Quality Account 2015 - 16
Contents Introduction
5
About us • Our vision • Our values • Clinically led • SASH+
7 7 7 8 8
• Research • Diabetes • Dermatology • Care of the elderly • Breast cancer • Cardiology
30 32 33 34 34 35 36 36 36 36 36 37 39 39
Safe • Incident reporting • Duty of Candour • Safety thermometer • Falls • Pressure damage • World Health Organisation (WHO) safer surgery checklist • Infection prevention and control • Healthcare acquired infection • Learning • MRSA BSI • Tackling norovirus • Cleanliness • Safeguarding • Children’s safeguarding • Adults safeguarding
12 12 12 13 13 14
Caring • Patient experience • Friends and Family Test • Patient Opinion • Inpatient survey • Nutrition • Mixed sex accommodation • End of life care
14 15 15 15 16 16 17 17 17 18
Responsive • Reducing need for admissions • Access to services • Length of stay • Discharge • Readmission to hospital • Coding • Data quality
40 40 40 41 41 42 42 42
Effective • NICE • Mortality • Enhancing quality • Audit • Review of services • Participation in clinical audit • National confidential enquiries • Patient reported outcome measures (PROMS) • Dementia • Venous thromboembolism (VTE) • Stroke • Fractured neck of femur (hip) • Chronic obstructive pulmonary disease (COPD) • Goals agreed with commissioners
20 20 20 21 21 21 22 23
Well-led • Staff survey • Staff Friends and Family Test • Our achievements • Our focus • Care Quality Commission • Information governance
44 44 45 45 45 46 46
Our priorities for 2016-17
48
27 28 28 28 29
Glossary
50
Appendices
53
29
What our partners say
54
29
Keep in touch
59
Surrey and Sussex Healthcare NHS Trust
Statement of directors’ responsibilities 53
3
4
Quality Account 2015-16
Introduction This is the fifth quality account that we have produced since I took up the role of chief executive late in 2010 and, in many ways, it is the most significant for the future of the hospital and the services it provides for its patients and for its population. Having received a comprehensive review of services from the Care Quality Commission in 2014 and receiving a Good rating across all five domains we agreed with our clinical and administrative workforce that we wanted to use this platform to do something really special and achieve the rating of Outstanding for all of our services by the time we are next inspected. This is a very difficult challenge because it is not solely within our gift. We not only need to identify and deliver further improvement from what is a high baseline; we also need to improve more than other organisations. Recognising the scale of this challenge we responded to a call from the NHS Trust Development Authority (now known as NHS Improvement) to take part in an exciting development programme in partnership with the Virginia Mason Institute (VMI) in Seattle. The hospital at Virginia
Mason earned the title of America’s hospital of the decade because of the way in which it puts patient safety first in all conversations about the delivery of care and clinical pathways. With nearly 15 years of experience they have a wealth of understanding about what the processes and activities are that must happen for every patient, every time, to ensure as good an outcome for that patient as possible. They differentiate naturally between activity that adds value to the patient journey and that which does not and they understand the importance of a culture which stops a pathway when it is found to be unsafe and only restarts when the problem has been rectified. This approach has led to a methodology of improvement that is understood and embraced by all their staff and has seen a 75% reduction in complaints, clinical incidents and litigation. We consulted with staff through our clinical chiefs, our patient safety executive and our all staff meetings where there was huge support
Surrey and Sussex Healthcare NHS Trust
to take on the challenge of a five year improvement programme and this decision was endorsed by Trust Board. This approach was very important in being chosen as one of the five hospitals who have now started to work with VMI in what became an intensely competitive process and it was this, together with our track record of improvement as described in previous Quality Accounts, which convinced the international panel that we were worth investing in. The year 2015-16 has been an exciting one however it has also been a difficult year, perhaps one of our most difficult final quarters with unprecedented unscheduled demand on our emergency department and ward beds despite a mild winter. Patients have experienced longer waits, more cancellations and more
‘I am very grateful to all the lovely staff who dealt with us. You all do a great job in what must sometimes be very difficult circumstances. Thank you.’ 5
bed moves when admitted than we would want for them. This reality has been experienced by many of our neighbouring hospitals as well and this year we are involved in service redesign across Sussex and east Surrey that will try to deliver a better patient experience across a wide geography as well as work with Surrey Health Partners and the Kent, Surrey and Sussex Academic Health Science Network (AHSN), which will look at alternative care and staffing models, enabled by emergent technology, that promote independence and wellness in our out of hospital population. This is at the heart of Simon Stevens’, chief executive of NHS England, five year forward view. Against this background we have agreed six academic posts cofunded by the hospital and the University of Surrey to help design, implement and evaluate new models of care for older people and we will be out to advert for the professors of medicine and nursing by the time you are reading our quality account. I am well aware of the fantastic job our staff do, perhaps most especially the personal assistants and reception staff who often are the people dealing with patients and their loved ones when pathways aren’t running smoothly and who are responsible for repairing our relationship with our users, day in and day out. In this context I 6
was delighted with our best ever result from the national staff survey where as well as being in the top 20% of hospitals for our return rate, we were in the best 20% nationally for 17 of the 32 key findings. We also receive positive responses to our staff Friends and Family Test. It is this staff attitude of being happy to work with us and be treated by us and recommend us to others that will enable us to achieve all we want to together. Once again there is a lot in this quality account and I hope you will find it interesting to read. It describes the things we have done to improve patient safety and experience and the effectiveness of the care we offer. It has sections on our clinical audit programme and the learning we have taken from this important aspect of governance and once again there is a narrative about the research undertaken by our clinicians. The recruitment to clinical trials is one of the things we should talk about more this year as it is an accepted indicator of the quality of services that others look at and judge us by. There are also sections on some of the national indicators which enable NHS England and our commissioners to compare us with other providers and a section on what our external partners say about us and about our priorities, which we arrive
at in consultation with them. In an organisation as large and complex as ours there will be many priorities for different groups and services and as staff become more confident with our improvement methodology they will naturally set their own targets for harm-free care. We are in the process of agreeing our CQUIN (Commissioning for Quality and Innovation) programme with our commissioners and we will continue to work with the AHSN on all its improvement projects including the national patient safety collaborative. However, over and above this we have agreed a focus within our Virginia Mason partnership, which we call SASH+, on the flow of cardiac patients through the hospital, referral, assessment and treatment of our outpatients who are seen by the Trust and on the recognition and management of diarrhoea. We have also agreed that we will pay particular attention to falls, to the risk management of venous thromboembolism and to alternatives to admission for some of our frailest patients and service users. We believe that this year, and going forward, these are areas we want to be the best and safest in, for our community, as we strive to be outstanding in all we do.
Michael Wilson CBE Chief executive Quality Account 2015-16
About us Surrey and Sussex Healthcare NHS Trust provides extensive acute and complex services at East Surrey Hospital in Redhill alongside a range of outpatient, diagnostic and planned care at Caterham Dene Hospital, The Earlswood Centre, and Oxted Health Centre in Surrey and at Crawley and Horsham Hospitals in West Sussex. Serving a population of over 535,000 we care for people living, working and visiting east Surrey, north-east West Sussex, and south Croydon, including the towns of Crawley; Horsham; Reigate and Redhill.
St George’s University Hospitals NHS Foundation Trust and Royal Sussex County Hospital Brighton. East Surrey Hospital has 691 beds and ten operating theatres – along with four more theatres at Crawley Hospital in our day surgery unit. We are a major local employer, with a diverse workforce of around almost 4,000 providing healthcare services to the community we serve. The Trust is an Associated University Hospital of Brighton and Sussex Medical School.
Our vision Safe, high quality healthcare that puts our community first
Our values Dignity and respect
East Surrey Hospital is the designated hospital for Gatwick Airport and sections of the M25 and M23 motorways. It has a trauma unit, which cares for seriously injured patients in partnership with the major trauma centres at
We value each person as an individual and will challenge disrespectful and inappropriate behaviour
One team We work together and have a ‘can do’ approach to all that we do recognising that we all add value with equal worth
Compassion We respond with humanity and kindness and search for things we can do, however small; we do not wait to be asked, because we care
Safety and quality We take responsibility for our actions decisions and behaviours in delivering safe, high quality care Surrey and Sussex Healthcare NHS Trust
7
Clinically led We are a clinically led organisation, focused on putting people first. Our services are led and managed through four divisions:
reducing waste and variation and improving quality. More than sixty NHS trusts applied and in July 2015, after a highly competitive selection process, the five Trusts chosen to participate in a five year development programme were announced by the Secretary of State for Health in a speech to the House of Commons.
Cancer Chief Dr Ed Cetti Associate director Jane Griffiths (from January 2016)
Chief nurse Victoria Daley Medicine Chief Dr Ben Mearns
(from October 2015) Dr Virach Phongsathorn (until September 2015)
Associate director Alison James (from August 2015)
Chief nurse Nicola Shopland Surgery Chief Dr Barbara Bray Associate director Natasha Hare Chief nurse Jamie Moore Surgery Chief Dr Zara Nadim
(from December 2015) Dr Debbie Pullen (until November 2015)
Associate director Bill Kilvington Chief nurse Michell Cudjoe
(Head of midwifery)
8
SASH+ - our Virginia Mason journey Sue Jenkins, director of strategy and Kaizen Promotion Office (KPO) lead introduces us to the SASH+ transformation partnership with the Virginia Mason Institute. In March 2015 the NHS Trust Development Authority, now called NHS Improvement, invited expressions of interest from NHS Trusts to be part of a development programme, which aims to fundamentally improve the quality, performance and financial sustainability of the organisations selected to take part as well as share learning with others. The programme is a partnership with the Virginia Mason Institute (VMI) based in Seattle in the USA, who have developed a transformational management system that has successfully helped them deliver better care by
The five Trusts are: • Surrey and Sussex Healthcare NHS Trust • Barking, Havering and Redbridge University Hospitals NHS Trust • The Leeds Teaching Hospitals NHS Trust • The Shrewsbury and Telford Hospital NHS Trust • University Hospitals Coventry and Warwickshire NHS Trust Virginia Mason has a 346 bed medical center (hospital) and also delivers general primary and specialist services to the people of Seattle. Over the course of the last fifteen years, the Virginia Mason Medical Center has become one of the safest and highest rated hospital organisations in the USA, culminating in them being recognised with the prestigious ‘Hospital of the Decade’ award. Following a visit to the Toyota car manufacturing factory in Toyota City, Japan, VMI adopted and adapted Toyota’s production system to develop the Virginia Mason Production Quality Account 2015-16
System, which is based on traditional Japanese culture and methodological improvement techniques with Lean processes at its heart. At Surrey and Sussex Healthcare NHS Trust this work is part of our SASH+ programme of improvement. Ultimately, our aim is to put our patients at the forefront of everything we do, improving safety and quality by reducing waste as much as possible. We will continue to develop and embed a culture of innovation and improvement which meets the needs of patients. Our teams will use tried and tested tools and techniques to demonstrate how their part of the organisation runs day to day and be able to demonstrate how they improve the journey for patients on a continuous basis. Improvement and reducing waste will become part of the day job – for everyone, all of the time. We already have a great platform to build on having seen the transformation that has taken place in recent years. We know that as an organisation we are in a much better place today than we were five years ago. More importantly, we know that patients receive care that is safer; of higher quality; with better outcomes and supporting a better experience. Reflecting the Japanese influence on the programme some of the references and language
used are Japanese in origin, for example: Kaizen Continuous incremental improvement Genba Where the work actually happens Sensei One who has gone before Our Kaizen promotion office (KPO) team lead the transformation programme. Nationally, the chief executives from each of the five participating Trusts have formed the Transformation Guiding Board (TGB), which oversees and provides strategic direction for the programme and sets priorities, key themes and outputs. Locally, the participating Trust has a Trust Guiding Team (TGT) which meets monthly and is responsible for oversight and delivery of the improvement work for their organisation. Led by the chief executive, our SASH+ TGT has strong clinical leadership involvement – membership of the TGT includes: • • • • • •
Medical director Chief nurse Chief of medicine Chief of surgery Chief of education Director of strategy and KPO (Kaizen Promotion Office) lead • VMI executive sensei
Surrey and Sussex Healthcare NHS Trust
programme of improvement work has been underway. Being part of the SASH+ work will provide more rigor, pace and scale to the benefits that are being achieved. Management of diarrhoea This value stream starts at the onset of symptoms and ends when the symptoms have been resolved.
investment of £4.5m in our cardiology service with the development of two state of the art angiography laboratories, the opening of the new Surrey and Sussex Heart Centre and the appointment of additional specialist staff including two new consultant cardiologists. We have already identified three initial value streams (workstreams) to start on. They are: Inpatient flow – cardiology The value stream starts from when the patient is referred to the cardiology team and ends when the patient is discharged or transferred from the cardiology ward. In response to the increasing demand for cardiology services we have recently made a significant 10
Outpatients This value stream starts from when the decision to refer for an outpatient appointment is made, usually done in primary care, and ends when the patient has attended their first follow up appointment or been discharged (whichever is sooner). This value stream has been chosen in light of the CQC rating for this service which was scored as requiring improvement. Over the past 18 months a structured
Diarrhoea has been chosen as it is an issue that potentially effects patients in all parts of the hospital and has a significant impact on the experience of patients during their hospital stay. We think this is an important area where we can be much better and have a significant positive impact on the quality of care for patients as well as in areas of hospital acquired infections. All three value streams are underway and many changes are already implemented and being planned. Our SASH+ transformation work will take time to deliver and embed at least five years. We are proud to be part of this exciting partnership and look forward to continuing to improve the high quality care we provide to local people. Quality Account 2015-16
‘The enthusiasm and pro-active approach from everyone already taking an active part in our initial SASH+ value streams is fantastic. It is so rewarding to see and hear about the positive difference being made to the care we provide and to the experience of our patients.’ Michael Wilson Chief executive
Surrey and Sussex Healthcare NHS Trust
11
Safe We aim to: Deliver safe services and be in the top 20% compared to our peers Incident reporting There is a steady increase in the numbers of incidents being reported on a monthly basis. We believe this reflects more patient activity and willingness to report over the year. We have robust processes in place to capture incidents. We have provided training to staff and there are various policies in place relating to incident reporting. The 2015 NHS staff survey showed that Trust staff, when asked about their confidence and security in reporting unsafe clinical practice, responded positively, placing the Trust in the top 20% within the country. The first national benchmarking of the Trust’s capability to learn from incidents has been published and the Trust has benchmarked well nationally. This is positive assurance to support our efforts to continue to learn from incidents and share our findings. Duty of Candour Compliance with Duty of Candour has been 12
Patient safety incidents Level of harm
2012-13 2013-14 2014-15 2015-16
None to moderate
3,657
4,795
5,875
6,446
Severe harm/death
56
39
42
40
Total
3,713
4,834
5,917
6,486
% of severe harm or death incidents
1.5%
0.8%
0.7%
0.6%
required by NHS bodies since November 2014. Duty of Candour is based on the being open principles, which remain the same, but has a focus on formalising the ‘being open’ conversation and requires written documentation. The process is triggered when any unintended or unexpected incident could result in, or did result in severe harm, moderate harm, prolonged psychological harm or death of the patient.
a recording and monitoring process within the Datixweb incident reporting system. Written guidance is available on the Intranet explaining what information is required and when.
Duty of Candour fields are triggered when harm is reported as moderate or above. A monthly report is pulled from Datixweb on a monthly basis for discussion at the Patient Safety and Risk sub-committee. In addition the risk team have produced additional The Trust has developed tools to support staff in a Trust wide policy in the implementation of this accordance with Regulation policy and the regulation 20: Duty of Candour. The policy has been approved and requirements. These include; made available to all staff via task checklists, guidance and letter templates. the Intranet. The risk team Awareness has been raised have developed Quality Account 2015-16
‘There are five questions we ask of all care services. They’re at the heart of the way we regulate and they help us to make sure we focus on the things that matter to people.’
through divisional and department discussion. Duty of Candour training is included in the patient safety and incident programme and root cause analysis investigation training. Bespoke training is also provided to the FY2 doctors and surgical specialties.
Are they safe? Are they effective? Are they caring? Are they responsive to people’s needs? Are they well-led?
Safety thermometer The Trust achieved 95% or above compliance for ten of the twelve months. The Trust did not achieve the second objective of 97% throughout January to March 2016. Harm free
Harm free
(all harms) (new harm) % %
Apr 15
91.6%
96.0%
May 15
93.5%
97.3%
Jun 15
92.0%
95.2%
Jul 15
95.0%
97.7%
Aug 15
92.2%
94.8%
Sep 15
93.2%
96.7%
Oct 15
95.4%
97.6%
Nov 15
90.3%
95.0%
Dec 15
92.6%
96.2%
Jan 16
91.2%
95.1%
Feb 16
89.1%
93.8%
Mar 16
90.2%
94.5%
In 2016-17, we will focus on improvement and ensuring that the data for the safety thermometer is collected accurately and in a timely manner. Falls There has been a 6.12% increase in the number of falls recorded and there has been a 14.63% increase in the number of falls with harm. A key element of the 2015-16 falls strategy was to ensure timely and appropriate reporting of all falls. As a consequence the number of falls reported has increased. Despite this the Trust is not an outlier nationally for the incidence of falls. The Trust has a number of escalation areas which have been open for most of 2015-16 to manage fluctuations in capacity and demand and to protect patient flow. This reflects that generally inpatient activity was higher than the previous year resulting in a
Surrey and Sussex Healthcare NHS Trust
Care Quality Commission
larger number of patients using our services which may in part, explain the increase in the number of falls reported. In addition the Trust has experienced more complex and dependent case mix of patients requiring admission to in-patient beds. The Trust remains committed and focused on improving patient safety. In 2016 a new integrated re-ablement unit was opened on site in partnership with Surrey County Council and East Surrey CCG. The unit provides an appropriate rehabilitation environment for patients who have been assessed as medically ready for discharge. The Trust monitors the falls with harm per 1,000 beddays; the result has been broadly static for the last two years. 13
2014-2015
2015-2016
Total falls
1196
1274
Falls with harm
315
369
prevention of pressure damage • Improve public awareness of causes and prevention of pressure damage This will also support the cohesive working relationship with community providers to improve awareness and facilitate prevention strategies.
Falls with harm per 1,000 bed-days 2.5
2
1.5
1
0.5
The Trust is developing a new role to develop and oversee the Trust falls strategy. This post will work closely with the new consultant nurse for dementia. In 2016-17 we will continue to seek a reduction in the number of falls that cause harm to our patients. Pressure damage We have had no hospital acquired major pressure damage and we continue to put in place care plans which keep the level of minor damage to a minimum. The Trust monitors all hospital acquired skin damage and reviews individual cases at a fortnightly meeting chaired by the chief nurse. The Trust actively promotes effective prevention of pressure damage and is able to report that for the period April 2015 - March 2016, 14
Jan 16
Dec 15
Oct 15
Nov 15
Sep 15
Jul 15
Aug 15
Jun 15
Apr 15
May 15
Mar 15
Jan 15
Feb 15
Dec 14
Oct 14
Nov 14
Sep 14
Jul 14
Aug 14
Jun 14
Apr 14
May 14
Mar 14
Jan 14
Feb 14
Dec 13
0
there were 159 incidents acquired in our care, all graded as low harm (grade 2 pressure damage). This is reflective of the active engagement and support of clinical areas by our tissue viability nurse and the continued focus on pressure damage prevention at the fortnightly tissue viability meeting and patient safety sub-committee. The Trust tissue viability lead and patient safety and risk lead are active participants in the Kent, Surrey and Sussex Patient Safety Collaborative for Pressure Damage. The aim of this is to: • Improve clinical practice in primary prevention and treatment of pressure damage • Improve measurement and reporting of pressure damage across the region • Improve patient and family involvement in
World Health Organisation (WHO) safer surgery checklist The WHO checklist compliance is monitored each month. In 2015-16, 100% compliance was reported in nine of the last 12 months and 99% for the other three. We have continued to audit the quality of our safe surgery through 201516, which shows that the WHO safer surgery checklist is used in all areas where operations and procedures are carried out eg theatres; endoscopy and Limpsfield eye unit. An educational programme for all staff working in theatres and a review of the documentation has improved commitment and communication of all safety issues. In 2016-17, we will continue to audit the quality of our safer surgery priorities and ensure that all our premises are in-line with the national Safety Standards for Invasive Procedures. Quality Account 2015-16
Infection prevention and control
Infection - number of cases
Healthcare acquired infection For the prevention of C.difficile infection (CDI) there has been a continuing emphasis on initiatives to drive antimicrobial stewardship through the antimicrobial stewardship programme. Improving clinical assessment of patients with diarrhoea, their risk of CDI and management of CDI continues to be a focus and has included: tools to support clinical assessment, promotional ‘Stop Assess Send’ campaign, education and proactive support from the infection prevention and control nurses in clinical areas facilitating review of diarrhoea cases. Maintenance of isolation of patients with C.difficile for the duration of inpatient stay continues.
Clostridium difficile 34
Infection Prevention and Control (IPC) annual programme has included hand hygiene initiatives and audits of glove use (appropriate hand hygiene behaviour being fundamental to how gloves are used). MRSA infections are more likely if a patient has invasive devices or open sites such as intravenous lines, a urinary catheter or a wound, or if patients are carriers of MRSA. Over recent years there has been an overall reduction in MRSA blood stream infection, with focus on screening and interventions to reduce the risk of infection or spread of MRSA.
MRSA blood stream infections 2 Learning C. difficile: Each Clostridium difficile case has a root cause analysis carried out by members of the clinical team in conjunction with members of the infection prevention and control team. In 2015-16 34 Trust apportioned cases of C.difficile have been identified, 25 within the medical division, eight within the surgical division and one within women and children (15.3 C.difficile cases per 100,000 bed days). All 34 cases have been reviewed along with the co-ordinating commissioner to determine whether there have been any lapses in care. A lapse in care is defined as evidence that policies and procedures were not followed, regardless of whether the lapse contributed to the root cause of the infection; 21 cases were assessed as no lapse identified, ten cases
Surrey and Sussex Healthcare NHS Trust
were assessed as a lapse but this would not have affected the outcome and three cases assessed as a lapse in that a different outcome could reasonably have been expected had this lapse not occurred. The main themes from the RCA investigations include delays in: sending stool samples, multidisciplinary review of patients with diarrhoea and documentation of clinical assessment, awareness of treatment regime for CDI and time to isolation. Of those cases with complete investigations 32 had antibiotics preceding C.difficile diagnosis including 14 who also had antibiotics from primary care or another healthcare provider. Post-admission antibiotic prescribing as a contributory or attributable cause of C.difficile infection
15
‘Thank you everyone, you are, without exception, a credit to your chosen profession. Thank goodness for the NHS.’
was not identified in the cases. Lessons learned are disseminated within the divisions and across the Trust to support organisation wide learning. MRSA BSI: The first case occurred in a vulnerable patient due to prematurity (neonate) the likely cause being an intravenous device with lessons regarding care and documentation of the device identified. In the second instance of MRSA BSI the post infection review showed either a contaminant (when organisms that are 16
not actually present in the blood are grown in culture) or transient bacteraemia (transient presence of bacteria in the blood) from a respiratory source. The infection occurred in a known MRSA carrier and on investigation there were no deficiencies in the use of invasive devices or of skin integrity that contributed to this incident. Tackling Norovirus: Reducing the risk of outbreaks associated with Norovirus (causing diarrhoea and/ or vomiting) continues to be a challenge across all healthcare areas. The virus spreads easily and has an impact on not only healthcare but community establishments also such as schools and care homes. Collaborative working with community colleagues
regarding the management of norovirus continues and this includes regular open communication between community public health and infection control colleagues of suspected outbreaks, as well as actively engaging with community partners in Infection Prevention study days. There were six episodes of partial or full ward closures due to confirmed Norovirus occurring in spring and summer 2015. The infection prevention and control nurses will continue to actively engage in clinical areas including the emergency department and assessment areas, to support assessment of patients with diarrhoea and vomiting and intervening early to prevent spread of suspected Norovirus. We continue to aim to have a whole health economy approach in working more effectively on Norovirus control and reducing the risk of outbreaks in addition to the infection control programme which includes elements that will impact on not only Norovirus but all potential healthcare associated infection. In 2016-17 we will continue to aim to meet the Department of Health 2016/17 objectives of no more than 15 patients being affected by C.difficile infection and also zero preventable MRSA blood stream infection. Quality Account 2015-16
For C.difficile we will continue to focus on antimicrobial stewardship and on incorporating lessons learned into the forthcoming improvement plan for C.difficile infection. Management of diarrhoea is included as part of a wider SASH+ initiative and an innovative education programme using simulation learning is also in development by the infection prevention and control team. Improvements in the quality of care and management of invasive devices will remain a focus to reduce the risk of blood steam infections and those standard but fundamental aspects of preventing healthcare associated infection such as hand hygiene and environmental hygiene will continue to be incorporated into infection prevention and control activity. Cleanliness We have continued to focus on providing safe high quality standards of cleanliness in our wards and inpatient areas, which is frequently positively endorsed through patient and visitor feedback. We have made changes to the cleaning regimes in our receptions, corridors and common areas to ensure that our patients and visitors gain immediate confidence in the cleanliness of the hospital the moment they step into our buildings. In
2016-17 we will continue our focus on high standards of cleanliness throughout the hospital and to listen to all feedback from patients and visitors, wherever possible implementing changes that will enhance their experience and confidence. Safeguarding The Trust is committed to protecting the safety and wellbeing of vulnerable children and adults. Annual reports are provided to our Board where key issues and statutory requirements are discussed and demonstrated. Children’s safeguarding Safeguarding activity across the organisation is increasing, demonstrated by the increase in safeguarding referrals and daily contact through the safeguarding office. At the year-end there had been 6,165 information sharing forms and 1,402 referrals to Children’s services completed. This is an increase of 27% of information shared with external agencies giving us evidence that the increase in training at both level 2 and 3 and adhoc training across the Trust is changing practice and increasing awareness of children’s safeguarding. Safeguarding principles are well embedded in hospital practice throughout the Trust. Staff, from a range of specialities, consistently demonstrate they have considered vulnerable children in relation to any
Surrey and Sussex Healthcare NHS Trust
patient’s attendance at East Surrey Hospital, regardless of their age. During 2015-16 the safeguarding children’s team has worked with many internal and external partners across both Surrey and Sussex in a variety of activities to ensure that children are appropriately protected. These activities range from attendance at child protection conferences, child death reviews, strategy meetings with police and social services, training, external and internal safeguarding meetings and supervision; alongside daily management of child protection and safeguarding cases throughout the hospital. The children’s safeguarding team work in conjunction with the Local Safeguarding Boards to ensure their priorities are addressed. In 2015-16 we have delivered specific training on FGM (female genital mutilation), CSE (child sexual exploitation), domestic abuse and radicalisation in mandatory training and at an advanced level in key areas. We engage with MAECC (missing and exploited children’s committee) and MARAC (multi-agency risk assessment committee) in both counties. These priorities remain in place for 2016-17 along with emotional well-being and deliberate self-harm. 17
Adult safeguarding The introduction of the Care Act 2015 in April 2015 has had a huge impact on adult safeguarding. The Act places a duty on the Trust to raise concerns regarding neglect and or abuse. It encompasses personalisation and is outcome focused, thus putting the patient at the centre of the enquiry. The Act has also introduced domestic abuse, self-neglect and modern slavery (which also carries its own duty, the Modern Slavery Act 2015) to adult safeguarding. There is also a view that adult safeguarding will work closely with safeguarding children to ensure there is a smooth transition from child to adult services. The thresholds have changed for what is considered to be a safeguarding concern. The team have implemented a number of changes to practises to ensure compliance for example; the team now meet regularly with the emergency department to review referrals. The change to the thresholds is noticeable in the activity with a total of 57 concerns raised in 2015-16 regarding the Trust; there were 24 in 2014-15. The Trust raised 377 concerns during 2015-16 compared with 269 the previous year. This increase may be as a result of training and awareness amongst staff. The lowering of thresholds has also had 18
an impact on reporting and raising concerns. Prevent continues to be a priority for the safeguarding team. The Counter-Terrorism and Security Act 2015 came into force on the 1 July 2015. It contains a duty on specified authorities to have due regard to the need to prevent people from being drawn into terrorism. This is also known as the Prevent duty. Training has been set at 100% compliance by July 2018, to ensure the Trust is in line with this, the Workshop to Raise Awareness of Prevent (WRAP) is being added as a stand-alone session on the mandatory and statutory training (MAST) day for clinical staff. All other staff will receive basic awareness training within safeguarding
training. The safeguarding team have successfully recruited four further WRAP trainers to assist with training. The main priorities for the adult safeguarding team will focus on domestic abuse awareness, reporting and referral on to partner services. Training and awareness is a continued priority, including WRAP, Mental Capacity Act and Deprivation of Liberties training. Quality Account 2015-16
Surrey and Sussex Healthcare NHS Trust
19
Effective We aim to: Deliver effective and sustainable clinical services within the local health economy National Institute for Health and Clinical Excellence (NICE) The Trust continues to ensure all NICE technology appraisals are fully implemented at the Trust with oversight from the Trust Drugs and Therapeutic Committee, which reports progress through our Clinical Effectiveness Committee to the Board. A focus for this year is to ensure the all new guidance issued is quickly reviewed and action plans put in place where the Trust is able to fully implement the guidance. This has included a shift towards more in depth baseline assessments of new guidance with areas of partial compliance brought to the Clinical Effectiveness Committee to ensure actions to move towards full compliance are implemented. In 2015-16, significant progress has been made to ensure we meet the guidance for both heart failure patients and patients 20
with atrial fibrillation (AF) and the Trust expect to become fully compliant with these guidelines over 2016-17 with the appointment of a heart failure specialist nurse to follow up patients after a hospital admission and the development of new a policy for the management of patients with AF. Mortality Mortality rates continue to show the Trust as better than the national average when using data from Dr Foster Intelligence. The Trust also continues to use this data to identify any potential alerts and where rates show as being statistically outside the acceptable range, an in depth clinical review takes Summary of hospital-led mortality indicator 2015-16 Trust value
0.928
Trust banding
2
Lowest (national)
0.670
Highest (national)
1.210
Percentage of deaths with palliative (end of life) care coding Trust value
31.94
Lowest (national)
10.078
Highest (national)
50.8513
Average (national)
25.73
place. For all alerts which were investigated this year, no concerns were raised over the standards of care received by patients, with learning mainly focussed on the correct recording of medical conditions. For the national indicator – Standardised Hospital Mortality Ratio (SHMI) which includes death within 30 days of discharge, the Trust also performs better than the national average and the rate has steadily improved over the last year. The mortality group continue to focus on the learning of our morbidity and mortality meetings with our divisions highlighting any learning at the meeting to allow for learning to be disseminated across the Trust. Quality Account 2015-16
Enhanced recovery This year, significant improvements have been made across all the three monitored pathways to see the Trust now in line with the rest of the region in the implementation of the ERP pathways.
Enhancing Quality Over the last year, the Kent, Surrey and Sussex Academic Health Science Network (AHSN) has continued to run and expand the Enhancing Quality and Recovery Programme and the Trust has continued to work collaboratively across the region to maximise quality improvements across all clinical pathways. The Trust has continued to perform in line with other Trusts in the treatment of patients with community acquired pneumonia whilst for heart failure, following a switch to more stringent targets based on the National Heart Failure database, the Trust has continued to be one of the best performing in the region for implementation of the key measures.
bundle which will help patients better manage their condition and reduce the frequency of hospital readmissions. Early results, once again, show Trust performance amongst the best in region. The programme has also recently expanded to focus on the fractured neck of femur pathway and we recently began submitting our national hip fracture database data to the AHSN to allow benchmarking across the region and closer collaboration on making improvements to the patient’s pathway.
We also commenced data collection for the chronic obstructive pulmonary disease patients following on from our work during 2013/14 focussed on delivering a discharge Surrey and Sussex Healthcare NHS Trust
Audit Review of services During 2015-16, Surrey and Sussex Healthcare NHS Trust provided 38 different acute services and eight specialised services to NHS patients (these numbers are based on the service specifications included in the contracts with Clinical
‘The current team demonstrates strong commitment to ERP principles and is supported well at executive and programme lead level in the organisation. The Trust has worked to raise awareness and enthusiasm amongst their staff, implemented improved documentation and the team are able to demonstrate reduced variation across their enhanced recovery pathways as well as reductions in length of stay for patients in some pathways.’ KSS AHSN in recent peer review
21
Commissioning Groups and NHS England). We have reviewed all the data available to us on the quality of care in all of these services. The income generated by the NHS services reviewed in 2015-16 represents 100% of the total income generated from the provision of NHS services by Surrey and Sussex Healthcare NHS Trust for 2015-16. We have repeated the ‘Deep Dive’ programme which takes a detailed look at services at speciality level, seeking assurance and evidence that we are compliant with the five quality domains defined by the Care Quality Commission (CQC). The outcomes of these are reported to the safety and quality committee. We continue to develop the quality programme to ensure inclusion of all services within this review. Divisions receive information on a monthly basis on patient safety, clinical effectiveness and patient experience for their areas. They report on their services at monthly governance meetings and to the executive committee for quality and risk and at performance reviews. Participation in clinical audit Clinical audit involves improving the quality of patient care by looking at current practice and modifying it where necessary. We take part in regional 22
% of cases Cases required Submitted that were submitted Acute Coronary Syndrome or Acute Myocardial Infarction (MINAP)
309
100%
Bowel cancer (NBOCAP)
155
80%
Cardiac Rhythm Management (CRM)
318
100%
Case Mix Programme (CMP) - ICNARC
695
100%
Coronary Angioplasty/National Audit of PCI
480
100%
Diabetes (Adult)
7006
100%
National Diabetes Inpatient Audit
89
100%
Diabetes (Paediatric) (NPDA)
All
100%
Elective surgery (National PROMs Programme)
705
100%
Falls and Fragility Fractures Audit Programme (FFFAP)
31
100%
Head and neck oncology (DAHNO)
Submitted by RSCH
Lung cancer (NLCA)
230
Major Trauma: The Trauma Audit & Research Network (TARN) Maternal, Newborn and Infant Clinical Outcome Review Programme (MBRRACE-UK)
30 - 37% All
Medical and Surgical Clinical Outcome Review Programme, National Confidential Enquiry into Patient Outcome and Death (NCEPOD)
100%
100%
See following text
National Cardiac Arrest Audit (NCAA)
154
100%
National Comparative Audit of Blood Transfusion programme
19
100%
National Emergency Laparotomy Audit (NELA)
178
100%
National End of life Care Audit 2015
79
100%
National Heart Failure Audit
307
100%
National Joint Registry (NJR)
473
100%
National Parkinson’s Audit
20
100%
Trust participated report not broken down to trust level
National Prostate Cancer Audit National Vascular Registry
Submitted by BSUH
Neonatal Intensive and Special Care (NNAP)
All
100%
Oesophago-gastric cancer (NAOGC)
89
90%
Renal replacement therapy (Renal Registry)
N/A
100%
Rheumatoid and Early Inflammatory Arthritis
107
100%
Royal College of Emergency Medicine - Procedural sedation
30
100%
Royal College of Emergency Medicine - VTE in patients with lower limb immobilisation
75
100%
Royal College of Emergency Medicine - Vital signs in children
96
100%
Sentinel Stroke National Audit Programme (SSNAP)
Quality Account 2015-16
and national clinical audits. Sometimes there are also national confidential enquiries that investigate an area of healthcare and recommend ways to improve that area of healthcare. During 2015-16, 34 national clinical audits and four national confidential enquiries covered NHS services that Surrey and Sussex Healthcare NHS Trust provides. During that period we participated in 100% national clinical audits and 100% national confidential enquiries of the national clinical audits and national confidential enquiries in which it was eligible to participate.
National confidential enquiries Mental Health
Organisational Questionnaire returned and data submission underway
n/a
Acute Pancreatitis
3
75%
Sepsis
2
40%
Gastrointestinal Haemorrhage
2
66%
to take the following actions to improve the quality of healthcare provided:
Anaesthetic machine checks The anaesthetist has primary responsibility for checking that equipment is working prior to use and a record of this check must be detailed in the anaesthetic room/theatre logbooks. An initial audit was prompted from three separate safety incidents The national clinical audits relating to faulty equipment. and national confidential When the original audit enquiries that Surrey and was undertaken the results Sussex Healthcare NHS Trust showed poor compliance was eligible to participate with carrying out these during 2015-16 are shown safety checks. The action in the table on the left. plan introduced training sessions for operating The national clinical audits department practitioners and national confidential (ODPs) and junior enquiries that Surrey and anaesthetists which involved Sussex Healthcare NHS Trust a demonstration and written participated in, and for test. An email was also sent which data collection was to the entire department completed during 2015-16, for awareness. Following are listed in the table above implementation of these alongside the number of cases submitted to each audit actions the re audit showed 77% increase in compliance or enquiry as a percentage on the original audit and the of the number of registered post training surveys were cases required by the terms very positive. A separate of that audit or enquiry. The module on machine safety reports of 138 national and checks is now due to be local clinical audits were included in the induction reviewed by the provider in of all new trainees and 2015-16; Surrey and Sussex Healthcare NHS Trust intends ODPs. Interim refresher Surrey and Sussex Healthcare NHS Trust
sessions for all existing trainees and consultants will be made available and a demonstration video is scheduled by the end of the year as an extra resource for the department to use on conducting the ideal machine check. This will also be available on the staff Intranet for general access. Urology consent audit The consent audit is undertaken annually by all specialties to ensure that options for treatment are communicated to patients before surgery, leading to informed and deliberate consent and to ensure that compliance is maintained. Consent forms for elective and emergency urology cases were collected prospectively over one week. The results showed that the procedure consented for matched the procedure conducted in 100% of cases. All forms were legible and all had the benefits and risks listed; 54% of forms were BAUS (British Association of Urological Surgeons) forms which are procedure specific and are pre-printed with the risks, benefits and alternatives for various urological treatments. 23
The action plan stipulates that the use of the BAUS forms should continue to be encouraged as they represent a standardised and quality assured consent form with no concerns relating to legibility. It is recommended that they are made more easily accessible to consenting surgeons (eg on specific wards) so that they are available at pre assessment. The plan is to implement education and awareness of the BAUS forms to practitioners at departmental meetings and continue to build on the good practice currently shown in the department with regards to consent compliance. Compliance with completing the information sharing form within the neonatal unit – March 2016 Guidelines have been put into place within the neonatal (NNU) setting which requires all babies who stay on the unit for more than four hours to have an information sharing form completed. The aim for the audit was to ensure staff are compliant with the above safeguarding standards and to establish if information sharing forms are fully completed with all the key patient demographics and filed in the case notes. We concluded that there is good compliance with following our Trust policy and can provide assurance that the process for completing an 24
information sharing form and completing it correctly is being adhered too within the neonatal setting. An action plan to re-audit has been scheduled and will be added to the divisional and specialty audit programme for 2016-17. National maternity survey 2015 The national maternity survey carried out in 2015 asked women in England about their experiences of NHS maternity services. The 2013 survey of women’s experiences of maternity care in England showed that the care provided did not always match women’s needs. Key findings from the 2015 maternity survey highlighted statistically significant differences between the survey results from 2013 and 2015.
the results of 2013 survey where the Trust was ‘worse than’ other Trusts in two of the three benchmarked areas. An extensive action plan has been devised to further enhance maternal experience within the maternity setting and will be monitored closely through relevant governance reporting mechanisms. National paediatric diabetes audit 2014-15 The outcome report 2013-14 from the Royal College of Paediatrics and Child Health (RCPCH) demonstrates that while the quality of care for children and young people with diabetes in England and Wales is improving, there remains considerable variability across the two nations and local regions; with a significant number of patients receiving
We demonstrated improvements in performance, increasing our rating to ‘about the same’ as other trusts, in relation to the three benchmarked areas of care. Improvements were seen in the areas where actions were put into place in response to
Quality Account 2015-16
inadequate diabetes care. The data provided in this latest report is designed for use by clinical teams to drive improved outcomes in their diabetes services. Each year the NPDA becomes a more powerful benchmarking tool to ensure young patients with diabetes are receiving the high standards of care recommended by the National Institute for Health and Care Excellence (NICE). As a Trust: • The completion rate for all seven key care processes was better than the national average • The adjusted mean HbA1c for the unit was similar to the figure nationally • The percentage of patients receiving
structured education compared less favourably than nationally • Significantly more children on intense insulin therapy (four or more injections and pump therapy) than when compared nationally We plan to: • Strengthen education provided to families, carers and patients to improve outcomes Insulin pump users to have an annual review for their skills with pump trouble shooting • Ensure all patients have school care plans which will be followed through with education • Ensure patients with high Hba1c seen as per high HbA1c pathway and continue to implement level 3 carbohydrate counting The plan will be monitored closely through relevant governance reporting mechanisms.
Complications after large loop excision of the transformation zone (LLETZ) Quality assurance visit recommendation regarding the NHSCSP Publication No.20 - Colposcopy programme. The aim of the audit was to compare our practice against the standards within the publication and identify patients who had a complication such as infection/bleeding after LLETZ, specifically those requiring hospital admission and/or theatre episode. The percentage of patients admitted for complications after LLETZ should be less than national standard of 2 %, our local unit admission rate is 0.5 %. Primary haemorrhage requiring a haemostatic technique in addition to the treatment method applied must be less 5% however it was difficult to obtain accurate data due to presentation of information on the Cerner system. Information regarding any colposcopy re-admissions should be escalated to the colposcopy unit and a Datix incident form must be completed. Examples of improvements to care delivered by the clinical audit programme can be found on the next page.
Surrey and Sussex Healthcare NHS Trust
25
Women and children
Women and children
Surgery
Speciality
Speciality
Speciality
Gynaecology (Miss Gorti)
Gynaecology (Pat Cook)
Ophthalmology
Audit title
Audit title
Audit title
GA LLETZ
Complications after LLETZ
Record Keeping Audit
Rationale
Rationale
Rationale
The QA visit identified that the National average less than 20 % our rate is 20.9%.
QA visit recommendation regarding NHS CSP 20 Colposcopy programme.
Annual Trust audit against Royal College Physicians’ ‘Approved Generic Medical Record Keeping Standards’ first published in 2007.
Aims
Aims
The audit is to identify the reasons for GA LLETZ and to reduce the number of patients requiring GA.
Aim to identify patients who had a complication such as infection/ bleeding after LLETZ specifically those requiring hospital admission and/or theatre episode. Compare to standard in NHSCSP 20. Primary haemorrhage that requires a haemostatic technique in addition to the treatment method applied must be less 5%. The proportion of cases admitted as inpatients must be <2%.
Findings/ lessons learnt Documentation was incomplete and the figures were not accurate.
Recommendations •
To improve documentation
•
Improve counselling
•
Consider sedation rather than GA
Findings/ lessons learnt Percentage patients admitted for complications after LLETZ should be less than 2 % national standard our local unit admission rate is 0.5 %.
Recommendations It was recognised that the data collection could be improved.
Aims To monitor the compliance of Record keeping in the ophthalmology department at ESH in line with national guidelines. Where necessary, to improve record keeping within the department - maximising patient safety and improving quality of care.
Findings/ lessons learnt Partial compliance. Whilst the 100% targets were not achieved in relation to the audit standards in some areas, a good level of record keeping was demonstrated for most standards. Further changes should be made to improve compliance.
Recommendations Trusts should reinforce with clinical and administrative staff that it is everyone’s responsibility to ensure that medical notes are kept in good order and that they have a professional duty to maintain high standards of record keeping. Doing it well and ensuring the required standards are met is fundamental to effective patient care. Consider distribution of Record Keeping standards poster. Where standards fall short, educate and plan to re-audit within 6 months.
26
Quality Account 2015-16
Medical
Cancer
Speciality
Speciality
Rheumatology
Cancer Nursing (Lisa Jacques)
Audit title
Audit title
Cardiovascular Risk Assessment in RA patients.
Neutropenic Sepsis
Rationale National Clinical Guidelines Re audit.
Aims •
•
Check if clinicians assess cardiovascular risk as part of annual review, as advised by BSR guidelines - RA patients. Increase awareness of importance of cardiovascular disease as cause of morbidity and mortality in RA patients.
Findings/ lessons learnt •
We are not following the recommendations regarding annually cardiovascular risk assessment in RA patients.
•
Our sample shows a high cardiovascular burden, especially amongst men, with only a small percentage of patients on treatment.
Patient reported outcome measures (PROMS) Patient Reported Outcome Measures (PROMs) assess the quality of care delivered to NHS patients from the patient perspective. Currently covering four clinical procedures, PROMs calculate the health gains after surgical treatment using pre and postoperative surveys.
Rationale Cancer peer review, NICE guidelines.
Aims •
Assess 1hr to antibiotic compliance.
•
Assess Neutropenic sepsis pathway compliance.
Findings/ lessons learnt •
39% compliance with 1hr to antibiotic.
•
MASCC Score used in 50%
Recommendations Continue to work with Trust wide sepsis working group.
PROMs measure a patient’s health status or healthrelated quality of life at a single point in time, and are collected through short, self-completed questionnaires. This health status information is collected from patients through PROMs questionnaires before and after a procedure and provides an indication of the outcomes or quality of care delivered to NHS patients. The most recent data available shows:
2015-16
Eligible episodes
Trust average health gain
Recommendations
Groin hernia
155
*
0.087
None
National average
20343
0.085
0.084
Hip replacements
97
0.434
0.428
National average
38241
0.436
0.436
Knee replacements
128
0.321
0.270
National average
40175
0.323
0.315
Varicose veins
50
*
0.095
National average
5652
0.093
0.095
*Data suppressed due to small numbers. No data = no figures to report Single index measure which ranges from 0 to 1, where 1 is the best possible state of health
27
Dementia The Trust has appointed a new consultant nurse for dementia and older people. Having recently started in post his primary aims are to embed the Butterfly Scheme and roll out Dementia Friends training across clinical and non-clinical areas. Led by the clinical nurse specialist, we provided dementia and delirium training to cover the requirements of The National Skills Framework (2015) Tier 1 training and this also includes the addition of: • Key skills relating to the care of people with dementia or delirium being treated within the emergency department (ED) and acute medical and surgical admission environments • Clear guidance for staff on how and where to signpost carers for support with specific emphasis on accessing East Surrey Carers Support Association and West Sussex Carers within the hospital The training focussed on the frontline of the emergency unplanned care pathway in: • Emergency Department (ED) • Acute Medical Unit (AMU) • Surgical Assessment Unit (SAU) The training was provided for all medical and nursing staff, including nursing assistants. We also conducted a survey of people who care for someone with dementia or 28
who has had delirium and this will report to the Board once completed. We conducted the survey to try to help us to better understand the experience of people who care for someone with dementia when using our services. We are keen to understand all the elements of carers’ experiences and so wanted to know about their experience when the person with dementia they care for is accessing our services and also when they themselves access our services. We are keen to also understand the experience of accessing both inpatient and outpatient services and all aspects of the patient journey from communication to the facilities and from the care received through to the quality of information received. SASH also remains committed to completing successful focus groups and are seeking to use our links with the Alzheimer’s Society, West Sussex Carers and East Surrey Carers Support Association to gain further direct access to potential participants for these important learning events. In line with current work to pilot a new carers passport within SASH, it has also been agreed that the task and finish group overseeing this pilot project will be asked to consider the feasibility of including at least one ‘front door’ service in this initial pilot. We will also review the Dementia standard operating procedure (SOP), developing it further so that
it aligns with our local health and social care strategies. Once completed SASH will consider actions and learning from the survey and how these might be addressed particularly by utilising links with West Sussex Carers and East Surrey Carers Support Association within the hospital. Venous thromboembolism (VTE) Over the last year, 95% of patients looked after by us had a formal VTE assessment carried out on admission and recorded in the notes. We also have a multi-disciplinary team reviewing any cases where a patient develops a venous thrombosis either whilst an inpatient, or within 90 days of discharge. In 2015-16 it was assessed that in all cases of in-patient or recently discharged patients with VTE all possible efforts had been made to prevent the development of the condition including the correct assessment, diagnosis and preventative treatment. Stroke Following on from the Surrey and Sussex Stroke Service review, the Surrey Collaborative have requested providers submit proposals on how they can deliver the entire stroke pathway. The Trust was able to evidence how it would ensure sustainable delivery of the national standards within Sentinel Stroke National Audit Programme (SSNAP) and the local SE SCN quality standards in order to achieve Quality Account 2015-16
an ‘A’ rating and achieve integration across the whole pathway including ESD and community care. Fractured neck of femur (hip) Our hip fracture unit continues to be very busy with over 500 fractures this year. We have seen a sustained improvement in the best practice results and the mean-time to surgery (26.5 hours) remains below the national average (31.4hours). 30 day mortality also remains low at 3.9% (national average is 6.1%). Length of stay is 20.6 days with the national average being 21 days. Increasing amounts of data are being collected about patient outcomes at 30 days following surgery but this has been removed from the National Hip Fracture Database (NHFD) programme and replaced by data at 120 days, which we are now collecting. The clinical team have been taking part in the Academic Health Science Network’s Hip fracture: enhancing quality programme. The AHSN program focuses on enhancing quality across a number of areas and we are looking to focus initially on analgesia and pain assessment peri-operatively and delirium assessment post operatively. As a result we are again looking at improving the access to fascia iliaca nerve blocks in the preoperative period and having these performed under ultrasound guidance in the
theatre area, which allows a catheter to be inserted providing more sustained and pro-longed analgesia. In 2015-16 we will continue to improve the quality of care we deliver to patients who have broken their hip. We will aim to improve our best practice tariff results and the metrics collected as part of the AHSN programme. We will improve the tracking of longer term outcomes and the number of patients able to be admitted to a specialist ward within four hours. In addition we will improve pain assessment pre and postfracture and improve the assessment and management of delirium following surgery. Chronic obstructive pulmonary disease (COPD) Over the year we have continued to implement the British Thoracic Society chronic obstructive pulmonary disease discharge bundle, with regional monitoring of the following standards by the Academic Health Science Network: • Patient reviewed by respiratory consultant before discharge • Personalised selfmanagement plan received before discharge, including an emergency drug pack • Referral for pulmonary rehabilitation and point of contact for patient on discharge • Advice on smoking cessation • Follow up contact after discharge
Surrey and Sussex Healthcare NHS Trust
Performance over the year with the latest available date to September 2015 ranked the Trust as one of the best performers in the region, with significant impacts on the reduction in the readmission of COPD patients. Goals agreed with commissioners Clinical Commissioning Groups (CCG) hold the NHS budget for their area and decide how it is spent on hospitals and other health services. This is known as commissioning - East Surrey, Surrey Downs, Crawley and Horsham and Mid Sussex CCGs are the four main commissioners of our services. They set us targets based on quality and innovation. A proportion of our income in 2015-16 was conditional on achieving quality improvement and innovation goals agreed between Surrey and Sussex Healthcare NHS Trust and any person or body we entered into a contract, agreement or arrangement with for the provision of NHS services, through the Commissioning for Quality and Innovation (CQUIN) payment framework. For this year we had locally agreed CQUINs for: • Ward accreditation • Discharge processes • Enhancing quality and recovery Further details of the agreed goals for 2016-17 and for the following 12 month period are available on request from: clinical.audit@sash.nhs.uk 29
Participation in clinical research Clinical research involves gathering information to help us understand the best treatments, medication or procedures for patients. It also enables new treatments and medications to be developed. Research must be approved by an NHS Research Ethics Committee. 30
Quality Account 2015-16
The key reason for our commitment to research is to improve clinical treatments, care and outcomes for our patients. We want to offer our patients the opportunity to be involved in research activities in order to improve patient experience and
enable them to benefit from improved health outcomes. Our performance in delivering research as measured against the National Institute of Health Research (NIHR) national performance metrics is strong with increases in both the number of different
research studies for patients to engage with and improvements in study set up so that our patients are offered early access to new studies. The table below shows numbers of research studies and number of pharmaceutical industry studies over past four years.
Number of studies open to recruitment
Number of pharmaceutical industry studies*
Number of research participants
Number of new studies meeting NIHR first recruit benchmark
2012-13
38
5
6116
N/A
2013-14
40
5
506
N/A
2014-15
45
11
771
66%
2015-16
50
12
488
100%
*Included within total number of studies
One of the key ways of offering new treatments to our patients is through participation in pharmaceutical clinical trials. Our strengthening relationship with the pharmaceutical industry is enabling us to offer our patients access to the newest treatments. The Trust supported the recruitment of patients to 50 different high quality studies - 12 of these studies were pharmaceutical
industry sponsored studies. In 2015-16 we recruited 488 patients as participants in high quality multi-centred research studies approved by a research ethics committees. Our key priorities are to: • Increase number of patients participating in research studies • Increase number of high quality National Institute for Health Research (NIHR) Portfolio research
We have highlighted research activity in five different areas of the organisation:
Diabetes Surrey and Sussex Healthcare NHS Trust
studies open at our Trust • Maintain our high quality research management processes and enhance performance in project delivery • Develop our infrastructure, staff and facilities, to support research • Become a preferred partner for the pharmaceutical research industry and increase our research income from commercial contracts
Dermatology
Breast cancer
Care of the elderly
Cardiology 31 9
Diabetes Working with our local Clinical Commissioning Group (CCG) and GPs to research whether motivational communication supports lifestyle changes which could prevent type 2 diabetes. The SASH diabetes research team recruited 38 people into a national study assessing whether mobile technology can help to sustain lifestyle changes and prevent type 2 diabetes. The research participants were identified by their GPs as being at high risk of developing diabetes and every participant received detailed advice from the research team on diet and physical activity choices at the beginning of the trial. Afterwards, each person was allocated at random to one of two groups. The first group receives standard treatment, while the second also receives healthpromoting text messages. These messages provide individualised information on healthy eating, physical activity, lifestyle and smoking cessation. The research participants will be followed up every six months for two years, to check blood sugar, cholesterol, body weight, waist and hip measurements, diet and 32
lifestyle. Mobile technology is also being used to measure heart rate and physical activity. If anyone develops diabetes, their participation in the research study will end but they will be referred promptly for treatment. Commenting on the research, Dr Ben Field, consultant endocrinologist said:
â&#x20AC;&#x2DC;Itâ&#x20AC;&#x2122;s great that East Surrey CCG and SASH have worked together to make this trial available to our local population. Until recently, there was nothing to offer these patients except advice to eat less and exercise more. Now, we will find out whether mobile, individualised, motivational communication can support lifestyle change and reduce the risk of developing diabetes.â&#x20AC;&#x2122; Quality Account 2015-16
Dermatology Incorporating clinical trial research activities into clinical practice means that patients can be offered alternative treatments and clinicians gain experience in using new dermatology products. Our dermatology department have successfully embedded a research culture into their core clinical activity and are able to offer patients a research pathway at the right point in their treatment journey.
able to recruit the first UK patient into two, consecutive, international clinical trials.
A wide variety of research studies can be offered as part of clinical care and patients welcome the alternative choices available.
â&#x20AC;&#x2DC;When the possibility of being involved in a trial was put to me, I was very interested. I was given all the pros and cons surrounding the trial, which gave me the confidence to volunteer. I have not been disappointed, the care and attention I have received has been outstanding, from a friendly, caring and competent team of lovely individuals. I am well into the trial now, and await further results with interest.â&#x20AC;&#x2122;
A sustained growth in pharmaceutical industry sponsored trials activity has allowed us to offer clinical trial participation in three disease areas (actinic keratosis, eczema and rosacea). The teamâ&#x20AC;&#x2122;s ability to recruit to time and target and meet National Institute of Health Research (NIHR) performance targets has been recognised by our commercial partners and also by the NIHR.
One of our research participants, Michael Chapple, describes his experience so far:
During 2015-16, the dermatology team were Surrey and Sussex Healthcare NHS Trust
33
Breast cancer Care of the elderly A research collaboration between research academics and clinicians at SASH Research studies help us to explore what works best so that we can improve care for our patients and focus our NHS resources in areas where they can be most effective. SASH has been chosen as one of three sites across the country to take part in a new research study. Sixty-five of our patients agreed to be interviewed by university researchers following their discharge from hospital as part of a study which aimed to identify themes and factors leading to emergency admissions. The interviews focused on the patientâ&#x20AC;&#x2122;s experience of emergency 34
admission and what might have prevented or delayed the timing of those admissions. Fifty-nine staff members were also interviewed as part of the study and the anonymous research results will be shared with clinicians and care providers across the country and used for staff training and service improvement. The study is aiming to look at the factors which influence admissions to hospital to ultimately see if there a means of caring for patients in the environment they wish there care to be (be that home or a hospital).
Breast cancer research that seeks to provide patients with further information regarding their future recurrence risk. A new breast cancer study has offered oestrogen receptor positive, early stage breast cancer patients within Kent, Surrey and Sussex the opportunity to be very much involved in the scientific shift towards personalised medicine. Patients for whom the decision on whether to treat with adjuvant chemotherapy is not clear cut can benefit by testing their tumour further with validated gene-expression tests providing further information regarding the biology of their cancer and subsequently future Quality Account 2015-16
Cardiology Patients who have experienced an acute coronary event have been offered participation in a research study which seeks to find out if an additional medication can prevent further cardiovascular events (e.g. heart attacks or strokes) within the 12 months after a hospital admission.
recurrence risk. The overall aim of the research is to investigate the feasibility of using this test in large numbers of patients in the south-east of England and explore how it affects chemotherapy treatment decisions. The idea of the study has been very well received by patients and since opening in October 2015, 13 patients have been recruited.
‘I found the extra test very helpful in deciding whether or not to have chemotherapy. In addition, everyone involved in the study was very kind and took the time to explain what was happening.’
Surrey and Sussex Healthcare NHS Trust
Experiencing a major health event in life, such as a heart attack, can be a stressful experience; to then be approached about becoming part of a worldwide study, is something that the patient has to consider carefully. Research often involves additional tests and clinical visits and close monitoring during the patient’s involvement in a study, which can be for two to five years. Some of our patients have felt that they want to “give something back” by becoming part of a research study; all research participants do this altruistically to further improve the treatment for patients in the future. Since the trial started, the research cardiology team have recruited thirteen patients. One of our first research participants, Julian Heathcock, from West Sussex, who has been part of the study for 2 ½ years
summarises his experience and involvement:
‘I’ve always had an interest in science and research and I was very pleased to be offered the chance to actually be part of some real research by being a subject in a drug trial. There are some real immediate benefits to me too, I get much more regular and wide ranging health checks which can pick up problems a lot earlier than if I weren’t on the project. And I get a sense of fulfilment too, that I am doing something of real world use.’
35
Caring We aim to: Ensure patients feel cared for and cared about Patient experience Friends and Family Test (FFT) Staff engagement in proactively seeking patients’ views remains varied, with some areas performing better than others. FFT response rates within the emergency department are above the national average and the FFT score for this area has consistently been in the top 20 trusts in the country for the last six months. Data continues to be used make improvements to services; these can be at a very local level or Trust-wide. Focus groups and hot topic events have been held during the year to seek the views of service users and also to inform the wider community of specific services the Trust provides. A set of standards of behaviour has been launched under the ‘One team one way’ initiative. These provide a clear and transparent set of expectations of how all staff should behave at work. In 2016-2017 we will continue to encourage staff 36
to ask patients to comment on their care using the established channels such as the FFT, Your Care Matters and Patient Opinion. We will also continue to review what is said and make improvements where we can.
about any of the services provided by a particular Trust. It also provides us with an opportunity to respond to comments that have been made and follow up issues that have been raised.
We plan to increase the opportunities for patient representatives, governors and members to become involved in initiatives across the Trust and provide greater opportunities for them to tell their stories and learn from what they tell us.
In the past 12 months 362 stories have been posted and stories and responses have been read 72,078 times. A clear protocol has been established to identify who should be responding to stories that are posted on the site. Over the last year there has been a noticeable increase in clinical engagement with Patient Opinion.
Friends and Family Test scores
Emergency Department
95.5%
95.5%
2015
2016
Inpatient (excluding day cases)
95.3%
95.4%
2015
2016
Patient Opinion Patient Opinion is an independent website where people can tell their story
Inpatient survey This indicator is calculated as the average of five survey questions from the national inpatient survey which is carried out each year. Each question describes a different element of the overarching theme responsiveness to patients’ personal needs. The questions are: • Were you involved as much as you wanted Quality Account 2015-16
•
•
•
•
to be in decisions about your care and treatment? Did you find someone on the hospital staff to talk to about your worries and fears? Were you given enough privacy when discussing your condition or treatment? Did a member of staff tell you about medication side effects to watch for when you went home? Did hospital staff tell you who to contact if you were worried about your condition or treatment after you left hospital?
Responsiveness to inpatients’ personal needs 2014-15 Inpatient survey Trust value 67.7 Lowest (National) n/a Highest (National) n/a 2015-16 Inpatient survey Trust value 68.2 Lowest (National) 58.9 Highest (National) 86.2
From what was observed there are some wards that fully operate protected mealtimes. We will continue to work with all wards to make improvements as recommended by the report. During the past year we have fully updated and re-launched the Trust’s oral nutrition and hydration policy which includes the new MUST (Malnutrition Universal Screening Tool) nutritional screening tool and nutritional care plans. We have also introduced a range of new nutritional supplements and fortified milk for our patients as a way to maximise their nutritional intakes. These products have been well received by patients. The dietitians and catering department actively supported Nutrition and Hydration Week 2016 during which wards were provided with a range of resources to emphasise the importance of nutrition and hydration. Adult patients
were provided with a high energy drinks and snack round and paediatrics received a lolly pop round as a means to promote the importance of nutrition and hydration. The dietitians have completed a nutritional analysis of a new two week menu cycle, due to be launched later this year. Changes have been made following feedback both from patients and from last year’s PLACE inspection. In 2016-17 we will continue to make improvements to protected mealtimes. The nutrition and hydration steering group and the oral nutrition and hydration group will continue to monitor progress. We will continue to monitor feedback and make adjustments as necessary.
Since the last survey, we have made improvements in three of the five questions and the average overall score improved as well. We will continue to look for improvements in these areas in 2016-17. Nutrition Our dietitians recently completed an audit of protected mealtimes as part of Nutrition and Hydration Week 2016. Surrey and Sussex Healthcare NHS Trust
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38
audit was carried out, a multidisciplinary team has developed a new end of life care (EOLC) plan under the stewardship of the EOLC Steering Group. It was launched in November 2015 and is being embedded into the ward areas with support from the palliative care team. End of life care has featured on the consultant and nontraining doctors mandatory and statutory training (MAST) programme over the last year, raising the profile of EOLC care at the Trust.
Mixed sex accommodation Care is routinely delivered within single sex ward environments. However if patients require a higher level of care or admission to a specialist environment this may not always be possible. Our teams will always
provide care in a sensitive way to maintain patient privacy, dignity and choice. Additional use of screens are used in such areas for example: critical care, post anaesthetic care unit and the emergency department. There were no inappropriate mixed sex breaches during 2015-16. We will continue to ensure that there are no mixed sex breaches and to enhance the privacy and dignity experience for all our patients. End of life care SASH participated in the fifth National Audit of Care of the Dying Patient in Hospitals. Since the national
Surrey and Sussex Healthcare NHS Trust
Other notable achievements include expansion of the palliative care team with the addition of three new cancer nurse specialists (CNS) and one further to start in May 2016, and the appointment of a second consultant post in January 2016. SASH have registered on the â&#x20AC;&#x2DC;Transforming end of life care in acute trustsâ&#x20AC;&#x2122; programme during the last year, with initial focus on recognition of dying and auditing use of the EOLC plan as above. In 2016-2017 we will audit the EOLC plan. The expansion of the palliative care team will allow a seven day a week, 9am-5pm, palliative care service to start in summer 2016 (currently achieved by only 37% of Trusts). 39
Responsive We aim to: Become the secondary care provider of choice for our catchment population Reducing need for admissions Over the year the Trust focussed on avoiding preventable admissions for patients aged over 75 by facilitating assessment and treatment of both clinical and non-clinical needs in a care setting outside of the hospital through a process called discharge to assess. This has enabled improvements that deliver integrated discharge processes that ensure timely,
effective management of patient flows and improves communication with patients, carers and relevant health and social care teams. This has worked well in the emergency department with 25 patients per week discharged through a therapies based team.
had a prompt response, facilitated by assessments taking place in the home environment therefore the needs of patients have been better identified with appropriate packages of care put in place.
Access to services This year, 2015-16, was a challenging year for both An inpatient model is currently under review as the emergency and elective key roles identified to support access standards with growth in emergency the process of discharge to assess by the CCGs were not department (ED) attendances, non-elective recruited to this year. As a admissions and outpatient result, there are gaps in the referrals. This growth put process around case finding and pulling patients through pressure on the capacity of Bletchingley Ward where the the Trust across beds, clinics and diagnostics. discharge to assess expertise has been invested. Despite this challenge, the Trust achieved all but two Where the process has of the key access standards worked well, patients have on an annual basis â&#x20AC;&#x201C; the four hour ED standard and the cancer two week rule - breast symptomatic standard. Performance for all measures is shown in the following table:
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Quality Account 2015-16
Apr 15
May 15
Jun 15
Jul 15
Aug 15
Sep 15
Oct 15
Nov 15
Dec 15
Jan 16
Feb 16
Mar 16
Annual
ED 95% in 4 hours
95.9%
95.8%
94.6%
90.9%
94.3%
Cancer TWR
93.5%
91.9%
92.9%
93.1%
93.0%
Cancer TWR Breast Symptomatic
93.3%
93.6%
94.5%
87.9%
92.2%
Cancer 31 Day Second or Subsequent Treatment (Surgery)
100.0%
100.0%
100.0%
97.2%
99.0%
Cancer 31 Day Second or Subsequent Treatment (Drug)
100.0%
100.0%
100.0%
100.0%
100.0%
Cancer 31 Day Diagnosis to Treatment
98.4%
99.2%
96.9%
96.3%
97.6%
Cancer 62 Day Referral to Treatment Standard
86.3%
83.8%
86.6%
85.1%
85.4%
Cancer 62 Day Referral to Treatment Screening
90.0%
93.1%
93.8%
97.2%
93.4%
RTT Incomplete Pathways % waiting less than 18 weeks
93.6% 93.5% 92.6% 92.2% 92.0% 92.1% 92.2% 92.0% 92.1% 92.0% 92.0% 92.2%
92.4%
RTT Patients over 52 weeks on incomplete pathways
0
0
0
0
0
0
0
0
0
0
0
0
0
Percentage of patients waiting 6 weeks or more for diagnostic
1.0%
0.2%
0.8%
1.0%
0.1%
0.5%
1.0%
0.1%
0.5%
0.0%
0.0%
0.0%
0.3%
Despite narrowly missing the ED four hour standard the Trust benchmarks in the upper quartile nationally for this measure. The Trust also benchmarks in the upper quartile for the diagnostic standard and above average for the cancer 62 Day referral to treatment standard. The cancer two week wait; cancer two week rule breast symptomatic and referral to treatment incomplete pathways benchmark below average and are a key focus for 2016-17.
Discharge The Trust reviewed its discharge processes with the aim to improve and streamline timely discharge that better addressed the needs and experiences of patients and families and to develop effective discharge pathways through consistent, timely, communication and coordination. To understand the effectiveness of the current integrated discharge processes and service the Trust audited its compliance with National Standards for Effective Discharge to determine
Surrey and Sussex Healthcare NHS Trust
any correlational links between compliance, noncompliance with standards and to identify delayed discharge challenges attributed to the Trust and the wider economy. An action plan was developed from the audit which included improvements to documentation of the patients estimated date of discharge to facilitate planning as well as patient information on discharge processes. This has also linked in patient flow elements of our SASH+ value stream 41
The Information Governance Clinical Coding Audit (IG Audit) in 2015-16 looked at 200 finished consultant episodes (FCEs) for accuracy of both diagnosis and treatment: Information governance clinical coding audit
98% 96% 94%
Average (national)
*
Adults and over 16s
11.47
*
Average (national)
11.08
*
*This indicator on the HSCIC Indicator Portal was last updated in December 2013 and the next update is due to take place in August 2016.
Coding Clinical Coding is the translation of medical terminology as written by the clinician, to describe a patientâ&#x20AC;&#x2122;s complaint, problem, diagnosis, treatment or 42
92% 0% Secondary procedures correct
*
Primary procedure correct
11.31
92%
Secondary diagnoses correct
2012-13
Primary diagnosis correct
Under 16s
2011-12
91.70%
100%
94.07%
There is a national expectation that patients who are admitted for episodes of care should not need to be readmitted soon after they are discharged. The Trust uses the Dr Foster quality monitoring tool as part of its reviews of readmissions - this tool shows a 28 day readmission rate based on latest data published on the Health and Social Care Information Centre: Compendium of Population Health Indicators.
The process is bound by National Standards issued by the Health and Social Care Information Centre (HSCIC). The mechanism for receiving payment is called Payment by Results (PbR).
94.20%
Readmission to hospital Percentage of patients readmitted within 28 days of discharge
reason for seeking medical attention, into a coded format which is nationally and internally recognised.
96.52%
work, in partnership with the Virginia Mason Institute, which is looking at discharge processes from the point of admission.
Standards Course and help our experienced coders work towards accreditation by supporting them to sit the National Clinical Coding Qualification (NCCQ). Our aim is to continue to deliver 100% coded activity at post-inclusion ensuring no loss of income to the Trust due to un-coded or miscoded episodes. Depth of coding has increased from previous year, and is maintaining the green RAG (red; amber; green) rating at 6.5 (diagnosis codes per finished consultant episode (FCE) we will continue to work with clinicians to ensure coding accurately reflects clinical diagnosis. Ongoing training programmes for clinical coders are planned for continuous professional development. We are keen to have ongoing clinical engagement in all aspects of coding and particularly in mortality coding. The long-term plan is to set up divisional coding leads to liaise with the clinical leads of those particular divisions which in turn will improve both mortality and morbidity coding.
These accuracy levels mean the Trust achieved Level 3 in the Information Governance Assessment Requirement 11-505 for 2015-16.
Data quality Data quality measures whether we record patientsâ&#x20AC;&#x2122; NHS and GP numbers in their notes as well as ethnicity and other equality data.
In 2016-17 we will continue to train new trainee coders using the Clinical Coding
The chief operating officer has overall accountability for the quality of data provided Quality Account 2015-16
to the Trust Board and executive committee. The Trust has a data quality strategy which describes the agreed strategic actions to improve data quality. The information team meets regularly to discuss data quality and provides regular updates to the information governance steering group on the completeness and validity of data available to the Trust. We have a data quality team that is responsible for the day to day management of data quality. The team undertakes national data quality checks, reviews the
challenges from the Clinical Commissioning Groups (CCGs) and checks clinical coding daily. The data is also checked externally by Indigo 4 Services Limited, who provide services to a range of NHS organisations.
to improve systems where potential is identified, these recommendations are developed into actions which are managed locally and ultimately monitored by the audit and assurance committee.
The internal audit plan includes reviews of general data quality, workforce data quality, mortality reporting and information governance. Internal audit also carries out audits of systems that provide narrative on elements of data quality, such as Board assurance framework reviews and financial feeder system audits. Internal Audit will make recommendations
NHS number and GP practice code validity Surrey and Sussex Healthcare NHS Trust submitted records during 2015-16 to the Secondary Users Service for inclusion in Hospital Episode Statistics, which are included in the latest published data.
NHS Number compliance IP
OP
The percentages of records in the published data show in the tables and charts below.
GP Practice compliance ED
Total
IP
OP
ED
Total
NHS Valid
117,639 505,501
89,893
713,033
NHS Valid
115,956 496,291
88,425
700,672
All
118,218 506,372
91,256
715,846
All
118,218 506,372
91,256
715,846
98.5%
99.6%
96.9%
97.9%
%NHSValid
99.5%
99.8%
%GPPValid
98.1%
98.0%
Percentage comparison 100% 98% 96% 94% 92% 90% 88% 86%
0% Inpatient (IP)
Surrey and Sussex Healthcare NHS Trust
Outpatient (OP)
Emergency Department (ED)
Total
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Well-led We aim to: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Staff survey Results from the national NHS Staff Survey have ranked Surrey and Sussex Healthcare NHS Trust in the top 20% of hospitals nationally as a place to work and receive treatment and also as somewhere patients receive quality treatment and care. Our staff also rated highly that they felt their role makes a difference to patients and that they were part of a strong team delivering excellent healthcare. The national NHS Staff Survey took place between September 2015 and the end of November 2015 and over 62% of Trust staff responded. All NHS organisations are required to participate in the survey. The results contribute to the Trustsâ&#x20AC;&#x2122; registration with the Care Quality Commission (CQC). Responses are analysed by the Survey Coordination Centre (Picker Institute) and the results and 44
NHS Benchmark Reports are published in February each year. We are very proud of our improvements in our Staff Survey results which put Surrey and Sussex Healthcare NHS Trust in the top 20% nationally for:
Using feedback from patients to inform decisions about the care provided Managers being interested in the health and well-being of staff
Staff motivation
Satisfaction with resourcing and support
Staff recommending the Trust as a place to work or receive treatment
Staff confidence and security in reporting unsafe clinical practice
Effective team working
Quality of appraisals
Support from managers Quality training, learning or development
Staff Friends and Family The Staff Friends and Family Test (FFT) is conducted in quarter 1; quarter 2; and quarter 4 with the National Staff Survey taking place in quarter 3. The table below shows the Trust results which benchmark well against the national scores. In quarter 4 the Trust trialled the use of additional questions as part of the staff FFT which gives us the opportunity to undertake an in year review of staff views which will support the overall engagement work.
‘I am proud of the commitment of all our staff to making a difference to the people we care for and delighted that this is reflected in how motivated they feel and in their recommendation of SASH as a place to work and to receive care.’ Michael Wilson Chief Executive
As a place to work
As a place to receive care
SASH
National Average
SASH Trust Rank Order
Quarter 1
72%
63%
53
Quarter 2
76%
62%
Quarter 4
77.5%
62%
Our achievements We are proud of the commitment and contribution that our staff make to our achievements and the difference this makes to patient care, which we see reflected in the positive feedback we receive from the people we care for. Our staff also take an active role in initiating and implementing service improvements to further enhance the quality of care we provide for local people.
SASH
National Average
SASH Rank Order
Quarter 1
84%
79%
81
24
Quarter 2
86.5%
79%
53
18
Quarter 4
87%
79%
56
Our annual Staff Recognition Awards ceremony celebrates and acknowledges the valuable contribution made by individuals and teams.
a strong connection with the vision and values of the organisation and we have focused on the following areas, which continue to have a positive impact.
The nominations recognise the high level of staff engagement and their involvement in developing and transforming the culture of our organisation and improving our patients’ experience of care.
• Health and wellbeing for all staff • Supporting personal development through the achievement review (appraisal) process • Developing supportive management and leadership • Involvement of staff in decision making • Ensuring every role counts
Our focus Our engagement work supports our work to ensure that all SASH staff maintain
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Our staff engagement activities continue to provide staff with opportunities to learn and share their views and suggestions. These activities include : • TeamTalk briefings • Chief executive’s weekly message • Executive drop-in sessions • Annual NHS Staff Survey - the response rate for the Trust was 62% in 2015, which is in the highest 20% when compared against other acute Trusts and an improvement on the 56% response rate in 2014 • Trade Union Survey Care Quality Commission The Care Quality Commission (CQC) regulates and inspects health organisations across England and the Trust continues to remain registered with no conditions. The Care Quality Commission (CQC) carried out a focused follow up inspection of the Trust’s outpatients services in January 2016. This was a positive inspection and provided assurance that the Trust had met the requirements of the regulations and introduced systems to regularly assess and monitor the quality of outpatient services. The issues that had been identified during the previous inspection 46
(2014) had been resolved. The CQC did make some further recommendations that the Trust should put in place for improvements around staff knowledge of the Mental Capacity Act, incident reporting processes and signage, but these were not considered as serious enough to be a breach of the regulations. The Trust has now put in place an action plan to resolve these issues.
annual submission process provides assurances to the Care Quality Commission, other organisations and to Intelligent Monitoring: individuals that personal The CQC ended Intelligent Monitoring in June 2015 when information is dealt with legally, securely, efficiently we were rated at Band 6. and effectively. Information governance We have made significant In line with the Information improvements in the Governance Toolkit accessibility of medical requirements the Trust records and if required completes an annual can now retrieve archived Information Governance patient records within one Assessment. For 2015-16 hour. This ensures that our the Trust achieved an overall clinicians are working with score of 77% and was the most up to date patient graded as ‘satisfactory’, the information. highest level available. The Quality Account 2015-16
â&#x20AC;&#x2DC;The nursing staff on the ward were always very friendly and always introduced themselves. I was very impressed in the way that I was treated right from start to finish.â&#x20AC;&#x2122; Surrey and Sussex Healthcare NHS Trust
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Our priorities for 2016-17 Everything that we feature in our quality account can be seen as a priority area for thinking about improvement in patient care and includes: • Clinical audit • Falls prevention • Managing diarrhoea • Reducing length of stay • Ambulatory care pathways • Frailty services • Incident reporting • Developing our learning However, having consulted widely and been chosen to partner with the Virginia Mason Institute in Seattle, there is an ambition to do more in some of the areas where we are not an outlier, but where we want to be leaders in harm-free care or in setting a goal of as good a patient experience as possible.
across Kent, Surrey and Sussex, for the academic input they are providing alongside our internal work to develop new ways of theme analysis and better learning, which we believe will be useful across our three counties. We are better than average for England on patient falls in our care, but we want to be better still and falls prevention will also be a key theme this year as we believe that the improvement we are looking for will be delivered in parallel with an overall better care experience for patients from our multidisciplinary work force.
In a similar vein, we believe we should be able to better protect patients from the thrombotic complications We have improved our clinical of illness and immobility audit infrastructure and in not just while they are in 2016-17 we expect to see our care, but also following both better incident reporting discharge. This will also be and more completed audits an area of focus this year. with lessons to learn that come from the incidents. Another diagnosis that is We believe we are a learning upsetting for patients, and organisation but we also contributes not to just to believe we can improve their management but also further and this is a key how we run our wards and goal. We are grateful to achieve flow for patients the national patient safety into and out of our hospital collaborative, as implemented is diarrhoea. Through our 48
work on infectious diarrhoea it has become apparent that our pathways of recognising, assessing and managing patients with diarrhoea are not perfect. This area of work is forming a SASH+ value stream and we are seeking a step change in management of this condition. Our services run at very high bed capacity and this means there are many times when patients who require admission cannot access the ward bed that is ideal for their care. We can address this both through admitting fewer patients when high quality alternatives can be found and by reducing length of stay for patients, freeing beds earlier for the next patient who needs it. We will work on ambulatory care pathways and frailty services this year as high quality alternatives to admission and we will also work to draw patients more quickly to their ideal care location so that medical, nursing and therapy input can align quicker in the patient journey. One particular group of patients where we will apply particular focus is those at the end of life. We are working in a new way with
Quality Account 2015-16
our community to be better at identifying patients whose illnesses and decline are becoming irreversible so that better plans can be made and patients and families can have confidence. Our CQC inspection in 2014 asked us to improve our environment and services for outpatient care. They re-inspected us in 2016 and confirmed we had made the improvements they expected. Nonetheless this is also an area in which we can do more and outpatients is our second SASH + value stream this year It is our expectation that this work will be reflected in further improvement in both national patient and staff surveys. This year we have shared our priorities with our shadow Council of Governors and received positive feedback on our plans.
Surrey and Sussex Healthcare NHS Trust
‘It’s hard to just pick one individual from a great team, because on my arrival to my departure everybody was excellent.’ 49
Glossary Acute Trust A Trust is an NHS organisation responsible for providing a group of healthcare services. An acute Trust provides hospital services, for example, Surrey and Sussex Healthcare NHS Trust. But not mental health hospital services, which are provided by a mental health Trust. Audit Commission The Audit Commission regulates the proper control of public finances by local authorities and the NHS in England. The Commission audits NHS trusts to review the quality of their financial systems. It also publishes independent reports that highlight risks and good practice to improve the quality of financial management in the health service, and, working with the Care Quality Commission, undertakes national value-formoney studies.
50
govern the organisation and to deliver its objectives. Care Quality Commission The Care Quality Commission (CQC) is the independent regulator of health and social care in England. It regulates health and adult social care services, whether provided by the NHS, local authorities, private companies or voluntary organisations. Visit: www.cqc.org.uk Clinical audit Clinical audit measures the quality of care and services against agreed standards and suggests or makes improvements where necessary.
Visit: www.auditcommission. gov.uk
Clinical Commissioning Group Clinical commissioning groups are predominantly GP-led groups of local healthcare professionals that commission the local health services for their catchment population, based on the needs of the patient population.
Board (of Trust) The role of the Trustâ&#x20AC;&#x2122;s Board is to take corporate responsibility for the organisationâ&#x20AC;&#x2122;s strategies and actions. The chair and non-executive directors are lay people drawn from the local community. The chief executive is responsible for ensuring that the Board is empowered to
Commissioners Commissioners are responsible for ensuring adequate services are available for their local population by assessing needs and purchasing services. Clinical Commissioning Groups are the key organisations responsible for commissioning healthcare services for their area. They commission services, Quality Account 2015-16
including acute care, primary care and mental healthcare, for the whole of their population with a view to improving the health of their population.
people elected from and by the membership base.
Hospital Episode Statistics Hospital Episode Statistics is the national statistical data Commissioning for Quality warehouse for England of and Innovation the care provided by NHS High Quality Care for All hospitals and for included a commitment to NHS hospital patients treated make a proportion of providers’ elsewhere. income conditional on quality and innovation, through the National Institute for Commissioning for Quality Health and Clinical and Innovation (CQUIN) Excellence payment framework. The National Institute for Health and Clinical Community services Excellence is an independent Health services provided in the organisation responsible for community, for example health providing national guidance visiting and on promoting good health podiatry (footcare). and preventing and treating ill health. Department of Health The Department of Health Visit: www.nice.org.uk is a department of the UK government but with National patient surveys responsibility for government The National Patient Survey policy for England alone Programme, coordinated by on health, social care and the Care Quality Commission, the NHS. gathers feedback from patients on different aspects Foundation Trust of their experience of recently A type of NHS Trust in England received care, across a variety that has been created to of services/settings. devolve decision-making from central government Visit: www.cqc.org.uk control to local organisations and communities so they are more responsive to the needs and wishes of their local people. NHS Foundation Trusts provide and develop healthcare according to core NHS principles – free care, based on need and not on ability to pay. NHS Foundation Trusts have members drawn from patients, the public and staff and are governed by a board of governors comprising
NHS Choices The first port of call for the public for all information on the NHS. NHS Information Centre The NHS Information Centre is England’s central, authoritative source of health and social care information. Acting as a ‘hub’ for high quality, national, comparative data for all secondary uses, they deliver information for local decision makers to improve the quality and efficiency of frontline care. Visit: www.ic.nhs.uk Providers Providers are the organisations that provide NHS services, for example Surrey and Sussex Healthcare NHS Trust. Registration From April 2009, every NHS Trust that provides healthcare directly to patients must be registered with the Care Quality Commission (CQC).
“A special mention to the porters who play a vital role in the hospital, they always had a smile and were happy to help”
Surrey and Sussex Healthcare NHS Trust
51
52
Quality Account 2015-16
Appendices Statement of directors’ responsibilities The content of this report was agreed with the Trust’s executive team, senior clinical staff (Executive Committee for Quality and Risk), the Safety and Quality Committee and the Trust Board. Our priorities for quality improvement in 2014-15 are based on our Quality Strategy and follow consultation through our clinical divisions with staff, and with our other stakeholders, including patients and their carers. The report has been reviewed by: • Crawley, Horsham, Mid Sussex Clinical Commissioning Group • East Surrey Clinical Commissioning Group • Surrey Downs Clinical Commissioning Group • Surrey Health Scrutiny Committee • West Sussex Health and Adult Social Care Select Committee • Healthwatch Surrey • Healthwatch West Sussex
responsibilities in respect of the Quality Account. The directors are required under the Health Act 2009 to prepare a Quality Account for each financial year. The Department of Health has issued guidance on the form and content of annual Quality Accounts (which incorporates the legal requirements in the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 (as amended by the National Health Service (Quality Accounts) Amendment Regulations 2011). In preparing the Quality Account, directors are required to take steps to satisfy themselves that:
They have been invited to review the report and their comments are included. Statement of directors’ Surrey and Sussex Healthcare NHS Trust
the Quality Account present a balanced picture of the Trust’s performance over the period covered the performance information reported in the Quality Account is reliable and accurate there are proper internal controls over the collection and reporting of the measures of performance included in the Quality Account,
and these controls are subject to review to confirm that they are working effectively in practice the data underpinning the measures of performance reported in the Quality Account is robust and reliable, conforms to specified data quality standards and prescribed definitions and it is subject to appropriate scrutiny and review the Quality Account has been prepared in accordance with Department of Health guidance The directors confirm to the best of their knowledge and belief that they have complied with the above requirements in preparing the Quality Account. By order of the Board
Alan McCarthy Chair 30 June 2016
Michael Wilson CBE Chief executive 30 June 2016 53
What our partners say We invited our stakeholder partners to review this Quality Account and have received the following responses and comments from them. Please note that, in response to their feedback, we have included additional information in this report.
Crawley, Horsham and Mid Sussex, East Surrey and Surrey Downs Clinical Commissioning Groups (CCGs) The CCGs are pleased to be offered the opportunity to comment on Surrey and Sussex NHS Trust Quality Account for 2015-16. The Quality Account provides information across a wide range of quality measures and gives an overview of care provided by the Trust. The CCGs acknowledge the achievement in the participation of the Virginia Mason development programme and notes the Trust top 20% position for learning from incidents. Commissioners throughout the year seek assurance in a number of forums where presentation of a wide range of indicators in quality, safety and performance is presented and discussed between the Trust and the CCGs. We therefore acknowledge the quality account mirrors the information given 54
to the commissioners throughout the year, and the strengthened governance improvements made during the year has been noted. We note and support the Value Work streams priorities for inpatient flow, cardiology, outpatients and the management of diarrhoea within your Virginia Mason partnership, SASH+. The Commissioners also acknowledge the excellent areas of attainment in the Friends and Family Test, and the staff survey with an overall performance in the top 20%. This shows that both the patients recommend your services, and staff would recommend the hospital to relatives, and is a good place to work. Within the report the Trust identified their achievements to date, and also areas where their service delivery requires further improvement. The CCGs will support the Trust in achieving these improvements as identified within the quality account through existing contract mechanisms and collaborative working
throughout 2016-17. There has been an increase in the number for serious incidents relating to patient falls. We acknowledge although below the National threshold, we are pleased to note that the Trust will focus on further improvements for falls management, ambulatory care pathways, and frailty service, and the appointment of a Consultant Nurse for Dementia. All CCGs note the challenges within the report, and most have been reflected and clearly evidenced within the document. All commissioners would like to have seen more about data relating to pressure damage and elimination of mixed sex accommodation as it is rated as compliant with no breaches or reports of pressure damage. The commissioners are pleased to endorse this quality account for 2016-17, and we look forward to continuing our good relationships so we can all drive forward the 2016-17 priorities for quality improvements for our local populations. Quality Account 2015-16
Surrey Wellbeing and Health Scrutiny Board The Wellbeing and Health Scrutiny Board welcomes the opportunity to comment on Surrey and Sussex Healthcare NHS Foundation Trust’s Quality Account for 2015-16. The Trust is thanked for working with the Board over the last year. The Board in particular welcomes the Trust’s continued efforts to achieve the rating of Outstanding in its next inspection. The Board thanks the Trust for its submitted evidence on the resilience of Surrey’s urgent care systems during winter. This was considered on 16 September 2015 alongside the evidence of other Trusts. On 3 May 2016 the Board was provided with an update on the collaborative work being undertaken by the Trust with the Virginia Mason Institute. The Board notes that this work presents an exciting opportunity for the Trust in 2016-17, and would invite further evidence at a future date on the impact of this collaboration for the benefit of the Trust, its patients and their families. The Board commends the Trust for a clear and well-presented Quality Account, particularly in relation to level of detail and supporting commentary. It provides strong evidence of how the Trust has maintained
its performance at a time of considerable demand and resource pressures. The Board would suggest, however, that the priorities for 201617 could be presented in summary form prior to the more detailed contents in order to assist clarity of purpose. The Board would also invite the Trust to expand on the evidence related to patient experience in future reports, as this would support a number of the key assertions it makes regarding its performance. The Board notes the significant increase in information shared with external agencies in relation to children’s safeguarding (as detailed on p16), and welcomes this as evidence of growing staff awareness in this area. The Board would encourage the Trust to look at the underlying causes related to the increase in the number of falls with harm (as detailed on p12), in order to identify whether it is result of improved reporting or an area requiring further attention. The Board congratulates the Trust on a positive Quality Account, and welcomes its priorities for 2016-17. It looks forward to working with the Trust to monitor and support these in the year ahead.
Healthwatch Surrey As the independent consumer champion for health and social care, we
Surrey and Sussex Healthcare NHS Trust
have been asked to comment within this Quality Account. Our organisation exists to give the people of Surrey and voice to improve, shape and get the best out of health and care services. We have chosen to use this opportunity to reflect the views and experiences of people that have interacted with us. Local people interact with Healthwatch Surrey in excess of 10,000 times each year. These interactions take place on the high street, in other public locations, in places where services are delivered and in the course of providing our own services (information, advice and NHS Complaints Advocacy). We also undertake activities that focus on understanding the views of those that are often seldom heard. In the 12 months up to 31 March these interactions led to 2,485 experiences being shared with us. • 101 of these related to services at Surrey and Sussex Healthcare NHS Trust • A significant number of the experiences shared with us have been negative (45%), however a number of positive experiences have also been shared with us about this service (30%). There is a lower proportion of negative experiences (45%) reported to us about this service than for hospital 55
services generally in Surrey (53%) • There is a lower proportion of negative experiences (45%) compared with the general sentiment reported to us about health and care services (51%) • The strongest theme within the negative experiences reported to us is ”lack of communication” (12 experiences) - both between health professionals and health professionals and patients • A number of the negative experiences reported to us demonstrated that the Trust’s four core values of dignity and respect, one team, compassion and safety and quality were not always met. Based on the experiences shared with Healthwatch Surrey for all NHS services it is clear that making it easier to make an NHS complaint remains a top priority for people
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• This evidence should be considered alongside other data presented by the Trust and within a wider context, which includes: • Healthwatch Surrey has had a good level of engagement with the Trust in the previous 12 months and has been able to provide important insight into positive and negative experiences of local people • The Trust has taken action based on the information provided by Healthwatch Surrey • The Public Health Service Ombudsman – which deals with complaints not resolved by the NHS – has reported that in 2015 they undertook five investigations into complaints that could not be resolved between local people and the Trust • Regulatory bodies – Monitor and NHS Trust Development Authority – have published the Learning From Mistakes League (March 2016) within which the Trust appeared 66th out of the 230 NHS trusts in England and was identified as having a ‘good reporting culture’
• Healthwatch Surrey has a close working relationship with the Care Quality Commission and regularly shares information to inform their inspection activity • We look forward to continuing to work with the Trust to ensure that the people of Surrey have a voice to improve, shape and get the best from health and social care services. We look forward to continuing to work with the Trust to ensure that the people of Surrey have a voice to improve, shape and get the best from health and social care services.
Healthwatch West Sussex Introduction Healthwatch West Sussex (HWWSx) are pleased to be invited to comment on Surrey and Sussex Healthcare NHS Trust (SaSH) draft Quality Account (QA) for 2015-16. We are interested to read of the Trust’s success in being selected by NHS Improvement to be one of only five Trusts across England and Wales to work in partnership with Virginia Mason Institute (VMI) on a five year development programme. We assume this development programme will reflect the content of the Five Year Forward View as published by NHS England which Quality Account 2015-16
has the basic requirements of Transformation and Sustainability. We commend the Trust’s stated aspiration to build on the Care Quality Commission’s rating of “Good” and to achieve “Outstanding” across the five domains. We further commend the Trust for recognising and expressing the failures in service experienced by patients in 2014-15. Our commentary not only reflects the content of the Trust’s draft QA but is also drawn from patient experience as recorded in our Client Relationship Management (CRM) system. HWWSx received both positive and negative comments from patients. In summary: Positive Emergency care Excellent care for patient and family A&E Staff efficient, friendly and professional Cleanliness of hospital particularly assessment area Negative Time spent waiting across several services. his issue reported in 2014-15 QA response Discharge inadequate arrangement and lack of follow up care. This
issue reported in 2014-15 QA response
would like to see what plans will be put in place with timescales and outcomes Staffing identified. We are pleased poor attitude, inconsistency of to see the Trust continues to consultant and general staffing build on partnership working levels in some areas. with local authorities and others to develop seamless Further anonymised details can care pathways and facility be supplied if required. outpatient care as part of the non-admission policy. Safety Reported improvement We note that data quality 2015-16 and accuracy of coding were identified as a We note the improvement in priority in 2014-15 and are MRSA and pressure damage disappointed to see no or cases but are disappointed very little improvement in that once again the rate of these areas. C Difficile infection has not reduced as much as expected. Patient experience It is difficult to accurately Reported improvement analyse the information 2015-16 reported within the draft QA. It appears that accurate data As the independent patient’s has proved an issue again voice we welcome the Trust’s for the Trust and therefore efforts to hear directly from it is hoped that the focus patients and carers. The Trust on accuracy will support the is to be commended for development and delivery proactively seeking patents’ of improvement plans in a view through Friends and timelier manner. The increase Family Test (FFT) and for in identifying and sharing setting up focus groups, concerns with appropriate “hot topic” events to seek authorities over children’s service users’ views, and safeguarding is for implementing a set of to be welcomed and standards of behaviour for appears to be the result of all staff – a negative issue wider staff training. reported to us. Effectiveness Reported improvement 2015-16 Although the Trust has participated in a number of audits (reporting on these is included in the draft QA) there is no evidence of implementation of the recommendations. HWWSx
Surrey and Sussex Healthcare NHS Trust
We would wish to see continued evidence of improvements made as a result of patient feedback in the 2016-17 QA. Although the report states that there will be increase opportunities for patient representatives and others to become involved and tell their stories in order that the Trust learns 57
from these, we see no information as to how this will be implemented. HWWSx are pleased to note an increase in clinical engagement over the last year with Patient Opinion. The Trust achievement of being in the top 20% of hospitals nationally as a place to work and receive treatment can only enhance service users experience and is to be applauded. Priorities for 2016-17 Integrated re-enablement unit in partnership with Surrey County Council and East Surrey CCG HWWSx would wish to see a similar arrangement set up for West Sussex patients with timescales and expected outcomes included. West Sussex service user would then benefit from reduced length of stay, alternatives to hospital admission and access to the ambulatory care pathway. It is hoped that this priority will address issues reported to us. Improved clinical audit infrastructure Focus on safer surgery priorities in line with national Safety Standards for invasive procedure is welcomed in order to reduce hospital acquired infection rates. HWWSx would wish to see evidence of learning and service change as a result of this priority. Infectious diarrhoea HWWSx is pleased to see 58
continued emphasis on staff training on infection prevention and control across all areas. Childrenâ&#x20AC;&#x2122;s safeguarding This priority is within the body of the text. We commend the Trust to include childrenâ&#x20AC;&#x2122;s safeguarding training in 2016-17 priorities and to consider how best to achieve smooth transition to adult safeguarding services as appropriate. Falls West Sussex has an increasingly elderly population and therefore this priority should significantly improve the patientâ&#x20AC;&#x2122;s experience and wellbeing. End of Life Care This has become a national focus and we are pleased to see the Trust not only has registered on the Transforming End of Life Care in acute Trusts but proposes to audit their end of life care plans in 2016-17. HWWSx would welcome receiving the outcome of this audit. Outpatient care and environment This priority can only enhance the patient experience and is to be welcomed. It is hoped that improvements in this area will ensure speedy transfer to appropriate inpatient facilities as required. It would be helpful if HWWSx could receive updates on the continued use of FFT, Your
Care Matters and Patient Opinion to evidence service change. Conclusion from a patient perspective As an organisation representing patient interests, viewing evidence of service improvement is of primary importance to us. HWWSx recognises that involvement with the development programme in partnership with the Virginia Mason Institute is likely to challenge the Trust on several fronts. We look forward to being informed on a regular basis of initiatives which result in an improved journey through the Trust and beyond for West Sussex residents and their families. We look forward to continuing to building an open, transparent and mutually respectful relationship with the Trust in order to support continuous improvement in the delivery of healthcare.
West Sussex HASC West Sussex HASC have responded to let us know that as they have not carried out any formal scrutiny of Surrey and Sussex Healthcare NHS Trust services that they will not be commenting on our Quality Account 2015-16. Quality Account 2015-16
Keep in touch Surrey and Sussex Healthcare NHS Trust provides emergency and non-emergency services at: East Surrey Hospital Redhill Surrey RH1 5RH Tel: 01737 768511 Surrey and Sussex Healthcare NHS Trust provides non-emergency services at Crawley Hospital which is managed by NHS Property Company. Crawley Hospital Crawley West Sussex RH11 7DH Tel: 01293 600300
We also provide a number of services at four community sites: Caterham Dene Hospital Church Road Caterham Surrey CR3 5RA Tel: 01883 837500 Horsham Hospital Hurst Road Horsham West Sussex RH12 2DR Tel: 01403 227000 Oxted Health Centre 10 Gresham Road Oxted RH8 0BQ Tel: 01883 734000 Surrey and Sussex Healthcare NHS Trust Trust Headquarters Canada Avenue Redhill Surrey RH1 5RH Tel: 01737 768511 Email: enquiries@sash.nhs.uk www.surreyandsussex.nhs.uk
Surrey and Sussex Healthcare NHS Trust
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Need help or advice? The Patient Advice and Liaison Service (PALS) focuses on improving services for NHS patients. It aims to: • advise and support patients, their families and carers • provide information on NHS services • listen to your concerns, suggestions or queries • help sort out problems quickly on your behalf You can contact PALS by: • telephone: 01737 768511 x 6922 or 6831 (for all sites) • e-mail: pals@sash.nhs.uk • writing to: PALS, c/o East Surrey Hospital, Redhill, Surrey RH1 5RH You can ask a member of staff to contact PALS on your behalf This information is available in other languages and formats including audio tape, large print and braille. For further information please contact PALS (Patient Advisory Liaison Service) on 01737 231958 or email: enquiries@sash.nhs.uk
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