S
Safety Thermometer The NHS Safety Thermometer is a local improvement tool for measuring,
monitoring and analysing patient harms and ‘harm free’ care. http://www.
hscic.gov.uk/thermometer
Schwartz Round This offers healthcare staff scheduled time to openly and honestly discuss
the social and emotional issues they face in caring for patients and families.
Secondary Uses Service (SUS) A national NHS database of activity in trusts, used for performance
monitoring, reconciliation and payments.
Sepsis A potentially fatal whole-body inflammation (a systemic inflammatory
response syndrome) caused by severe infection.
Serious Incidents An incident requiring investigation that results in one of the following:
• Unexpected or avoidable death
• Serious harm
• Prevents an organisation’s ability to continue to deliver healthcare services
• Allegations of abuse
• Adverse media coverage or public concern
• Never events.
Shaping a Healthier Future
(SaHF)
A programme to improve NHS services for people who live in North West
London bringing as much care as possible nearer to patients. It includes
centralising specialist hospital care onto specific sites so that more expertise
is available more of the time; and incorporating this into one co-ordinated
system of care so that all the organisations and facilities involved in caring
for patients can deliver high-quality care and an excellent experience.
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Single sex accommodation A national indicator which monitors whether ward accommodation has
been segregated by gender.
Summary Hospital-level Mortality
Indicator (SHMI)
The Summary Hospital-level Mortality Indicator (SHMI) is an indicator which
reports on mortality at trust level across the NHS in England. The SHMI
is the ratio between the actual number of patients who die following
hospitalisation at the trust and the number that would be expected to die
on the basis of average England figures, given the characteristics of the
patients treated there.
V
Venous thromboembolism (VTE) An umbrella term to describe venous thrombus and pulmonary embolism.
Venous thrombus is a blood clot in a vein (often leg or pelvis) and a
pulmonary embolism is a blood clot in the lung. There is a national indicator
to monitor the number of patients admitted to hospital who have had an
assessment made of the risk of them developing a VTE.
Languages/ Alternative Formats
Please call the Patient Advice and Liaison Service (PALS) if you require this information in
other languages, large print or audio format on: 01895 279973. www.thh.nhs.uk
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