enc 12 qa report 2010 final with feedback 3 15 06 10 - nhs · 2010-07-01 · • gtt (global...

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CONTENTS Part 1

Contents

Glossary Page 3

Chief executives statements of quality Page 4 – 6

Part 2 Page 7

Prioritising Quality Improvements Page 7 - 8

Participation in Clinical Audits Page 8 – 12

Commissioning for Quality Innovation and

Improvement

Page 13- 23

Care Quality Commission Page 23 – 24

Data Quality Page 24 - 25

Privacy & Dignity Page 25 - 28

Part 3 Page 28

Mortality Rates Page 28 – 30

Health Care Associated Infections Page 30 – 32

Venous Thromboembolism Page 32

Falls Page 33 – 36

Identifying Deteriorating Patients Page 36 - 37

Patient Experience Page 38 – 41

Complaints Page 42 – 45

Serious Untoward Incidents Page 46 - 47

Compliance with Stroke Pathway Page 48 - 49

Smoking During Pregnancy Page 52 -53

Compliance with NICE Page 53 - 56

Feedback Page 57 – 59

Amendments Page 61

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GLOSSARY

• A & E ( Accident & Emergency) • APMS (Alternative Provision of Medical Services) • BTS (British Thoracic Society) • CABG(coronary artery bypass graft) • CBSA (Commissioning business Support Agency) • C-Diff (Clostridium Difficile) • CEMACH (Confidential Enquiry into Maternal and Child Health) • CMPD (Case Mix Programme Database) • CQC (Care Quality Commission) • CQR (Clinical Quality Review) • CQUIN (Commission for Quality and Improvement) • DANHO (Data for Head and Neck Oncology) • Dare (Directorate of Audit, Research and Evidence Based Practice) • DVT (Deep Vein Thrombosis) • GTT (Global Trigger Tool) • HCAI (Health Care Associated Infections) • HSMR (Hospital Standardised Mortality Ratio) • ICNARC (Intensive Care National Audit & Research Centre) • MEWS (Modified Early Warning Score) • MINAP (Myocardial Infarction Audit Project) • MRSA (Methicillin-resistant Staphylococcus aureus) • NAPTAD (National Audit of Psychological Therapies for Anxiety and

Depression) • NBOCAP (National Bowel Cancer Audit Programme) • NCEPOD (National Confidential Enquiry into Patient Outcome and Death) • NDA (National Diabetes Audit) • NHFD (National Hip Fracture Database) • NICE (National Institute for Health and Clinical Excellence) • NJR (National Joint Registry) • NLCA (National Lung Cancer Audit) • NNAP (National Neonatal Audit Programme) • NPSA (National Patient Safety Agency) • OPD (Out Patient Department) • PCT (Primary Care Trust) • PE (Pulmonary Embolism) • PROMS (Patient Reported Outcome Measures) • SBAR (Situation, Background, Assessment, Recommendation) • SfBH (Standards for Better Health) • SIRI (Serious Investigations Requiring Investigation) • SUI (Serious Untoward Incident) • TARN (Trauma Audit & Research Network) • VTE (Venous Thromboembolism) • WHO (World Health Organisation)

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PART 1 CHIEF EXECUTIVE’S STATEMENT OF QUALITY The George Eliot Hospital NHS Trust is delighted to present their first Quality Accounts. The production has been a journey that started in April 2008 when the Trust publically outlined its commitment to improve quality through the implementation of its five point plan to reduce Hospital Standardised Mortality Rates (HSMR) by: •.prevention of infections •.reduction of potentially harmful events •.patients being in the right ward with the right skills available •.cleanliness of the hospital •.improve coding of patients treatment The success of the plan is due to the commitment and dedication of staff who have measured the quality of the service they provide to patients and set improvement goals. This culminated in their efforts being recognised through a national award for patient safety by the Nursing Times in November 2009. We strive to create an open and just culture that values knowing where we are in terms of the quality of care we provide, learning from events when things go wrong and rewarding high performing teams who demonstrate continuous improvement. It is only through being transparent about the quality of care we provide and listening to feedback from the people we serve that we can ensure continuous improvement of the services we provide. Overview At George Eliot Hospital our mission is to improve the health and wellbeing of our local communities by providing excellent services to meet their healthcare needs, as close to home as possible, through innovation and collaboration with professional health and social care partners. The George Eliot Hospital NHS Trust is a single site hospital on the outskirts of Nuneaton, Warwickshire. We provide a range of traditional district general hospital health services including medical, surgical and maternity care. However, the hospital’s management and clinical teams are committed to delivering the Department of Health’s vision to provide care closer to people’s homes and are currently developing an exciting strategy for the future of the hospital and the way it provides care to local people. The Trust was awarded a 5 year ‘Alternative Provision of Medical Services (APMS)’ contract, to deliver a GP led health centre in Camphill from 1st October 2009. The development of this service has enabled the Trust to deliver our strategy to be the provider of choice, delivering fully integrated care provision closer to home. We serve a population of approximately 250,000 from the surrounding areas of Nuneaton and Bedworth, North Warwickshire, South West Leicestershire and Northern Coventry and work closely with other hospitals for services like cancer, pathology and coronary heart disease, amongst others. The hospital also provides some services such as physiotherapy and occupational therapy in the community.

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The Trust has achieved notable successes in 2009/10. The Trust won the Patient Safety category at the Nursing Times awards and gained ‘highly commended’ in the same category at the Health Service Journal. These recognitions highlight the innovative ways we are providing and embedding best practice into the everyday working life at the hospital. We were rated 4 out of a possible 5 for Patient Safety in the Dr Foster Hospital Guide 2009. Mortality rates, both standardised and actual have dropped to an all time recorded low and Hospital Standarised Mortality Rate (HSMR) reduced to below 99 in 2009/10, better than the national benchmark of 100. The reduction in HSMR is a reflection of improvements in patient care, reduction in healthcare associated infections (HCAI), and improved patient safety. This is evidenced by a reduction in the number and severity of falls and the audited data which positively shows the embedding of systems within the Trust to identity deteriorating patients at an early stage. We have strict cleanliness standards and carry out frequently audits of compliance against these standards. Regular meetings of key managers, senior Nursing staff, and Doctors, enhances communication of information to all staff. This has ensured that best practice is maintained and innovation encouraged. As a result the number of Health Care Associated Infections (HCAI) e.g. C-Diff and MRSA bacteraemia for 2009/10, is at its lowest level since the data was recorded within the Trust. In 2009/10 the Trust met the majority of national targets including those set for Cancer treatment and 18 week referral to treatment pathways. The Trust is mindful that in addition to maintaining and improving the good practice that already exists, our priorities for 2010/11 must be to improve quality of care in these areas. We have been registered with the Care Quality Commission (CQC) regulations with no conditions set. Our governance structure has undergone a strengthening process over the past year, with better defined delegation and progression of responsibility and assurance up to Board Level. Patient Safety, care and experience, is a standing agenda item and is reported monthly through the Patient Safety Group to the Board of Directors in the Integrated Performance Report. The Trust is committed to the importance of internal and external audits. Outcomes of audits can give assurance that the Trust is following best practice but these also serve to highlight areas of weaknesses or poor practice. These can then be reviewed and re-audited when appropriate action has been taken. However, the Trust acknowledges that there are significant weaknesses in the current system. The Trust has implemented a system of registration for all audits which is managed by the DARE Department (Directorate of Audit, Research and Evidence Based Practice) Staff and Patient survey results have highlighted areas for improvement, particularly communication across the Trust. Our aim is to empower our patients and staff to give feedback, whether this is positive or negative. The Trust wants to encourage a listening culture and to be proactive rather than reactive in our approach to improving patient care and experience and staff experience working within the Trust. A contract has been agreed with North Warwickshire and Hinckley College to deliver a customer care programme for all front line hospital staff.

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In the last 6 months we have carried out service reviews in every speciality to ensure clinical viability and compliance with National Standards and requirements. To the best of my knowledge the information contained in this Quality Account is accurate. Sharon Beamish Chief Executive

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PART 2 PRIORITISING QUALITY IMPROVEMENT How we have prioritised our quality indicators 2010/11 The quality accounts indicators have been selected by the Trust’s Board of Directors following analysis of the previous year’s performance. These have been chosen specifically to reflect the Trust’s recognition of the need to prioritise and target improvements over the next year. These indicators are consistent with the Trust’s intention to improve what it perceives to be the three most important clinical areas within the hospital: 1. Patient safety 2. Effectiveness of care 3. Patient experience. Within each of these areas, the Trust has chosen a series of specific priorities to demonstrate improvement. Over the next few pages, next to each area, there will be a summary of the Trust’s position, looking back at the past year (and longer if applicable) and looking forward to the coming year, stating how the organisation plans to achieve its targets. The Trust recognises that greater formal public engagement is required and the Quality Account priorities for 2010/11 are to be presented and discussed at community borough forums that are taking place across the county. PRIORITY 1: PATIENT SAFETY A. Mortality rates – Standard and actual B. Healthcare associated infections e.g. C-Diff & MRSA C. Venous Thromboembolism D. Patient falls E. Identification of deteriorating patients PRIORITY 2: PATIENT EXPERIENCE A. National & Local Patient survey results B. Complaints C. Serious untoward incidents PRIORITY 3: EFFECTIVENESS OF CARE A. Compliance with Stroke pathway B. Smoking during Pregnancy C. Compliance with NICE guidelines D. Audit of compliance with NICE Recommendations

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REVIEW OF SERVICES During 2009/10 the George Eliot Hospital NHS Trust provided and sub-contacted 33 NHS services. The George Eliot Hospital NHS Trust has reviewed all the data available to them on the quality of care in 15 of these services. The income generated by the NHS services reviewed in 2009/10 represents 84% of the total income generated from the provision of NHS services by the George Eliot Hospital NHS Trust for the period of 2009/10. Participation in clinical audits

During 2009/10, 17 national clinical audits and 2 national confidential enquiries covered NHS services that George Eliot Hospital NHS Trust provides. During that period George Eliot Hospital NHS Trust participated in approximately 53% national clinical audits and 100% national confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to participate in. The national clinical audits and national confidential enquiries that George Eliot Hospital NHS Trust was eligible to participate in during 2009/10 are as follows: Type of Audit

Continuous; all patients

Name of Audit or Confidential Enquiry

NNAP: neonatal care NDA: National Diabetes Audit

ICNARC CMPD: adult critical care units NJR: hip and knee replacements NLCA: lung cancer NBOCAP: bowel cancer MINAP (inc ambulance care): AMI & other ACS Heart Failure Audit NHFD: hip fracture National Elective Surgery PROMS: Four operations National Continence Audit British Thoracic Society respiratory diseases audit

• BTS Oxygen • BTS Asthma • BTS NIV • BTS Pneumonia

Sentinel stroke audit CEMACH: perinatal mortality NCEPOD single audit all patients

National Mastectomy and breast reconstruction

National Oesophago-gastric cancer audit

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The national clinical audits and national confidential enquiries that George Eliot Hospital NHS Trust participated in during 2009/10 are as follows: Type of Audit


Name of Audit and Confidential Enquiry

NNAP: neonatal care ICNARC CMPD: adult critical care units NJR: hip and knee replacements NLCA: lung cancer NBOCAP: bowel cancer MINAP (inc ambulance care): AMI & other ACS Heart Failure Audit NHFD: hip fracture National Elective Surgery PROMS: Four operations National Continence Audit British Thoracic Society respiratory diseases audit

• BTS Oxygen • BTS Asthma • BTS NIV • BTS Pneumonia

Sentinel stroke audit CEMACH: perinatal mortality NCEPOD Single audit all patients


Single audit all patients


The national clinical audits and national confidential enquiries that George Eliot Hospital NHS Trust participated in, and for which data collection was completed during 2009/10, are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry. Type of Audit


Name of Audit and confidential enquiry % of no of registered cases required by the terms of the audit or enquiry

NNAP: neonatal care 100% ICNARC CMPD: adult critical care units 100% NJR: hip and knee replacements 100% NLCA: lung cancer 100% NBOCAP: bowel cancer 100% MINAP (inc ambulance care): AMI &

other ACS 100%

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Heart Failure Audit 80% NHFD: hip fracture 100% National Elective Surgery PROMS: Four

operations 84.8%

National Continence Audit British Thoracic Society respiratory

diseases audit • BTS Oxygen • BTS Asthma • BTS NIV • BTS Pneumonia

Sentinel stroke audit Every two years CEMACH: perinatal mortality 100% NCEPOD 100% Single audit all patients


100%

Single audit all patients


100%

The reports of 9 national clinical audits were reviewed by the provider in 2009/10 and George Eliot Hospital NHS Trust intends to take the following actions to improve the quality of healthcare provided;

Audit or Confidential

Enquiry Actions planned or taken Progress

NNAP Neonatal Care Improve neonatal transfer arrangements

Action completed

ICNARC CMPD: adult critical care units

report awaited. Action plan to be developed.

ongoing

CEMACH: perinatal mortality

Improve awareness of perinatal Risk – specific focus on gestational diabetes and patient education.

completed

NLCA: lung cancer MDT strengthened and a more defined care pathway developed. More efficient in relation to radiology and imaging.

completed

NJR: hip and knee replacements

Hip and knee pathways defined and all joint replacements registered.

completed

MINAP (inc ambulance care): AMI & other ACS

Coronary care unit care pathway now published with specific patient information programmes

completed

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developed by specialist nurses NHFD: hip fracture Hip fracture pathway

implemented including osteoporosis screening now in place.

Completed

National Elective Surgery PROMS: Four operations

Participating rate last April – October 84.8% (national average 48.2%).

To increase participation rates for varicose veins and groin hernias.

National Continence Audit

Awaiting national report- data submitted

Completed

Sentinel stroke audit Actions implemented following participation in 2008.

Data to be submitted 2010


Single Audit


Single Audit

The Trust does not participate in the following audits due to the fact that we do not provide these services within the Trust.

• Congenital heart disease : paediatric cardiac surgery • Renal registry: renal replacement therapy • DAHNO: head and neck cancer • Adult cardiac surgery: CABG and valvular surgery • Pulmonary hypertension audit • NAPTAD: anxiety and depression • TARN: severe trauma • NHS Blood and transplant: intra-thoracic liver and renal transplants • NHS blood and transplant: potential donor audit • Adult cardiac interventions

Audits where we do provide the service but have not participated in the audit.

• NDA and National Diabetes Audit – data collected but not submitted • National dementia care (registered to participate 2010-11) • National falls and bone health audit (registered to participate 2010-11) • National kidney care audit • College of emergency medicine: pain in children: asthma, fracture • National Comparative audit of Blood Transfusions. • Action plans in place to ensure future participation

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Local Clinical Audits The reports of 17 local clinical audits were reviewed by the provider in 2009/10 and George Eliot Hospital NHS Trust intends to take the following actions to improve the quality of healthcare provided

• Increase provision of guidelines on Trust intranet • Collection of adverse medication error data for teaching • Improve emergency way pathways for sepsis, pneumonia, coronary care and

emergency assessment. • Increase awareness of hospital infection control • Improve implementation of NICE guidance in the Trust • Improve VTE (Venous Thromboembolism) treatment and education • Improve provision of WHO (World Health Organisation) Surgical checklist • Improve treatment of high glucose patients

Participation in clinical research The number of patients receiving NHS services provided or sub-contracted by George Eliot Hospital NHS Trust in 2009/10 that were recruited during that period to participate in research approved by a research ethics committee was 430. This increasing level of participation in clinical research demonstrates George Eliot Hospital NHS Trust commitment to improving the quality of care we offer and to making our contribution to wider health improvement. George Eliot Hospital NHS Trust was involved in conducting 11 clinical research studies. George Eliot Hospital NHS Trust completed 70% of these studies as designed within the agreed time and to the agreed recruitment target. George Eliot Hospital NHS Trust used National systems to manage the studies in proportion to risk. Of the 15 studies given permission to start 100% were given permission by an authorised person less than 30 days from receipt of a valid complete application. 100% of the studies were established and managed under National model agreements and 100% of the two eligible researchers involved used a research passport. On 2010 reporting period the National Institute for health Research (NIHR) supported 5 of these studies through its research network.

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Commissioning for Quality Innovation and Improvement (CQUIN) Goals agreed with commissioners

Use of the CQUIN payment framework: • A proportion of The George Eliot Hospital NHS Trust income in

2009/10 was conditional on achieving quality improvement and innovation goals agreed between The George Eliot Hospital NHS Trust and Warwickshire PCT through the Commissioning for Quality and Innovation payment framework.

• Further details of the agreed goals for 2009/10 and for the following 12 month period are available on request from The Commissioning Department, George Eliot Hospital NHS Trust.

CQUIN PERFORMANCE INCENTIVE SCHEMES

Ref Indicator Quality Domain Indicator Type Weighting

6a 1. All inpatients to have a discharge plan including: • Estimated date of discharge

within 2 days of admission • Evidence that discussed with the

patient and family 2. Appropriate discharge planning

demonstrates reduction in readmission and excess bed days.

Safety Effective discharge planning aims to: Reduce the length of stay, Decrease excess bed days Reduce readmission rates and Improved user experience. Process Outcome

30%

6b 90% of patients ready to leave hospital will have the necessary documentation/information within 4 hours of the decision to discharge ie GP Letter, patient information, medication, transport arrangements & follow-up appointments in hospital and/or community

Experience

Improved patient experience through timely and comprehensive discharge arrangements Process

20%

6c 25% of all patients are surveyed on their experiences by year end resulting in demonstrable change

Experience

Patient Survey Process Outcome

20%

6d All pregnant women, who smoke, are encouraged to quit or reduce intake:

• 100% record of smoking history taken, and smoking advice given at booking

• Record of patient accepting/refusal to smoking cessation services

• Referral to smoking cessation services

100% of smokers who are willing are referred on to smoking cessation services:

• Demonstrate increases in

Effectiveness

Reduction in the women who smoke, or a reduction in the frequency/amount of smoking during pregnancy in order to improve the baby’s safety during gestation and postnatal period, as a result of referral processes Process

15%

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referrals to the smoking cessation service

6e Development and implementation of a Dementia Pathway for the acute elements of the pathway in partnership with all key stakeholders including: • Participation in all aspects of the

pathway development • Co-operation and joint working with

stakeholders • Implementation of the acute aspects

of the pathway

Innovation

Develop and implement in partnership with key stakeholders a Dementia Pathway Process Outcome

15%

Detailed Indicator Form – Discharge Planning

Indicator ref 6a

Indicator name Effective Discharge Planning

Quality domain Effective discharge planning resulting in a reduction in the length of stay, excess bed days and readmission rates and also improved user experience.

Indicator type Safety

Weighting 30%

Indicator definition 1. All inpatients to have a discharge plan including: • Estimated date of discharge within 2 days of admission • Evidence that discussed with the patient and family

2. Appropriate discharge planning demonstrates reduction in readmission and excess bed days.

Numerator 1. 90% of inpatients with an estimated discharge date within 2 days of admission.

2. Audit against the care plan of evidence discharge discussed with family & patient in 90% of cases

3. Audit demonstrating 90% assessments for completion has met agreed standards reporting exceptions and reasons

4. By exception written evidence to demonstrate joint working to resolve barriers and blockages to discharge.

5. Number of readmissions month on month 6. Number of excess bed days by ward

Denominator Number of elective and non-elective inpatients (excluding day cases, maternity & deaths) discharged per month

Rationale for inclusion To improve discharge planning arrangements, with the aim to reduce length of stay, reduce excess bed days, reduce number of inappropriate readmissions to hospital

Data source

Numerator – provider internal audits against patient records, activity data and written documentation to demonstrate joint working (to be developed and agreed) Denominator - CBSA

Organisation responsible for data collection

• Acute trust to provide information against above numerator • Contract monitoring information from CBSA for excess bed

days and readmission rates

Frequency of collection/reporting Collected monthly and reported quarterly to the Clinical Quality Review Group

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Baseline period / date Baseline information for Discharge plan will need to be developed during first 6 months 09/10

Baseline value (incl 95% CIs)

Final goal value

Final Goal Value for this CQUIN = 30% of tbc = By end of Quarter 4 Part 1 Discharge Plan (100% of CQUIN 1 value): 90% of all inpatients through 09/10 have a discharge plan. A reduction in payment of 0.9% will be made for every 1% underachieved Part 2 Demonstrate appropriate discharge planning reduces readmission and excess bed days (data collected but no financial consequences)

Final goal period / date 2009/2010

Final goal reporting date April 2010

End of financial year value if goal not set for end of financial year

tbc

End of financial year reporting date 31 March 2010

Assessment of goal achievement for indicators with substantial inherent variability

Inherent variability unlikely. 1% variation accounted for in numerator standard 7 to allow for bed capacity difficulties.)

Rules for partial achievement of indicator goal

To agree a sliding scale within the first year but 95% achievement will be required in subsequent years any exceptions will need to demonstrate continual improvement and learning.

Value Period / date Reporting date In-year milestone 1 • Gather baseline information for

monitoring documented discharge date

• Evidence of raising awareness and implementation plan to achieve the scheme

• Establish an agreed process for monitoring compliance

• Define and agree weighting for achievement and consequence of breach

To be agreed

April 09 – Sept 09

Monthly update at CQR

In-year milestone 2 • Q3 – 75% compliance (within Q3)

(95% numerator 7). • Q4 – 95% compliance (within Q4)

(99% numerator 7).

To be agreed

Oct 09 – March 10


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Detailed Indicator Form – Effective Discharge

Indicator ref 6b

Indicator name Communication and patient information to support effective discharge

Quality domain Improved patient experience through timely and comprehensive discharge arrangements

Indicator type Experience

Weighting 20%

Indicator definition Complete and timely information is available to patients within agreed timescales prior to discharge.

Numerator 90% of patients ready to leave hospital will have the necessary documentation/information within 4 hours of the decision to discharge ie GP Letter, patient information, medication, transport arrangements & follow-up appointments in hospital and/or community (monthly audit of 2 high turnover wards, one surgical and one medical)

Denominator Number of elective and non-elective inpatients (excluding day cases, maternity) discharged per month from the identified wards

Rationale for inclusion To improve patient experience when being discharged from hospital resulting in more effective and safe discharges

Data source

Numerator – provider internal audits against patient records (to be developed and agreed) Denominator – provider audit Data collected by provider and quarterly reported to CQR.


Acute trust to provide information against above numerator

Frequency of collection/reporting Collected snapshot audits monthly and reported quarterly to the Clinical Quality Review Group

Baseline period / date Baseline information to be developed during first 6 months 09/10


Final goal value

Final Goal Value for this CQUIN = 20% of tbc = Quarter 3 – 70% of patients have appropriate discharge information Quarter 4 - 90% of patients have appropriate discharge information Sliding scale for compliance starting at 50% rising to 90% 50% is 50% CQUIN 6b value rising by each % value for each % achieved, up to 90% achievement when 100% of CQUIN value is achieved Less than 50% results in 0% CQUIN value

Final goal period / date 2009-10



tbc

End of financial year reporting date

17

31 March 2010 Assessment of goal achievement for indicators with substantial inherent variability

Inherent variability unlikely



Value Period / date Reporting date In-year milestone 1 • Gather baseline information for

monitoring • Evidence of raising awareness and

implementation plan to achieve the scheme

• Establish an agreed process for monitoring compliance

• Define and agree weighting for achievement and consequence of breach

To be agreed


Monthly update at

CQR

In-year milestone 2 • Q3 – 70% compliance (within Q3) • Q4 – 90% compliance (within Q4)

To be agreed

Oct 09 – March 10

Monthly update at

CQR

In-year milestone 3

Detailed Indicator Form – Patient Experience

Indicator ref 6c

Indicator name Improved patient experience through patient survey

Quality domain To improve patient experience when under the care of the Acute Trust resulting in more effective, safe, care and high quality patient experience.

Indicator type Experience

Weighting

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20% Indicator definition 25% of in patients are surveyed by year end resulting in

demonstrable change. A proportion/number of other attendees (eg OPD, A&E) may also be surveyed (numbers to be agreed). Self completion patient surveys:

• Surveys of patients undertaken in all areas. • Survey results and recommendations documented and

discussed with ward/area team. • Survey results communicated to appropriate committees. • Actions from surveys carried out.

Numerator 25% patients will have a survey or local equivalent in each specialty. Recommendations and action plan to be developed and monitored following survey discussion at team meeting.

Denominator Total number of survey respondents and response rate. Rationale for inclusion To improve patient experience when admitted/attending the

hospital resulting in more effective, safe care and high quality patient experience.

Data source

Numerator – provider internal surveys against specific criteria (to be developed and agreed) Denominator – provider inpatient statistics CQC - inpatient survey. PROMS. National Surveys. Local Surveys. Trust – Numbers, action plans and themes.



Frequency of collection/reporting Collected once for each specialty in year, one speciality to be reported quarterly to the Clinical Quality Review Group

Baseline period / date Observation tool to be agreed with the PCT in first quarter prior to commencement


Final goal value

Final Goal Value for this CQUIN = 20% of tbc = By Quarter 4 – 25% of patients surveyed and action plan agreed Between 20% to 24% of patients surveyed, results in 50% of total CQUIN value 25% of patients surveyed results in 100% of CQUIN 6c value Below 20% results in 0% of CQUIN 6c value

Final goal period / date 2009/10



tbc



Reporting variability unlikely. Outcome ie >1 identification of unsatisfactory interaction may result. Assessing achievement of the goal will be linked to an agreed action plan and non re-occurrence (if necessary further observational exercises on that ward to demonstrate non re-occurrence.)

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To be achieved in year. Any exceptions will need to demonstrate continual improvement and learning.

Value Period / date Reporting date In-year milestone 1 • Actions for any surveys in

quarter 4 may not be carried out by end of quarter 4

To be agreed

April 2010


Detailed Indicator Form – Smoking in Pregnancy

Indicator ref 6d

Indicator name Reduction in Smoking During Pregnancy

Quality domain

Reduction in the women who smoke, or a reduction in the frequency/amount of smoking during pregnancy in order to improve the baby’s safety during gestation and postnatal period, as a result of referral processes.

Indicator type Effectiveness

Weighting 15%

Indicator definition All pregnant women, who smoke, are encouraged to quit or reduce intake:

• 100% record of smoking history taken, and smoking advice given at booking

• Record of patient accepting/refusal to smoking cessation services

• Referral to smoking cessation services

100% of smokers who are willing are referred on to smoking cessation services Demonstrate increases in referrals to the smoking cessation service

Numerator 100% of all recording of smoking status.

100% of smokers given smoking advice. 100% of smokers offered smoking cessation services. 100% of smokers who are willing are referred on to smoking cessation services.

Denominator Number of maternity bookings per month (excluding DNAs)

Rationale for inclusion To improve information and advice in order to encourage attendance at smoking cessation services, with a view to reducing prevalence of smoking in pregnancy.

Data source Numerator – provider internal audits against patient records and % of people referred onto smoking cessation services Denominator – provider database (eg evolution or similar)

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Acute trust to provide information against above numerator Data collected by provider and quarterly reported to CQR.

Frequency of collection/reporting Collected monthly and reported quarterly to the Clinical Quality Review Group

Baseline period / date Baseline information for smoking cessation will need to be developed during first 3 months 09/10


Final goal value

Final Goal Value for this CQUIN = 30% of tbc = 100% Recording of data (50% of this CQUIN value) 100% Referral of willing participants (50% of this CQUIN Value) If 80% or less are referred this results in 50% less of this CQUIN value. Sliding scale starts at 50% of CQUIN paid for 80% of referrals

Final goal period / date Quarter ending March 2010



tbc



Inherent variability unlikely


To agree a sliding scale within the first year but 95% achievement.

Value Period / date Reporting date In-year milestone 1 • Gather baseline information

for monitoring • Establish an agreed process

for monitoring compliance • Define and agree weighting

for achievement and consequence of breach

To be agreed



Detailed Indicator Form – Dementia Pathway

Indicator ref 6e

Indicator name Dementia Pathway

Quality domain Develop and implement in partnership with key stakeholders a Dementia Pathway

Indicator type Innovation

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Weighting 15%

Indicator definition Development and implementation of a Dementia Pathway, for the acute elements of the pathway in partnership with all key stakeholders including: • Participation in all aspects of the pathway development • Co-operation and joint working with stakeholders • Development of a documented, agreed, pathway and action

plan for implementation • Demonstrate patients with dementia, in the Trust, are

following the pathway, and care is given according to the pathway (threshold to be agreed)

• Dementia awareness training commissioned and commenced as part of the pathway development – to be implemented year 2.

Numerator Development of a documented, agreed, pathway and action plan for implementation • 1st draft of pathway developed • Pilot of pathway • Revisions to pathway agreed • Further testing of pathway Demonstrate 90% of patients with dementia are following the pathway, and care is given according to the pathway 50% of clinical staff trained in Dementia awareness

Denominator Pathway developed Number of patients with Dementia, and Numbers receiving care following the pathway (on all wards and A&E) Number of clinical staff in Trust

Rationale for inclusion To improve dementia patients’ experience by ensuring that safe and effective care is given, communication channels are clear, and cross boundary working is achieved. Implementation of the national Dementia strategy within Coventry and Warwickshire. (This is also aligned to our partner PCT’s [NHS Coventry’s] world class commissioning project for Dementia, developing a multi-disciplinary pathway for Dementia patients.)

Data source Pathway documentation Provider internal audits against care plan (to be developed and agreed)



Frequency of collection/reporting

• 1st draft of pathway developed – September 2009 • Pilot of pathway – October 2009 – January 2010 • Revisions to pathway agreed – January 2010 – February

2010 • Further testing of pathway – March 2010 onwards Pathway report to the Clinical Quality Review Group Summary report of progress of development of pathway quarterly to the Clinical Quality Review Group Pilot audit data of implementing of the pathway during quarter 3, 1st pilot testing during quarter 4 Further testing from Quarter 1 2010/2011

Baseline period / date Pathway to be developed during first 9 months 09/10 Baseline information to be developed during first 9 months 09/10


Final goal value Final Goal Value for this CQUIN = 15% of tbc =

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Quarter 2 end – Completed pilot pathway developed (100%) Quarter 4 end - 50% implementation of pathway (allowing for piloting and amending with a view to 100% implementation from 2010/2011). Quarter 4 – 50% of clinical staff (in post as at 1st February 2009) have had training by 31st March 2009 (excluding leavers, those on maternity leave, long-term sick, secondment or sabbatical, or PCT/SS/PFI staff working for the Trust) Failure to achieve pathway development is 50% of CQUIN value. Failure to pilot test pathway is 50% of CQUIN value.

Final goal period / date Quarter ending March 2010



tbc

End of financial year reporting date

31 March 2010


Full participation in the development process expected. Implementation threshold agreed at 50% for year end, in order to allow for piloting. Further negation for 100% may be required for subsequent years. Threshold for training accounting for staff on leave etc.



Value Period / date Reporti

ng date In-year milestone 1 • Negotiate and plan for pathway development • Evidence of implementation of the pathway • Establish an agreed process for monitoring

compliance • Define and agree weighting for achievement

and consequence of breach

To be agreed



In-year milestone 2 • Q4 – 50% compliance for implementation

training (within Q4)

To be agreed

Oct 09 – March 10


CARE QUALITY COMMISSION (CQC) George Eliot NHS Trust Hospital is required to be registered with the Care Quality Commission. The George Eliot NHS Hospital Trust’s current registration status is as of 31st March 2010 that it is registered without qualifications or improvement notices. The Trust is registered to carry out regulated activities at George Eliot NHS Hospital, Eliot Way, Nuneaton CV10 7DJ and at Camphill GP led Health Centre, Ramesden Avenue, Nuneaton CV10 9EB as shown: Regulated Activity Location Treatment of disease, disorder or injury George Eliot Hospital &

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Camphill GP led Health Centre Assessment or medical treatment for persons George Eliot Hospital detained under the Mental Health Act 1983 Surgical procedures George Eliot Hospital & Camphill GP led Health Centre Diagnostic & screening procedures George Eliot Hospital & Camphill GP led Health Centre Maternity and midwifery services George Eliot Hospital Termination of pregnancies George Eliot Hospital. The Care Quality Commission has not taken enforcement action against George Eliot NHS Hospital Trust during 2009/2010. George Eliot NHS Hospital Trust was subject to periodic reviews by the Care Quality Commission and the last review was on 9th June 2009. The CQC’s assessment following that review was that the George Eliot Hospital NHS Trust had not provided sufficient evidence to support a declaration of compliance for the full year (2008/09) with Standard for Better Heath C04b – Safe use of medical devices. The CQC’s assessment was that there was inadequate evidence to demonstrate reasonable assurance that the training in the use of medical devices provided to staff was reviewed and audited; and there was limited audit activity evidence to demonstrate that single use items are not reused. As a result of this feedback The George Eliot NHS Hospital Trust, has taken the following action by introducing training evaluation forms in relation to training in the use of medical devices and developing a data-base is being developed that will improve the management and delivery of that training. Further development work will continue into 2010/11. In addition, the terms of reference of the Trusts’ Medical Devices Management Group have been revised to include monitoring of compliance with Standards for better health (SfBH) C04b (now CQC registration standard: Outcome 11); and existing audit tools have been modified to ensure that single-use devices are not reused. The George Eliot Hospital NHS Trust completed all the above actions by the 31st March 2010. Hygiene Code On 25th November 2009, the CQC provided a report from an assessment which took place on 4th November 2009 of the Trust’s compliance with the Code of Practice on Healthcare Acquired Infections. The CQC found no evidence that the Trust had breached the regulation to protect patients, workers and others from the risks of acquiring a healthcare-associated infection.

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George Eliot NHS Hospital Trust has not participated in any special reviews by the Care Quality Commission during 2009/10. DATA QUALITY George Eliot Hospital NHS Trust submitted records during 09/10 to the secondary uses service for inclusion in the hospital episodes statistics which are included in the latest published data. The percentage of the published data which include the patient’s valid NHS number was:

• 99.6% for admitted patient care • 99.5% for outpatient care • 98.6% for accident and emergency care

INFORMATION GOVERNANCE TOOLKIT. George Eliot Hospital NHS Trust score for 09/10 for information quality and records management assessed using the information governance toolkit was:

• 84.0 % CLINICAL CODING ERRORS George Eliot Hospital NHS Trust was subject to the payment by results clinical coding audit during the reporting period 09/10 by the Audit Commission and the error rates reported in the latest published audit for that period for the diagnosis and treatment coding were:

• primary diagnosis incorrect 31.0% • secondary diagnosis incorrect 31.7% • primary procedures incorrect 15.1% • secondary procedures incorrect 22.0%

This is below the standard expected and the Trust is taking steps to improve coding in 2010/2011. PRIVACY & DIGNITY Treating individuals with dignity and respect are core values of the NHS and as such are fundamental principles of care. It is everyone’s responsibility to ensure that standards of privacy are maintained and that dignity in care is preserved. Whilst there are many opportunities to promote dignity there are also challenges to overcome. Embedding dignity and respect at every level of the organisation is essential and should not been viewed as the sole the responsibility of any one group of staff. This second audit provides evidence that actions are being taken to improve standards of privacy and dignity.

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The Essence of Care benchmark audit provides useful insight into issues that impact on the ability to provide dignified care. The findings can be cross referenced with other important sources of information e.g. national patient surveys, staff surveys and complaints in which everyone has a part to play. The 7 factors included in the Essence of Care Privacy and Dignity audit examine the following areas:

• Attitudes and Behaviours • Personal World and Personal Identity • Personal Boundaries and Space • Communicating with Staff & Patients • Confidentiality of Client Information • Privacy, Dignity & Modesty • Availability of an Area for Complete Privacy

Themes identified in the audit The themes identified in the audits fall into three broad categories:

• People relating to factors 1, 2, 3 and 4 i.e. behaviours, attitudes • Places relating to factors 3 ,6 and 7 i.e. physical environments,

organisational culture

Privacy & Dignity Comparison April 2009 & 2010

0%

20%

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120%

Total 62 92 93 100 80 93 93 98 97 100 93 100 97 100 88 100 95 95 93 97 98 97 100 97 90 100 94 100 87 98 97 100 91 100 86 89

09 10 09 10 09 10 09 10 09 10 09 10 09 10 09 10 09 10 09 10 09 10 09 10 09 10 09 10 09 10 09 10 09 10 09 10

A&E / SAU

Adam Bede

Alex Bob Caterina CCU Dolly DPU Eliz EMU Felix ITU Mary Garth

Melly Nason OPD OPD D Vic

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• Processes relating to factors 4, 5, 6 and 7 i.e. care giving activities

Analysis of the results has identified some common themes also identified in February’s audit of communication. The need to promote good communications between staff, patients and carers to ensure that care is personalised and that personal choice is supported with clear information is a challenge that needs to be addressed consistently across all staff and professional groups. People At the time of last years audit the Privacy and Dignity policy had still to be approved. However, this has been available since October 2009 and is available on the SharePoint web site. Staff are frequently reminded to refer to the policy and check their performance against its content. The use of interpreters and the need to maintain patient confidentiality was raised as a potential area of concern for some areas. In general staff do identify when interpreters are needed outside of using family members but are sometimes unclear how to access services outside of normal working hours. The Champions for Older People Study day focuses on individualised care and the promotion of dignity. The Royal College of Nursing Defending Dignity resource materials provide the framework to enable staff to think about the topic in relation to their roles and identify where small changes can make a big impact on patient satisfaction. The way forward Work towards completion of the delivering same sex accommodation programme within the Trust is an important step forward to improving care environments. Arrangements for the identification of single gender washing and toilet facilities were implemented last year and measures to be taken this year involves a dedicated estates improvement plan. Protecting the privacy of patients behind curtains is a perennial challenge for staff not only in terms of stopping interruptions and removing the risk of exposing patients whilst care is in progress but also terms of maintaining patient confidentiality. A ward culture which respects that drawn curtains signify the need to maintain privacy is by far the most effective means of ensuring that staff uphold the patient’s privacy and dignity. The issue of confidentiality and begin able to carry out sensitive discussions in ward areas behind closed curtains is more problematic. The limitations of physical ward environments in relation to having accessible quiet areas for breaking bad news requires thought and planning to overcome. Ward offices are normally multifunctional and used by lots of people, avoiding interruptions is within the gift of the nurse in charge to deliver. Ward managers are required to look creatively at their areas to identify solutions where possible. As identified in last months Hygiene audit, by encouraging the use of bathroom and shower facilities to promote independence and self care, privacy and dignity is also maintained. Promoting patient centred care and assisting patients to access these

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facilities routinely for washing and toileting rather than at the bedside is a leadership responsibility for qualified nurses. In view of the environmental work which is about to begin on ward bathrooms and shower rooms it is vital that staff and patients are involved in looking at accessibility, safety and privacy. INITIATIVES 2010/11 INITIATIVE ACTION OWNER DATE Promote privacy whilst carrying out caring duties to protect patients dignity when using washing and toilet facilities

Privacy & dignity essence of care audit first completed in April 2010. The first re-audit is due in July 2010 and then October 2010

Ward managers Review by end of July 2010

To carry out environmental assessments of washing and toileting facilities to look at privacy and dignity, accessibility and safety

As above Ward managers Matrons

Review by end of July 2010

Encourage patients to wear day clothes where appropriate

Nursing staff to identify suitable patients and invite them to wear day clothes if appropriate and relatives / carers are able to provide and launder extra clothing throughout the patients stay

Ward managers Review at the end of July 2010

Encourage staff to become Dignity Champions and rise to the Dignity Challenge

Bi monthly Champions study days scheduled for 2010/11 dealing with the core elements of the Dignity Challenge. Champions for Older People Link meetings scheduled on a monthly basis. Minutes and progress against projects circulated. Second evaluation report due October 2010

Matron for older people

October 2010

Review environments to identify how private spaces can be created to support patients and carers when sensitive or difficult conversations need to take place without being overheard

Ward office spaces to be included in local ward actions which need to be put into place on an individual case : case basis as situations arise.

Ward managers

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PART 3 PRIORITY 1: PATIENT SAFETY 1A - MORTALITY RATES The rationale The Hospital Standardised Mortality Rate (HSMR) is an indicator of healthcare quality that measures whether the death rate at a hospital is higher or lower than you would expect. The national benchmark is 100 and all Trust’s aim to keep their rate as low as possible. Current status The Trust’s HSMR for 2009/10 was 98.6 which is below the Nation benchmark of 100. The Chart below shows hospital deaths rates against the National target.

Aim Reduce the Trust’s HSMR to below 90 by March 2011. Areas for improvement •.Improvements to rates of Health Care Associated Infections(HCAIs) (see priority B), • Increase in Venous Thromboembolism (VTE) risk assessments, (see priority C) • Reduction in patient falls, (see priority D)

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• Improvement in the identification of deteriorating patients (see priority E). •.Improvements in patient coding. Initiatives in 2009/10 •.Monitoring of standardised mortality rates by consultant and specialty. • Auditing of notes using the Global Trigger Tool (GTT) and 3 x 2 matrix •.Investigation of Dr. .Foster alerts. •.Involvement of NHS Warwickshire in mortality meetings. Initiatives for 2010/11 Initiative Action Owner Date Introduction of early warning electronic detection software.

Trial commencing in September 2010 on emergency assessment unit. Wireless network upgrade to be undertaken to support technology.

Associate Medical Director

September 2010 September 2010

Training of additional staff on the use of the GTT a tool used to identify adverse events in patient care from the patients notes.

Identify individuals to undertake further training. Identify training.

Director of Nursing and Associate Medical Director

March 2011 Completed June 2010 Staff identified and training undertaken.

1B - HEALTH CARE ASSOCIATE INFECTIONS The rationale Health Care Associated Infections (HCAIs) are infections acquired in hospitals or as a result of health care interventions. The Trust has a zero tolerance policy in relation to HCAIs and works tirelessly to eliminate this. Current status In 2009/10 the Trust had five cases of MRSA and 79 of Clostridium Difficile. The Trust also met its hygiene code target for 2009/10. Aim • To achieve the MRSA objective figure for 2010/11 of 2 or less post 48 hour

MRSA Bacteraemia cases. • To achieve the local stretch objective for 2010/11 of 46 or less post 48 hours

Clostridium difficile Infection (CDI) cases Cumulative C diff graph 2009/10

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Cumulative C.diff graph 2009-10

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Areas for improvement •.Further reduction in incidence of HCAIs. •.Improvement in the Trust’s antibiotic policy compliance. Initiatives in 2009/10

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•.Introduction of cleaning audits. •.Introduction of new method of deep cleaning known as ‘fogging’ • Hand hygiene compliance audits • Insertion and ongoing care of peripheral line cannula and urinary tract catheters audits • Monitoring of Antibiotic usage. • Isolation of symptomatic patients with diarrhoea/vomiting into side-rooms and whole bay cleaning. All audits are reported at ’Back to Basics’ Meetings, with the exception of the monitoring of Antibiotic usage audit, which is reported at the monthly Hospital Infection Prevention and Control Committee. Initiatives for 2010/11 INITIATIVE Action Owner Date New deep clean programme.

To have an annual deep clean programme

Director of Ops Head of Hotel Services

31.03.2011

Continued refurbishment of clinical areas.

Integrated into the estates plan

Director of Ops Head of Estates

31.03.2011

Increase in en-suite facilities in ward side rooms.

Integrated into the estates plan

Director of Ops Head of Estates

31.03.2011

raising and monitoring cleaning standards

Participation in the internal and external P.E.A.T audits. Weekly auditing using the national cleanliness standards and weekly feedback of scores at back to basics meeting.

Director of Ops Head of Hotel Services

31.03.2011

Management of Invasive Devices

Ongoing staff training. The use and audit of the high impact intervention care bundles e.g.

Peripheral line insertion and ingoing care.

Central line insertion and ongoing care Urinary catheters insertion and ongoing care

Medical Director Clinical Directors

31.03.2011

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1C - VENOUS THROMBOEMBOLISM The rationale Venous Thromboembolism (VTE) is a condition in which a blood clot (thrombus) forms in a vein. Blood flow through the affected vein can be limited by the clot and may cause swelling and pain. This can in turn lead to a pulmonary embolism (PE). Current status The Trust did not carry out an audit of VTE risk assessments in 2009/10. No statistics are currently available for 09/10 as to risk assessments carried out or details of thromboprophylaxis (medication given as a precautionary measure to prevent blood clots) prescriptions. However, the Trust has in 2010/11 carried out two audits, and further audits will be carried out on a regular basis. Compliance with completing risk assessment forms remains low. Aim From 1 June 2010, 90% of patients must receive a VTE risk assessment and thromboprophylaxis prescribed and administered where clinically indicated. Areas for improvement •.More robust risk assessments, prescription and administration of Thromboprophylaxis •.Audits to confirm compliance with NICE guidelines Initiatives in 2009/10 •.Development of risk assessments and prescribing regimes •.Introduction of anticoagulants for hip and knee replacement surgery Initiatives for 2010/11 INITIATIVE ACTION OWNER DATE Implementation of a National Risk Assessment Tool, based on NICE Guidelines

NATIONAL RISK ASSESSMENT TOOL IMPLEMENTED

ASSOCIATE MEDICAL DIRECTOR

01/06/10

Improved monitoring of VTE policy compliance.

COMPLIANCE WITH RISK ASSESSMENT IMPLEMENTED AND RESULTS

ASSOCIATE MEDICAL DIRECTOR

01/06/10

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WILL BE REPORTED THROUGH THE THROMBOSIS GROUP

Monitoring and root cause analysis of all patients developing a VTE or PE within 90 days of admission

RCA TO BE COMPLETED ON ALL PATIENTS WHO DEVELOP VTE / PE WITHIN 90 DAYS OF ADMISSION OUTCOME REPORTED VIA THE THROMBOSIS GROUP

CHAIR OF THE THROMBOSIS GROUP

01/07/10

DVT thrombo-prophylaxis awareness event planned for 19th May 2010 for all staff

EVENT TOOK PLACE AS PLANNED ON 19/05/10

Implementation of updated Anti-embolism Stocking Policy, in line with current guidance

ANTI- EMBOLISM STOCKING POLICY HAS BEEN UPDATED AND RATIFIED . IMPLEMENTATION PLAN TO BE DEVELOPED AND POLICY ROLLED OUT

ANTICOAGULATION NURSING TEAM & THROMBOSIS GROUP

30/09/10

1D - PATIENT FALLS The rationale Incidence of patient falls have a direct impact on patient length of stay and morbidity and mortality rates. 20 – 30% of falls on average are preventable. Existing falls prevention strategies have resulted in a 20.5 % reduction in falls since 2007.

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Current status The Trust’s emphasis on reducing inpatient falls has resulted in a 20.5% reduction over the period 2007-2009. Chart below – Falls chart April 06-February 2010

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Chart showing number of no harm to patient fall incidents reported;

Total number of falls reported April 2009 - March 2010

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No harm incidents

Aim To reduce incidences and severity of patient falls by 30% in 2010/11 compared to 2009/10.

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To reduce the number of incidents suffered by high risk frequent fallers, following multi-factorial assessment, intervention and through effective deployment of falls prevention interventions and equipment Areas for improvement •.Improving access to the Trust’s falls clinic. Initiatives in 2009/10 The introduction of fall prevention mats for vulnerable patients, that alert ward staff if they are trying to climb out of bed. All ward staff have been trained on the use of the mats. Initiatives for 2010/11 Initiative Action Owner Date Improved training and better use of risk assessments

Falls risk assessments / care planning included as part of the weekly nurse sensitive indicator audit / programme. Falls prevention training included as part of the bi-monthly Champions for Older People training. Ad-hoc training provided on request for areas experiencing difficulties with particularly high risk patients or increased incidents of falls.

Matron for Older People

Next review December 2010

Changes to nurse’s documentation

Assessment and core care plans reviewed. No change required.

Matron for Older People

July 2011

To contribute data to the National Falls and Bone Health Audit in older people

Organisational audit begins September 2010 Data input September – December 2010.

Matron for Older People until such time as Ortho – geriatrician or other clinical lead identified.

September 2010

To review existing services and develop improvements, in line with Warwickshire Falls and Bone Health Strategy.

Liaison with community services and PCT. County wide review of Warwickshire strategy. Falls service (clinic) review.

Matron for Older People Project Manager General Manager for Medicine

September 2010

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Warwickshire Falls and Bone Health Implementation Plan 2010 – 2013 The current work of the Falls Group is looking at how the Trust can meet the objectives of the Warwickshire Falls and Bone Health strategy which outlines three broad principles:

• Reducing avoidable hip fractures in older people by 10% through developing and implementing an effective county wide Falls & Bone Health Care Pathway

• Health promotion across the general population and awareness raising regarding how to stay in good health in later life

• To develop integrated Falls and Osteoporosis services

External agencies e.g. Falls Co-ordinator, PCT representative and Camp Hill Centre Manager are invited to the meetings for their specialist contribution to the project which is being facilitated by Paula Crosby. This work will also feed into the improvement plan project for fractured neck of femur. National falls and Bone Health in Older People Audit 2010 The Trust has enrolled in this years’ audit beginning in September 2010, which is focusing on two groups of patients:

• Group 1 Non – hip fragility fractures • Group 2 Hip fractures •

It is hoped that this will coincide with the appointment of an Orthogeriatric Consultant who will be able to lead on aspects of the audit 1E - IDENTIFYING DETERIORATING PATIENTS The rationale When there is a failure to detect changes in patients who are becoming more acutely unwell, this may contribute to an increase in the number of hospital cardiac arrests and poor patient outcomes. A subsequent, unplanned admission to critical care or return to theatre, may lead to significant increased length of stay and costs. Current status The Trust currently carries out regular MEWS (Modified Early Warning Score) and the SBAR (Situation - Background - Assessment - Recommendation) communication tool was introduced in 2009. Results of these audits are reported at ‘Back to Basic’ Meetings weekly. The Critical Care Outreach Team at George Eliot NHS Trust faced the same challenges in empowering ward staff to recognise the deteriorating patient in acute care as many other teams around the UK. As a result, the team worked hard to come up with a way of extending the work already done with Early Warning Scoring Systems (EWS) by looking at how observations were charted in the Trust and how they could be enhanced.

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The National Patient Safety Agency (NPSA) identified the common themes of deterioration and resuscitation as areas where specific incidences have occurred, the Critical Care Outreach Team concentrated their efforts around deterioration primarily by:

• Improving recognition of patients at risk. • Improving recognition of those who have deteriorated. • Ensuring help is summoned early. • Responding to calls for help.

Aim All deteriorating patients are recognised in a timely manner and appropriate action taken. Zero tolerance. Areas for improvement Situation, Background, Action & Recommendations (SBAR) communication training tool, is currently being undertaken by all nursing staff who take patient observations. Initiatives in 2009/10 •.The introduction of a review for all unplanned admissions to intensive care. •.The Trust will audit 20 sets of patient notes a month using the global trigger tool (GTT) and 3x2 matrix to identify the rate of adverse incidents. •. Modified Early Warning System (MEWS) currently used within the Trust and its use audited. Initiatives for 2010/11 INIIATIVE Action owner date Role out of the SBAR communication tool across the Trust.

Identify the format of the SBAR tool. Role out by ward Audit completion of SBAR

Matron for ITU and Critical Care

March 2011

Robust feedback and action plans developed, based on the findings of the GTT and MEWS audits.

Utilise the Institute web based data base. Identify forum for feedback.

Associate Medical Director

March 2011

PRIORITY 2: PATIENT EXPERIENCE 2A - PATIENT SURVEY RESULTS (NATIONAL AND LOCAL) The Trust participated in the National and Local Patient Surveys

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Current status National Surveys 2009/10 The Trust participated in the National Inpatient and Outpatients survey in 2009/10 the results from which were published in May 2009 and February 2010. Inpatient Survey The majority of comments were very positive, praising staff and the service they provided. Improvements were reported against the overall discharge process and patients’ feeling they were being treated with respect and dignity. A number of areas achieved similar results as in previous years but reduced satisfaction reported in areas around bathroom facilities, security and overall care and communication. Outpatient Survey Patient comments reflected the positive side of the department focusing on the pleasant manner, helpfulness and attitude of staff. Generally our results demonstrated an improvement in some standards; however, these fell below national trends in many areas. Trends identified for improvement include environment, all aspects of communication to include clear reasons for delays, patient information and signposting following the appointment. The Trust is taking a number of steps to resolve the trends identified during 2009/10 and will continue throughout 2010/11. Aim To improve the patient experience and be in the top 10% of Trust’s nationally in relation to the outcomes of National Patient Surveys. Initiatives for 2009/10 •Signs have been placed on bathroom doors to make clear the gender of the facility. •Department of Anaesthesia has introduced a checklist procedure to ensure that patients receive all required information pre-operatively. • Issues around noise at night taken forward with nursing staff at regular ‘back to basics’ meetings As a result of the Inpatient and Outpatient National Surveys and other patient feedback the following are planned. Initiatives for 2010/11 Initiative ACTION OWNER DATE Communication skills and customer care training is currently being developed in partnership with North Warwickshire

To role out across the Trust

Head of Training & Development

September 2010

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and Hinckley College and will be offered to all staff. Ward information available on some wards and being developed in other wards about discharge and after care

Information Booklets for bedsides

Deputy Director of Nursing

December 2010

Increased cleaning schedule in the outpatient department

Cleaning schedule to be improved

Hotel services Manager and Matron for Outpatients

Review of outpatient departmental working practices

Work in progress Matron for outpatients Deputy Director of Operations

December 2010

Improved seating plan in the outpatient department and provision of information screen and television

Work in progress Matron for outpatients and Estates and Facilities Manager

December 2010

Ensure patients receive medication prior to discharge from hospital

Work in progress Chief Pharmacists, Director of Nursing and Matrons

December 2010

Ensure customer care is on all team agendas, including anonymous feedback from any complaints or rationales.

Corporate strategy for agenda on all wards. Preset proforma

Deputy Director of Nursing

November 2010

Patient Information kiosks (4) have been provided at various locations. These will be actively promoted with information in all departments.

Provide information leaflets in all departments and communication to all staff. I kiosk to be moved to provide feedback

Patient advice and liaison Manager

01.09.2010

Local Survey 2009/10 Impressions Software The Trust has an online survey linked to the web page. Although this has been extensively promoted only 239 responses were logged. These results, although small, reflected the findings of national surveys with poor communication and insufficient patient information featuring as the main rationales. Local Patient Satisfaction Survey 2009/10 A telephone survey commenced in June 2008 to obtain immediate feedback on patients thoughts regarding their care whilst an inpatient at the George Eliot Hospital NHS Trust (GEH). The purpose of this is to highlight areas of concern and good

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practice, thus enabling the organisation to learn from these experiences and take appropriate action rapidly. Patient discharge details are gathered on a daily basis with a view to contacting patients 24 hours following discharge. Results are collated to identify trends and these are forwarded to Medical Director for inclusion in the monthly Board Report and for reports to Patient Safety Group and Patient Experience Group. Copies are also sent to ward areas so that they can display results on their notice boards and take relevant action where applicable. Survey outcomes 2009/10 •Patients discharged during this period total 5,000 •Patients contacted 2,500 (50%) •Patients contacted – message left on answer phone 1,000 ( 20% ) •Patients contacted – No Answer phone facility / incorrect telephone number recorded 1,500 (30%) •Outpatients Department – Patients contacted 134 for a period of 3 months (27%) long delays Trends arising from feedback;

• Lack of Communication between clinical staff, patients and families. • Staff attitudes - nursing staff / HCSW comments that were deemed to be

unacceptable to the patient. • A lack of advice regarding aftercare for patients on discharge by medical &

nursing staff for surgical procedures. • Rationales with hospital acquired pressure areas not being explained and

passed correctly to community nurse. • Wounds requiring intervention from other agencies not communicated

properly

COMPARISONS WITH 2008/09 NATIONAL SURVEY RESULTS 2008 Vs LOCAL 2008/2009

Question National survey Local survey

The patient felt they were always treated with respect and dignity

74% 90%

The rating for doctors and nurses working well together was excellent

29% 90%

The rating for the care received was excellent

37% 90%

The patient was asked to give 7% 90%

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their views on the quality of care during their hospital stay The patient saw posters / leaflets in hospital explaining how to complain

24% Not asked

The patient wanted to complain about the care received in hospital

13% Not asked

Overall Survey findings 2009/10 The national survey of adult in patients conducted by the Care Quality Commission does not reflect similar responses from that of the local GEH survey (telephone). The questions we ask are in a different format so it is considered that the response rate has been very positive towards the care, treatment and environment compared with those from the national survey. Initiatives for 2010/11 Initiative Action Owner Date Introduction of electronic data capture before patient discharge, with questions more closely aligned to the National Patient Survey.

Questions have been developed and are being piloted using a paper based system before any modifications are made and they will then be uploaded on to electronic hand held devices. Plan to commence electronic data collection

Head of Patient involvement / PALS & Volunteers

Pilot commenced 24/06/10 01/09/10

2B - COMPLAINTS The rationale The Trust welcomes feedback about the services it provides and indeed encourages patients and visitors to provide feedback when they have had a positive experience at the Trust and also when things did not meet their expectations.

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Issues highlighted by complaints are used to review the services the Trust provides and make changes and improvements where appropriate. Aim To reduce the number of patient complaints received. Current status The Trust received 294 complaints in 2009/10, five of which were withdrawn by the complainants, therefore 289 were investigated. 96 of these complaints were responded to within 25 days. Between April and September 2009 there were some staffing issues within the Customer Services Department which resulted in a re-organisation of the Department. This, in conjunction with significant internal changes in the way complaints were investigated at Divisional level, resulted in a reduction in the number of complaints responded to within our 25 working day time limit. There were periods during the year when the general management/deputy General Managers were not up to establishment and this also contributed to response times falling outside of the 25 working days. (The response times have now significantly improved). As per the NHS Complaints Policy, where complaint responses are not going to meet the 25 working day time limit, a ‘holding’ letter should be sent to the complainant requesting an extension of time for the investigation to be completed. This is usually in cases where the complaint is particularly complex and/or involves numerous members of staff and where the complaint involves more than one Trust/organisation. Since September 2009 the Customer Services Department has written to all complainants where the investigation would not be completed within the 25 working days. There was a significant increase in the number of complaints regarding the A&E Department, which alleged missed fractures, concerns over diagnosis and some issues of staff attitude. These were reviewed by a team led by the Medical Director – at the time findings concluded there was a shortage of senior doctor cover and high locum usage. CQC commented during their visit in November 2009 that our numbers of A&E complaints is well below the national average. The complaints received for the out-patients department relate to five out-patient areas, and relates to issues such as waiting times for appointments, delays in clinics, delays in clinic letters going to GPs, communication, concerns around clinical advice/treatment given and attitude of staff. Trends that were identified as a result of complaints were ‘aspects of clinical care/treatment’, ‘aspects of nursing care/treatment’ and ‘communication’.

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NO

. OF C

OM

PLA

INTS

AN

D R

ES

PO

NS

ES

WITH

IN 2

5 DA

YS

0 5 10 15 20 25 30 35APRIL '09M

AYJUNE

JULY

AUGUSTSEPTEMBER

OCTOBER

NOVEMBER

DECEMBER

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FEBRUARY

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NT

H

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. CO

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DE

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ITH

IN 25 D

AY

S

Analysis

The T

rust analyses complaints by area/speciality and by category looking for

trends and themes. T

he main areas identified by com

plainants within the

Trust are:

CO

MP

LA

INTS

BY

CA

TE

GO

RY

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Adms, discharge, transfer arrgmnts

Aids, appliances & equipment

All aspects of care/treatment

Aspects of clinical care/treatment

Aspects of nursing care/treatment

Cancelled appts

Cancelled operation/procedure

Car parking/charges

Communication

Confidentiality

Delay in clinic letters to GPs

Delay issuing Death Cert

Delays/waiting time to be seen

Dignity, respect & privacy

Drug error

Environment

Hotel services

Infection control

In-patient in DPU

Lack of staff

Lost property

O/P appt letters

Pain relief

Records not available

Referrals/process

Smoking on site

Staff attitude/behaviour (medical)

Staff attitude/behaviour (nursing)

Staff attitude/behaviour (admin)

Staff attitude/behaviour (other)

Test results

Waiting time for appt

Waiting time for emergency surgery

Waiting time for operation/procedure

CA

TE

GO

RY

NUMBERS

A

reas • O

ut-Patients departm

ents – delays in clinics, delays in clinic letters going to G

Ps, com

munication, concerns around clinical advice/treatm

ent given and attitude of staff.

44

• A&E – alleged missed fractures and concerns over diagnosis. • Day Procedures Unit – cancelled operations/procedures, waiting time to

go in for procedure, in-patients in DPU and staff attitude. • Lydgate – environment and nursing care/treatment.

COMPLAINTS BY AREA/SPECIALITY

0

10

20

30

40

50

60

70

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Ale

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Ana

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ly W

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E.M

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Est

ates

/Fac

ilite

s

Felix

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t

G.U

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Gen

eral

Sur

gery

Gyn

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ervi

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.

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Mat

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Med

ical

Rec

ords

Mel

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Pae

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Pat

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AREA/SPECIALITY

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S

Areas for improvement Areas of concern highlighted from complaints during 2009/10 were: •Various Aspects of clinical care/treatment. •.Various Aspects of nursing care/treatment. •.Communication. Initiatives in 2009/10 A number of actions have been taken in response to trends identified from patient complaints: •.A review of complaints relating to A&E, led by the medical director, following a significant increase in complaints. •.The MRI request form revised to identify potential patients not suitable for the Trust scanner along with information being sent out to Trust clinicians to remind them of restrictions of the scanner. •.A complaint folder has been piloted on one ward for all staff to review complaints received relating to that area.

45

Initiatives for 2010/11 Initiative Action Owner Date Review and update the Trust’s complaints policy.

Update existing Trust Policy.

Customer Services Manager

1 August 2010

Improve awareness of the policy and the systems in place

Present at Corporate Induction Programme. Talk at ward/ departmental meetings.


1 January 2010 - ongoing

Improve the number of complaints responded to within 25 days.

Ensure complaints remain high priority for the Division. Chase as appropriate and provide support, as necessary.

Divisional General/Deputy Managers Customer Services Manager

Benchmarking of complaint data, comparing the Trust with other comparative Trusts.

Approach equivalent sized Trusts, i.e. Warwick and Burton, for data on 6-monthly rolling basis


1 July 2010 (for last 6 months of data for 2009/ 2010)

Monitor actions taken as a result of a complaint to reduce the likelihood of similar themes occurring.

Send out action sheets for completion with each new complaint. General Managers/ Deputies to complete action sheet and ensure actions undertaken

Customer Services Manager Divisional General/Deputy Managers

1 July 2010 1 July 2010

Improved analysis of complaint trends and themes

Analysis of complaints rec’d by area, by type and also specifically by individual staff members.


1 January 2010 - ongoing

46

2C - SERIOUS UNTOWARD INCIDENTS (SUI’S) The rationale The Trust has a strong incident reporting culture, with 3160 incidents being reported during 2009/10. All members of staff are actively encouraged to report any incident that potentially poses a threat to patient safety or services delivered within the Trust. Of the 3160 incidents reported, a small number of these (37) are considered serious as defined by the National Patient Safety Agencies categorization, and therefore are reported as an SUI. The rest of the incidents reports are no harm incidents. All reported incidents are appropriately investigated depending on the severity of the incident. Actions developed and lessons learnt and shared across the organisation. However, serious SUI’s require a full root cause analysis (an in-depth comprehensive investigation to identify all contributing factors). In order to prevent a similar event from reoccurring it is important that such incidents are robustly investigated and the outcomes shared within and beyond the organisation. All identified SUI’s within the Trust are reported to the Strategic Health Authority and Primary Care Trust as per policy. Current status During 2009/10, the Trust reported 3160 incidents via its internal reporting system. Of these incidents, 37 were SUI’s that were externally reported. Please see graph below for monthly breakdown of SUI’s

47

Aim To reduce the number of patients who experience harm as a result of adverse incidents within the Trust. Areas for improvement •The two main trends identified during 2009/10 for SUI’s, were Clostridium Difficile (C-diff, 22 cases) where noted on the death certificate and MRSA (bloodstream bacteraemias, 5 incidences). •Timeliness of completion of root cause analysis investigations. Initiatives in 2009/10 •Continued efforts to reduce HCAIs (see area 1 priority B). •Falls reduction programme (see priority area priority1D)

SUI's By Month 2009/10

0

1

2

3

4

5

6

7

8

9

Apr-09 Jun-09 Aug-09 Oct-09 Dec-09 Feb-10

Month

Incidents

48

Initiatives for 2010/11 INITIATIVE ACTION OWNER DATE Updating SUI policy, to ensure that it closely aligns with PCT and SHA SUI policy. To include the change from SUI to the new term ‘SIRI’ (serious incidents requiring investigation).

Update existing policy to ensure aligns with PCT, SHA & NPSA policies and only incidents that match the criteria are considered as serious incidents requiring investigation.

Risk/ H&S Manager July 2010

Education and training in carrying out robust ‘root cause analysis training’ for all Managers within the appropriate time frame.

Further develop incident investigation training to ensure all leads are comfortable with using the NPSA template for investigation paperwork. Introduce facilitation of SIRIs centrally.

Risk/ H&S Manager July 2010

PRIORITY 3 - EFFECTIVENESS OF CARE 3A: COMPLIANCE WITH THE��STROKE PATHWAY The rationale Stroke patients spending most or all of their time on a dedicated stroke ward are statistically more likely to receive the most appropriate care in a timely manner and therefore rehabilitate to their maximum ability, post stroke episode. Current status 38.21% of stroke patients discharged in 2009/10 spent 90% of their stay on the Felix Holt dedicated stroke ward. Aim 80% of admitted patients spending 90% of their time on a dedicated stroke ward. Areas for improvement •.Increasing awareness of the direct admission initiative so all patients suffering from a suspected stroke are admitted to the stroke ward and are immediately placed in

49

the care of the specialist stroke team. • All stroke patients receive CT scan within 24hrs of admission. • Increase the percentage of stroke patients, spending 90% of their stay on the Felix Holt dedicated stroke ward. Initiatives in 2009/10 •.All patients suffering from a suspected stroke are now brought directly on to the specialist stroke ward. Initiatives for 2010/11 INITIATIVE ACTION OWNER DATE Continue to audit length of stay for stroke patients.

All discharges are audited as part of the monthly Vital Signs, information is issued by Allan Davis and Check by Maggie Hall for any anomalies

Head of Information Management Stroke Co-ordinator

Monthly

Continue to develop the Trust’s stroke outreach team to rehabilitate more stroke patients in the community

The Stroke Out Reach Team currently offers every Stroke discharge, an assessment at home from the most appropriate member of the team. An individual therapy programme is devised, this includes Physiotherapy, Occupational Therapy, Speech Therapy, Swallow Assessments and Dietary Advice, Psychological Support.

Therapy manager Dietetic Manager SALT Manager Psychology Manager

ongoing

Increase the percentage of patients receiving their CT scan within 24hrs of admission, in line with National Targets.

Audited monthly as part of the Vital Signs Direct Admissions to Felix Holt, All Stroke CT request forms Stamped for easy recognition. Liaison with the CT staff to arrange scan when 24 hours deadline is approaching.

Head of Information Management Stroke Co-ordinator Sisters Stroke Unit CT Radiographers

Monthly

Increase the percentage of patients spending 90% of their time on the stroke ward, in line with National Targets.

Audited monthly as part of the Vital Signs. Direct Admissions to Felix Holt, enables a more effective pathway and prompt access to investigations. 10 Stroke beds

Head of Information Management Stroke Co-ordinator Manager Felix Holt Ward Clinical Sister Felix Holt and Adam Bede Ward

Monthly

50

available on Adam Bede Ward. Aiming to improve the flow from Felix Holt Ward to Adam Bede, by daily liaison between the 2 wards, Ensure joint working through, joint weekly MDT meeting, training sessions and stroke strategy meetings.

51

3B: SMOKING DURING PREGNANCY The rationale The links between smoking and numerous health problems are well known as are the affects that smoking can have on a baby both during and after pregnancy. Smoking during pregnancy has been shown to have a negative impact on the development of a child’s brain and body. Research has also shown that if all pregnant women gave up smoking, the number of stillbirths and cot deaths could be reduced by around 10%. Current status Between July 2009-February 2010 17.3% of maternity clients were smokers at the time they gave birth (see graph for breakdown).

Smoking at Delivery

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%

Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10

Yes

No

Areas for improvement Encouraging expectant mothers and other family members, to stop smoking so as to promote a healthy environment for the new born. Aim To increase the numbers of pregnant mothers who have stopped smoking by the time they deliver their babies. Initiatives in 2009/10 Changing the referral process for pregnant mothers who smoke so referral to the smoking cessation service was ‘opt out’ rather than ‘opt in’. Initiatives for 2010/11 INITIATIVE ACTIONS OWNER DATE Further training for midwives on encouraging

Community midwives have been trained

SHA SMOKING CESSATION LEAD

31/12/10

52

expectant mothers to stop smoking.

In house training to assist clients with their endeavors to stop smoking and are supporting the client group

Midwives to take a more persistent approach to promote the benefits of stopping smoking.

Midwives are linking with occupational health to reduce staff smoking and then encourage client group by leading by example to stop smoking. Reviewing the trust policy and re-enforcing the fact that the site is non smoking for clients and staff.

HOM/HR 30/10/10

Promotion of a ‘smoke free home’ for babies

Issuing cot death leaflets to all ante natal & post natal clients. Referring other family members along with the mother for stop smoking support where they are open to this to ensure that there is support in place to encourage a smoke free environment for baby.

ALL MIDWIFERY STAFF

01/06/10

3C: COMPLIANCE WITH NICE��GUIDELINES The rationale

53

The National Institute for Clinical Excellence (NICE) was set up as a special health authority for England and Wales in 1988 with a remit to provide patients, health care professionals and the public with authoritative, robust, reliable guidance on current best clinical practice. All members of Trust staff have a responsibility to work according to the best evidence available to them, including NICE guidance. Aim To be compliant with NICE guidelines that are relevant to the services provided by the Trust. Current status There are processes in place to ensure implementation of NICE Guidance as far as possible and identify barriers to implementation. Not

Relevant1

Not Relevant2

Implemented Awaiting response

Pending3

Intervention procedure guidance

34 4 1 0 4

Clinical guideline

2 0 5 1 5

Technology appraisal

4 2 7 4 0

Public Health guidance

3 0 1 0 0

Total 43 6 14 5 9 Areas for improvement •.Auditing of compliance •.Early resolution of difficulties in fully implementing the guidance •.Ensuring action planning and tracking Initiatives in 2009/10 •.Review of NICE implementation policy •.Proactive approach to compliance and report back to DARE •.Feedback from clinical networks to confirm compliance Initiatives for 2010/11 Initiative Action Owner Date

54

NICE guidelines implementation to be delegated to a named senior clinician within the directorate to ensure responsibility and accountability.

Monthly meetings with GMs Attendance at Directorate meetings

Clinical Audit Officer Education & Research Manager Audit & Effectiveness Nurse

Ongoing 1st Oct 2010

Moving forward, it will be the role of the General Manager to monitor progress of the implementation and ensure audit of compliance using an implementation tracking sheet and it will be the responsibility of the clinical director to ensure NICEguidance is implemented and audited.

Attend staff induction Monthly meetings with GMs Attendance at Directorate and Back to Basics meetings



3D: AUDIT OF COMPLIANCES WITH NICE RECOMMENDATIONS The rationale Clinical audit is the review of clinical performance against agreed standards and the appropriate refining of clinical practice as a result of the audit. As such, it is now recognised as an effective mechanism for improving quality of care patients receive. Aim •.Audits will be in place to confirm compliance with NICE guidance •.Base action plans on outcomes of audits performed and re-audit appropriately Current status •.Registration, monitoring and reporting of clinical audits is currently very weak Areas for improvement •.All areas Initiatives in 2009/10 •.review of policy and amendment of procedural documents Initiatives for 2010/11

55

Initiatives Action Owner Date Notes Regular audit management meetings through DARE

Directorate and Trust-wide meetings to be combined

Education & Research Manager

1st Oct 2010 Discussion with CDs specialty and audit leads

Work will commence to embed a ‘clinical audit culture’ into the organisations as a whole and to ensure protected time is provided for the implementation of NICEguidance and clinical audit of compliance

Attend staff induction Monthly meetings with GMs Attendance at Directorate and Back to Basics meetings Attendance staff and F1/F2 Induction Introduction to DARE workshops DARE Newsletter



DARE Workshop to include section on report writing

Correct use of Consultant ‘supporting activity’ time

Job plans General Managers & CDs

a.s.a.p.

Work to ensure the registration, monitoring and reporting of clinical audit is improved to ensure they are professionally undertaken and completed.

Online form Publicly available (read only) database with recommendations

Clinical Audit Officer Education & Research Manager Clinical Director

1st Oct 2010 DARE Workshop to include section on report writing

Feedback received from Overview & Scrutiny committee, Patient Forum and NHS Warwickshire.

GEORGE ELIOT PATIENT FORUM

To whom it may concern: Ref Quality Accounts 2009/2010

56

Thank you for inviting the George Eliot Patient Forum to comment on the Quality Accounts. As there is very little overlap between the detail in the Accounts and the Forum’s Work plan we feel unable to make significant comment. However, we would like clarification on two issues.

1. page 3 Chief Executive Statement of Quality. The population for the area served by the Trust is quoted as 250,000. We feel this is a gross understatement. 250,000 represents the population of Nuneaton and Bedworth only. At least 400,000 is a more realistic figure to include North Warwickshire, South West Leicestershire and North Coventry.

2. page 25 Clinical Coding Errors. As laymen, we are rather alarmed that the

error rate for both primary and secondary diagnosis is 31%. This seems a very high figure to us but may be our lack of understanding. Please clarify.

Signed: Derek Kenny Margaret Cooper (Chairman) (Administrator)

Overview and Scrutiny Committee feedback George Eliot Hospital NHS Trust The Warwickshire Health Overview and Scrutiny Committee welcomes the opportunity to comment on this draft Quality Account. Having considered the document at its meeting on 24th May 2010 it wishes to make the following observations which it believes will be of assistance to the trust.

• The committee was generally impressed by the report, by the work being undertaken by the trust and by the improvements to service that have been made. The committee was particularly pleased to see that the document provided an explanation of why indicators had been selected.

In terms of improving the document:

57

• The Quality Account relies very heavily on the use of acronyms. Whilst the committee recognises that these have their uses it feels that the document should at the least contain a glossary of terms.

• The document currently contains no reference to consultation with stakeholders. This should be addressed.

• The section concerning complaints (p36) would benefit from expansion. For example whilst 96 complaints were responded to within 25 days what of the 193 that were not. There may be a valid reason for this but the Quality Account should explore the matter further for the reader to fully understand it.

• The same section (complaints) would benefit from the inclusion of trend data. • Benchmarking data should be included where appropriate to enable the

reader to compare performance with peer organisations. An example of where this approach would be helpful can be found on page 25 - Clinical Coding Errors. Is “31% primary diagnosis incorrect” good or bad? How does this compare with other similar hospitals?

• Trend data should be used to illustrate year on year performance • Although to most readers the charts are easily understood others may find the

absence of labels on the axes confusing. SUIs on page 39 is an example. • Some of the charts do not reproduce well in monotone. Consideration should

be given as to how this might be addressed. • Data should be included on no harm patient safety incidents. Perhaps this

could be allied to 1D – Patient Falls. • Patient dignity requires a specific section. • The account should make more explicit the links between what has happened

and what will happen in the future. There are instances in the document where plenty of attention is given to explaining the challenge but little detail is provided on how it will be addressed. An example of this is patient falls where on p31 it states that there will be changes to nurses documentation but does not expand on what these will be or how they will improve the situation.

• Related to the preceding point is the need for an action plan to be included. The committee considers that as well as looking back on what has been achieved the Quality Account should be clear on what actions are proposed, when they will be undertaken, the target(s) they seek to meet (outputs and outcomes) and who will be responsible for them. This will enable public and partners to hold the trust to account when, in a year’s time, this process is undertaken again.

STATEMENT FOR GEORGE ELIOT HOSPITAL NHS TRUST NHS Warwickshire and NHS Coventry (the commissioners) have reviewed the Quality Account provided by George Eliot Hospital NHS Trust (GEH). In relation to information and data within the document that relates to items contractually discussed throughout the year at Clinical Quality Review meetings both commissioners can corroborate this Account. Attendance and engagement at these meetings have been excellent.Information provided within this Account that does not form part of those Quality Review meetings cannot be corroborated by either commissioner. The commissioners are concerned about the public and staff reported experience of services provided by GEH as seen in the National Inpatient Survey and National Staff Survey. Commissioners will work with the Trust to improve performance in these areas over the forthcoming year. GEH has improved stroke targets over the year but commissioners will be working with the Trust to improve them further.

58

The commissioners closely monitor their providers’ management of serious untoward incidents (SUIs) (those resulting in serious harm or death) and has seen improvement in GEH management of SUIs. The Trust is now compliant with best practice. George Eliot Hospital NHS Trust was subject to a number of external reviews in 2009/10 by both NHS Warwickshire and other reviewing bodies. Any actions arising from such reviews are monitored through monthly quality review meetings with the Trust. Summary details of those visits can be found below: • NHS Warwickshire Unannounced Emergency Care Pathway Visit – May 2009 The visiting team ‘walked through’ the emergency pathway from the reception

desk through the different areas ranging from minor to major emergencies. Seven recommendations were made and an action plan developed by the Trust which is monitored through the clinical quality review process although concerns remain about the difficulty to recruit medical staff to this area.

• NHS Warwickshire Review of the Stroke Pathway at George Eliot Hospital NHS Trust -

The visit identified that overall the Trust has a very good Stroke Unit and Pathway. The visiting team felt that if the recommendations were embraced and implemented the service would be an exemplar in the Region. Recommendations were made in relation to improving stroke targets.

• Neonatal Network review-September 2009 The report identified some areas for development and the Trust has developed an

action plan in response to this.

• West Midlands Quality Review Service: Care of the Critically Ill and Critically Injured Children Peer Review visit – October 2009

This review found four immediate risks, two of which were immediately rectified by the Trust. The remaining two risks are being addressed through alternative pathways for admitting children and are being monitored by regular review through the clinical quality review process.

• Care Quality Commission (CQC) Healthcare Acquired Infection report-November 2009

Of the fifteen measures inspected, CQC had concern in one area; this area has subsequently been addressed to the satisfaction of CQC.

• NHS Warwickshire Themed Review of Capacity and Discharge Planning-November 2009

No immediate risks were identified although a number of recommendations for improved practice were made. These will be monitored by the commissioners through 2010/11. NHS Warwickshire is working with GEH and Warwickshire County Council to improve the transfers of care from hospital to community care and hopes this will allow GEH to improve on the timeliness of its discharge of patients.

• NHS Warwickshire Themed Review of Children’s Safeguarding Services-January 2010 Overall the panel was delighted with the exemplar progress made and found the quality of evidence provided of an exceptionally high standard

59

Warwickshire LINKS Warwickshire LINK welcomes the invite to comment on the Quality Account. We also welcomed the joint meeting held with the Health Overview and Scrutiny Committee to discuss the accounts. We recognise that this is the first year of this process and that the timetable was short.

Warwickshire LINK would like to make the following commentary to the account

• We would like to see greater proactive efforts on the part of the Trust to establish a stronger relationship with the LINK.

• The LINK agrees with the Health Overview and Scrutiny comments regarding the need for a glossary of terms explaining acronyms, better use of charts.

• Greater reference to how stakeholders are involved in the work of the Trust through consultation needs to be addressed.

• The need for benchmarking data where appropriate will enable readers to compare performance with peer organisations.

• Trend data should be incorporated to allow year on year performance in future Accounts.

• Patient dignity is an important area that warrants a specific section.

• Action plans need to be included.

When the reports are presented next year we would hope to see further progress against action plans and performance measures, where specified.

Amendments following Feedback received:

• A glossary has now been included in the accounts • Consultation with constituents regarding the priorities set by the Trust for

2010/11 and future priorities are being addressed at locum community form meetings across the area.

• Complaints – expansion on information around complaints not answered within 25 working days included. Graph showing trends on page 39.

• Page 41 refers to no harm events regarding patients. Page 31 includes a chart showing no harm incidents reported April 2009 – March 2010.

• A specific section on Patient Privacy and Dignity has been included on pages 27 – 29.

• Action Plans included for all sections with timescales and owners

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